Characteristics of patients requiring prolonged length of stay in a surgical intensive care unit in Barbados.

OBJECTIVE: To evaluate the clinical characteristics and costs incurred for patients who stayed for a prolonged period in a surgical intensive care unit (ICU). DESIGN AND METHODS: Data of all patients admitted to a surgical ICU in Barbados during the period of two years from July 1999 to June 2001 were prospectively collected. Demographic data, diagnoses on admission and Acute Physiology and Chronic Health Evaluation (APACHE II) score were recorded. Costs for treatment were calculated from using a cost block model. The characteristics of patients who had a prolonged stay (> 14 days) were compared with a concurrent cohort of patients who stayed less than 14 days. RESULTS: Of 438 admissions, 58 (13.2%) stayed in the ICU for more than two weeks. The overall age, hospital outcome, APACHE II scores in the prolonged stay group were significantly higher than that of the patients who stayed less than two weeks. Cost analysis showed about six times more expenditure in the long stay patients (dollar US 3800 vs dollar US 24000). Of the prolonged stay ICU patients, 29.2% would have required only a step-down unit due to less severity of illness as evidenced by their low mean APACHE II scores [7.3 +/- 2.6 (SD)] compared to overall mean APACHE II score 10.7 +/- 7.5 (SD). CONCLUSION: The study highlighted the need for a step-down unit and a protocol to transfer eligible patients to such a unit.

Knowledge, attitudes and practice of medical students at the Cave Hill Campus in relation to ethics and law in healthcare.

OBJECTIVES: The purpose of this study is to assess the knowledge, attitudes and practices among medical students in relation to medical ethics and law. The results of the study will be a useful guide to tutors of medical students and curricula designers. METHODS: A thirty-item self-administered questionnaire about knowledge of law and ethics, and the role of an ethics committee in the healthcare system was devised, tested and distributed to all levels of students and staff at the Queen Elizabeth Hospital in Barbados (a tertiary care teaching hospital) in 2003. The data from the completed questionnaires were entered into an SPSS database and analyzed using frequency and multiple cross-tabulation tables. RESULTS: Completed responses were obtained from 55 (96%) of the medical students. Medical students generally attested to the importance of ethical knowledge but felt that they knew little of the law. Students varied widely as regards the frequency with which they saw ethical or legal problems, with a quarter seeing them infrequently, but another quarter seeing them every day. They received their knowledge from multiple sources and particularly from lectures/seminars, and found case conferences the most helpful. Only a few students felt that text books had been helpful. Students were generally knowledgeable about most ethical issues, but many had uncertainties on how to deal with religious differences in treating patients, on the information to be given to relatives, and how violent patients should be treated. CONCLUSIONS: The results of the study highlight that medical students felt an inadequacy of knowledge of law as it pertains to their chosen career Since most of their knowledge of law was obtained from lectures, these should be reviewed and other avenues of tuition explored. The study also highlights the need to identify the minority of students who have problems with their ethical knowledge and to devise means whereby any deficiencies can be discussed and modified.

Immunologic aspects of unknown primary melanoma.

Immune responses of 36 patients with stage II unknown primary melanoma were compared to those of 83 stage II patients with known primary melanoma. The two groups of patients were similar in age, sex, and extent of disease. Delayed cutaneous hypersensitivity to dinitrochlorobenzene (DNCB) was nearly identical in both groups. Patients with unknown primary melanoma had a mean level of reactivity of 4.7 +/- 0.37 and the patients with known primary had a mean level of 5.0 +/- 0.17. Of unknown primary patients 4.2% were unreactive to DNCB and 4.8% of known primary patients were unreactive. Antibodies to cultured melanoma cells were slightly more prevalent in serum from the unknown primary patients (67%) than from known primary patients (45%), but mean titer of positive sera did not differ significantly. Lymphoproliferative assays did not demonstrate differences in lymphocyte reactivity among the two groups when tested with Concanavalin A, mixed leukocyte culture, or unstimulated lymphocyte blastogenesis. No differences could be detected in these assays of humoral and cellular immune responses when patients with unknown primary melanoma were compared to those with known primary melanoma and similar clinical characteristics.

An evaluation of two methods of limb salvage in extremity soft-tissue sarcomas.

Between 1983 and 1990, 38 sequential patients with stage II to III soft-tissue sarcoma of the extremities, as defined by the American Joint Committee on Cancer, were treated. Eighteen patients were treated with intra-arterial doxorubicin hydrochloride, limb salvage surgery, and radiation (group A). Twenty patients in group B were treated with cisplatin, isolated limb perfusion, limb salvage surgery, and radiation. The study was not randomized, but all patients were treated prospectively using one of the two protocols. The two groups were similar demographically and had similar lengths of survival without disease. There was only one local recurrence in the series, and this occurred in a group B patient who underwent perfusion with the lowest dose of cisplatin. Regional perfusion with either intra-arterial doxorubicin hydrochloride or cisplatin combined with limb salvage surgery and postoperative radiation are highly effective in preventing local recurrences and preserving functional extremities in patients with soft-tissue sarcoma. There was no difference in results between these two methods.

The role of stereotactic biopsy in assessment of nonpalpable breast lesions.

BACKGROUND: When mammography identifies a lesion suspicious for cancer, stereotactic needle core biopsy (SCNB) and needle localization (NL) surgical biopsy are options for obtaining tissue. This study compared the results of these two biopsy methods in evaluating nonpalpable radiologically suspicious breast lesions. METHODS: Records of 292 women who underwent SCNB or surgical biopsy at two institutions were reviewed over 28 months. The women were separated into two groups, under 50 years of age and 50 years of age and older. RESULTS: A total of 70 women over the age of 50 had stereotactic biopsy. One hundred and three had NL biopsies. The rate of positivity was 37% and 33% for stereotactic and NL biopsy respectively (P = 0.693). A total of 44 women under the age of 50 had stereotactic biopsy. Seventy had NL biopsies. The rate of positivity was 7% and 21%, respectively, for stereotactic and NL (P = 0.082). NL surgical biopsy costs on average $2354.00. SCNB averages $949 including follow-up mammogram. CONCLUSION: SCNB is a cost-effective, accurate method of breast biopsy. This report retrospectively compares SCNB with surgical open biopsy aided by NL. The cost savings occurred primarily in surgeon's fees and anesthesia fees. We found no statistical difference in < 50- or > 50-year-old patients in the frequency of the diagnosis of breast cancer when comparing the two types of biopsies.

Problems in diagnosis and management of desmoid tumors.

Thirty-two primary desmoid tumors occurred in 29 patients. The median patient age was 32 years, and 55% of the patients were females. An antecedent history of trauma at the tumor site was elicited from 28% of patients. Thirty-one of 32 primary tumors were completely excised at initial presentation. Five tumors were treated with adjuvant radiotherapy. The overall recurrence rate for primary and recurrent lesions was 60%. The recurrence rate in children (88%) was more than twice that found in adults (38%). A single recurrence did not significantly increase the likelihood of a subsequent recurrence. Greater than 90% of all recurrences took place within 3 years of treatment. The rate of recurrence was not clearly influenced by the status of histologic margins, although this was examined in less than half the tumors. Desmoid tumors are aggressive neoplasms that exhibit a strong propensity for local recurrence. They should be treated as low-grade malignancies with documentation of histologic margins and close clinical follow-up within the framework of a tumor registry.

Pharmacokinetics, toxicity, and short-term results of cisplatin hyperthermic isolated limb perfusion for soft-tissue sarcoma and melanoma of the extremities.

Fifty-nine patients with melanoma or soft tissue sarcoma of the extremities underwent hyperthermic isolated limb perfusion utilizing cisplatin and wide local excision. Doses of cisplatin ranged from 0.75 to 2 mg/kg. The mortality and morbidity rates were 0 and 6.8 percent, respectively. Pharmacokinetic studies indicate that cisplatin is rapidly bound to perfused tissues and remains bound for 1 month. Maximum tumor response in sarcomas occurs 1 to 2 weeks after perfusion, compared with 1 month after perfusions with l-phenylalanine mustard and actinomycin D. Local and regional recurrence rates were 0 and 3.4 percent, respectively, at 1 year. Further studies of hyperthermic limb perfusions with cisplatin are warranted.

Breast carcinoma in situ. A retrospective review of 112 cases with a minimum 10 year follow-up.

We have retrospectively reviewed 112 cases of in situ carcinoma of the breast treated between 1960 to 1972, with a minimum 10 year follow-up to correlate treatment with outcome. We concluded that bilateral simple mastectomy with low axillary dissection is the treatment of choice for intraductal or lobular carcinoma in situ. This conclusion was based on the early age at diagnosis, the high incidence of bilaterality, and the long latency and probable progression from the in situ stage to the invasive stage. Lesser procedures can be endorsed for those patients of advanced age or who have associated medical problems whose life expectancy is estimated to be 10 years or less. Patients who refuse bilateral mastectomy should undergo biopsy of the involved or opposite breast at 3 to 5 year intervals regardless of physical findings or mammographic suspicions, especially when severe epithelial dysplasia is encountered in the biopsy specimens. This nonpalpable but potentially curable lesion remains difficult to detect even by mammography.

Liposarcoma of the leg.

Forty-eight patients with liposarcomas of the leg were reviewed. Patients were treated by three approaches: wide local excision, amputation, and regional hyperthermic perfusion. Deaths from distant metastases occurred at a similar rate in all groups. The local recurrence rate was 43 percent in the wide excision group and 29 percent in the amputation group. No perfused patient had a local recurrence. This study demonstrates that hyperthermic regional perfusion and excision are superior to wide excision or amputation in preventing local recurrence for a liposarcoma of the leg and allow salvage of a functional limb.

Advanced squamous cell carcinoma of the maxillary sinus. Results of combined regional infusion chemotherapy, radiation therapy and surgery.

Sequential intraarterial chemotherapy using bleomycin and methotrexate followed by high dose radiation and surgery was evaluated in 10 patients with stage III and IV squamous carcinomas of the maxillary sinus. Seven of 10 patients had extensive tumor necrosis in the surgical specimen, and no evidence of residual tumor was found in 4 of these patients. After a median follow up period of 24 months, there has been only one local recurrence in resected patients. Three patients died from pulmonary metastases. Although many unanswered questions remain regarding the efficacy of triple therapy for maxillary sinus malignancy, these results are encouraging and establish that surgical resection and healing are not compromised by preoperative chemotherapy and radiation.

Antethoracic jejunal esophagoplasty. An alternate method of repair.

Antethoracic jejunal esophageal reconstruction is an effective alternative method of repair and should be considered when difficulty is expected with the standard approaches. The primary difficulty with this mode of repair is related to the vascular supply of the jejunum. However, with careful evaluation and management of the pedicle, ischemia of the graft may be avoided. If vascularity appears less than optimal, the proximal anastomoses should be delayed and the graft placed in the subfascial tunnel. If the cervical jejunal portion becomes necrotic, this space may be bridged later with an isoperistaltically positioned free graft utilizing microvascular techniques.

Endocrine ablation for metastatic breast cancer: a reappraisal of hormone receptors.

PIP: Other indicators of hormone sensitivity, besides estrogen receptor (ER) content, such as response to oophorectomy, antiestrogens, prolactin suppression, and correlation with progesterone receptors (PR), were evaluated in the hope of further improving selectivity and response of patients undergoing endocrine ablation for metastatic breast cancers. 225 patients have undergone full endocrine ablation in the last 30 years at this hospital, 208 by adrenalectomy and 17 by hypophysectomy. 206 of these patients could be retrospectively reviewed, and of these there were objective responses to therapy in 50% of patients. ER analyses were performed in 1 or more breast cancer specimens in 113 of these patients. ER study showed that a patient who was ER+ and responded to a functional test of endocrine sensitivity had a 70-80% chance of also benefiting from adrenalectomy or hypophysectomy. Conversely, patients with absent or unknown hormone receptors who failed therapeutic trials of endocrine sensitivity had little or no chance of responding to major ablation; these cases are best treated with multiagent chemotherapy. The value of sequentially treating selected patients with endocrine manipulation in addition to chemotherapy was also studied. Patients who failed to respond to endocrine manupulation survived slightly over 2 years on chemotherapy, whereas patients who responded to major ablation lived with metastases an average of 4 years, whereas complete responders lived with metastatic disease an average of 6 years. By life table analysis, total survival of ER+ vs. ER- patients as well as responders vs. nonresponders was highly significant^ieng

Multiple simultaneous and sequential estrogen receptor values in patients with breast cancer.

Fifty-nine women had multiple estrogen receptor assays done, either simultaneously or sequentially. Eighty-six percent of the patients who had multiple synchronous estrogen receptor assays from various metastatic sites showed no significant discrepancy in estrogen receptor values. When estrogen receptor assays were done sequentially without intervening therapy, 83.5 percent of the patients maintained their initial positivity or negativity. However, when the second estrogen receptor determination was preceded by either chemotherapy or hormonal therapy, 33 percent of the patients had a significant discrepancy in estrogen receptor values. The most common discrepancy was estrogen receptor-positive tumors becoming estrogen receptor-negative, although a small number of patients were found whose receptor values became more positive after hormonal ablation.

Results of oophorectomy by menstrual and estrogen receptor states in patients with metastatic breast cancer.

The records of 204 women with metastatic breast carcinoma treated by oophorectomy were analyzed. Premenopausal women had a response rate of 50 percent. Forty-one percent of postmenopausal women responded. Those who responded had an average duration of response of 22 months and a length of survival twice that of the nonresponders. There was a better than 60 percent correlation between response to oophorectomy and response to further endocrine ablation. Response to endocrine manipulation is more a function of the hormonal sensitivity of the carcinoma than of menopausal status.

Brunner's gland hyperplasia.

Brunner's gland adenomas are uncommon benign duodenal tumors. They are an infrequent cause of upper gastrointestinal hemorrhage and duodenal obstruction but can occasionally mimic duodenal malignancy in their presentation. Conservative endoscopic or surgical resection followed by a regimen of antacids and H2 antagonists is the treatment of choice.

Ultralight aircraft safety and regulation.

Ultralight aircraft evolved from adding power to hang gliders. Ultralight aviation is now the fastest growing sport in America. The safety of these aircraft is of concern but information regarding accidents and fatalities has been meager. To date, the only major source of statistics has been the Experimental Aircraft Association, which tabulated 101 accidents with 20 fatalities over a 3.5-year period. Until October 1982, there were no FAA regulations governing these aircraft. This report reviews the evolution of ultralight aircraft regulation and the available accident information.

Disseminated melanoma presenting as a catastrophic event.

The possibility of a patient with malignant melanoma having a catastrophic event as the presenting sign of tumor dissemination cannot be dismissed. Should such an event occur, it would pose not only a risk to the patient, but also a potential risk to others. Since 1971, 712 patients with malignant melanoma have been evaluated. Twenty patients presented with brain metastases and an additional 12 patients developed brain metastases simultaneously with other organ involvement. Four patients (0.6%) had a catastrophic event, such as a stroke or seizure, with no antecedent symptoms. Microstaging of a primary melanoma by the methods of Clark and Breslow, in addition to the recognition of the presence or absence of regional lymph node metastases, provides reliable information for predicting the probability of tumor dissemination. Patients with deep primary melanomas or with lymph node metastases should be advised regarding their participation in potentially hazardous occupations or recreations.