Combined chemotherapy and radiotherapy for carcinomas of the anus.

Abdominoperineal resection (APR) has been the treatment of choice for squamous cell carcinoma of the anus; however, chemotherapy combined with radiotherapy (CT-RT) has now replaced APR as the primary treatment. Since 1983, 17 patients with carcinoma of the anus have been treated at Wenatchee Valley Clinic Tumor Center. Fourteen of these patients were treated with radiotherapy concurrently with administration of 5-fluorouracil (5-FU) and mitomycin C. Local control at 6 weeks post-treatment occurred in all 14 patients. Four of the 14 patients treated with CT-RT died, 2 of recurrent cloacogenic carcinoma, 2 of other cancers, and 1 of deep vein thrombosis. Five patients with stage III cancer were free of obvious disease at an average of 27 months follow-up. CT-RT seems to be successful for local control of anal carcinoma and, based on other studies, provides improvement in long-term survival when compared with APR.

Mason gastric bypass. Long-term follow-up and comparison with other gastric procedures.

The Mason gastric bypass as performed over 8 years on 171 patients for the treatment of massive exogenous obesity. The first 26 patients had a large pouch constructed, and poor long-term weight loss occurred. In the last 6 years, 145 patients had a smaller pouch with a 5.5 percent immediate postoperative complications rate. One early death resulted. Late complications and revisions were few. In the last 145 patients there were only 9 who did not maintain a weight loss of greater than 25 percent of their total weight. This group of 145 patients have lost an average of 42 percent of their total weight (121 pounds) and 72 percent of their excess weight. The stapled Alden gastric bypass and horizontal gastroplasties, when compared with the Mason gastric bypass, have similar complications with the potential for poor weight loss after long-term follow-up due to channel enlargement or staple-line leakage. The Mason gastric bypass is an excellent surgical method of weight loss.

Clinical utility of open lung biopsy for undiagnosed pulmonary infiltrates.

Open lung biopsy (OLB) is often performed as the definitive diagnostic procedure in patients with undiagnosed pulmonary infiltrates, but controversy exists as to the clinical utility of this practice. A retrospective review of 50 consecutive patients who underwent OLB for undiagnosed pulmonary infiltrates was done to assess the diagnostic value as well as the frequency with which these results affected therapy and mortality. Histologic tissue diagnoses were obtained in all patients. Specific pathologic diagnoses were obtained in 56% of patients, nonspecific in 44%. Lobar or lateralized infiltrates were more likely to yield a specific diagnosis (87%) than diffuse, bilateral infiltrates (42%). Thirty-four patients (68%) had previously had a nondiagnostic transbronchial biopsy; 58% of these patients had a specific diagnosis established by OLB. Twelve patients (24%) were in acute respiratory failure at the time of OLB; this group had a 50% mortality rate as compared with only 2.6% for patients not in acute respiratory failure (p less than 0.01). Therapy was altered (new specific or nonspecific treatment initiated or therapy withdrawn) in 78% of patients undergoing OLB. Thirty-day in-hospital survival was significantly higher in patients for whom either specific or nonspecific therapy was indicated and initiated versus those in whom no therapy was initiated or all therapy was withdrawn (mortality: 5.5% versus 35.7%; p = 0.01). Mortality was not related to the presence of immunosuppression or to the finding of a specific diagnosis. The overall mortality rate of 14% in this series compares favorably with mortality rates found in similar series, reflecting differences in patient populations and possibly the timing of intervention. OLB remains a clinically valuable diagnostic tool in selected patients.

Is nasogastric suction necessary after elective colon resection?

It is commonly held that nasogastric suction is necessary after colon resection to prevent small and large bowel distension, wound complications, and anastomotic problems. In this retrospective study of 118 patients undergoing colon resection for malignancy or inflammatory disease, 83 underwent postoperative nasogastric suction and 35 did not. A wide variety of postoperative variables were evaluated in these two groups of patients and few differences were found. However, there were trends toward shorter postoperative hospital stays, and less abdominal distension, nausea, and vomiting could be discerned in the patients who did not undergo nasogastric suction. This retrospective study suggests that routine nasogastric suction may not be necessary or useful after elective colon resection.

Experience with gastric bypass for massive obesity.

Gastric bypass was performed for the control of massive, exogenous obesity on 50 patients. There was a preoperative average weight of 134 kg. The average weight of these patients at one year was 85 kg, at 2 years was 87 kg and at 3 years was 93 kg. There were five patients who failed to lose 25% of their preoperative weight. An early major complication rate of 10% occurred with one death. Cholelithiasis occurred at some time in 38% of these patients.

Improvement of walking abilities after robotic-assisted locomotion training in children with cerebral palsy.

OBJECTIVE: To measure functional gait improvements of robotic-assisted locomotion training in children with cerebral palsy (CP). DESIGN: Single-case experimental A-B design. SETTINGS: Rehabilitation Centre Affoltern am Albis, Children's University Hospital Zurich, Switzerland (inpatient group) and Neurology Department of the Dr von Haunersches Children's Hospital Munich, Germany (outpatient group). PARTICIPANTS: 22 children (mean age 8.6 years, range 4.6-11.7) with CP and a Gross Motor Function Classification System level II to IV. INTERVENTIONS: 3 to 5 sessions of 45-60 minutes/week during a 3-5-week period of driven gait orthosis training. MAIN OUTCOME MEASURES: 10-metre walk test (10MWT), 6-minute walk test (6MinWT), Gross Motor Function Measure (GMFM-66) dimension D (standing) and dimension E (walking), and Functional Ambulation Categories (FAC). RESULTS: The mean (SD) maximum gait speed (0.78 (0.57) to 0.91 (0.61) m/s; p<0.01) as well as the mean (SD) dimension D of the GMFM-66 (40.3% (31.3%) to 46.6% (28.7%); p<0.05) improved significantly after the intervention period. The mean (SD) 6MinWT (176.3 (141.8) to 199.5 (157.7) m), the mean FAC (2.6 (1.7) to 3.0 (1.6)) and the mean (SD) dimension E of the GMFM-66 (29.5% (30.3%) to 31.6% (29.2%)) also showed an increase, but did not reach a statistically significant level. CONCLUSION: These results suggest that children with CP benefit from robotic-assisted gait training in improving functional gait parameters.

Feasibility of robotic-assisted locomotor training in children with central gait impairment.

Intensive, task-specific training enabled by a driven gait orthosis (DGO) may be a cost-effective means of improving walking performance in children. A paediatric DGO has recently been developed. This study was the first paediatric trial aimed to determine the feasibility of robotic-assisted treadmill training in children with central gait impairment (n=26; 11 females, 15 males; mean age 10 y 1 mo [SD 4 y]; range 5 y 2 mo-19 y 5 mo). Diagnoses of the study group included cerebral palsy (n=19; Gross Motor Function Classification System Levels I-IV), traumatic brain injury (n=1), Guillain-Barré syndrome (n=2), incomplete paraplegia (n=2), and haemorrhagic shock (n=1), and encephalopathy (n=1). Sixteen children were in-patients and 10 were outpatients. Twenty-four of the 26 patients completed the training which consisted of a mean of 19 sessions (SD 2.2; range 13-21) in the in-patient group and 12 sessions (SD 1.0; range 10-13) in the outpatient group. Gait speed and 6-Minute Walking Test increased significantly (p<0.01). Functional Ambulation Categories and Standing dimension (in-patient group p<0.01; outpatient group p<0.05) of the Gross Motor Function Measure improved significantly. DGO training was successfully integrated into the rehabilitation programme and findings suggest an improvement of locomotor performance.

Effects of paralysis with pancuronium bromide on joint mobility in premature infants.

To study the effects of muscle paralysis on joint mobility, we compared eight premature infants treated with pancuronium bromide with a control group. A significant reduction was observed in hip and knee flexion, and in ankle dorsal extension, which tended to resolve in time. We conclude that muscle paralysis reduces the mobility of selected joints; spontaneous activity appears to prevent long-term contractures.

[Congenital lymphangiectasis of the lungs (so-called primary and secondary forms) and lymph vessel dilation in hyaline membrane syndrome]. / Kongenitale Lymphangiektasien der Lungen (sogenannte primäre und sekundäre Formen) und Lymphgefäserweiterunge bei Hyaline Membranen-Syndrom.

In five cases of congenital pulmonary lymphangiectasis, light microscopic features of the lungs and measurements of their lymph vessel lumina are presented. All lung sections show the same histologic characteristics: a network of partly tubular, partly cystically enlarged lymph vessels within large areas of connective tissue. The lung sections in four cases with pulmonary vein outflow obstruction, the so-called secondary form according to NOONAN et al. [28], do not differ from those in primary lymphangiectasis without obstruction in the pulmonary vein outflow area. The author's own observations are discussed together with 57 cases from the literature. Among the 26 cases of secondary lymphangiectasis are 15 children with aberrant pulmonary veins, and 11 children with hypoplasia of the left side of the heart. Clinically, both forms present with neonatal asphyxia and massive respiratory distress, usually with a fatal outcome within the first few days of life. Hyaline membrane disease may be accompanied by pulmonary lymphangiectasis to a degree that renders its distinction from congenital lymphangiectasis difficult. The lungs in 5 cases with hyaline membrane disease are compared to those in 5 cases of congenital lymphangiectasis. In the former, distended lymphatics are primarily interlobular in location, while in congenital lymphangiectasis they are also found in the subpleural and periarterial tissues. In addition, they are widened to a lesser degree than in the congenital form. In the latter the lymphatic vessel walls are markedly thickened, and the pulmonary lesions, particularly the signs of immaturity, typical for hyaline membrane disease, are lacking.

Neonatal Escherichia coli meningitis: spinal adhesions as a late complication.

We describe two boys who had severe spinal complications in adolescence after a favorable initial recovery from neonatal Escherichia coli meningitis. Due to spinal granulomatous adhesions, one boy died after an attempted scoliosis operation (high cord lesion). The other showed severe progressive neurological deterioration with spinal and cerebellar symptoms. Conclusion The severe complication of chronic arachnoiditis with spinal adhesion may occur many years after neonatal acute bacterial meningitis.

[Triploidy as a cause of midtrimester gestosis(author's transl)]. / Triploidie als Ursache von Schwangerschaftsgertose im 2. Trimeron

The authors report a case of triploidy in a prematurely born child. The pregnancy was complicated by severe toxemia beginning during the second trimester and terminating in preeclampsia leading to cesarian section in the 33th week of gestation. The externally female child was underweight, hypotonic and asphyctic and died shortly after birth. She exhibited a complex brain malformation including excessive hydrocephaly, cebocephaly and aplasia of the piturary gland, and multiple dysmorphic signs. Autopsy revealed hypoplasia and dysplasia of the adrenal glands; no uterus, tubes and ovaries were present, but no testes were found. The placenta showed localized hydatidiform degeneration and was relatively large. The karyotype was 69,XXY, and with the aid of fluorescence markers, paternal origin of the additional haploid chromosome set was demonstrated. Typical findings in pregnancies with fetal triploidy are discussed and the possibility of prenatal diagnosis of triploidy by chromosome analysis in cultivated amniotic fluid cells is pointed out.