Ureteral endometriosis and ovarian mucinous cystadenoma presenting with acute pyonephrosis.

BACKGROUND: Endometriosis is a common disease, but ureteral involvement is rare. Nonspecific clinical presentations of ureteral endometriosis may result in diagnostic difficulty. AIM: To discuss the diagnosis and management of such a case. METHODS: To report a case of ureteral involvement with endometriosis and review the literature. RESULTS: The case presented with right lower quadrant pain giving rise to initial diagnostic possibility of acute appendicitis. Subsequent evaluation revealed the diagnosis of right pyonephrosis due to midureteral endometriosis with right ovarian mucinous cystadenoma. CONCLUSION: The diagnosis of ureteral endometriosis requires a high index of clinical suspicion. The importance of ultrasound in the evaluation of acute abdomen in women can not be overemphasised.

Neutrophil intracellular kill following thermal injury. Different bactericidal capability for patients' organisms and laboratory organisms.

Sixteen patients with septic complications of severe thermal injury were studied with respect to neutrophil intracellular-killing power against clinical isolates from the patients themselves and against other laboratory organisms. Simultaneous measurements of neutrophil chemotaxis, helper/suppressor lymphocyte ratios, and serum IgG concentrations were also carried out. Neutrophils from patients who survived had diminished intracellular-killing capacity for their own organisms, but normal capacity for killing laboratory organisms either matched or unmatched with the patients' own isolate's species. In these patients, the chemotactic index, the lymphocyte helper/suppressor ratio, and the serum IgG concentration remained within normal limits. Neutrophils from patients who died failed to kill their own, as well as laboratory, organisms. In these patients, the chemotactic index, lymphocyte helper/suppressor ratio, and IgG concentration were significantly diminished. The biological implications of these findings are noted.

Effect of immunoglobulin G therapy on serum antibody titers to cytomegalovirus in burn patients.

We attempted to determine the incidence and significance of cytomegalovirus infection and the effect of immunoglobulin G infusions on specific cytomegalovirus titers in burn patients. On admission, 48 percent of a group of 120 patients (mean burn size 28.5 percent of the total body surface area) were seronegative, including 95 percent of all patients under 20 years of age. Subsequently, 4 of a subgroup of 26 patients (15 percent) had development of a primary infection, and 1 of these patients died from overwhelming bacterial infection. Immunoglobulin G infusion used in the prophylaxis of the septic complications achieved high titers of cytomegalovirus-specific immunoglobulin G, as well as the subsets immunoglobulin G1 and immunoglobulin G3 which are also active against cytomegalovirus.

A combined regimen for the prophylaxis of Curling's ulcer.

After severe thermal injury, acute gastroduodenal mucosal lesions occur in up to 80 per cent of patients. Prior to prophylactic antacid therapy, one-third of these lesions progressed to ulceration, which frequently resulted in major life-threatening hemorrhage. Antacid treatment regimens have dramatically reduced this complication. However, the incidence of occult complications that result in increased morbidity has remained unchanged. We evaluated prospectively a combined treatment regimen using antacid, an H2-receptor antagonist, and enteral feeding in 60 patients who had serious burns (mean burn size, 36% body surface area) in this series. The incidence of both overt and occult complications was 3 per cent and in no patient did a perforation develop nor was operative intervention required. No patient died of the complications of Curling's ulcer. Combination therapy may be of value in other patients prone to stress ulceration.

Chronic rupture of abdominal aortic aneurysms.

Chronic rupture of the aorta is a rare condition. In this report, the presentation, diagnosis, and management of two patients with this complication is described. Chronic rupture may occur without hypotension and may mimic several other conditions. CT scans are superior to ultrasound in diagnosis and evaluation. Emergency repair is not necessary in clinically stable patients and careful preoperative planning may diminish morbidity and mortality.

Natural history of subclavian steal syndrome.

Eighty-two patients presenting with subclavian steal syndrome (36 men, 46 women; median age, 66.5 years) were studied. All patients underwent clinical and noninvasive evaluation. Diagnosis was based on both a 20 mmHg difference in blood pressure between arms and reversed blood flow in the vertebral artery. Twenty-one patients (25.6%) had a transient ischemic attack or cerebrovascular accident before the study. In 16 patients (19.5%), the anterior circulation was involved and the vertebrobasilar circulation was effected in 5 patients (4.8%). Fifty-five patients were followed for one to six years (mean 4.1 years). During this period three patients died. Noninvasive studies showed that 39 patients (70.9%) had progression of disease in the carotid arteries and that 10 of these 39 (12.1%) exhibited a transient ischemic attack or cerebrovascular accident, and eight patients (9.7%) required carotid endarterectomy. No patient had a stroke involving the vertebrobasilar circulation, but four patients (4.8%) had a transient ischemic attack. Three other patients had revascularization procedures performed for arm ischemia. Patients with subclavian steal syndrome are more likely to experience a transient ischemic attack or cerebrovascular accident involving the carotid circulation than the vertebrobasilar circulation. Noninvasive evaluation of the carotid arteries and the posterior circulation should be included in the long-term follow-up of these patients.

A new algorithm for calculation of blood loss in excisional burn surgery.

One hundred and two patients who sustained thermal injury and who underwent 155 excisional procedures were prospectively studied in order to determine an accurate blood loss formula. Blood loss (mean +/- S.D.) is expressed as the percentage of the total blood volume lost for each per cent of body surface area excised and autografted. There was no significant difference between the blood loss for the overall group of procedures (4.1 +/- 0.24) and the various subgroups indicating that the outcome was not influenced by the method, extent or timing of excision or by the use of tourniquets. From the authors' calculations, approximately 196 ml of blood is required for each per cent of body surface area excised and autografted.

Long-term disability following high-voltage electric hand injuries.

Fifty-eight patients who sustained high-voltage electric hand injuries over a ten-year period were reviewed to determine the incidence of long-term disability. Patients were divided into two groups, depending on whether or not they had sustained a current or noncurrent injury. Follow-up ranged between three months and nine years, with an average of 29.5 months. In Group A' (current group), 34 patients had 52 hand injuries. In this group, 21 patients required operative intervention to relieve vascular or neurologic compression. Thirty percent of explored limbs were subsequently amputated. Of the remaining extremities, 42% had normal function while 58% had diminished or greatly diminished function. There were 24 patients in Group B (noncurrent group) with 35 hand injuries. Function was diminished in 23%, greatly diminished in 14%, and absent in 3% of cases. The amputation rate and the residual functional deficit in Group A concurs with those of previously reported series. Although there is a significant inevitable morbidity after noncurrent injuries, many patients may benefit from nerve/muscle conduction studies and physical therapy.

Prophylactic intravenous immunoglobulin replacement in high-risk burn patients.

Twenty patients with extensive thermal injury were entered into a prospective randomized double-blind trial of prophylactic intravenous immunoglobulin administration. Ten patients received intravenous immunoglobulin and ten, albumin controls. No statistically significant difference was found between mortality rates, mortality rates from sepsis, the incidence of positive blood cultures, the positive quantitative wound biopsies, urine cultures, or positive intravenous line cultures. No significant improvement was noted in assays of neutrophil chemotactic index or intracellular kill, assays of lymphocyte function, or helper/suppressor ratio. We did, however, note significant improvement in the incidence of polymicrobial blood cultures, cytomegalovirus titers, and blood endotoxin concentration in treated patients. While the high incidence of inhalation injury (16 out of 20 patients) and, therefore, the disproportionately high mortality rate (40% overall) in the study group do not permit extension of these observations to the burn patient population at large, certain cautious recommendations may be made with regard to the use of intravenous immunoglobulin G in the management of burn patients.

Autoantibody formation in burn patients after inhibition of suppressor T cell activity with polymyxin B.

After thermal injury, treatment with polymyxin B blocks suppressor T cell activity by uncoupling endotoxin-mediated T cell activation, but the effect on autoantibody formation is unknown. We examined the presence of antinuclear antibodies to native DNA; to soluble antigens Ro/SSA, La/SSB, Sm, nRNP; and to antiepithelial antibodies in 12 burn patients before and after treatment with polymyxin B and in 24 samples from control burn patients. Low titer antinuclear antibody activity was detected in 25% of pretreatment and 78% of posttreatment samples (p less than 0.01) and in 16.7% of control patients. One polymyxin B-treated patient had a significant antinuclear antibody titer both before and after treatment. Antiepithelial antibodies were detected in 16.7% of early polymyxin B-treated samples and 11.1% of late samples (p less than 0.05) but were also present in 20.8% of controls. Antibodies to native DNA, Ro/SSA, La/SSB, Sm, and nRNP were not detected in any sera.

To tunnel or not to tunnel catheters for parenteral nutrition.

The effect of subcutaneous catheter tunnelling on the incidence of catheter sepsis and on catheter life span in the absence of a nutrition team was determined in a prospective controlled clinical trial. Eighty one patients who received 92 courses of parenteral nutrition had 110 catheters inserted. Alternate catheters were tunnelled. Four patients who received parentheral nutrition for less than 48 hours were excluded from the study. Catheter related sepsis occurred in one tunnelled (1.8%) and 4 non-tunnelled catheters (7.6%) (P greater than 0.05 NS). Mean life span of tunnelled catheters was 21 days (range 5-37 days) compared to 12.6 days for non-tunnelled (range 3-19 days) (P less than 0.05). Six non-tunnelled catheters became displaced, a complication which did not occur with tunnelled catheters (P less than 0.01). In conclusion subcutaneous tunnelling of silicone catheters prolongs catheter life span but does not significantly influence catheter sepsis.

The prognostic value of nucleolar organiser regions in colorectal cancer: a 5-year follow-up study.

Nucleolar organiser regions (AgNORs) are loops of ribosomal DNA which reflect the cellular activity or malignant potential of the cell and are identified by a specific staining technique. The purpose of this study was to assess the prognostic value of AgNORs in colorectal cancer and to compare it with other accepted prognostic methods. We studied 164 patients who were surgically staged for colorectal cancer and who had complete follow-up data available for 5 years. Using a highly specific silver staining and counting technique each patient was given an AgNOR score. There were 5 Dukes' C tumours, 108 were Dukes' B and 5 were Dukes' A. No cancer deaths occurred in patients with Dukes' A tumours. The incidence of well-differentiated, moderately-differentiated and poorly-differentiated tumours was 37.2%, 53.7% and 9.1%, respectively. Non-survivors had significantly higher AgNOR scores compared with survivors (mean value +/- SD, 14.2 +/- 0.9 vs 8.2 +/- 0.6, P less than 0.0001). In a regression analysis model AgNOR score was the most significant individual variable for predicting survival (chi 2 = 15, P less than 0.01) when compared with Dukes' classification, histological grade, tumour depth or vascular invasion.

Reduction of the local toxicity of intraperitoneal chemotherapy; an experimental model.

Intraperitoneal (I.P.) administration of chemotherapeutic agents, in particular, cisplatin and bleomycin is successfully used in the treatment of ovarian and gastrointestinal malignancies. Their use however, is limited by the rapid development of adhesions. The vinca alkaloid group of chemotherapeutic agents has been shown to impair the acute inflammatory reaction, which plays an important role in adhesion formation, thereby providing the rationale for addition of vindesine to an I.P. regimen containing cisplatin and bleomycin. A rat model was used to study the effects of various I.P. chemotherapeutic regimens on adhesion formation. Four groups were studied (30 rats/Group). Regimens used included Group A (Saline), Group B (Vindesine 0.1 mg/kg), Group C (Cisplatin 5 mg/kg and Bleomycin 0.2 mg/kg), and Group D (Cisplatin 5 mg/kg, Bleomycin 0.2 mg/kg and Vindesine 0.1 mg/kg). In order to grade adhesion formation, animals were sacrificed on days 2, 14 and 28, with the severity of adhesions graded on a scale of I-IV in order of increasing severity. Adhesion formation in Group A (Saline) and Group B (Vindesine) was similar. The addition of Vindesine to Group C (Cisplatin and Bleomycin) resulted in a significant reduction in adhesion formation (p less than 0.01). The results of this experimental study suggest that the local toxicity of I.P. chemotherapy may be reduced by the inclusion of a vinca alkaloid.

Surgical management of primary hyperhidrosis.

Primary hyperhidrosis, although lacking a precise definition and of unknown aetiology, disrupts professional and social life and may lead to emotional problems. A variety of treatment methods are used to control or reduce the profuse sweating which involves mainly the palms, soles and axillae. The simplest method, the application of topical agents, is usually attempted first for axillary and plantar sweating. Iontophoresis may provide relief especially in patients with plantar or palmar involvement. In severe cases operative intervention is necessary. Excision of sweat glands is successful in patients with axillary hyperhidrosis but the role of suction-assisted removal of axillary sweat glands remains to be determined. Sympathectomy remains the standard by which other treatments must be judged. For upper thoracic sympathectomy a variety of surgical approaches are used with satisfactory relief of hyperhidrosis. Complications related to the surgical approach, such as Horner's syndrome, brachial plexus injuries, pneumothorax and painful scars may occur, while following sympathectomy compensatory hyperhidrosis is usual and hyperhidrosis may recur. Plantar hyperhidrosis which may be exacerbated or ameliorated by upper thoracic sympathectomy and which fails to respond to non-operative intervention is relieved by lumbar sympathectomy.

Arm ischemia secondary to giant cell arteritis.

Patients with severe ischemic symptoms that fail to respond to steroid therapy, despite a dramatic and continuous drop in the erythrocyte sedimentation rate, may require arterial bypass surgery to overcome arterial ischemia caused by arteritis. We report the case of a patient with bilateral subclavian artery occlusion secondary to giant cell arteritis who responded well to steroid therapy and arterial reconstructive surgery. The patient has remained well for five years.