Changing attitudes in the management of cancer of the breast.

Opportunity to assess changes in the management of cancer of the breast over the past 7 years was afforded by analysis of responses to questionnaires that were part of an annual questionnaire course. Comparison of responses to questionnaires conducted in 1971 and 1977 identified important features of approaches to this disease and indicated the way in which changes have occurred. Diagnostic needle aspiration increased from 24% (1971) to 54% (1977). In both surveys surgeons reported employing mammography infrequently. Use of modified radical mastectomy increased from 15% (1971) to 60% (1977). Employment of classical radical mastectomy decreased from 83% (1971) to 37% (1977). Surgeons considering biopsy of the contralateral breast to be unnecessary decreased from 47% (1971) to 14% (1977). Skin grafting, after a mastectomy, decreased from 40% (1971) to 24% (1977). Though oophorectomy is still the preferred initial treatment for premenopausal patients with advanced disease, preference for chemotherapy in postmenopausal patients increased from 5% (1971) to 23% (1977). Surgeons approving of reconstruction with implants after mastectomy for carcinoma increased from 30% (1971) to 49% (1977). Following mastectomy in patients with positive axillary nodes, 58% of our respondents employ chemotherapy with several drugs and 34% prefer irradiation.

Shortened endotoxin-activated clotting times in patients with carcinoma.

Isolated human monocytes generate tissue factor when stimulated with endotoxins. This tissue factor generation provides a convenient marker of monocyte activation. Furthermore, the only circulating blood cell capable of generating large quantities of tissue factor is the monocyte. Therefore, the addition of endotoxin to citrated blood, and the determination of the recalcification times after incubation, yields a measure of monocyte activation. In order to determine whether monocyte activation as measured by this technique varies between patients with carcinoma and healthy volunteers, recalcification times were evaluated. The recalcification time and range for 19 healthy volunteers (controls) was 6.55 min (5.3-8.5) for the saline incubated sample and 5.69 min (4.6-7.2) for the endotoxin-activated sample. The results for 13 patients with carcinoma are 4.81 min (3.3-6.3) for the former and 3.17 min (2.0-4.3) for the latter. These results show that the longest recalcification time with endotoxin incubation for patients with carcinoma was lower than the lowest recalcification time in the control group. Whether this simple test can be of use in the diagnosis and monitoring of patients with carcinomas is currently being investigated.

Increased lethality of endotoxemia in murine frostbite.

Because frostbite (FB) is associated with increased intravascular coagulability, it is reasonable to assume that endotoxin, by enhancing platelet aggregation, will adversely affect FB. Swiss mice (25 +/- 2 g) were anesthetized, and the tails of the animals totally immersed in a freezing solution of equal volumes of ethylene glycol and water (-18 C) for 8 min. The tails were then thawed at room temperature (24 C). Half an hour after removal from the freezing solution, the animals were given either (Group A) 0.1 cc saline I.P. or (Group B) 0.1 mg E. coli endotoxin (055:B5; 1/3 LD50 dose) in 0.1 cc saline IP. A third group (Group C), was given the same dose of endotoxin but was not subjected to frostbite. Survivals in each group at 2 weeks were as follows: (A) 14/14 (100%), (B) 4/20 (20%), (C) 13/14 (93%). Using Fisher's exact test, A versus B P less than .001; B versus C P less than .001; A versus C NS. The data presented here emphasize the increased lethality of endotoxemia in murine FB.

Beneficial effects of ethanol on experimental burns.

Alcohol has been demonstrated to produce cutaneous vasodilation. The burn wound is characterized by a compromised microcirculation which is amenable to pharmacologic manipulation to improve the final outcome of the injury. Various agents including heparin, aspirin, nonsteroidal anti-inflammatory agents have been employed to maintain a patent microcirculatory bed. Ethanol has been used in the present study in a murine burn model as a vasodilator administered immediately preburn and post-burn. Preburn administration of ethanol significantly improved the mean burn severity at 48 hr compared to ethanol given post-burn. Ethanol, acting as a vasodilator, improves dermal circulation post-burn and reduces the overall extent of injury.

Changing attitudes toward management of cancer of the colon and rectum.

Changes in the attitudes of surgeons toward the management of cancer of the colon and rectum over a 5-year period were assessed by analysis of responses of general surgeons to a 21-item questionnaire on colon cancer from 1978 and 1983. Comparisons of the responses revealed that the use of routine preoperative liver scans has decreased from 57 to 45 per cent. Transanal resection of villous adenoma of the rectum is used more often (44% in 1983 versus 34% in 1978). For obstructing carcinoma of the colon, a two-stage procedure is used more often, with 46 per cent of the respondents in favor of this approach in 1983 compared with 29 per cent in 1978. The use of staplers for colon anastomoses following resection has also increased with 44 per cent surgeons in 1983 using this technique always or frequently compared with 21 per cent in 1978. Following anterior resection, 66 per cent of respondents in 1983 seldom or never use a transverse colostomy (54% in 1978). The number of surgeons closing the perineal wound over suction drains following an abdominoperineal resection has increased from 46 per cent (1978) to 63 per cent in 1983. Sphincter-saving procedures for carcinoma of the rectum are used by a large number of surgeons in 1983 (29% versus 9% in 1978). An increase is noted in the use of preoperative radiation therapy for selected cases of rectal cancer (53% in 1978 to 68% in 1983).(ABSTRACT TRUNCATED AT 250 WORDS)

Current attitudes in the management of obstructive biliary tract disease.

The current attitudes of surgeons towards the management of obstructive biliary tract disease were assessed by analyzing the responses of general surgeons to a 20-item questionnaire. The responses indicate that ultrasound is the most favored initial diagnostic test for suspected choledocolithiasis. Ninety-nine per cent of the respondents always or almost always insert a T-tube following exploration of the common bile duct for stones. For patients with stone impacted at the ampulla of Vater, sphincterotomy with or without sphincteroplasty is recommended by 86 per cent of surgeons. However, differences are noted in the approach to management of malignant lesions in the biliary tract. For carcinoma of the head of the pancreas, at laparotomy, if the lesion is resectable, 59 per cent of the surgeons will perform a Whipple procedure, nine per cent a total pancreatectomy, and 28 per cent recommend bypass only. For unresectable carcinoma of the head of the pancreas, 73 per cent perform cholecystojejunostomy, and 26 per cent prefer choledocojejunostomy. In addition to the biliary bypass, only 57 per cent perform a gastric bypass routinely. The favored treatment (62%) for unresectable common bile duct tumors is an internal bypass. However, following bypass, only 45 per cent recommend further treatment with radiation and/or chemotherapy. Therefore, it appears that there is agreement on the treatment of biliary obstruction due to stones. Differences are noted, however, in the approach to the management of malignant disease.

Effect of splenectomy on acute inflammation.

It is becoming increasingly evident that platelets play a significant role in the inflammatory process. Heterogeneity has been demonstrated among platelets, and evidence has been presented that the spleen retains the youngest and hemostatically most effective platelets. The present study was designed to determine what effect splenectomy, by removing a special population of platelets, would have on acute inflammation as manifested by carrageenan-induced murine foot pad edema. Swiss white mice (25 +/- 2 g) were anesthetized and subjected to splenectomy (Group A, n = 13) or to celiotomy only (Group B, n = 15). One week later, carrageenan (0.1 cc of 1% solution) was injected into the right hind foot pad of each animal. The mice were killed 3.5 hr later, and both hind paws amputated at the tibio-tarsal joint and weighed individually. The change in weight of the experimental hind paw relative to control was expressed as edema index for each animal. The inflammatory reaction, as manifested by carrageenan edema, was significantly (P less than 0.001) decreased in those animals subjected to splenectomy. The mean edema index in Group A was 62.8 per cent compared to 80.9 per cent in Group B. The results of this study indicate that splenectomy decreases inflammation as manifested by carrageenan-induced edema. Splenectomy eliminates a population of platelets having greater functional capabilities than those found in the peripheral circulation and impairs the organism's ability to respond to injury.

Paradoxical effect of burns in diabetic mice.

Since the microcirculation is impaired in diabetes and since burn injury is associated with microvascular thrombosis, the purpose of this study was to determine whether diabetes increases the severity of burns. Swiss white mice were made diabetic with alloxan, and control animals received saline. One week later, animals with over 2000 mg/dl urine sugar and the control animals were anesthetized and burned uniformly on the back with a steel disc at 100 C for 10 sec. At 24 hr, burn severity was evaluated on a scale of 0 to 4 using gross and microscopic criteria. The mean burn severity of the diabetic mice was 0.80 +/- .15 and that of the control mice was 3.22 +/- .09 at 24 hr (P less than 0.001.). At 5 days, the differences of the burn severity between the two groups were still significant, but 5/10 (50%) of the diabetic mice and none of the control mice died. In diabetic mice, through burn severity appears mild in the wound, the mortality is high. Therefore, the criteria for initial evaluation of the diabetic with burns need to be reassessed.

Thromboelastographic evaluation of mini-dose heparin in minor surgical procedures.

Five dogs weighing approximately 10 kg were anesthetized with pentobarbital sodium 30 mg/kg intravenously (IV) and an initial sample of blood was drawn by jugular venipuncture for control values of thromboelastography (TEG). Immediately after venipuncture, mini-dose heparin (80 units/kg) was administered subcutaneously. One hour later, 0.5 ml blood was obtained by (A) jugular venipuncture for TEG, and an indwelling catheter immediately introduced into a femoral vein by cut-down. Blood samples for TEG were obtained via cut-down at (B) 15 min (C) 30 min, and (D) 60 min after cut-down. Low-dose heparin had no effect on the hemostatic parameters as measured by TEG and did not prevent the accelerated coagulation associated with surgery.

Cold-induced hypercoagulability in vitro: a trauma connection?

Injury severity score and hypothermia can lead to a high level of mortality when combined clinically. In acute trauma, the presence of a coagulopathy is difficult to treat and the aim is prevention. Aliquots of whole blood from healthy human volunteers (n = 9) were added to saline (control) and saline plus endotoxin (activated). The control and activated groups were divided and subjected to 60 minutes of normothermia (24 degrees C) or hypothermia (0 degrees C). The samples were returned to 37 degrees C; then the recalcification times were determined using fibrin formation and the viscous drag as the determining factors. The activated hypothermic group showed a decreased recalcification time of 345 (+/- 48.9) seconds compared to 405 (+/- 60.8) for the activated normothermic group (P less than 0.001). When the normothermic and hypothermic groups were compared without endotoxin added, the differences were not significant. The authors conclude that the effects of endotoxin on clotting time are worsened by hypothermia in vitro and act synergistically to possibly cause the coagulopathy seen in trauma patients.

Complete cartilaginous duplication of the rib cage found in a cadaver: a first reported case.

We discovered a unique case of complete cartilaginous duplication of the rib cage in a cadaver, never previously described in the literature. A retrospective review of the patient's medical records revealed an antecedent history of progressive tobacco-related emphysema leading to death from end stage respiratory failure. Prior imaging studies consisting of plain radiographs and computed tomograms of the chest had failed to show several underlying cartilaginous duplications of the rib cage. The clinical significance and the potential contribution of this entity to this patient's clinical course remains unanswered.

Current attitudes in the management of thyroid cancer.

The opportunity to assess the current attitudes of surgeons in the management of thyroid cancer was afforded by the responses to a questionnaire that was part of a "Questionnaire Course." The majority of the 72 respondents have a conservative surgical approach to thyroid cancer, find frozen section useful, recommend total thyroidectomy for medullary cancer, seldom or never split the sternum in performing thyroidectomy, and recommend visualization of the recurrent laryngeal nerves and the parathyroids. Opinions however, are divided on several other issues. Forty-two per cent (versus 34%) request ultrasound before removal of a "cold nodule." For follicular carcinoma, 44 per cent perform lobectomy with isthmustectomy, 29 per cent perform total ipsilateral lobectomy and subtotal contralateral lobectomy, and 23 per cent perform total thyroidectomy. Following lobectomy for follicular carcinoma, recommended treatments are radioactive iodine (25%), thyroid suppression (21%), and total thyroidectomy (48%). For anaplastic cancer, 44 per cent perform total thyroidectomy and 40 per cent perform radiation therapy. Histologically positive nodes are managed by modified radical neck dissection (61%) or by "berry picking" (23%). It is concluded that despite agreement on several therapeutic approaches for thyroid cancer, certain controversial issues remain unresolved.

Protective effect of previous burn on murine endotoxemia.

Major body burns suppress the immune system, at least temporarily. However, it has not been demonstrated that following recovery from burn injury, the burned subject can become immunocompetent. This study was designed to test this hypothesis. Swiss-Webster mice (25 +/- 2 gm) anesthetized with intraperitoneal pentobarbital sodium were given full thickness burns on a depilated area of the lower back with a stainless steel tube (2 cm diameter) at 100 C for 10 seconds. Control mice were anesthetized, depilated in the same manner, but sham burned. Six weeks later, (the burn wound was completely healed, and the mice weighed 33 +/- 4 gm) each animal was given 0.3 mg of Escherichia coli endotoxin (055:B5) in saline intraperitoneally. The 24- and 72-hour survivals for the control animals were 31/45 (69%) and 13/45 (29%), respectively; while the 24- and 72-hour survivals for the post burn mice was 26/27 (96%) and 14/27 (52%), respectively (P less than 0.05). All animals surviving 72 hours recovered. These data clearly demonstrate that the survival from endotoxemia is significantly increased in animals that have been previously burned. This observation indicates that the immune system is stimulated 6 weeks postburn.

Spigelian hernia.

Six cases of spigelian hernia are reported, including three unusual ones: (1) the presence of an acutely inflamed appendix in the hernial sac; (2) a patient with multiple associated hernias; and (3) a woman with a strangulated spigelian hernia occurring with endometrial carcinoma. The anatomy, etiology, clinical features and management of these hernias are discussed.

Von Haberer-Finney gastrectomy revisited.

Von Haberer and Finney independently introduced end-to-side gastroduodenostomy for gastrointestinal reconstruction. Clinical appraisal of this procedure with hemigastrectomy is the basis of this report. From 1967 to 1982, 113 duodenal ulcer patients underwent the operation. Indications were intractability in 58 patients, hemorrhage in 36, perforation in two, and obstruction in 17. Truncal vagotomy was performed on all patients except in five with intractability, 19 with hemorrhage, two with perforation, and 17 with obstruction. There were three postoperative deaths (2.7%). Nine patients were lost to follow-up, seven of whom were operated upon 5 or more years previously. Thus far, there has been no clinical evidence of recurrent ulcers or of dumping. Five patients, all chronic alcoholics, were below normal weight. The Von Haberer-Finney gastrectomy has certain distinct advantages: 1) direct inspection of the interior of the descending duodenum is possible during duodenotomy; 2) anatomic continuity of the gastrointestinal tract is established; 3) duodenal stump perforation does not occur because the duodenum can be decompressed via a nasogastric tube passed through the anastomosis; 4) afferent loop syndrome cannot occur; and 5) iron deficiency anemia is less likely because the duodenum is not bypassed.

Detrimental effects of ethanol on murine frostbite.

Many references have been made concerning the adverse effects of ethanol in human frostbite. The lack of experimental evidence to support this belief prompted the authors to undertake this investigation. Nineteen Swiss-Webster mice (25 +/- 2 gm) were given intraperitoneal injections of 0.2 cm3 of 50 per cent ethanol (group A) or 0.2 cm3 saline (group B). Thirty minutes later, the animals were anesthetized with pentobarbital (group A 30 mg/kg; group B 50 mg/kg). Lower barbiturate dose was used in group A because of the synergistic central nervous system depressant effect when combined with alcohol. Tail lengths of all animals were measured. The tails were immersed in a 50 per cent ethylene glycol solution (-18 C) for 6 min and then thawed at room temperature (24 C). At 24 hrs, tail circulation was assessed by length of tail perfused with the vital dye alphazurine 2 gm given intraperitoneally. Mortality to 14 days was recorded. All animals survived the initial anesthetic and/or alcohol administration. Group A had a statistically significant (P less than 0.001 Students t test) decrease in length of tail perfused compared with group B at 24 hours (0.98 +/- 0.19 cm versus 2.58 +/- 0.23 cm). Fourteen day survival was 10 per cent in group A compared with 89 per cent in group B (P less than 0.001, chi-square test). We conclude that ethanol has significant adverse effects on tissue perfusion and mortality associated with severe murine frostbite.

The effect of age on severity of murine burns.

There is a higher mortality in elderly subjects with burns. Whether the same amount of heat will cause a greater degree of thermal injury in elderly subjects and thus account, in part at least, for this increased mortality has not been determined and was, therefore, the purpose of this study. Swiss white mice, 1-year-old (elderly) and 3-months-old (young) were anesthetized with pentobarbital sodium and burned uniformly on a depilated area of the back with a steel disc at 100 F for 10 seconds (10% body burn). Burn severity was evaluated in a blinded manner by gross and microscopic criteria at 1, 2, and 4 days postburn. The mean burn severity 1 day postburn was significantly less in the elderly mice compared with the young mice (1.72 versus 3.22, (P less than 0.001). On the 2nd and 4th days postburn, no differences were noted in the degree of burn severity between the two groups. The early apparent diminished burn severity in the elderly mice was unexpected. Possible mechanisms to account for this difference in the old animals may relate to decreased cutaneous microcirculation, alteration in chemical composition of the skin, and the effects of thromboxane A2 and prostaglandin I2. The clinical relevance of these findings concerns the need for more careful clinical management with intentional overassessment of the initial degree of the thermal damage.

Appendicitis versus pelvic inflammatory disease. A diagnostic dilemma.

In order to determine whether any clinical or laboratory findings were helpful in differentiating acute appendicitis (AP) from acute pelvic inflammatory disease (PID), this retrospective study was undertaken. Records of all female patients 12 to 50 years of age, undergoing laparotomy with a preoperative diagnosis of AP over the past 15 years, were reviewed and pertinent data recorded. In comparing AP (n = 106) with PID (n = 39), longer duration of symptoms, relationship of onset of pain to the menstrual cycle, and frequent requests for gynecological consultation distinguished the PID from the AP cases. Although complete reliance cannot be placed on any clinical or laboratory finding in differentiating AP from PID, the final satisfactory outcome justifies laparotomy when the diagnosis cannot be established by other means.

Procoagulant effect of aqueous humor on in vitro clotting of blood and plasma.

Fresh and previously frozen aqueous humor was found to shorten the recalcification time of both canine citrated blood and human citrated plasma. This state of accelerated coagulation was dose related and preliminary studies indicate that aqueous humor acts as a procoagulant rather than a thromboplastin-like substance.

Effect of a butter-rich diet on murine frostbite.

A simple reproducible, humane model for producing frostbite in rodents is desirable. We have developed such a model and have investigated the effects of a butter-rich diet on severe cold injury. Mice (25 +/- 2 g) were randomly divided into two groups (n = 10). One group was given a standard rodent diet and the other group a butter-enriched (25%) rodent diet for 1 month. Under pentobarbital sodium anesthesia the mice were placed in a plastic funnel with the stem removed so that the entire tail protruded. The tails were submerged in a freezing solution (-18 degrees C) for 8 min. The mice received no further treatment. Tail lengths were measured 2 weeks after freezing to determine the amount of tail surviving from cold injury after autoamputation. Mean tail lengths (cm +/- SD) for the two groups were as follows: butter-rich diet, 4.3 +/- 1.8; standard diet, 7.3 +/- 2.0 (P less than 0.002). A high saturated-fat diet has a deleterious effect in murine frostbite. This simple model can be employed to test various modalities in the treatment of frostbite.