Risk of death or incapacitation after heart transplantation, with particular reference to pilots.

Pilots who have received a heart transplant may subsequently want to resume flying. This study was undertaken to determine whether a group of heart transplant recipients who had a particularly low risk of sudden unexpected death could be identified from clinical data. An event, "rapid-onset death," was defined incorporating a number of possible causes of death that could result in a heart transplant recipient-pilot losing control of an airplane. The survival of 3676 patients undergoing a first heart transplantation was 85% and 73% at 1 and 5 years, respectively, the hazard function having a high early phase of risk. When time zero was moved to the beginning of the second year after transplantation, the freedom from "rapid-onset death" at posttransplantation year 2 and posttransplantation year 5 was 96.8% and 88%, respectively. For patients who had both a "normal" coronary angiogram and no episodes of acute heart rejection during the first year transplantation, the probability of "rapid onset death" during the second posttransplantation year was 1.4%, and given the same circumstances, during the third posttransplantation year the risk of "rapid-onset death" was 1.6%. This information is potentially useful to the Federal Aviation Administration for policy decisions regarding this issue.

Malignant carcinoid syndrome: two case reports.

The malignant carcinoid syndrome (MCS) is a rare complication of malignant carcinoid neoplasms, fewer than 200 cases having been reported since its description by Thorson in 1954. Its signs and symptoms vary with the site of the primary neoplasm, and MCS is now recognized as one member of the large family of endocrine tumors--APUDOMAS). Although MCS remains uniformly fatal, significant palliation can be provided some patients with current surgical and chemotherapeutic management. All signs and symptoms in MCS, except evidence of the destruction of the tricuspid and pulmonic valves, can be reproduced experimentally. The factor causing this lethal complication has not been identified. Two previously unreported cases of MCS, each from the gastrointestinal (GI) tract, are presented. This brings the world's total report cases to approximately 210.

A surgical technique for resecting malignancies invading the facial nerve and petrous pyramid.

Certain head and neck malignancies tend to invade branches of the cranial nerves and progress centripetally. The maxillary and mandibular divisions of the V (trigeminal) nerve are the most commonly invaded, but the VII (facial) nerve may harbor extensions of primary parotid malignancies and/or skin cancers originating in or near the ear. Paresis of the VII nerve signifies a serious but not entirely hopeless situation if countered with an appropriate surgical procedure. The optimal treatment of malignancies invading cranial nerves is surgical excision, which may necessitate removal of substantial portions of the cranium. Surgical pursuit of a malignancy in the facial nerve leads to a direct confrontation with the petrous pyramid of the temporal bone. Resection of the petrous pyramide is surgically feasible, but, if performed en bloc, extracts a high morbidity and mortality. An alternate technique in which the soft tissue and bones are removed disjunct is advocated. In this technique, the soft tissues are excised flush with the surface of the temporal bone. After making perforator and burr openings in the squamous temporal bone, a subtotal temporal craniectomy is completed with rongeurs. A prerequisite for success with this technique is the rotation of a large scalp flap and other local flaps to cover the exposed meninges and carotid arteries. A resume of four cases using this technique is presented. The age of the patients, the type, stage, and duration of the malignancies, and other factors which might influence the end stage results are given.