The composition of serous fluid after axillary dissection.

OBJECTIVE: To analyse the composition of the serous fluid formed after axillary dissection. DESIGN: Descriptive study. SETTING: University hospital and teaching hospital, The Netherlands. SUBJECTS: 16 patients whose axillas were dissected as part of a modified radical mastectomy for stage I or II breast cancer. MAIN OUTCOME MEASURES: Chemical and cellular composition of axillary drainage fluid on the first, fifth, and tenth postoperative days compared with the same constituents in blood and with reported data on the composition of peripheral lymph. RESULTS AND CONCLUSION: On the first postoperative day the drainage fluid contained blood contents and a high concentration of creatine phosphokinase (CPK). After day one it changed to a peripheral lymph-like fluid but containing different cells, more protein, and no fibrinogen, making coagulation impossible. The reduction in the fluid production must be caused by other wound healing processes, such as formation of scars and connective tissue.

A prospective randomized trial of high versus low vacuum drainage after axillary dissection for breast cancer.

BACKGROUND AND METHODS: The influence of negative pressure on fluid production and complication rates after axillary dissection for breast cancer was studied in a prospective randomized trial. Patients were randomized for either a high or a low vacuum drainage system. Drainage volumes and complication rates were recorded. RESULTS: No statistically significant differences were found between the low vacuum group (n = 68) and the high vacuum group (n = 73) in volume (728 ml versus 780 ml) and duration (9.5 days versus 10 days) of seroma production, number of wound complications (5 versus 6), or infections (3 versus 2). There was a significant positive relationship between body mass index and seroma production, independent of the drainage system (P = 0.002). The drainage volume of the separately drained breast wound after mastectomy and lumpectomy was larger for the high vacuum system (55 ml versus 100 ml, P = 0.02). Vacuum loss was more frequent in the high vacuum drain group (11 versus 2, P = 0.01), where as leakage around the drain occurred more often in the low vacuum group (18 versus 6, P = 0.004). CONCLUSION: There are no differences in axillary fluid production or wound complication rates after axillary dissection and subsequent drainage between high and low vacuum drainage systems.

Forgotten injury: a late benign complication of an unremoved shrapnel fragment--case report.

A patient is described with a mortar shell shrapnel fragment in the anterior compartment of the right lower leg that had been in situ for 46 years without causing symptoms, when a large hematoma leading to a "chocolate cyst" developed around it. Initially, the patient was thought to have a malignant tumor. Roentgenograms and CT scans showed shrapnel fragments, and the cyst was removed surgically. A digital subtraction angiogram ruled out any other involvement.

The transtibial route for femoral to anterior tibial artery bypass.

OBJECTIVE: To assess the applicability of the transtibial route, via a drilled hole in the tibia, for femoral to anterior tibial artery bypass surgery. DESIGN: in a pilot study of 10 patients the preoperative arm/ankle systolic blood pressure indices were compared with those after operation. Patients were followed for 2 years. RESULTS: of the 10 patients, one was lost to follow-up and two had occlusions of their bypasses. After two years the remaining seven still had patient bypasses, with arm/ankle systolic blood pressure indices that were significantly higher than those before operation (p < 0.05). CONCLUSION: The transtibial route, via a drilled hole in the tibia, is a viable alternative to other methods for femoral to anterior tibial artery bypass surgery.

The synergism of atropine and the cholinesterase reactivator HI-6 in counteracting lethality by organophosphate intoxication in the rat.

Rats were intoxicated with two different S-aminoalkyl-phosphonothioate cholinesterase inhibitors, viz. I-1 (S-diethylaminoethyl-O-cyclohexyl-methyl-phosphonothioate), which has a mixed central/peripheral mode of action, and I-2, the methiodide derivative of I-1, which acts almost solely peripherally. It was found that atropine did not have any beneficial effect on lethality in the case of an I-2 intoxication but did so, although only slightly, in the case of I-1. Therefore, the effect of atropine against I-1 intoxications must be mediated through central mechanisms, the peripheral parasympatholytic effect being negligible in counteracting lethality. Furthermore atropine antagonized the convulsions caused by intoxication with I-1. The oxime used as a reactivator of inhibited acetylcholinesterase, HI-6, was more effective than atropine against either organophosphate. In the case of an I-2 intoxication HI-6 proved extremely active. It is, therefore, concluded that HI-6 acts mainly peripherally. It was also found that HI-6 has a slight anticonvulsive action. The combination of HI-6 and atropine had a large synergistic effect in the case of I-1, but in the case of I-2 hardly any synergism was observed. Obviously, the combination of the oxime and atropine is particularly effective when the toxicant has a mixed central/peripheral action. In such intoxications the acetylcholinesterase reactivation in the respiratory neuromuscular synapse by the oxime is supplemented by the central action of atropine, which improves respiratory control at the level of the central nervous system.

In vivo distribution of organophosphate antidotes: autoradiography of [14C]HI-6 in the rat.

In order to visualize the distribution of HI-6 in the rat after iv administration, autoradiographic experiments were carried out with [14C]HI-6, labeled at the carbon of the carboxamide moiety. Autoradiography clearly confirms penetration of HI-6 into the central nervous system. Considerable radioactivity was found in the cerebrum, the cerebellum, and the choroid plexus. No significant activity was detected in the pontomedullary region or the spinal cord. Peripherally, [14C]HI-6 is observed in large amounts in kidneys, heart, liver, nose, bladder, testes, and marrow-containing bone. The gastrointestinal tract was largely devoid of any radioactivity. The relative absence of HI-6 in the pontomedullary region renders centrally mediated influences of HI-6 on hemodynamic and respiratory parameters less likely.

Identification of two metabolites of the cholinesterase reactivator HI-6 isolated from rat urine.

Two metabolites, isolated from the urine of rats given the cholinesterase reactivator HI-6 intravenously, still contained quaternary nitrogen atoms and therefore could not be extracted from aqueous solutions by organic solvents. Both metabolites were isolated by preparative high performance liquid chromatography and were identified using mass spectrometry, gas chromatography, infrared spectrometry, ultraviolet spectrometry and proton nuclear magnetic resonance spectrometry. The structures were confirmed by in-vitro preparation of the compounds. both metabolites contained 2-pyridone moieties. One had an intact pyridinium-aldoxime moiety, and therefore could still be therapeutically active. The excretion of unchanged HI-6 together with the two identified metabolites does not provide for a 100% mass balance, indicating that in the rat, other, as yet unidentified, metabolites must be formed.

Kinetic profile in blood and brain of the cholinesterase reactivating oxime HI-6 after intravenous administration to the rat.

The kinetic profile of the oxime HI-6, a potent cholinesterase reactivator, after iv administration of 0.1325 mmol/kg (50 mg/kg) to rats is described. The blood concentrations measured over a period of 300 min can be described by a two-compartment open model. Excretion occurred only by the kidney. Approximately 60% was excreted in unmetabolized form. Brain tissue concentrations were significantly above the detection limit of the HPLC analysis procedure even when a correction was made for the amount of HI-6 present in brain blood. The concentration in brain tissue is built up according to a rapid equilibration mechanism. Disappearance of HI-6 from brain occurred slowly compared to the elimination of HI-6 from blood. These findings are discussed in the light of the existing knowledge on the kinetic behavior of polar solutes in the central nervous system. Whether the concentrations of HI-6 built up in the brain are relevant for the therapy of organophosphate intoxications cannot be determined from the experiments described.

Determination of some pyridinium aldoxime compounds by means of ion-pair reversed-phase high-performance liquid chromatography: application in biological material.

Two reversed-phase high-performance liquid chromatographic systems are presented for the separation and assay of the pyridinium aldoximes benzyl-P2A, HI-6 and obidoxime in aqueous solutions and biological samples. The systems involve a 5-micrometer C18 silica gel stationary phase. The eluent consists of methanol, acetic acid buffer (pH 4.80), a counter ion (per-chlorate or n-octanesulphonate) and a surfactant. The compounds were detected spectrophotometrically at 304 nm. In the concentration range used, linear plots of concentration versus extinction were obtained, both in blood and in water. Detection limits plots of concentration versus extinction were obtained, both in blood and in water. Detection limits, even in blood are satisfactory (0.5-1 microM). Evidence of presented that, at least for HI-6, the addition of counter ions to the system does not lead to the formation of ion pairs to be retained by partition, but rather to a mechanism based on adsorption chromatography.