Small airway testing and smoking in predicting risk in surgical patients.

A prospective study was performed on 185 surgical patients without overt respiratory disease to determine whether three sensitive tests for early airway obstruction or cigarette smoking at the time of hospitalization were useful in identifying the patient at risk for a postoperative pulmonary complication. Subjects were evaluated by questionnaire. Pulmonary function testing consisted of the single breath nitrogen test (SBN2) to determine the closing volume (CV) and slope of the alveolar plateau, and a maximum expiratory flow volume curve (MEFV) to determine expiratory flow at low lung volumes. Fifty-five patients had upper abdominal surgery and 130 a major surgical procedure under general or spinal anesthesia upon another part of the body. Ninety-six (52%) of the 185 patients were smokers. Seventy-nine patients (43%) had one or more abnormal function parameters. The CV was abnormal in 59, alveolar plateau in 18, and MEFV in 12. Fifty-four percent of smokers and 30 percent of nonsmokers had abnormal small airway tests. Sixteen of 185 patients (8.6%) developed a postoperative respiratory complication determined by review of the hospital record. Eleven were in the 96 smokers, but 13 were in the 79 patients with abnormal small airway tests. The incidence was highest (38%) in smokers with an abnormal alveolar plateau who underwent upper abdominal surgery. Identification of the patient at risk was better served by tests of small airway abnormality than by smoking history alone.

Can postoperative pulmonary complications after elective cholecystectomy be predicted?

To determine predictors of postoperative morbidity in elective cholecystectomy patients, the authors examined prospectively the consequences of age, sex, active and past smoking, respiratory history, obesity, type of surgical incision, and preoperative pulmonary function, upon the incidence of postoperative pulmonary complications and length of hospitalization. They identified 31 (14.8%) complications in 209 patients; 21 had atelectasis, 8 purulent bronchitis, and 2 pneumonia. These patients averaged 1.5 days longer in the hospital (p less than 0.001 by analysis of variance) than control patients. Abnormal spirometry (MEFV) and the single-breath nitrogen test (SBN2) were significant predictors of postoperative pulmonary complications (p less than 0.001 by discriminant analysis method). Active smoking and history of respiratory disease were associated with abnormal small airway function (p less than 0.001 by chisquare test), but did not predict postoperative morbidity. By analysis of variance, only a reduction in preoperative FVC emerged as predictive of prolonged hospitalization (p less than 0.001). These results were used to determine if the selection of patients by preoperative pulmonary function testing permits more cost-effective administration of respiratory therapy (RT) services. Neither the MEFV nor SBN2 had sufficient specificity to enhance the cost effectiveness of postoperative RT.

Clinical utility and monitoring of breast cancer by circulating immune complexes.

Circulating immune complexes (CIC) were estimated in 22 patients of breast carcinoma, 25 healthy control volunteers and 10 follow-up cases after mastectomy by polyethylene glycol precipitation (PEG pptn) test and Latex agglutination inhibition (LAI) test. CIC levels increased with advancing stage of breast carcinoma. Significant increase in CIC levels was observed in stage II (p < 0.01), followed by highly significant increase in stage III and IV (p < 0.01) as compared to the control group. Sharp decrease in CIC levels was observed three months after radical surgery in 9 post-operative patients. One patient remained seropositive by both tests, followed by a fatal outcome after four months follow-up. Seropositivity for CIC by PEG pptn test in patients of breast carcinoma was 72.72 percent as compared to 81.81 percent by LAI test. Combination of both tests increased total CIC positivity by 90.9 percent. Clinical utility and prognostic significance of CIC in monitoring breast carcinoma patients has been demonstrated by our study.

An unusual case of inguinal hernia with spontaneous evisceration.

Spontaneous evisceration is a very rare and potentially fatal complication of abdominal wall hernia. It has been commonly reported in the case of umbilical hernia in patients with chronic liver disease with tense ascites. With other hernias, such as incisional hernia and inguinal hernia, the complication has been reported only once. Here we present a case report of spontaneous evisceration in an inguinal hernia in a patient with comorbid chronic obstructive airway disease. Management of the condition using prosthetic mesh repair risks mesh infection, while the use of non-prosthetic repair risks recurrence of the hernia due to the absence of stout natural tissues. Use of a biological mesh for the condition seems quite plausible. Thorough saline washes of the eviscerated organ, excision of redundant/unhealthy skin and strict adherence to the fundamental principles of hernia repair is desired in managing the condition.

Prognostic significance of circulating immune complexes in cancer patients.

Circulating immune complexes (CIC) were estimated in 100 cancer patients and 25 healthy control volunteers by means of the polyethylene glycol (PEG) precipitation test and latex agglutination inhibition (LAI) test. Pathological levels of CIC were found in 47% of the patients by PEG precipitation test and in 59% of the patients by LAI test; both tests were positive in 33% of the patients. Consequently, the use of the two assays resulted in 73% seropositivity for CIC. The PEG precipitation test detects antigen-antibody complexes formed in the ratio of 2:1 (Ag2Ab), while the LAI test could detect immune complexes formed over an extended range of antigen-antibody ratio including complexes as small as 8S. CIC values were significantly higher by combined assays (P less than 0.001) as compared to individual assays (P less than 0.01) when compared with the control group. It was found that 75% of post-operative follow-up patients became seronegative for CIC in the combined assays, whereas the 25% of post-operative patients who remained seropositive for CIC showed recurrence within three months after surgery. Immune-complex deposition was demonstrated on malignant cells in vitro by direct immunofluorescence studies in 73.3% of patients, while 60% of patients revealed complement-fixing antigen-antibody complexes. It was found that 20% of patients showing positive immunofluorescence with anti-C3-antisera had decreased levels of CIC. Complement-mediated cytotoxic injury results in reduction of tumor cell mass and subsequent decrease in CIC. Necrotizing and leucocytoclastic vasculitis in the tumor mass was initiated by raised CIC levels in vivo in 71% of patients. Necrosis of malignant tumors was seen in 58% of patients, and hemorrhage in 36% of patients. These changes were considered to be an aftermath of immuno-complex vasculitis initiated by CIC.

Role of circulating immune-complexes as prognostic indicators of lympho-reticular and mesenchymal malignancies in children.

Circulating immune complexes (CIC) were estimated in 28 cases of Non-Hodgkin's lymphomas, Hodgkin's disease, bone and soft tissue sarcomas in the pediatric age group by polyethylene glycol (PEG) precipitation and latex agglutination inhibition (LAI) techniques. Results were compared with 25 age-matched controls. Highly significant CIC values were obtained by LAI technique (P less than 0.01) as compared to PEG pptn technique (P less than 0.05) in malignancy. However, seropositivity for CIC in lymphomas and Hodgkin's disease was 85.71 per cent by LAI test as compared to 57.14 per cent by PEG pptn test. In sarcoma group, seropositivity for CIC was 57.11 per cent by LAI test and 28.57 per cent by PEG pptn test. Combination of both these tests increases the sensitivity of immune complex detection in serum of cancer patients. CIC begin to rise in serum in early stages of neoplastic transformation, and the level of CIC is directly proportional to proliferating tumour mass in vivo.