Endoscopic resection of "giant" colorectal lesions: long-term outcome and safety.

BACKGROUND: Today, endoscopic resection is a standard procedure for the resection of colonic polyps. Before the establishment of endoscopic techniques, the surgical approach was a clearly preferred method for removal of polyps with a size larger than three centimeters. The safety and effectiveness concerning endoscopic resections of colorectal polyps also with a size of more than 3 cm have been demonstrated in numerous studies. PATIENTS AND METHODS: Data from 165 patients (age: 68 +/- 10.4 years) harboring 167 polyps with a minimum diameter of 3 cm were retrospectively evaluated. Objects of interest were macroscopic morphology and histopathology of the polyps, their localization in the colon, the modality of endoscopic resection and follow-up. In those cases with macroscopic signs of malignancy the patients were excluded. RESULTS: Successful endoscopic resections were obtained in 72.5 %. Therefrom, resection in the piecemeal-technique was necessary in 73.6 %. Recurrence polyps after endoscopic complete resections occurred in 26.3 % after a mean follow-up of 16 +/- 12.5 months. We registered a complication rate of 19.2 %. Relevant bleeding and perforation were registered as early complications in 18.6 %. We observed no intervention-related mortality. CONCLUSION: Endoscopic mucosal resection is a safe and efficient method even for removing giant colorectal polyps. Controls are recommended at defined intervals for detecting polyp recurrence.

Reversible pancreatic duct stricture after a blunt abdominal trauma.

A 32-year-old man developed acute pancreatitis with a main duct stricture resulting from blunt abdominal trauma sustained during a car accident 11 weeks before admission. No interventions were performed and unusually, after 3 months' follow-up, the pancreatic main duct stricture resolved and the patient remained asymptomatic. There are no other reports in the literature demonstrating resolution of pancreatic main duct stricture without any endoscopic or surgical treatment subsequent to a blunt abdominal trauma.

Symptomatic spondylolisthesis in adults: four decades later.

An average follow-up of 40 years was obtained for 12 patients with spondylolisthesis treated at Hines Veterans Administration Hospital between 1944 and 1951. In each case, the slip had been Grade 1 and at the L5-S1 level. Five had been treated conservatively and seven surgically with a Hibbs fusion from L4 to S1. Of the conservatively managed patients, all functioned well during their working years, although one did have chronic, nondisabling, low-back pain. This same patient demonstrated radiographic evidence of progression to a Grade 2 spondylolisthesis. Among those undergoing surgery, the poor results were confined to those patients whose fusion attempts failed. Management for low-grade spondylolisthesis should be conservative where possible. When the low-back pain is disabling and surgery becomes necessary, failure to obtain a fusion portends a poor clinical result.

Avoiding paraplegia during anterior spinal surgery. The role of somatosensory evoked potential monitoring with temporary occlusion of segmental spinal arteries.

Three patients paraplegic following anterior spinal fusion for congenital kyphoscoliosis were noted to have complete somatosensory evoked potential signal loss shortly after segmental arterial ligations at the apex of their respective kyphosis. This has prompted us to use temporary segmental arterial occlusion with somatosensory evoked potential monitoring prior to ligation during anterior spinal fusion. As a result, we have noted seven additional cases, out of a total of 44 cases monitored in this fashion, in which complete loss of somatosensory evoked potential signals, reversible by release of vascular clips, has occurred. For each of these additional cases the critical segmental arteries were identified and were not ligated, usually resulting in some modifications in the planned surgical procedure, and the patients remained neurologically intact. We recommend temporary segmental arterial occlusion with somatosensory evoked potential monitoring during thoracolumbar anterior spinal fusion to potentially avert ischemic neurologic injury. Based on published data and the experience described herein, this technique should be especially important in anterior spinal fusion for congenital kyphoscoliosis.

Emergency endoscopy.

The need for emergency endoscopy is a matter of debate. The time interval for emergency procedures remains to be defined. Most authors propose a time span of 24 h as emergency time, while some define a period of 72 h (especially in acute pancreatitis). Several studies have shown a possible benefit for a select group of patients. Four main indications are established for emergency endoscopy: acute gastrointestinal bleeding (variceal and nonvariceal), acute biliary pancreatitis and acute cholangitis. In the case of upper gastrointestinal bleeding, emergency endoscopy enables exact diagnosis and appropriate therapy, and provides important prognostic information. There is some evidence that emergent endoscopic injection therapy improves clinical outcome and reduces mortality in patients with acute ulcer bleeding. Patients do not benefit if endoscopy is performed only as a diagnostic procedure. Controversial results were published recently for emergency endoscopy in acute biliary pancreatitis. There is good evidence that emergency endoscopic retrograde cholangiopancreatography is helpful in patients with severe pancreatitis and stone impaction if performed within the first 24 h after onset of symptoms. However, emergency endoscopic retrograde cholangiopancreatography is not beneficial for patients with mild pancreatitis if performed later than 72 h (or 24 h) after onset of symptoms. There is a limited number of well established evidence-based indications for emergency endoscopy. Some other indications are still a matter of debate, and controversial opinions have been published.

Nursing staff responses to violent events in closed psychiatric wards: a comparison between attributional and cognitive-neo-associationistic analyses.

This paper examines the behavioural response of nursing staff in psychiatric wards to a patient's violent behaviour towards a staff member as a function of whether the patient's behaviour was presented as arbitrary or not. The participants were 133 nurses. They were given two vignettes describing an arbitrary and a non-arbitrary behaviour of a patient and were asked what the typical response in their ward to each event would be. The results show that when the patient's behaviour was perceived as arbitrary, staff was believed to respond with a therapeutic reaction more frequently than to non-arbitrary behaviour. Moreover, participants' professional characteristics played a greater role in the non-arbitrary scenario. It is suggested that a therapeutic response to a patient's violent behaviour requires a recognition that the patient's behaviour is consistent with his/her role as a patient. The implication of these results for Berkowitz & Heimer's (1989) cognitive-neo-associationistic analysis is discussed.

[Photodynamic therapy of dysplasias and early carcinomas in Barrett esophagus with a diode laser system--a pilot study]. / Photodynamische Therapie von Dysplasien und Frühkarzinomen bei Barrett-Osophagus mit einem Diodenlasersystem--eine Pilotstudie.

BACKGROUND: Photodynamic therapy (PDT) of dysplasia and early cancer of the esophagus could show good results in the potential of ablation. Unfortunately, the existing expensive and temperamental dye laser systems foiled a broad clinical use. In this pilot study, we investigated the feasibility of an inexpensive and maintenance-free diode laser system for PDT of dysplasia and early cancer in Barrett's esophagus. PATIENTS AND METHODS: Eight patients with Barrett's esophagus and/or early cancer were treated. As light source we used a diode laser system with a maximum power output of 2 W and a wavelength of 633 +/- 3 nm. One patient was treated initially with Photosan-3, seven patients received 5-aminolevulinic acid. RESULTS: In all patients we could achieve reduction in length and/or histologically proven downgrading. In three quarters of the patients, complete eradication of adenocarcinoma could be attained. Columnar-lined metaplastic epithelium could also be completely eradicated. CONCLUSION: PDT using a diode laser system is comparably effective in Barrett's esophagus/early cancer as PDT with dye laser systems. PDT is a gentle and effective technique with little side effects.

[Preliminary treatment results of relapsed or refractory acute leukemia using two and three drug regimens]. / Wstepne wyniki leczenia ostrych bialaczek opornych i nawrotowych przy zastosowaniu schematów dwu--oraz trzylekowych.

36 patients with relapsed (29) or refractory (7) acute lymphoblastic or nonlymphoblastic leukaemia received regimens employing 1-3 courses of mitoxantrone (or idarubicin), intermediate doses of cytarabine and etoposide. Complete remission (CR) was achieved in 30% of patients (5/15 ALL, 6/21 AML, 5 cases of refractory and 6 of relapsed leukaemia). Duration of CR was 3-6+ months (3 patients are still alive). Toxicity of the treatment was acceptable, however 5 patients with severe granulocytopenia died from sepsis.

[Diagnostic value of acidified glycerol lysis test (AGLT) in hereditary spherocytosis and selected hematologic diseases]. / Wartosc diagnostyczna testu lizy krwinek czerwonych w zakwaszonym glicerolu (AGLT) we wrodzonej niedokrwistosci sferocytowej i wybranych zespolach hematologicznych.

AGLT and osmotic fragility test (method according to Dacie) were performed in patients with hereditary spherocytosis, their relatives and in patients with other hematological diseases. Abnormal results of both tests were observed not only in all cases of hereditary spherocytosis but also in other patients with spherocytes present in the peripheral blood film. In our opinion, AGLT is a good screening test for hereditary spherocytosis and can replace the more time consuming Dacie's method.

[Prognostic value of the peroxidase index in patients with acute nonlymphoblastic leukemia]. / Wartosc rokownicza wskaznika peroksydazowego u chorych na ostra bialaczke nielimfoblastyczna.

In 91 patients with acute non-lymphoblastic leukaemia the peroxidase index was determined in blast cells or promyelocytes in bone marrow. Complete remission was obtained exclusively in patients with the value of the index 0-9% or over 69%. The duration of the remission and the survival time were significantly longer in patients with a high peroxidase index. This index may be useful for prediction of the course of acute non-lymphoblastic leukaemia in adults and its high value is associated with better prognosis.

[Morphological changes in peripheral blood and bone marrow in patients with myelodysplastic syndromes]. / Zmiany morfologiczne komórek krwi obwodowej i szpiku u chorych na zespoly mielodysplastyczne.

In 23 patients with myelodysplasia syndromes cytomorphological examinations of peripheral red blood cells and bone marrow cells were carried out. Apart from anisocytosis and poikilocytosis observed in all patients, the most frequent changes were macrocytosis and megalocytosis or erythrocytes and their precursors, presence of erythroblasts in peripheral blood and disturbances of megakaryopoiesis. None of these changes was characteristic in a given type of these syndromes.

[Results of selected cytochemical studies of mature granulocytes in myelodysplastic syndromes and various other hematologic diseases]. / Wyniki wybranych badan cytochemicznych dojrzalych granulocytów w przebiegu zespolów mielodysplastycznych i niektórych innych chorób ukladu krwiotwórczego.

The activity of alkaline phosphatase and peroxidase was measured in polymorphonuclears in 20 cases of myelodysplasia syndromes, 10 cases of chronic myeloid leukaemia. Reduced phosphatase activity was found in 5 cases and peroxidase activity in 3 cases of myelodysplasia syndromes. No evident correlation was noted between the activity of these enzymes and prognosis. Increased proportion of peroxidase-negative granulocytes was observed, moreover, in most cases of chronic myeloid leukaemia. The observations will be continued in larger material.

[Unclassified chronic myeloproliferative Ph(-); i(17q); +8 syndrome with mixed myelo-megakaryoblastic crisis--case report]. / Niesklasyfikowany przewlekly zespól mieloproliferacyjny Ph(-); i(17q); +8 z transformacja mielo-megakarioblastyczna--opis przypadku.

We present a case of a 17-year old patient with extreme hepatosplenomegaly, hyperthrombocytosis, hyperleucocytosis and the presence of myelo- and megakaryoblasts in the peripheral blood film. Numerous complications that occurred in the course of the disease made cytostatic treatment difficult. Since Ph chromosome and hybrid gene bcr/abl were absent, the diagnosis of unclassified chronic myeloproliferative syndrome in the phase of blast crisis was established. Immunophenotyping confirmed a mixed myelo- megakaryoblastic character of the crisis. In the differential diagnosis other myeloproliferative syndromes were taken into account including i(17q) syndrome. The patient died after a 13-month observation due to neoplasm progression and sepsis.

[Prognostic importance of DNA histograms of bone marrow cells in acute myeloblastic leukemias]. / Znaczenie prognostyczne histogramów DNA komórek szpiku w ostrych bialaczkach mieloblastycznych.

DNA histograms were studied in bone marrow cells in 25 patients with acute myeloblastic leukaemia before starting treatment. It was found that patients with complete remission showed a significantly higher proportion of cells in phase S of the cellular cycle (22 +/- 3%) than patients who failed to achieve remission (12 +/- 4%). Assessment of DNA citrograms of bone marrow cells may be one of prognostic factors in acute myeloblastic leukaemia.

[Treatment of low-malignancy lymphomas by spleen irradiation]. / Leczenie chloniaków o malej zlosliwosci napromienianiem sledziony.

The spleen was irradiated in 8 patients with chronic lymphatic leukaemia using RTG radiation in doses of 225 to 800 cGy for one treatment course. The follow-up after radiotherapy lasted 12.5 months on average. In 7 cases a considerable reduction was observed in the size of the spleen, and in 6 cases the absolute leucocyte and lymphocyte counts decreased by a mean of 46% and 50% respectively. In patients in late phase of the disease the improvement was short-lasting; 5 patients died (2 from infectious complications). In patients in early phase remissions of 30 months were obtained with normalization of the proportions or T and B cells During the radiotherapy a significant rise was observed in the per cent of granulocytes and a fall of albumin level. Increased gamma-globulin and uric acid levels and decreased hemoglobin level and erythrocyte count were not significant. Variable changes were noted in the platelet count. No bleeding tendency was noted. Spleen irradiation may be used in the treatment of non-Hodgkin lymphoma associated with malignant proliferation prevailing in the spleen, that is in chronic prolymphocytic leukaemia and hairy-cell leukaemia Favourable effects of spleen irradiation were observed in chronic lymphatic leukaemia and this induced us to use this method in our eight cases.

[Treatment of acute leukemias in adults. II. Preliminary analysis of the treatment results according to AR and RAMP programs]. / Leczenie ostrych bialaczek u doroslych. II. Wstepna analiza wyników leczenia wg programów AR i RAMP.

Thirty patients with acute non-lymphoblastic leukaemia were treated. They were randomly assigned to treatment according to programme AR (14 patients) and RAMP (16 patients). The groups were comparable for age and haematological state. Complete remission was obtained in 7 patients out of 14 treated by the AR programme and 6 out of 16 treated by the RAMP programme. The median duration of complete remission is as yet 15 weeks and 16 weeks respectively. The toxic side effects during treatment by the AR programme was statistically significantly higher than in the treatment by the RAMP programme. In the first group 42.8% of early deaths occurred, while in the second group 6.2% patients died early.

[Treatment of acute leukemias in adults. I. Results of intensive chemotherapy of 106 patients with acute leukemia]. / Leczenie ostrych bialaczek u doroslych. I. Wyniki intensywnej chemioterapii u 106 chorych z ostra bialaczka.

In a period of 5 years 106 patients with acute leukemia were treated (93 with acute nonlymphoblastic leukemia and 13 with acute lymphoblastic leukaemia. Four therapeutic programmes were used. Complete remission (CR) was achieved in 41% of patients, including 37% of those with acute non-lymphoblastic leukaemia and 77% with acute lymphoblastic leukaemia. The per cent of remissions obtained using different programmes was similar. During intensive induction treatment 22% of patients died, mainly of infections and bleeding tendency.

[Treatment of acute leukemias in adults. V. The effect of intrathecal cytostatic therapy on leukemic changes in the central nervous system]. / Leczenie ostrych bialaczek u doroslych V. Wplyw dokanalowego leczenia cytostatycznego na zmiany bialaczkowe w osrodkowym ukladzie nerwowym.

In a period of 5.5 years from 1975 to 1980 the neurological status of 82 patients with various forms of acute leukaemia was assessed at the Institute of Haematology and in 42 cases central nervous system involvement was found. These patients were treated by intrathecal administration of drugs according to three programmes. Remission after intrathecal treatment was achieved in 31 cases. No improvement of the neurological status was obtained in 31 cases. No improvement of the neurological status was obtained in 4 cases. Forty-eight patients without neurological signs received prophylactically intrathecal treatment which failed to prevent central nervous system leukaemia in 8 cases.

[Preliminary results of the treatment of acute leukemia with mitoxantrone]. / Wstepne wyniki leczenia ostrych bialaczek mitoksantronem.

Mitoxantrone is a new anthracenodione derivative with a high antineoplastic activity in proliferative diseases of the haemopoietic system. In the Institute of Haematology in Warsaw and in the Department of Haematology, Silesian Medical Academy in Katowice this agent was used in combination with cytarabine in 49 cases of acute leukaemia (35 with acute myeloid leukaemia and 14 with acute lymphoblastic leukaemia). The preparations used were Mitoxantrone (POLFA Works in Jelenia Góra) and Novantrone (Lederle). These agents were given intravenously in doses of 10-20 mg/m2 for 3 days in combination with cytarabine in three doses: 100 mg/m2 on days 1 through 7, and 1 g/m2 or 3 g/m2 every 12 hours on days 1 through 4 of the treatment. Complete remission was obtained in 17 cases (35%), including 13 with acute myeloid leukaemia (37%) and 4 with acute lymphoblastic leukaemia (29). The most frequent side effects were: long-lasting pancytopenia (in 100% of cases), hair loss (39%) and gastrointestinal toxicity (33%). No significant differences were noted in the effectiveness and toxicity between these two preparations. In the light of the presented results it may be accepted that the combination of mitoxantrone with cytarabine is an important advance in the treatment of acute leukaemias.

[Treatment of acute leukemias in adults. IV. Treatment results on 375 patients at 9 hematology centers]. / Leczenie ostrych bialaczek u doroslych. IV. Wyniki leczenia 375 chorych z 9 osrodków hematologicznych.

On the basis of standardized protocols of the therapeutic results of acute non-lymphoblastic leukaemias in adults sent to the Institute of Haematology in Warsaw from 8 haematological centres in Poland it was demonstrated that complete remission occurred in 34.4% of patients (129 out of 375 cases). The mean survival time of the patients treated intensively according to programmes I, II, III and IV 8.6 months, those of patients with complete remission - 13.5 months, patients without complete remission - 3.7 months. The most frequent cause of death (82.5%) were infections and/or haemarrhagic diathesis.