Surgical implications of sclerosing mediastinitis. A report of six cases and review of the literature.

Sclerosing mediastinitis is an uncommon disease associated with a multiplicity of clinical syndromes. The cause of this disorder is probably an abnormal fibroproliferative response to an inflammatory stimulus, most commonly a granulomatous infection secondary to Histoplasma capsulatum. The pathophysiology of this disease is predicated on the encasement of mediastinal vital organ structures within a dense fibrotic mass. This mass appears to emanate from an invasive chronic inflammatory process causing erosion as well as external compression of these structures. The following case reports illustrate the diversity of this disease entity, representing a patient population from the Ohio River Valley, endemic for histoplasmosis. The purpose of this report is to elucidate the various clinical manifestations of sclerosing mediastinitis and to correlate the pathologic process with a rational approach to treatment.

Adrenocortical carcinoma.

From 1962 to 1985, 47 patients with carcinoma of the adrenal cortex were treated at Memorial Sloan-Kettering Cancer Institute. There were 21 men and 26 women. Seventy-two percent of the tumors were functional and 28% were nonfunctional. Despite the advent of ultrasonography and computerized tomography, these tumors were infrequently diagnosed until they infiltrated adjacent organs or metastasized to distant sites. Only 30% of patients had tumors confined to the adrenal gland; their mean duration of survival was 5.0 years. Seventy percent of the patients had invasion of the kidney, lymph nodes, liver, diaphragm, and/or pancreas at the initial operation; their mean duration of survival was 2.3 years. Eight patients had reoperation for abdominal recurrences; three of the patients with abdominal recurrence and one additional patient underwent thoracotomy to resect localized lung metastases. The mean duration of survival of these nine patients was 3.5 years, not significantly different from the mean overall survival of 3.1 years. The duration of survival of all patients was not significantly correlated with age, sex, adjuvant therapy, or production of hormones by the tumor. Only two patients were deemed unresectable. Wide en-bloc dissection of the primary tumor, resection of contiguous organs for local invasion, and excision of resectable metastases in the liver and lungs remain the basis of therapy.

Unit responses in the ventrobasal thalamus (VPL) of the cat of bradykinin injected into somatic and visceral arteries.

Under light to moderate sodium pentobarbital anesthesia one half of the thalamic neurons displaying place and modality specific responses to low intensity mechanical stimulation of contralateral receptive fields also responded, by excitation or by inhibition, to bradykinin injections into somatic and visceral arteries. Partial or complete somatovisceral convergence was commonly seen in neurons with otherwise typical lemniscal properties. The response intensities varied considerably for different neurons; the responses to somatic bradykinin were always stronger than to visceral injections. The time course of the response was comparable to that seen in peripheral nerves, other central sites, and the behavioral reaction to bradykinin. Control experiments indicated the independence of the bradykinin responses from variations in blood pressure or general arousal effects. It is suggested that modulation of ventrobasal thalamic activity may be an important factor in central nociceptive processing.

Surgical debridement and intralesional steroid injection in the treatment of idiopathic AIDS-related anal ulcerations.

BACKGROUND: The treatment of idiopathic anal ulcerations in AIDS patients is still evolving. These patients suffer with severe incapacitating anal pain. PATIENTS AND METHODS: Relief of pain was achieved with the use of intralesional steroid injections. Twenty-one patients from 1990 to 1993 presented with severe anal pain of 4.5 months average durations (range 3 weeks to 2 years). The average CD4 count was 52.1 (range 0 to 150). Fourteen (67%) patients had a solitary ulcer, while 7 (33%) had complex ulcerations. RESULTS: All patients were treated by debridement of the ulcer, biopsy, and intralesional injection of steroids. Microscopic evaluation revealed nonspecific inflammatory changes, without histopathologic evidence of viral infection or malignancy. Viral tissue cultures were negative. Fifty-seven percent of patients required only one injection to achieve dramatic relief of pain. Forty-three percent necessitated additional injections at 2-week intervals. The average patient was injected 1.9 times (range 1 to 7), with 20 of 21 patients (95%) reporting good to excellent pain relief. CONCLUSION: AIDS anal ulcerations should be treated aggressively with surgical debridement, biopsy and intralesional steroids. The efficacy of this therapy suggests that symptoms are partially due to inflammatory mediators.

Anorectal pathology in AIDS.

Anorectal complaints are common in persons with AIDS and are being seen increasingly because advances in therapy for HIV, such as the new antiretroviral protease inhibitors, have resulted in longer life expectancy for those with HIV infection. In the past, many patients with HIV infection were seen at referral centers; now, however, primary care physicians as well as gastroenterologists and surgeons in the community are managing and caring for these patients. For this reason, it is important for clinicians to recognize the spectrum of anorectal disease in patients with AIDS, as well as its appropriate evaluation and management.

Sexually transmitted diseases and anal manifestations of AIDS.

During the past 20 years, there has been an increased use of the anorectum for erotic pleasure. Consequently, this has led to an overwhelming rise in sexually transmitted diseases (STDs) of the anus and rectum. It is important that surgeons involved with the care of colon and rectal disorders be familiar with each of these diseases. The recent AIDS epidemic has been a challenge to the medical community. Equally as challenging is the management of common anorectal disorders in the AIDS patient. AIDS not only influences the manner in which STDs present but is associated with its own spectrum of anorectal disorders. Discussion and management of STDs and anorectal disorders of AIDS patients are presented.

Superior vena cava syndrome: report of a new operative technique.

A case of superior vena cava syndrome secondary to longstanding benign obstructing disease is presented. A new method of surgical technique is detailed. Clinical manifestations, etiology, anatomy, diagnosis, and treatment of superior vena cava syndrome are reviewed and principles of successful surgical treatment of the venous system are elucidated. The multiplicity of clinical and experimental techniques utilized in the past is succinctly tabulated.

Helping friends in trouble.

AIDS: Helping friends in trouble; what do you do if you think a friend is being abused by someone they love? Women who are the victims of domestic violence need to be given space and support from friends, to determine how to deal with the abuse. Friends can help by listening, staying in touch, and being non-judgmental. As the final decision on dealing with the abusive relationship should come from the abused woman, several suggestions are presented to ensure her own safety. These suggestions include centralizing all important identification and documents for easy retrieval, getting medical attention, collecting evidence, and finding a safe haven. A toll-free number on domestic violence is provided for counseling and referral.^ieng

Sustiva may cause false positive on marijuana test.

AIDS: Sustiva may cause false positives on urine tests that screen for marijuana use. A false positive, however, is unlikely to appear on a second confirmatory test. If their urine is being tested, patients who take Sustiva should inform testers that the patients are on the drug.^ieng

Patient cards: storage and input for medical data.

The literature concerning the diffusion of innovations reveals that it is not surprising that a promising technology is confronting obstacles in its development and implementation. Alternative technologies also often appear that address the same or similar problems. Better information enables physicians to provide medical care that is less expensive and less error prone. The prescription of medications is reduced in number and cost when the prescribing physician knows the current and previous medications of the patient. The ordering of clinical tests is reduced in number and cost, and the ordering of timely retesting is more likely when physicians have before them information about previous testing of their patient. The challenge is in how the portability of the patient card and its ability to be self-contained can enhance medical practice.