The vanishing elective cholecystectomy. Trends and their consequences

During the 1980s, there have been ongoing changes in the policies and programs that govern the health care provision system. To assess the effect of these changes on patient care, the charts of patients undergoing cholecystectomy in 1980 (132 patients) and 1986 (108 patients) were reviewed and compared. The patients are increasingly over 60 years of age. The elective cholecystectomy is being replaced by procedures for more advanced disease as referrals of patients to the surgeon are delayed. The morbidity more than doubled. Compared with 1980, the policies and programs in effect during 1986 allowed fewer patients to undergo cholecystectomy (-18%), but required a markedly increased cost for those patients (+22%).

The protective effect of experimental subarachnoid haemorrhage on sodium dehydrocholate-induced blood-brain barrier disruption

The potential interactive effects between subarachnoid hemorrhage (SAH) and blood brain barrier (BBB) disruption were studied in a rat model. Experimental subarachnoid hemorrhage was produced in twenty rats (experimental group) by the intracisternal injection of blood. In ten additional rats (control group), saline was administered in place of blood. Analysis of mean blood pressure (MBP), intracranial pressure (ICP) and cerebral perfusion pressure (CPP) demonstrated an increase in ICP and MBP and a drop in CPP in all animals following intracisternal injection. Subsequent infusion of the left internal carotid artery with sodium dehydrocholate resulted in blood-brain barrier (BBB) disruption in both groups as evidenced by Evans blue staining of the infused cortex. The extent of BBB disruption was significantly greater in the control group than the experimental group. Analysis of the experimental group demonstrated that animals with the lowest pre-SAH MBP and the lowest CPP during the maximum blood pressure response to SAH demonstrated the greatest resistance to experimental BBB disruption. The possibility of ischemia as a contributing factor in BBB protection subsequent to SAH is discussed.

Isolated central nervous system metastasis from transitional cell carcinoma of the bladder: report of a case and review of the literature

Although systemic metastases from transitional cell carcinoma of the bladder occur frequently, involvement of the central nervous system is uncommon. We describe a patient with an isolated cerebral metastasis who had previously undergone resection of a Grade III, Stage B2 carcinoma of the bladder. We have been able to find only one previous case report of a solitary intracerebral metastasis from transitional cell carcinoma of the bladder without evidence of primary recurrence or additional sites of spread. Central nervous system metastasis from bladder carcinoma must be considered in the differential diagnosis of solitary intracerebral lesions.

Varicose ulcer of the upper extremity

Serious complications of local venous hypertension occur rarely in the upper extremity. These are most frequently the result of a dysfunctional arteriovenous fistula and may produce changes indistinguishable from those of chronic lower-extremity venous insufficiency. A combination of arterial and venous contrast imaging is essential for identifying major venous outflow obstruction and for planning appropriate surgical therapy.

Ependymal cyst of the quadrigeminal plate: case report

A patient with an ependymal cyst of the quadrigeminal plate is reported. The patient presented with headache, diplopia, and evidence of increased intracranial pressure. A nonenhancing cyst with hydrocephalus was demonstrated by computed tomographic scan. The cyst was subtotally resected using a transtentorial approach. The causes, clinical presentation, and treatment of quadrigeminal plate ependymal cysts are discussed, together with a review of the literature.

Meningioma with intratumoral fat

Fat within meningiomas is histologically not uncommon. Focal areas of low density on computed tomography scans within meningiomas have been demonstrated and are most often intratumoral cysts. The case presented demonstrates a focal area of low density within a meningioma that is proved histologically to be fat.

Management of solitary nonparasitic liver cyst

Solitary nonparasitic liver cysts are clinically rare and mostly nonsymptomatic. Occasionally, cases present with symptoms mainly because of the presence of a large cyst. In this report, the clinical features, diagnostic modalities, and current management of such cysts are described.

Gastrointestinal lipomas

We reviewed 15 years of experience with gastrointestinal (GI) lipomas at our institution. A series of eight patients was included, six of whom had lipomas in the colon and two, in the stomach. All eight patients were symptomatic. The diagnosis was not made preoperatively in seven cases, which accounted for surgical intervention in these patients. Colonoscopy was helpful in the diagnosis and treatment of the eighth patient. Advances in the diagnosis and treatment of GI lipomas include the use of computed tomographic scanning and colonoscopy.

Experience with lobular carcinoma of the breast. Emphasis on recent aspects of management

A total of 105 patients with lobular carcinoma of the breast were seen at two hospitals between 1966 and 1978. Mammography was found to be of limited value in the preoperative assessment of these patients. As reported by others, there was a high incidence of bilateral lobular neoplasia. In the patients with lobular carcinoma in situ for whom follow-up data were available, all were alive and well. In contrast to this, infiltrating lobular carcinoma was found to be as malignant a lesion as any other infiltrating breast cancer regardless of the operative procedure performed. These latter tumors were found to bind substantial levels of estrogen receptor proteins. From the information gained, it is suggested that early hormonal manipulation and/or chemotherapy may be advantageous in the patient with recurrent infiltrating lobular carcinoma in particular.

Scleroderma of the colon with obstruction: report of a case

A case of a patient who had colonic obstruction caused by scleroderma is described. The obstruction initially was treated by means of a colostomy, and later subtotal colectomy was carried out. This is the fifth report of a patient with symptomatic colonic scleroderma successfully treated by colonic resection. A review of colonic scleroderma is included.

Vagotomy and double pyloroplasty for peptic ulcer

Seventy patients with peptic ulcers (55 duodenal and 15 gastric) were treated by truncal vagotomy and doulbe pyloroplasty during the past four years. Clinical and experimental data as presented lead us to believe that transecting the pylorus twice produces an incontinent pyloric sphincter and a larger gastric outlet than is found in other methods of pyloroplasty. This decreases gastric stasis and has led to a lower ulcer recurrence rate (1.5%). In addition the untoward postoperative sequelae are minimal. The 70 patients treated (for the most pare consecutive cases) exhibited the usual complications of peptic ulcer disease. Thirty-three had intractable pain, 23 bleeding (15 massive), 13 obstruction, and one acute perforation. There were no operative or postoperative deaths and the only serious postoperative complication was unrelated to the double pyloroplasty. During the followup period four patients have died of unrelated diseases. Of the remaining 66 patients one developed a probable recurrent peptic ulcer which has responded to medical management. Four patients have intermittent dumping, three have mild diarrhea and one has failed to gain weight, Constipation and weight gain are more common complaints. It would appear that vagotomy with double pyloroplasty is a safe and effective operation for peptic ulcers and that further clinical trials are warranted.

The metabolism and binding properties of 3H-aldosterone in plasma and its sex dependence in adrenalectomized rats

The rates of clearance of plasma 3-H radioactivitivity following intravenous injection of 3-H aldosterone was demonstrated to be sex-dependent in adrenalectomized rats. The perchantage plasma radioactivity which is CH-2CL-2extractable is greater in female than in male rats from 5 min to 90 min postinjection; however the quantities of CH2-CL2-extractable label are not significantly different until 60 min postinjection. The quantities of nonextractable, water-soluble metabolites of adosterone (NEPD), which are markedly greater in the plasma of males, reach peak levels 30 min after injections of aldosterone, during the latent period of the hormone.N females, these polar metabolites (NEPD)are rapidly cleared from the blood. The quantities of 3-H-radioactivity associated with the plasma binding proteins are similar in both males and females. The unbound levels of aldosterone and its metabolities are significantly greater in the plasma of males. These findings indicate that the sex hormones may influence not only the metabolism of aldosterone in rats, but also the plasma levels of unmetabolized aldosterone and its metabolites.

Effect of metrifonate on blood cholinesterases in children during the treatment of schistosomiasis

In a controlled clinical trial, Tanzanian schoolchildren with urinary schistosomiasis, many of whom had coexisting hookworm infection, were randomly allocated to one of three groups that were treated with doses of 7.5, 10.0, and 12.5 mg per kg of body weight, respectively, of metrifonate, orally, up to 3 times at 14-day intervals. No serious side effects were observed during or after the administration of single or repeated doses. A few hours after medication, plasma cholinesterase was almost completely inhibited, regardless of the dose given, while erythrocyte cholinesterase was almost completely inhibited, regardless of the dose given, while erythrocyte cholinesterase was inhibited down to 40-60% of the pretreatment level, depending on the dose. Plasma cholinesterase was inhibited to a greater extent than erythrocyte cholinesterase but showed a more rapid recovery of activity. A moderate accumulation of unreactivated erythrocyte cholinesterase occurred at all dose levels with this regime. Four weeks after the last dose of drug, plasma cholinesterase activity was nearly normal in all the treated children. Erythrocyte cholinesterase activity returned to normal 8-15 weeks after the last dose. The therapeutic results confirmed the efficacy of metrifonate against Schistosoma haematobium. There was an additional though less striking effect against hookworm.