[Limitation of blood transfusions during hepatectomies. Study of 150 consecutive hepatic resections on healthy and pathological livers]

OBJECTIVE

Over the last 5 years, a policy to limit blood transfusions has been adopted in patients undergoing liver resection. The aim of this retrospective study was to report the results of 150 liver resections performed during this period.

METHODS

There were 63 major (42%) and 87 minor hepatectomies (58%). Resection was performed for malignant lesions in 64% of the patients. Vascular exclusion of the liver was used in large (> or = 10 cm) tumors and those located at the cavohepatic junction. Clamping of the portal triad or selective clamping of the pedicle of the portal lobe was used in peripheral lesions < 10 cm in diameter. Anesthesia was adapted to the type of vascular clamping and blood transfusions were deliberately limited. Red blood cells were transfused to maintain the hematocrit level above 25% in healthy patients and above 30% in patients with risk of coronary artery disease.

RESULTS

Ninety three patients (62%) did not receive blood transfusions. Three patients received more than 10 units of packed red blood cells (2%). 48% of patients with major hepatectomies and 72% with minor hepatectomies were not transfused. The rate of non transfused patients was 93% for benign lesions and 44% for malignant lesions. The presence of pathologic changes in non-tumor liver parenchyma did not influence the need for transfusions. Hospital mortality was 3% (5/150). There was no mortality in patients with normal non-tumorous livers, 14% in the presence of cirrhosis, and 12% in the presence of obstructive jaundice or steatosis > 50%. The specific morbidity rate was 7% in patients with normal livers and 54% in patients with abnormal livers.

CONCLUSION

This series shows that more than 60% of liver resections can be performed without blood transfusions. These results require an appropriate surgical technique and collaboration between anesthesiologist and surgeon. Thus hepatectomies in normal non-tumorous livers can be performed without mortality. In contrast, the presence of abnormalities of the non-tumorous liver parenchyma remains a major risk factor.

The MAN antigens are non-lamin constituents of the nuclear lamina in vertebrate cells

The characterization of the human antiserum designated MAN has led to the identification of a subset of non-lamin proteins that are exclusively located at the nuclear periphery in all vertebrate cell types examined, from human to fish. Immunoreactive protein species were shown to comprise three major polypeptides of Mr 78000, 58000 and 40000. These antigens co-partitioned with the nuclear lamina during in situ isolation of nuclear matrices from lamin A/C-positive and -negative mammalian cells. Using double immunofluorescence, the spatial relationship of MAN antigens to type-A and type-B lamins was further examined throughout the cell cycle of lamin A/C-positive mammalian cells. In interphase HeLa and 3T3 cells, MAN antigens colocalized with both types of lamins at the periphery of the nucleus, but were absent from intranuclear foci of lamin B. As HeLa cells proceeded into mitosis, MAN antigens were seen to segregate from lamins A/C and coredistribute with lamin B. Lamins A/C disassembled during late prophase/early prometaphase and reassociated with chromatin in telophase/cytokinesis. In contrast, MAN antigens and lamin B dispersed late during prometaphase and reassembled on chromosomes in anaphase. Altogether, our data suggest that MAN antigens may play key functions in the maintenance of the structural integrity of the nuclear compartment in vertebrate cells.

Changing patterns in pediatric mortality, Maputo Central Hospital, Mozambique, 1980-1990

OBJECTIVES

To present an analysis of the Department of Paediatrics' statistics on hospital mortality, covering the period through 1980-1990.

METHODS

Basic information was recollected from logbooks of the Department's wards. Descriptive statistics are estimated on death and its main causes. The proportion of deaths in relation to total admissions and in relation to global in-hospital mortality are computed and their changes over time documented.

RESULTS

The data show an important decrease of in-hospital global mortality in spite of the increase of the number of admissions over time. The pattern of the main causes of death changed, and the authors postulate that the change is attributed to a dramatic change in the epidemiological pattern of childhood morbidity in Maputo City, especially due to measles vaccination. In parallel, the study suggests an increase in the prevalence of severe malnutrition.

CONCLUSIONS

Hospital statistics, while dependent on socio-economic conditions, can be significantly changed by Public Health interventions. Monitoring and analysing hospital statistics is important for documenting epidemiological changes, and also to suggest community interventions. From that point of view, epidemiological surveillance and hospital statistics are complementary.

Intrahepatic cholangiocarcinoma. Results of aggressive surgical management

OBJECTIVE

To report the results of a deliberately aggressive surgical management in patients with intrahepatic cholangiocarcinoma.

DESIGN

A case series of patients with intrahepatic cholangiocarcinoma.

SETTING

A tertiary care university hospital in a metropolitan area.

PATIENTS

From 1989 to 1993, 19 patients with intrahepatic cholangiocarcinoma underwent laparotomy, with a 74% resectability rate (14 liver resections). In addition, two selected patients with a slow-growing tumor underwent orthotopic liver transplantation after limited recurrence following resection in one case and after exploratory laparotomy in the other.

INTERVENTIONS

The 14 liver resections included six right or left hepatectomies and eight extended right or left hepatectomies. Total vascular exclusion of the liver was used in nine cases (64%) and resection of the biliary confluence with reconstruction was used in six cases (43%).

RESULTS

There was one postoperative death (7%). There were four postoperative biliary fistulas (28%). Overall actuarial 1- and 2-year survival rates were 58% and 32%, respectively. The 1- and 2-year survival rates were 100% after curative resection (no lymph node invasion, clearance margin of < or = 1 cm, and solitary tumor [five cases]) and 48% and 10% after palliative resection. Median survival was 14 months for the whole series and 27 and 9 months following curative and palliative resections, respectively. The two liver transplant recipients are alive and free of disease at 25 and 31 months.

CONCLUSION

These results support aggressive surgical management in patients with intrahepatic cholangiocarcinoma, including complex liver resection procedures and selective use of orthotopic liver transplantation.

Characterization of the 2H12 antigen as a nonshuttling human isoelectric variant of the nucleolar protein B23

It has become obvious that a better understanding of the nucleolar compartment should encompass the elucidation of structural and functional relationships between its molecular constituents. Using a mouse monoclonal antibody referred to as 2H12, we have identified a human epitope that appears to be implicated in the regulatory events governing the elaboration and stabilization of the nucleolar architecture. By immunofluorescence and immunoblotting, the 2H12 monoclonal was shown to be directed against a nucleolar protein with a relative mobility of 38-40 kDa and an isoelectric point of 5.1 that is present in human cells, regardless of their proliferation state. No reactivity was detected in cells from other species, implying that the targeted epitope could be unique to humans. Investigation of the fate of the epitope throughout the cell cycle led to evidence that its immunoreactivity was phosphodependent and suggested that the disassembly and reassembly of the nucleolar apparatus during cell division is accompanied by dephosphorylation/phosphorylation modifications at this site. In a series of double immunofluorescence experiments and two-dimensional immunoblotting analyses, it was demonstrated that the 2H12 antigen corresponds to an isoelectric variant of the human nucleolar protein B23 that is most prominent during interphase. Tightly associated with the nuclear matrix, this human B23 isoelectric variant did not shuttle between the nucleus and the cytoplasm but remained sequestered within the human nucleolus during mobility assays in human-murine heterokaryons.

Residual organic debris on processed surgical instruments

This preliminary study describes the degree of cleanliness of three categories of surgical instruments after processing (ie, decontamination, inspection, sterilization). The three categories were reusable laparoscopic, reused disposable laparoscopic, and conventional surgical instruments. The objective of the study was to identify from visual inspection and microscopic examination residual particles, stains, or liquid on processed instruments. The investigators studied 32 instruments selected at random from a hospital's supply of processed surgical instruments. On visual inspection, 90.6% (29/32) of the instruments appeared clean. Microscopic examination with a photomicrographic system, however, revealed residual debris on 84.3% (27/32) of the instruments. The quantity of residual debris on both types of laparoscopic instruments (ie, reusable, reused disposable) was equivalent. The conventional instruments contained less residual debris than the laparoscopic instruments. Sites that contained residual debris included junctions between insulating sheaths and activating mechanisms of laparoscopic instruments and articulations and grooves of forceps. More research is needed to determine the prevalence and clinical significance of these findings.

Basic fibroblast growth factor modulates the aminophospholipid translocase activity present in the plasma membrane of bovine aortic endothelial cells

Vascular endothelial cells form the inner nonthrombogenic lining of the large blood vessel. Through back-exchange and fluorescence recovery after photobleaching experiments and using the two fluorescent lipids 1-acyl-2-[6-[N-(7-nitrobenz-2-oxa-1,3-diazol-4-yl)amino] hexanoyl]glycerophosphocholine and 1-acyl-2[6-N-(7-nitrobenz-2-oxa-1, 3-diazol-4-yl)amino]hexanoyl]glycerophosphoethanolamine, we have recently shown that an energy-dependent and protein-dependent aminophospholipid translocase activity is present in the plasma membrane of cultured bovine aortic endothelial cells, which specifically transports phosphatidylethanolamine from the outer leaflet toward the inner leaflet of the membrane lipid bilayer. In the present study, using the same approach and 1-acyl-2-[6-[N-(7-nitrobenz-2-oxa-1,3-diazol-4-yl)amino]hexanoyl] glycerophosphoserine as the probe, it is shown that this conclusion is also valid for phosphatidylserine. Furthermore, evidence is presented indicating that this aminophospholipid translocase activity can be maintained, suppressed, and restored at will, depending on the conditions of cell incubation. Thus, the translocase activity is detected for cells maintained in their normal culture medium or in a serum-free incubation medium [Dulbecco's modified Eagle's medium (DMEM)] supplemented with the basic fibroblast growth factor, whereas inhibition is observed for cells exposed for at least 2 h to DMEM. The translocase activity is restored when these pretreated cells are further incubated at least for 1 h in the presence of serum or of basic fibroblast growth factor. In view of the importance of basic fibroblast growth factor as a mitogenic and differentiating agent for vascular endothelial cells, various growth factors were tested (acidic fibroblast growth factor, epidermal growth factor, platelet-derived growth factor, transforming growth factors alpha and beta, vascular endothelial growth factor, interferon gamma, tumor-necrosis factor, insulin, and interleukin 4). Only basic fibroblast growth factor was active in the maintenance and restoration of the translocase activity. With respect to the effects of serum, evidence is presented showing that high-density lipoproteins might play a role in the control of the translocase activity. However, the positive effects of basic fibroblast growth factor, serum and high-density lipoproteins on the translocase activity were suppressed when experiments were carried out in the presence of an anti-(basic fibroblast growth factor) IgG, thus indicating that in all cases, basic fibroblast growth factor was directly involved in the modulation of the aminophospholipid translocase activity present in the plasma membrane of bovine aortic endothelial cells.

[Surgical treatment of severe ulcerous hemorrhages: predictive factors of operative mortality]

OBJECTIVES

Multivariate analysis of operative mortality in patients with bleeding peptic ulcer.

METHODS

Seventy-eight consecutive patients, who underwent emergency surgical treatment for bleeding peptic ulcer were reviewed retrospectively. There were 49 males and 29 females, with a mean age of 64.3 years, 2/3 of whom had associated medical disease. Surgical treatment was conservative in 63 cases: oversewing or ulcer excision, alone (n = 29) or associated with vagotomy (n = 34); and was radical in 15 cases: antrectomy+vagotomy (n = 10) or partial gastric resection (n = 5).

RESULTS

There were 17 (21.8%) postoperative deaths and 19 (24.3%) bleeding recurrences. The causes of death included 9 bleeding recurrences, 7 organ failures and one duodenal leakage. On multivariate analysis, previous medical illness (cirrhosis or cardiac insufficiency (P < 0.001), shock at admission (P < 0.001), prolonged delay until surgery (P < 0.001), and bleeding recurrence (P < 0.001) were independently associated with increased mortality. In contrast, the type of surgical procedure did not influence postoperative mortality, whereas bleeding recurrence was more frequent in case of conservative surgery (P < 0.03) and anticoagulation therapy (P < 0.01).

CONCLUSION

These results suggest that surgical treatment of bleeding peptic ulcer should be proposed early in high-risk patients. A radical procedure should be favoured since it reduces bleeding recurrence rate without increasing operative mortality.

Orthotopic liver transplantation with preservation of the caval and portal flows. Technique and results in 62 cases

Sixty-two OLTs in 61 patients were performed using a technical modification reported recently, including total hepatectomy with preservation of the inferior vena cava, partial clamping of the native vena cava, and side-to-side cavacaval anastomosis. We further modified the technique by adding the early construction of a temporary end-to-side portacaval shunt, and, more recently, by using an end-to-side caval reconstruction. With this technique, the caval and portal flows were maintained throughout the procedure. Hemodynamic parameters were analyzed prospectively during the operative period and remained stable at all stages of the procedure. Venous bypass was avoided in all cases without need for increased fluid infusion. Operative time and transfusion requirements were 6.8 +/- 1.6 hr and 9.8 +/- 4.3 U of packed RBC, respectively. There were no specific complications or deaths due to the technique used and hospital mortality was 10% (6/61). The technique used in this study is a safe adjunct to the technical armamentarium of clinical liver transplantation. Its main advantage seems to be hemodynamic stability throughout the procedure, obviating the need for venous bypass or fluid overload.

Multimodal adjuvant treatment and liver transplantation for advanced hepatocellular carcinoma. A pilot study

BACKGROUND

Orthotopic liver transplantation has been used in a large number of patients with primary liver cancer because it increases the possibilities of resection of large tumors. Despite isolated cases of prolonged survival, however, the results of liver transplantation for advanced tumors have been universally disappointing because of high rates of tumor recurrence. In an attempt to reduce the recurrence rate, a pilot study testing a multimodal adjuvant treatment in patients undergoing liver replacement for hepatocellular carcinoma was undertaken.

METHODS

The treatment consisted of preoperative hepatic arterial chemoembolization (iodized oil, doxorubicin, and gelatin sponge) and radiotherapy (5 Gy in one fraction immediately before surgery), and postoperative systemic chemotherapy with mitoxantrone. Nine patients entered this study. The tumor was solitary in two cases (5 cm and 8 cm) and multifocal in seven cases (2-9 nodules, 3-9 cm). The postoperative TNM stages were II in one case, III in one case, and IVA in seven cases.

RESULTS

Chemoembolization and radiotherapy were performed in seven cases each (five patients had both treatments). All patients underwent liver transplantation with conventional immunosuppression. One patient died of heart failure 4 days after surgery. The remaining eight patients received 4 to 10 courses of chemotherapy (mean 9). The main toxicity of chemotherapy was leucopenia. Two patients died of recurrence: one at 7 months and one at 11 months. Six patients are alive, five of them without evidence of disease, with a mean follow-up of 30 months (range 16-45) after liver transplantation. The 3-year actuarial survival is 64%.

CONCLUSIONS

These results show that an aggressive adjuvant therapy can be used in association with liver transplantation in the treatment of advanced hepatocellular carcinoma without increased mortality and suggest that such a protocol could be effective in preventing tumor recurrence.

The recipient splenic artery for arterialization in orthotopic liver transplantation

Adequate hepatic arterial reconstruction is essential for successful liver transplantation. In the case of insufficient recipient hepatic arterial flow, most surgeons recommend the use of the aorta for arterialization of the graft. We report here on a technique in which the recipient splenic artery is used in such a setting. The splenic artery is dissected from its origin on a 3-to-4 cm segment and divided. The proximal segment is flipped to the right and anastomosed to the graft's celiac axis in an end-to-end fashion. This technique was used in 7 of 79 orthotopic liver transplantations (9%) because the native hepatic artery was deemed to be inadequate for anastomosis. There were no complications related to the use of this technique and no arterial thromboses. Arterialization of hepatic grafts using the recipient proximal splenic artery is a simple, safe, and efficient technique that can be recommended in the presence of an inadequate recipient hepatic arterial flow.

An analysis of the communication of adult residents of a long-term care hospital as perceived by their caregivers

Different groups of caregivers (nurses, orderlies, professionals, student orderlies and volunteers) who were in frequent interaction with residents from a long-term care hospital were interviewed with a nominal group process. They were asked to identify concrete situations of communication in which residents with no trouble communicating, residents with aphasia and residents with dementia need to express and/or comprehend a message. A total of 196 statements were recorded and coded using a qualitative approach into different categories of communication acts specific to daily life situations and several categories of generic communication acts, which are unrelated to the daily routine of care and treatment. The results show that communication in daily life situations varies little in relation to the different residents. However, residents with language disorders are perceived to be less involved in generic communication acts than residents with no communication disorder. They also demonstrate that the perceptions of communication of the different caregivers vary. The results are discussed in relationship to the conception of an evaluation instrument for language-impaired long-term care residents, which will help in determining intervention as well as the objective evaluation of its effects.

Management of breast cancer in the elderly

The management of breast cancer in elderly women was analysed by a retrospective study of 150 women over 70 years old referred to our department between 1984 and 1988. 80 were T1-T2, 33 were T3 and 34 were T4. 107 were N0 and 43 were N1-N2. 16 women (11%) were in poor health, preventing conventional treatment. Treatment choice varied with age: 60% of the women aged 70-79 (group 1) and 23% of the oldest women (group 2) were treated conventionally. The use of surgery decreased with age and surgical procedures were conventional in only 85% of the group 1 women and in 56% of the group 2 women. Definitive radiation therapy was used more frequently in the oldest women, as was primary hormone therapy. Quality of follow-up also varied with age. Five-year survival rates were still high in both groups while relapses were frequent. Breast cancer was consequently a frequent cause of death. The increase in the proportion of elderly people with breast cancers over the next few years will require validated guidelines. Specific protocols and specific rules of management must be drawn up.

Effect of phenytoin on acute lung injuries in unanesthetized sheep

OBJECTIVE

To determine if the intravenous administration of phenytoin attenuates or prevents acute experimental lung injury.

DESIGN

Placebo-controlled, longitudinal animal investigative study.

SETTING

University research laboratory.

SUBJECTS

Sixteen yearling female lambs weighing 30 +/- 3 kg.

INTERVENTION

After administration of anesthesia, the animals were endotracheally intubated and mechanically ventilated. Using sterile techniques, four thoracotomies were performed. Through the left fourth intercostal space, cannulas for pressure measurements were inserted directly into the main pulmonary artery and left atrium. An ultrasound flow cuff for determination of cardiac output was placed around the main pulmonary artery. Through the left tenth intercostal space, the diaphragmatic and mediastinal parietal pleura were widely cauterized. Through the right tenth intercostal space, the caudal mediastinal lymph node was identified and divided at the caudal margin of the right pulmonary ligament, and a 1- to 2-cm portion of the node distal to the ligament was resected. The diaphragmatic and mediastinal parietal pleura were widely cauterized. Through the right sixth intercostal space, the efferent duct (or ducts) was identified, ligated at the site of entry into the thoracic duct, and cannulated. The lymph cannula was brought to the outside of the thorax through a separate stab wound.

MEASUREMENTS AND MAIN RESULTS

Unanesthetized sheep were studied 7 to 10 days after surgery. Hemodynamic, lung fluid balance, and arterial blood variables were measured in uninjured sheep and in sheep injured by intravenous infusions of Escherichia coli endotoxin (1 microgram/kg iv over 30 mins), air bubbles (0.056 to 0.074 mL/kg/min over 4 hrs), or oleic acid (0.06 mL/kg over 1 hr). The sheep were studied when untreated and after pretreatment with phenytoin. We found that the expected increase in protein-rich lung lymph flow with injuries, resulting from increased microvascular permeability in the lungs, was attenuated by phenytoin when the lungs were injured by endotoxin or air bubbles. In contrast, phenytoin had no effect on oleic acid-induced lung injury or on uninjured lungs.

CONCLUSIONS

Phenytoin attenuates acute lung injuries in sheep that are thought to be caused by stimulation of host inflammatory responses (e.g., endotoxin and air bubbles), but has no effect on direct injuries to the lungs (e.g., oleic acid). A plausible mechanism for this finding is phenytoin inhibition of polymorphonuclear leukocyte function.

Differences in the transbilayer and lateral motions of fluorescent analogs of phosphatidylcholine and phosphatidylethanolamine in the apical plasma membrane of bovine aortic endothelial cells

In the plasma membrane of various eucaryotic cell types, in particular blood platelets and erythrocytes, it is known that phospholipids are asymmetrically distributed between the two leaflets of the lipid bilayer and that this transverse asymmetry is controlled by an aminophospholipid translocase activity. In this respect, it was of interest to check whether there are differential transbilayer movements between amino- and neutral phospholipids in the apical plasma membrane of vascular endothelial cells which form the inner nonthrombogenic lining of the large blood vessel. In the first step we compared the transbilayer localization and also the rate of lateral motion of two fluorescent analogs of phosphatidylcholine and phosphatidylethanolamine, namely C6-NBD-PC and C6-NBD-PE, inserted into the apical plasma membrane of bovine aortic endothelial cells, in vitro. By the use of back-exchange experiments we have found that C6-NBD-PC could be removed from the cell membrane toward the culture medium regardless of the incubation conditions used, i.e., just after cell labeling at 0 degrees C or even after further cell incubation for 1 h at 0 or 20 degrees C. In contrast, C6-NBD-PE could be removed only when the cells were maintained at 0 degrees C. After incubation for 1 h at 20 degrees C, 85% of the probe molecules remained nonexchangeable, indicating probe translocation from the outer to the inner leaflet of the lipid bilayer. This "flip" process, which occurred at 20 degrees C, was abolished when the endothelial cells were preincubated with N-ethylmaleimide, diamide, vanadate (VO4(3-)) and vanadyl (VO2+) ions, a set of substances which inhibit aminophospholipid translocase activity in various systems, and with a combination of sodium azide and 2-deoxyglucose which led to nearly complete ATP depletion in the cells. Fluorescence recovery after photobleaching experiments were also carried out to specify more precisely the localization and dynamics of the probes in the two leaflets of the plasma membrane lipid bilayer. They produced lateral diffusion coefficients D of 1.2 +/- 0.05 x 10(-9) cm2/s for C6-NBD-PC and 2.8 +/- 0.3 x 10(-9) cm2/s for C6-NBD-PE, when the two probes were located in the outer leaflet of the plasma membrane, just after cell labeling at 0 degree C.(ABSTRACT TRUNCATED AT 400 WORDS)

Orthotopic liver transplantation in the presence of partial or total portal vein thrombosis: problems in diagnosis and management

From January 1989 to May 1992, 70 orthotopic liver transplantations (OLT) were performed in 69 patients, 53 of whom had cirrhosis (77%). Eleven patients (16%) had preoperative partial or total portal vein thrombosis (PVT). Ten of these patients had cirrhosis of various causes. PVT was total in three cases and partial in eight. Total PVT was detected preoperatively in all three cases. By contrast, partial PVT was diagnosed preoperatively in only three of the eight cases. In the five other cases of partial PVT, the obstruction was discovered intraoperatively during dissection of the portal vein. Surgical management of PVT consisted of phlebothrombectomy in ten cases followed by usual end-to-end portal anastomosis in nine cases and anastomosis of the graft's portal vein to the splenomesenteric confluence in one case. Atypical anastomosis of the graft's portal vein to a dilated choledocal vein was performed in one case of total PVT. There were no deaths or complications related to the presence of preoperative PVT or to its management. One patient died postoperatively of primary graft nonfunction at day 5. One patient had arterial thrombosis 3 months after OLT and was successfully retransplanted. Two patients died of recurrent carcinoma 3 and 7 months after OLT. Eight patients are alive 4 to 39 months after OLT. We conclude from this series that (1) the prevalence of preoperative PVT among patients transplanted for advanced cirrhosis may be high (19% of the cirrhotics in this series); (2) PVT is often partial and so difficult to diagnose preoperatively; (3) PVT, even when total, can be managed successfully during surgery and does not seem to affect survival.

Comparison of intramuscular and intravenous quinine for the treatment of severe and complicated malaria in children

To compare the efficacy and side effects of intramuscular (i.m.) and intravenous (i.v.) quinine, children in Mozambique with severe and complicated malaria between 6 months and 7 years were randomized to treatment with i.m. or i.v. quinine, both in a dosage of quinine dihydrochloride 20 mg/kg followed by 10 mg/kg every 8 h. Of 57 children treated with i.m. quinine, 4 died, 3 had neurological sequelae and 2 had sterile intramuscular abscesses. Of 47 children treated with i.v. quinine, 6 died and 1 had neurological sequelae. The mean parasite clearance time was 58.6 h in the i.m. group and 59.3 h in the i.v. group. Mean temperature clearance times were 56.1 and 51.8 h, and mean coma clearance times 40.4 and 38.7 h, respectively. None of these differences was statistically significant. Mean trough and peak concentrations of quinine were almost identical in the 2 groups, ranging from 10.5 to 12.6 mg/L, which is in the therapeutic non-toxic range. It is concluded that i.m. quinine is as effective as quinine by i.v. infusion in children with severe and complicated malaria; that minor local side effects can probably be avoided by using diluted quinine for i.m. injection; and that the optimal dose regimen for children with severe and complicated malaria in Africa at present is probably quinine salt 20 mg/kg followed by 10 mg/kg every 12 h.

[Liver transplantation associated with combined adjuvant treatment in hepatocellular carcinoma. Feasibility and preliminary results]

Combined adjuvant therapy was prospectively assessed in 7 patients receiving orthotopic liver transplantation for hepatocellular carcinoma complicating cirrhosis. The protocol included hepatic arterial chemotherapy while waiting for transplant, immediate preoperative liver irradiation, and early postoperative chemotherapy. There were no postoperative deaths, and morbidity included mainly hematologic toxicity of chemotherapy. Two patients died of tumor recurrence 6 and 14 months after transplant. The remaining 5 patients are alive and free of disease with a follow-up of 7 to 26 months. These results show the feasibility of aggressive adjuvant therapy in patients transplanted for hepatocellular carcinoma and suggest a possible effect of such a protocol on the prevention of tumor recurrence.

Polyadenylic-polyuridylic acid as an adjuvant in resectable colorectal carcinoma: a 6 1/2 year follow-up analysis of a multicentric double blind randomized trial

In a double blind study, patients with operable carcinoma of the colon and the upper rectum, who have undergone a macroscopically complete resection of their tumor, were randomized to receive either (i) polyadenylic-polyuridylic acid (AU), one i.v. injection of 60 mg (in 50 ml of solution) once a week for 6 weeks, or (ii) a placebo (P) one i.v. injection of 50 ml of a saline solution with the same schedule. From January 1983 to December 1986, 288 patients were enrolled: 145 in AU group and 143 in P group. The main clinical and pathological characteristics were equally distributed throughout the two groups. There was a significant difference (P < 0.02) in the overall survival (OS) between the two groups, in favor of the P group. The 5-year OS rate was 68% (SD = 4%) in the AU group versus 81% (SD = 3%) in the P group. Thus, AU as a single adjuvant, appears to be ineffective and therefore has no indication in the treatment of colorectal carcinoma.