Pancreatoduodenectomy: a complicated solution

1. Pancreatoduodenectomy is an effective operative procedure for benign large tumors and cancers of the pancreas and periampullary sites and extensive trauma to these areas. 2. Pancreatoduodenectomy may be performed in two stages: total excision of pancreas, subtotal excision, and pyloric exclusion procedures. 3. Carcinoma of the proximal pancreas is a serious medicosurgical problem, and radical pancreatoduodenectomy is the most effective form of therapy. 4. Pancreatoduodenectomy is a major operative procedure with serious intraoperative and postoperative complications that are directly related to the experience of the surgeon.

Transport, interactions and retention of plasma proteins in the intima: the barrier function of the internal elastic lamina

This paper presents a brief overview of our current understanding of the relation between plasma macromolecules and atherogenesis. Plasma proteins enter normal intima by vesicular transport across normal endothelium, and convective transport within the intima; accumulation depends mainly on molecular size and the molecular sieve properties of the internal elastic lamina. Within the intima the proteins may be modified; particularly striking changes occur in high density lipoprotein (HDL) and in fibrinogen. Fibrinogen appears to be converted to fibrin which is then lysed, providing a continuing source of fibrin degradation products (FDP). Fibrin also seems to be associated with a tightly bound, plasmin-releasable apo-B-containing lipoprotein; work in progress suggests that much of this fraction is accounted for by lipoprotein(a).

Patient personal injury litigation against dermatology residency programs in the United States, 1964-1988. Implications for future risk-management programs in dermatology and dermatologic surgery

A national survey reviewing patient injury litigation against US dermatology residency programs revealed that 50% of the respondents had experienced at least one lawsuit between 1964 and 1988. The northeast region reported the most legal activity. Fifty percent of the lawsuits related to therapeutic or surgical complications. Plaintiffs were successful in 37.9% of the lawsuits. The mean award was $26,505, and the largest reported award of $200,000 was for failing to diagnose herpes simplex in an immunocompromised patient. In view of several recent trends in dermatology, the amount of litigation against dermatologists may increase.

Fate of fibrinogen in human arterial intima

Fibrinogen and fibrinogen/fibrin-related antigen (total FRA) was measured in human normal intima and different types of atherosclerotic lesions and mural thrombi. The amount showed marked variation between groups of tissue samples, but within each group there was a significant correlation between levels of total FRA and low density lipoprotein (LDL), suggesting that some common factor must influence their influx or retention. The total FRA were analyzed by gradient sodium dodecyl sulfate polyacrylamide gel electrophoresis and immunoblotting with antisera to whole fibrinogen and fragments D and E, and fibrinopeptide A (FPA). All intimal samples (but not thrombi) contained fragment X, the first product of plasmin digestion of fibrinogen, but fragment Y was present in only half the samples, and no core-fragment E containing FPA was detected in any sample, suggesting that fibrinogenolysis is limited. By contrast, all samples contained fragment E, which was negative for FPA, so presumably derived from fibrin; they also contained fragments D-dimer and DY, which are characteristic degradation products of cross-linked fibrin. There were no differences between samples obtained during reconstructive vascular surgery and samples obtained at autopsy, so the patterns appear to represent the steady state. This implies that within the intima there is continuous formation of cross-linked fibrin and continuous fibrinolysis, both processes generating fragments that may have atherogenic properties.

Integration of formulary systems with centralized pharmaceutical procurement

The integration of formularies with pharmaceutical group purchasing and supply systems for multiple hospitals and ambulatory health centers in the Indian Health Service of the US Public Health Service is described. Two models by which these systems have been integrated are presented. The approach of one group of facilities for maintaining high-quality therapeutics in a cost-effective manner was to maintain separate P & T Committees and formularies for each facility, with one centralized drug procurement center. The other group developed a central P & T Committee and formulary to serve all area facilities, as well as continued to maintain a separate P & T Committee at each facility that could act between meetings of the central committee. These models of centralized procurement have provided both decreased drug costs and increased information on drug use within the multifacility systems. In both models, staff have reached consensus on drugs that will provide quality therapeutics in a cost-conscious environment.

Primary cancer of the lung in women

Analyses of the St. Francis Medical Center Cancer Registry for a 30-year period corroborated the publicized information of a gradual increase in the incidence of lung cancer in women and a recent decrease in the incidence among men. Our objectives were to highlight the biological and clinical features of lung cancer in women with the adoption and utilization of primary and secondary preventive measures.

Gastric cancer: views and overviews

During the periods 1960 to 1975 and 1976 to 1986, all primary cancers of the stomach at the St. Francis Medical Center were analyzed according to patient age, ethnic origin, sex, environmental and occupational hazards, diet, smoking and alcoholic intake habits, family history of cancer, signs and symptoms, diagnostic procedures, medicosurgical management, surgical cancer staging, surgical procedures, follow-up, and survival. These data are presented and reasons for the decline in the incidence of gastric malignancies in the US are discussed in relation to the increase reported here.

Repigmentation of vitiliginous skin by cultured cells

Epidermal cells from pigmented areas of a patient with vitiligo were cultured in MCDB-153 medium, which supports the clonal growth of undifferentiated keratinocytes and melanocytes. The cells were grown on collagen-coated substrata. After the cells reached semiconfluence, the composite of substratum and cells was emplaced onto dermabraded vitiliginous areas as a graft. Re-epithelialization of the grafted areas was complete after 2 weeks. Repigmentation was evident after 1 month and continued over the observation period of several months. There was complete and normal differentiation of the graft, including a normal distribution of melanocytes in the basal layer. Ultrastructural studies showed a normal distribution of melanosomes in the melanocytes and showed keratinocytes that were indistinguishable from the uninvolved skin.

An evaluation of the structure-activity relationships of a series of analogues of mephenesin and strychnine on the response to pressure in mice

1. A range of compounds structurally related to the centrally acting muscle relaxant mephenesin and to the chemical convulsant strychnine were synthesized and tested for their ability to alter the threshold pressures for the onset of high pressure convulsions in mice. 2. The ability of both groups of compounds to alter the threshold pressure for convulsions was found to be dependent on the nature of a simple molecular skeleton. Thus, compounds that possessed a negatively polarized group located both in the same plane as and some 4.5 A from an aromatic nucleus increased the thresholds whereas compounds with a positively polarized group at the same location reduced the thresholds. 3. These findings support the suggestion that pressure elicits convulsions via a selection action on a receptor protein complex rather than via some general perturbation of the lipid regions of cellular membranes.

Platinum-based combination chemotherapy for malignant mixed mesodermal tumors of the ovary

Although considerable clinical data are available to guide treatment decisions for patients with ovarian epithelial malignancies, therapy for the rare malignant mixed mesodermal (mullerian) tumor (MMMT) of the ovary is poorly studied. Ten untreated patients diagnosed with primary ovarian MMMT were managed with cis-platinum-based combination chemotherapy from 1980 to 1985. Six of the 10 patients were stage III suboptimal with evaluable residual disease; 4 of these 6 had CRs with a median duration of response of 13 months. The remaining 2 patients had PRs, of 2 and 11 months duration. Four patients had stage III optimal disease; 1 progressed at 7 months, 1 progressed at 16 months and the other 2 patients have no clinical evidence of disease at 12+ and 22+ months. Despite impressive initial response rates, survival overall was poor, with a median survival for all 10 patients of 16+ months.

Effect of investigator bias on clinical trials

Two clinical trials were performed to determine the relative efficacy of tioconazole, a new antifungal agent for treating patients with tinea pedis. One study compared the new agent with a placebo cream and the other with miconazole nitrate, an established effective antifungal agent. The investigators found a much higher "cure" rate for tioconazole when both treatment groups were known to receive active agents than the cure rate for tioconazole found in the placebo-controlled study. These results showed that the expectations of investigators can influence their clinical evaluations. Such bias could also influence the results of clinical trials.

Primary cancer of the pancreas: a surgical enigma

Pancreatic cancer is a frequent gastrointestinal malignancy with demonstrable increases in blacks. Predisposing factors are nonspecific but statistically relevant. Early signs and symptoms are vague and the duration prior to medical or surgical evaluation is typically more than four months. The overt clinical picture represents advanced stages of pancreatic cancer that are nonresectable. Positive results or prolonged survivals in excess of five years for curative surgical procedures are meager. The best approaches toward cancer of the pancreas are improvements in education, prevention, early diagnosis, palliative surgical procedures with adjuvant medical measures, and radical surgery in selective cases and under specific circumstances.

Effect of benzazole-related centrally acting muscle relaxants on HPNS

A series of benzazole-related, centrally acting muscle relaxants, comprising benzimidazole, chlorzoxazone, and zoxazolamine, were found to give substantial protection against the tremors and convulsions associated with the high pressure neurologic syndrome (HPNS) in the mouse. In this respect they represent a new class of nonanesthetic, anti-HPNS agents. Their anti-HPNS properties, like those previously established for the mephenesin group of centrally acting muscle relaxants, seem to be related to their ability to antagonize the convulsive action of strychnine. These findings are consistent with the suggestion that one of the principal effects of pressure, expressed as HPNS, arises from a perturbation of strychnine-sensitive mechanisms.

Investigations into the origin of the high pressure neurological syndrome: the interaction between pressure, strychnine and 1,2-propandiols in the mouse

1. The effects of a variety of structural isomers of the centrally acting muscle relaxant mephenesin on the high pressure neurological syndrome have been investigated. Threshold pressures for the onset of the behavioural signs, tremors and convulsions, were established. The effects of these compounds on the response to pressure were also compared with their ability to antagonize the convulsive action of strychnine. 2. The dose-response relationships for strychnine and picrotoxin were investigated at fixed pressures. Additionally, the dose-response relationship of strychnine, in the presence of mephenesin, at pressure was investigated. 3. All the isomers of mephenesin protected against the effects of both pressure and strychnine. The relative potency was found to be identical with respect to both. Mephenesin was clearly the most effective; it raised the threshold pressure for tremors by 2.5 times, that for convulsions elicited by pressure by 1.5 and the ED50 for strychnine convulsions by 1.6 times. Strychnine was found to be strictly additive with pressure whereas picrotoxin exhibited gross deviations from additivity. Mephenesin ameliorated the combined effects of pressure and strychnine equally. 4. The marked dependence on structure of the anticonvulsant activity of the mephenesin isomers can be interpreted as evidence that pressure acts not by some general perturbation of the membranes of excitable cells but rather via some specific interaction. The finding that strychnine and pressure are strictly additive supports the idea of specificity and also indicates that they may share a common mechanism in the production of convulsions. By analogy with the established mechanism of action of strychnine, it is suggested that the hyperexcitability associated with pressure might arise from an action on glycine-mediated inhibitory processes.

Rabbit model of disseminated syphilis: immunoblot and immunohistologic evidence for a role of specific immune complexes in lesion pathogenesis

Circulating immune complexes (CIC) containing Treponema pallidum proteins have been preliminarily implicated as inducers of a neutrophilic vascular reaction in early human cutaneous lesions of secondary syphilis. To clarify the role of specific CIC in producing cutaneous and renal lesions, 12 rabbits were studied at the following intervals after induction of disseminated syphilis: 20 days (4 rabbits: biopsies of normal and lesional skin for direct immunofluorescence (IMF) for (IgG, IgM, IgA, Clq, C3, C4), fibrin, and T. pallidum proteins; routine histology; and immunoblots of serum for CIC containing T. pallidum proteins); 21 days (4 rabbits: as at 20 days without IMF for T. pallidum protein); 23 days (4 rabbits: as at 20 days without IMF); 30 days (same 12 rabbits restudied with routine histology of normal and lesional skin; kidneys from 4 rabbits removed for routine, IMF, and electron microscopy (EM). Treponemal polypeptide antigen (MW-87 kd) was demonstrated in CIC from rabbits. Routine cutaneous histology showed evolution of lesions from an early neutrophilic vascular reaction to the typical lymphoplasmacytic reaction. IMF showed vessel-based immunoreactants in 3 of the 4 rabbits tested at 20 days and 1 of 4 at 21 days, and T. pallidum proteins in 3 of 4 rabbits at 20 days. Routine histology, IMF, and EM studies of glomeruli showed glomerular abnormalities, but no evidence of immune deposits containing specific T. pallidum protein. Skin and kidney studies of 4 controls were all negative. These data indicate a role for specific immune complexes in the pathogenesis of cutaneous lesions in this rabbit model.

Lafora's disease. The role of skin biopsy

Lafora's disease is a neurometabolic disease characterized by progressive myoclonus epilepsy. It is thought to be transmitted by autosomal recessive inheritance. The diagnosis of Lafora's disease is based on both clinical symptomatology and histologic detection of intracytoplasmic periodic acid-Schiff-positive inclusions, termed Lafora bodies. Despite the absence of cutaneous clinical findings, typical inclusions are present in eccrine duct cells and peripheral nerve of skin biopsies. By electron microscopy, the inclusions are electron-lucent and contain glycogenlike granules and filamentous material. Skin biopsy is a convenient and the least invasive method of establishing the diagnosis of Lafora's disease.

The screening Papanicolaou smear: contribution of the endocervical brush

Between September 1984 and February 1985, cervical cytologic smears were collected from 510 patients using a spatula and an endocervical swab. These smears were compared with those collected from 510 patients between September 1985 and February 1986 using a spatula and an endocervical brush. The use of the endocervical brush increased the number of smears that contained endocervical cells, for both reproductive-age and postmenopausal women. In women without previous radiation therapy, the rate of suboptimal smears (those without endocervical cells) fell from 12.0 to 1.7% when the endocervical brush was used. This modified smear collection technique improved the quality of the cytologic material.

Direct selection of a specifically blocked mutant of Actinomadura brunnea. Isolation of a third 8-methoxy substituted chlortetracycline

Actinomadura brunnea produces 2'-N-methyl-8-methoxychlortetracycline. A derivative of this strain has been isolated that is specifically blocked in methylation of the 2'-amino position. This isolate was detected by screening approximately 30,000 colonies of a mutagenized population of Actinomadura brunnea using a direct soft agar overlay with an Escherichia coli indicator. The antibiotic produced by the blocked mutant has been identified as 8-methoxychlortetracycline (Sch 36969) based upon its biological activity, relative mobility on TLC and HPLC, and spectroscopic data.