Surgical aspects of systemic necrotizing vasculitis

Thirty patients with systemic necrotizing vasculitis (SNV) of the polyarteritis nodosa type were reviewed. Eleven patients (36%) had only gastrointestinal manifestations of the disease. Four patients (13%) had only pulmonary involvement. Seven patients (23%) had both gastrointestinal and pulmonary manifestations of SNV. With use of an approved protocol from the National Institute of Allergy and Infectious Diseases of cyclophosphamide and prednisone, remission was attained in 29 of 30 patients (96%). However, 18 patients (60%) underwent major surgical procedures for either diagnosis or complications of the disease. Six patients underwent eight thoracotomies; six operations were required for diagnosis and two for drainage of right-sided empyemas. Ten patients underwent 14 exploratory laparotomies. Six abdominal explorations were performed for diagnostic purposes, and eight were required for treatment of complications. Two patients required digital amputations because of ischemic necrosis. Two patients (11%) developed five postoperative complications, one of whom subsequently died. Arteriographic studies were performed in 16 patients (53%). Vascular abnormalities consistent with those described for SNV were demonstrated in six cases (38%). There was no correlation of clinical manifestations, subsequent therapy, and arteriographic findings with regard to the development of intra-abdominal complications. Pulmonary complications occurred only in patients who had pulmonary infiltrates secondary to SNV.

Pharmacokinetics of doxorubicin in isolated lung of dogs and humans perfused in vivo

The pharmacokinetics of doxorubicin was investigated in the lungs of dogs and three pulmonary cancer patients perfused in situ. In the dogs, doxorubicin uptake increased with time but was saturable at perfusate concentrations above 20 nmol/ml. After 50 min, tissue levels were consistently higher than blood perfusate levels. The kinetics of doxorubicin uptake were well described by a simple diffusion model. Changes in the estimated kinetic model parameters suggested that the saturation of doxorubicin accumulation at higher concentrations was due to a decrease in the relative rate of uptake rather than a change in the rate of efflux. In the three human patients studied, doxorubicin accumulation in the perfused lung was considerably slower compared to dog lung, and the level of drug measured in human lung tumor biopsies was consistently less than surrounding tissue. The present study has shown that lung perfusion is technically feasible and may represent a means of delivering cytotoxic drugs to unresectable pulmonary tumors in humans.

Venous access: a prospective, randomized study of the Hickman catheter

This prospective, randomized study evaluated the risks associated with the Hickman catheter (HC) by a comparison of rates of placement and use complication, infection, treatment failure, and thrombogenicity with a group of patients with polyvinylchloride central venous catheters (CVC). Complications were studied prospectively. The patient populations of the two groups were similar and most patients were entered in the study because of prior venoablation. No significant difference in complication rates was noted for catheter placement complications, infection, or treatment failures. No catheter-related deaths occurred. Seven CVCs were exchanged for malfunction and one HC fractured and required repair. Venography was performed in seven patients in each group when the catheter was removed. The incidence of fibrin sheath formation was significantly increased in the HC group (P less than 0.05). One venous thrombosis was identified in a patient with a CVC. A separate group of patients with HCs who were not placed in the randomized study was followed. This group had a significantly higher incidence of septic complications than did the study group (P less than 0.005). We conclude that the HC is as safe as is the CVC when the conditions of placement and maintenance are rigorously controlled.

Analysis of prognostic factors in patients undergoing resection of pulmonary metastases from soft tissue sarcomas

The selection of objective criteria that can reliably predict survival in patients undergoing resection of pulmonary metastases remains controversial. Between 1974 and 1982, 487 patients with soft tissue sarcomas presented to the National Cancer Institute. Eighty patients underwent thoracotomy for putative metastases and 67 patients had histologically proved pulmonary metastases. The 3 year tumor-free survival rate was 30% by actuarial analysis. Patients with resectable metastases had significantly prolonged post-thoracotomy survival compared to those patients with unresectable metastases. The most significant preoperative predictors of survival were the tumor doubling time, the number of metastases on preoperative linear chest tomograms, and the disease-free interval. Patients with a tumor doubling time of 20 days or more had a significantly longer post-thoracotomy survival (22 months median) than patients with a tumor doubling time of less than 20 days (6 months median). Those patients with four nodules or less on preoperative tomograms had significantly longer post-thoracotomy survival times (23 months median) than those patients with more than four nodules (6 months median). Patients with a disease-free interval of more than 12 months had a longer post-thoracotomy survival (32 months median) than patients with a disease-free interval of 12 months or less (10 months median). Combining these three prognostic factors significantly increased the predictive ability of this model. These criteria provide an accurate and rapid method to identify preoperatively those patients who will maximally benefit from resection of pulmonary metastases from soft tissue sarcomas.

Monoclonal antibodies distinguish phase variants of Coxiella burnetii

Monoclonal antibodies (MAbs) directed against phase I and II variants of Coxiella burnetii were produced by fusing myeloma SP2/O-AG 14 cells with spleen cells from mice immunized with the chloroform-methanol extraction residue of phase I whole cells. Two hybridoma clones which distinguished the phase variants by microimmunofluorescence assay were isolated and characterized. The MAbs showing specificity for phase I cells (MAbI-1, immunoglobulin G, subclass 3 kappa) reacted with the hot phenol-water extract of phase I C. burnetii in immunodiffusion and enzyme-linked immunosorbent assays. MAbI-1 reacted with high-molecular-weight components from phase I phenol-water extract and whole cell in an immunoblot assay. Specificity of MAbI-1 for a carbohydrate epitope in the phenol-water extract was demonstrated by periodic acid inactivation of binding by a competitive enzyme-linked immunosorbent assay. Phase I antigenic sites were apparently well represented on the surface of cells as demonstrated by complete fluorescence and microagglutination. The MAb showing specificity for phase II cells (MAbII-1, immunoglobulin G, subclass 2b kappa) reacted with whole cells in the microimmunofluorescence assay, microagglutination test, complement fixation test, and the enzyme-linked immunosorbent assay. MAbII-1 reacted specifically with a 29,500-dalton surface protein as demonstrated by immunoprecipitation of 125I-surface-labeled cells. Although MAbII-1 reacted with detergent-solubilized protein, it did not react with sodium-dodecyl sulfate-denatured protein by immunoblot assay. This protein was not exposed on the surface of phase I cells, but chloroform-methanol extraction of phase I cells exposed the phase II epitope.

Survival following aggressive resection of pulmonary metastases from osteogenic sarcoma: analysis of prognostic factors

Between 1975 and 1982, 80 patients with osteogenic sarcoma were entered into prospective trials in the Surgery Branch of the National Cancer Institute. In 43 of these patients, pulmonary metastases developed as the initial site of recurrence, and 39 underwent one or more thoracotomies for resection of the disease. The actuarial five-year survival for the group of 43 patients with pulmonary metastases was 40%. Various prognostic factors were analyzed for their influence on survival after thoracotomy. Age, sex, location of primary tumor, tumor doubling time, and involvement of one or both lungs (bilaterality) were not significant in predicting survival. Prognostic factors that influenced survival, calculated by regression analysis, included the number of nodules on preoperative lung tomograms (negative correlation, p = 0.0004), disease-free interval (positive correlation, p = 0.0136), resectability (positive correlation, p = 0.002), and the number of metastases resected at thoracotomy (negative correlation, p = 0.0032). The presence of 3 nodules or less on preoperative full-lung linear tomography was found to be the single most useful preoperative prognostic factor. The application of these prognostic factors preoperatively may identify patients who will benefit optimally from thoracotomy.

Isolated lung perfusion with Adriamycin. A preclinical study

Isolated in vivo single-lung perfusion with an Adriamycin-containing whole-blood perfusate was performed in three groups of dogs after establishing adequate controls. The procedure, performed through a left thoracotomy, was followed two weeks later by a contralateral pneumonectomy. Survival following pneumonectomy was used as the ultimate end point in assessing perfusion toxicity. Groups I and II had high mortality rates but provided valuable information concerning perfusion methods, venous drainage techniques, drug dosage schedules, and perfusate flow rates. The group III study consisted of five dogs perfused for 45 minutes at flow rates sufficient to maintain mean pulmonary artery pressure at 12-15 mm Hg. An initial Adriamycin (Adr) dosage of 0.5 micrograms/ml in the plasma perfusate resulted in mean peak Adr lung tissue levels of 3.8 +/- 1.06 micrograms/g. All animals survived right pneumonectomy 19 +/- 4 days later. Three dogs have been killed and histologic examination showed only mild focal pleural and subpleural interstitial fibrosis. Based on these studies it is concluded that isolated single-lung perfusion is a reproducibly safe technique and that a dosage of Adr has been identified which produces no apparent toxity in a large animal model. A clinical trial is currently in progress.

Middle lobe syndrome

A review of the major literature dealing with the middle lobe syndrome shows that benign inflammatory disease is the most common etiological factor (62%), with bronchiectasis responsible for at least a quarter of the patients in these series. Early workers indicated that carcinoma rarely originates in the right middle lobe; however, 22% of patients reviewed had malignant tumors as a cause of the syndrome. The original view that bronchial compression was the pathophysiological abnormality leading to development of the syndrome has been rejected by more recent authors. The focus has now turned to the relative isolation of the middle lobe, especially when a complete minor fissure is present. This isolation prevents the aerating effects of collateral ventilation of the upper lobe from reaching the middle lobe and thus impairs the clearing of secretions from the middle lobe bronchus. Bronchoscopy and bronchography are vital in the rational approach to this syndrome. Severe stenosis of the bronchus or tumor can be seen endoscopically in about 40% of patients, and bronchography will demonstrate an anatomical abnormality more than 70% of the time. Both the surgical and the medical approaches to therapy have been endorsed strongly by various authors in the 30 years since the syndrome was described. It now appears that bronchoscopy and, if need be, bronchography should be undertaken to rule out an endobronchial lesion. Timing of these studies will depend on the patient's age, with early examination advocated for the older patient at high risk for lung cancer. If there is reasonable evidence that the process is benign, medical management should be attempted. Lobectomy is performed if malignancy is suspected or if medical therapy fails.

Biological properties of rabbit antibodies to a surface antigen of Rickettsia rickettsii

Because of the potential significance of external components of the obligate intracellular parasite Rickettsia rickettsii in host-parasite interactions, we have begun the first phase of a study to isolate and characterize surface antigens of this organism. An antiserum to a rickettsial surface component was obtained from rabbits inoculated with immune precipitates prepared by crossed immunoelectrophoresis of Triton X-100 extracts of R. rickettsii strain R. This antiserum (i) protected guinea pigs inoculated with 10,000 guinea pig 50% infectious doses of R. rickettsii against fever, (ii) prevented death of mice challenged with 2 50% lethal doses of R. rickettsii, and (iii) reacted in the microimmunofluorescence test with 9 of 13 spotted fever group serotypes tested. The location of this antigen on the rickettsial surface was demonstrated by immunoelectron microscopy with ferritin-labeled antibodies.

Median sternotomy for resection of pulmonary metastases

Thoracic surgeons have been reluctant to adopt the median sternotomy as a suitable approach to pulmonary operations. However, its lesser functional morbidity and the capability to assess both lungs are advantageous in selected patients. Examined herein is a concentrated experience with 53 median sternotomies in 46 patients for the resection of pulmonary metastases. Forty of the 46 patients had soft tissue or osteogenic sarcoma. Full-lung tomograms diagnosed but did not accurately reflect the extent of disease. Fifty-three percent more tumor nodules were found at median sternotomy than were seen on full-lung tomography. Eleven of 18 patients (61%) thought to have unilateral disease by full-lung tomography had bilateral metastases found at median sternotomy. Most median sternotomies involved wedge resections (mean 8.9 range one to 52). Two segmentectomies, six lobectomies, and one pneumonectomy were also performed. Repeat median sternotomy was accomplished seven times; one patient underwent four median sternotomies. Sixty-six percent of the nodules removed proved to be tumor. Complications included one reoperation for bleeding; three patients had air leaks for more than 1 week, including one bronchopleural fistula; four required respirator assistance for more than 3 days; and there were four major infections. There was no operative mortality. Because of its low morbidity, the high incidence of unsuspected bilateral disease, and the elimination of a second operative procedure, median sternotomy is the approach of choice for the surgical treatment of pulmonary metastases.

Thoracic mass lesions in immuno-incompetent patients

An aggressive surgical approach was used in the diagnosis and treatment of seven immuno-incompetent patients who presented with focal thoracic mass lesions. In five of the seven patients, minor diagnostic procedures had failed to provide a diagnosis. All seven patients were subjected to exploratory thoracotomy with resection and/or drainage of the involved area. Two patients had parenchymal masses, two had lung abscesses, two had empyemas with trapped lung, and one had a bronchial fistula. An accurate diagnosis and full resolution of the intrathoracic process was obtained in all patients. There was little morbidity and no operative mortality in this series. Resection of focal thoracic lesions in immuno-incompetent patients combines accurate diagnosis with precise therapy and is well tolerated in this high risk group of patients.

Interstitial pulmonary infiltrate following combined therapy for esophageal carcinoma

Seven patients with squamous cell carcinoma of the esophagus received radiation therapy in twice weekly 400 rad fractions over five weeks followed by esophagectomy. Four of these patients developed severe interstitial pulmonary infiltrates and died of pulmonary insufficiency 18-50 days after surgery. In three of these patients the infiltrates were detected within 24 hours of surgery while the infiltrate was not present until the eighth postoperative day in the fourth patient. Postmortem examination revealed widespread dilatation of interstitial and subpleural lymphatics. It is postulated that the combination of large fraction radiation therapy followed by extensive surgery resulted in lymphatic obstruction.

Percutaneous subclavian vein placement of the Hickman catheter

Vascular access by means of a permanently implanted cuffed silicone rubber catheter has become increasingly popular in the management of cancer patients. A method is described for the percutaneous placement of this catheter using a modified Seldinger technique. The catheter was successfully placed in 14 of 15 consecutive cancer patients using this method. The morbidity rates were low, and no deaths occurred because of the procedure. This technique allows rapid, accurate placement of the Hickman catheter in patients whose peripheral venous access sites have been exhausted.

Successful treatment of an esophageal stricture in a chimpanzee

An esophageal stricture was noted in a 10-yr-old chimpanzee who presented with dysphagia, vomiting, and weight loss. After radiographic, esophagoscopic, and histopathologic evaluation of the stricture, antegrade bougienage was performed. The animal began eating solid food again without regurgitating after the third dilation and since that time has been asymptomatic. Additional dilations were performed at 3 and 6 months post-stricture.

Comparison of effects of prostaglandin E1 and nitroprusside on pulmonary vascular resistance in children after open-heart surgery

Prostaglandin E1 (PGE1) is a vasodilator. Because the drug is metabolized by lung, we postulated a selective effect on pulmonary vasculature. Twenty-six patients aged 3 months to 16 year (mean, 6.5 years) were studied after repair of atrial septal defect (5), ventricular septal defect (10), tetralogy of Fallot (3), and other lesions (8). Fourteen patients also received nitroprusside. PGE1 (0.1 to 1.0 micrograms/kg/min) or nitroprusside (0.59 to 8.7 micrograms/kg/min) was infused through a central venous catheter until mean pulmonary or mean systemic arteria pressure decreases at least 10%. Prostaglandin E1 and nitroprusside both decreased mean systemic arterial pressure and systemic vascular resistance (P less than 0.05). Although both drugs caused an average decrease in pulmonary arterial pressure and resistance, nitroprusside produced a more consistent response. Side-effects limited the use of PGE1 in 5 patients. PGE1 is an effective vasodilator and has advantages for some patients, but it does not produce selective vasodilation of pulmonary vessels.

pH Determination in acidified foods: collaborative study

A proposed method for determining pH of acidified foods has been developed and subjected to collaborative study. The method appears to be both accurate and precise. Five samples consisting of pimientos, marinated pimientos, 2 pH buffer solutions, and chocolate syrup were sent to each of 12 collaborators along with a copy of the method. Two of the collaborators were FDA District laboratories while the remainder were representatives from industry, universities, and state health agencies. Many different types of pH meters and combinations of electrodes were used by the collaborators. The tabulated results from the collaborators are presented. The method has been adopted official first action.

External stent for repair of secondary tracheomalacia

Tracheomalacia was created in anesthetized piglets by submucosal resection of 3 to 5 tracheal cartilages. Measurements of airway pressure and flow showed that expiratory airway resistance is maximal at low lung volumes and is significantly increased by creation of the malacic segment. Cervical flexion increases expiratory airway resistance, whereas hyperextension of the neck reduces resistance toward normal. External stenting of the malacic segment reduces expiratory airway resistance, and the combination of external stenting and hyperextension restores airway resistance to normal except at low lung volume. Two patients with secondary tracheomalacia required tracheostomy and could not be decannulated after the indication for the tracheostomy was corrected. Both were successfully decannulated after external stenting of the malacic segment with rib grafts. Postoperative measurements of expiratory pulmonary resistance show a marked decrease from preoperative measurements. External stenting of symptomatic tracheomalacia reduces expiratory airway resistance by supporting and stretching the malacic segment and is preferable to prolonged internal stenting or tracheal resection.

The biology of Haemogregarina bigemina Laveran & Mesnil, a parasite of the marine fish Blennius pholis Linnaeus

Haemogregarina bigemina was found in all Blennius pholis which exceeded 5.0 cm in length, but in none measuring less than 3.5 cm. No exoerythrocytic development was recorded. The first B. pholis eggs hatched in May while the first patent infections of H. bigemina occurred from September onward in metamorphosed fish. Consequently, if the life cycle of H. bigemina includes a vector, that organism is active between May and September at least. Circumstantial evidence indicates that the hematophagous isopod, Gnathia maxillaris and not leeches, could be a vector of H. bigernina. Developmental stages of sporozoa were found in a small number of the isopods which had fed on infected B. pholis but the parasites could not be identified as H. bigemina with certainty. Subcellular organization, typical of sporozoa, was recorded by electron microscopy of H. bigemina.

The ultrastructure of a haemogregarine parasitic in Gehyra variegata (Duméril & Bibron, 1836)

The ultrastructure of the intra-erythrocytic stage of a haemogregarine in the gecko, Gehyra variegata, has been studied and numerous points of similarity to Plasmodium, Toxoplasma, Sarcocystis, Lankesterella, Eimeria and the M-organism were found. The protozoon was invested by a triple-layered pellicle, and possessed at least two micropyles. A conoid and apical rings were observed at the anterior end. Other cell constituents included nucleus, microtubules, endoplasmic reticulum, mitochondria, toxonemes and a variety of vacuoles. Loosely surrounding the parasite was an unusual convoluted membrane, which in appropriate planes of section, displayed corrugations on both surfaces. It was not clear whether this membranous structure should be regarded as an integral part of the protozoon or as an external coat which could be discarded upon emergence from the host red cell. Within its external sheath, the parasite lay in a periparasitic vacuole which was limited by a conventional unit membrane from the host red cell cytoplasm. The parasite did not exhibit any evidence of pinocytosis or phagocytosis.

Our sincere thanks are due to Dr E. H. Mercer, Professor J. D. Smyth and Dr M. J. Mackerras for advice. Miss N. Carroll gave technical assistance.

The control of Simulium damnosum at Abuja, Northern Nigeria, 1955-60

This paper gives a comprehensive account of the first six years of operation of an onchocerciasis control pilot project in an area of over 3000 km(2) in the Abuja Emirate, Northern Nigeria. Control was attempted by the use of DDT against the larvae of the vector, Simulium damnosum. For the first two years technical DDT in diesel oil was applied. Later, this insecticide was used in miscible liquid form; this formulation gave as good results as the technical DDT and was easier to handle and apply.The authors conclude that, by the methods and in the conditions described, 90% control (although not eradication) of S. damnosum can be achieved by the addition of DDT to river water and that the best results are obtained by application in the early wet season, from May to July.Although the cost of the operations was relatively high, it is thought that the concentration of DDT actually used could be lowered with no loss in efficacy and that this, together with some reduction in the number of treatment-points, might reduce costs to a level that could be met by a local administration.