Total parenteral nutrition at home: studies in patients surviving 4 months to 5 years

Total parenteral nutrition at home has been delivered to 12 patients surviving for periods ranging from 4 months to 5 years. The route used is a silicone rubber catheter introduced into the superior vena cava. The mean survival of uncomplicated catheters is 15.8 months, but in 4 patients it is in excess of 28 months. The delivery system is a simple pneumatic infusor set, portable and safe to use, and not requiring complicated electronics. All patients have maintained ideal body weight and have been socially rehabilitated, with two exceptions. Detailed metabolic studies are presented and the data include routine biochemical analyses, liver function tests, liver biopsy results, blood aminograms, the plasma phospholipid fatty acid pattern, the plasma lipoprotein pattern, and blood vitamin and trace element profiles. Based on these findings a nutrient program is recommended and discussed.

Nucleoprotein-coated latex particles in the serologic diagnosis of systemic lupus erythematosus. A comparative clinical and serologic study

A commercially available test for systemic lupus erythematosus employing nucleoprotein-coated latex particles has been evaluated both clinically and serologically. The sera from all 40 subjects with active SLE had positive latex tests, while all 28 sera from healthy adults had negative latex tests. False-positive latex tests were observed in five of 13 antinuclear factor-positive patients with other chronic inflammatory diseases. Specific DNAase and RNAase digestion of the latex particles suggested the false-positive results were due to DNA moieties, other than native DNA, coating the latex particles.

Surgical treatment of hydatid disease of the liver

Hydatid disease in southern Ontario is becoming more frequent because of infection in the large immigrant population. Review of 25 cases of hydatid disease of the liver has clarified the clinical features, diagnostic approach and methods of treatment. The commonest presenting symptoms were pain, mass or hepatomegaly, and jaundice. Diagnosis was confirmed, and cysts were localized, by Casoni skin testing, hepatic scanning and angiography. Surgical treatment consisted either of resection, excision or enucleation, and evacuation of the cyst. Two patients were treated by left lateral segmental resection, 6 by either wedge excision of the cyst or enucleation, and 14 by evacuation of cyst contents with or without drainage with the aid of a technique designed to prevent spillage of cyst contents at operation. None of the 14 treated by means of this technique developed recurrent disease, but in 4 of the patients treated by wedge excision or enucleation the cyst contents spilled at operation, resulting in recurrent disease in 2. Controlled cyst evacuation, with tube drainage for infected cavities and those communicating with the biliary tract is the recommended form of treatment in the management of hepatic hydatid disease.

Protein-sparing therapy in postoperative patients. Effects of added hypocaloric glucose or lipid

In patients receiving hypocaloric total parenteral nutrition, protein sparing with infusions of amino acids alone is alleged to occur because low insulin levels allow mobilization of endogenous fat. Four groups of patients studied for their first four postoperative days received all their nutrition parenterally as: 150 g per day of glucose, protein (as amino acids, 1 g per kilogram per day) alone, protein plus 50 g per day of soybean-oil emulsion or protein plus 150 g per day of glucose. All groups of patients receiving protein had lesser negative nitrogen balance than patients receiving glucose alone. The addition of glucose to protein did not increase negative nitrogen balance. The protein-sparing effect of amino acids appears to be a function of the infused amino acids alone and is not related to the degree of endogenous fat mobilization.

Liver scan in Budd-Chiari syndrome

Seventeen liver scans were performed in seven patients with occulsion of hepatic veins: the Budd-Chiari syndrome. When some, but not all liver veins were occluded, markedly diminished uptake over the affected segments was usually seen (absence of uptake may occur in acute infarction and in chronic cases). When all major liver veins are occluded, markedly diminished uptake is seen over the peripheral parts of the right and left lobes with a triangular midline area of normal or excessive activity. The latter effect is probably caused by uptake in segments surrounding the inferior vena cava (frequently the caudate lobe) that have direct venous drainage. This liver-scan appearance is characteristic enough to warrant consideration of the Budd-Chiari syndrome as the first diagnosis. Good correlation existed between selective venography and liver-scan findings. The usefulness of liver scans in the followup after portocaval shunting is illustrated in one patient.

Marlex mesh for repair of abdominal wall defects

The best synthetic material available for repair of abdominal wall defects associated with an insufficiency of tissue is Marlex mesh. Among 14 patients with large hernias and 3 who underwent tumour resection only 2 manifested recurrence of the defect. In three of these patients infection developed, but its control made it unnecessary to remove the Marlex. In another three with gross infection of the abdominal wall, Marlex was used successfully to provide abdominal wall closure.

Pathogenesis of cutaneous lesions in acute meningococcemia in humans: light, immunofluorescent, and electron microscopic studies of skin biopsy specimens

Biopsy specimens of the skin were taken from 10 patients with acute meningococcemia who exhibited mainly maculopurpuric lesions. The specimens were studied by light, electron, and immunofluorescent microscopy in an attempt to obtain information on the pathogenesis of vascular injury. Light microscopy disclosed a large number of Neisseria meningitidis organisms, both in the endothelial cells and being phagocytized by neutrophils. Vascular injury was characterized (by means of both light and electron microscopy) by endothelial necrosis, thrombosis, and necrosis of other elements of the vascular wall, such as muscle cells and pericytes. Immunoglobulins and complement were also found in the vascular wall in most cases. Hypercoagulability was demonstrated in some patients. These findings suggest that the cutaneous lesions of meningococcemia fulfill most of the gross and histologic criteria of the local Shwartzman reaction, but that immunological factors probably contribute to pathogenesis.

Canine small bowel transplantation. A study of the immunological responses

A canine small bowel allograft model was used to determine the effects of radiation to the graft in modifying the immunological effects of the passenger leukocytes. When untreated allografts were transplanted, death of the recipient animals occurred at a mean of nine days. The allograft was well-preserved and showed no signs of rejection. The reasons for attributing death to graft-versus-host (GVH) disease are discussed. When allografts were treated with 150 rads prior to transplantation, allograft rejection occurred, with death of the recipient animals at a mean of 9.2 days. This was the only group in which cell-mediated immunity developed. When allografts were treated with 50 rads, prolonged survival of the recipients to a mean of 28 days was noted. It is postulated that in this group a balance was struck between the allograft rejection reaction and GVH disease, with prolongation of allograft survival.

Immunostimulation with intraperitoneally administered bacille Calmette Guérin for advanced malignant tumors of the gastrointestinal tract

Thirty-five patients with advanced malignant tumors of the stomach, pancreas, biliary tract or colon were treated intraperitoneally with bacille Calmette Guérin and, subsequently, were given orally booster doses of bacille Calmette Guérin and one of two schedules of cytotoxic drugs. Patients with all types of tumors responded, but this was most marked in patients with metastases to the liver from primary carcinoma of the colon.

Oral bacille Calmette Guérin immunostimulation in malignant melanoma

Forty-seven patients representing all stages of malignant melanoma have been treated orally with bacille Calmette Guérin as an adjunct to standard treatment regimens. This is a preliminary study, but it appears that orally administered bacille Calmette Guérin in localized disease may delay the development of local recurrence and distant spread. In patients with disseminated melanoma but without intracranial metastases, the survival time is increased from 4.0 to 12.7 months. It has no effect on the progress of disease in patients with intracranial metastases or in those with hepatic metastases from intraocular melanoma.

The Warren (distal splenorenal) shunt for portal hypertension

The Warren distal splenorenal shunt, designed to decompress esophagogastric varices selectively while preserving portal venous inflow to the liver, was performed in 18 patients who had bled from esophageal varices. In 14 cirrhosis was micronodular, in 3 it was macronodular, and in 1 primary biliary. Two patients died within 1 month of surgery (operative mortality, 11%). Three patients died between 2 and 12 months after operation (1-year mortality, 28%). All five patients who died within 1 year had severe liver disease at the time of operation. None sustained further hemorrhage. Only one survivor requires protein restriction and none have fluid retention.

The immediate palatal plate

The immediate palatal plate is therapeutically beneficial for relief of temporomandibular joint pain, for reduction of occlusal trauma with and without selective grinding, for orthodontic tooth movement as a disarticulating device, and for relief of pericementitis subsequent to periodontal surgery. The immediate palatal plate is durable and well tolerated by patients and has established itself to be more than just an interim appliance.

Scintigraphy and arteriography in the diagnosis of diseases of the liver

Arteriograms and scans performed over a five-year period on 60 patients with suspect hepatic disease have been reviewed. The diagnosis was proved in every case by biopsy, autopsy or laparotomy. Scintigraphy correctly predicted the presence or absence of disease in 75% and arteriography in 75% of cases. Fifty-four of the patients had hepatic disease. In 81% of these the accurate diagnosis of diffuse or localized disease was made by one or both techniques. Arteriography is preferred for the detection of localized lesions, but diffuse processes are more readily demonstrated by scintigraphy.