Liver Metastases from Gastric Carcinoma: Report of a Patient Treated with Adoptive Immunotherapy (Tumor-Infiltrating Lymphocytes plus Interleukin-2 and Subsequently Local-Regional Lymphokine-Activated Killer Cells plus inTerleukin-2)

A 37-year-old patient with liver metastases from gastric cancer was treated with a double adoptive immunotherapy regimen comprising tumor-infiltrating lymphocytes plus interleukin-2 and subsequently local-regional lymphokine-activated killer cells plus interleukin-2 because of an extremely high in vitro cytotoxic specific activity on established gastric cancer cell lines. The necrosis verified in the center of the hepatic metastasis would appear to demonstrate treatment efficacy, but no clinical response was seen. In vitro cytotoxicity data alone are insufficient to predict the clinical efficacy of adoptive immunotherapy.

Managing latent tuberculosis infection and tuberculosis in children

Tuberculosis (TB) is a major cause of childhood morbidity and mortality worldwide. The aim of this review is to describe the management of the child with TB and latent tuberculosis infection (LTBI). To develop this article, a working group reviewed relevant epidemiological and other scientific studies and established practices in conducting LBTI and TB in children. The article describes how to manage the child with LTBI, considering transmission and infectiousness of tuberculosis, contact screening and prioritization of contacts and recommendations on treatment of children with LTBI and how to manage the child with TB considering the susceptibility of children to developing tuberculosis, epidemiology and classification of tuberculosis in children, diagnosis and treatment.

Tuberculosis diagnostic delay and therapy outcomes of non-national migrants in Tel Aviv, 1998-2008

Non-national migrants have limited access to medical therapy. This study compares diagnostic delay and treatment outcomes of non-insured non-national migrants (NINNM) with insured Israeli citizens (IC) in the Tel Aviv tuberculosis (TB) clinic between 1998 and 2008. Patient delay was the time from symptoms onset to doctor's visit, while system delay was measured from doctor visit to anti-TB therapy administration. We randomly sampled 222 NINNM and 265 IC. NINNM were younger than IC, had lower male to female ratio and fewer smoked. They had less drug/alcohol abuse, more cavitations on chest radiography, longer patient and shorter system delay. Mean patient and system delays of all patients were 25 ± 14 and 79 ± 42 days, respectively. In multivariate analysis, being NINNM, asymptomatic or smoking predicted longer patient delay, while being asymptomatic or having additional co-morbidity predicted longer system delay. Treatment success in sputum smear-positive pulmonary TB NINNM was 81% and 95.7% in IC (p=0.01). Treatment success was not associated with patient or system delay. In multivariate analysis, work security and treatment adherence predicted treatment success. NINNM had longer patient delay and worse therapy outcome, while IC had longer system delay. Both delays should be reduced. NINNM should be informed that TB therapy is free and unlinked with deportation.

A shifty diagnosis: Cogan's syndrome. A case report and review of the literature

Cogan's syndrome is defined as a chronic inflammatory disease of unknown origin, an autoimmune disease, characterized by bilateral sensorineural hearing loss, vestibular symptoms, inflammatory ocular manifestations with variable risk of developing into a systemic disease. The onset of disease is variable but is often characterized by isolated ocular symptoms or acute ear and/or vestibular manifestations, variably associated. The diagnosis of Cogan's syndrome can be a challenge as is evident in the case described here since it is based only on the association between bilateral ocular and vestibuloauditory symptoms with no specific diagnostic tests available.

Outcome of laparoscopic transabdominal preperitoneal inguinal hernia repair

The long-term efficacy of laparoscopic inguinal hernia repair is unknown. This retrospective study was conducted to determine the efficacy of this operation in comparison with the open technique and to evaluate the possible factors of recurrence. We have evaluated the clinical outcome in a group of patients who underwent laparoscopic procedures between January 1995 and December 1996, with the aim of assessing the incidence of recurrence and of long-term complications. Sixty-three patients underwent laparoscopic transabdominal preperitoneal repair by use of a large mesh. We were able to examine 58 of these patients at a median follow-up time of 15 months since their operation. Four patients had developed a recurrence, and two patients had significant symptoms consistent with nerve damage. The recurrence rate of 7% is similar to that reported for open operations but higher than that reported for early follow-up after laparoscopic operations. Our study illustrates the value of long-term follow-up for the assessment of efficacy following laparoscopic inguinal hernia surgery.

Conditioned inhibition of antibody response and CD4 positive cells

Animals were assigned to three experimental groups, conditioned (cyclophosphamide-glucose treatment; C group), non-conditioned (cyclophosphamide-commercial pellet treatment; NC group) and placebo (saline solution-glucose treatment; P group). The three groups were injected intraperitoneally (i.p.) with sheep red blood cells. An hemagglutination assay according to standard procedures was performed along with the flow cytofluorometric analysis of leukocyte surface antigens CD4, CD8 and CD45. C group consumed less food on Days 3 and 6 than on Day 0, NC animals showed no changes in food consumption throughout the experimental period, whereas an increasing trend was observed for P animals. The proportion of T lymphocytes expressing CD8 and CD45 did not differ significantly among C, NC and P groups. Group C showed the lowest proportion of T lymphocytes bearing CD4, whereas Group P displayed the highest. The antibody response was lower in the Group C than in the groups NC and P. We conclude that, although the mechanisms by which humoral conditioned immunosuppression occurs in mice is still unknown, a reduced T helper-mediated activation of B-cells may play an important role in producing conditioned humoral response.

[Ambulatory surgery in French public hospitals. Present and future. "Public hospitals" group of the French Association of Ambulatory Surgery]

OBJECTIVES

To assess ambulatory surgery practices in France, make an inventory of projects for the creation of ambulatory structures and analyze the perception of different hospital personnel of ambulatory surgery.

METHODS

A questionnaire was sent to 541 public hospitals with a surgery unit in France. The first part of the questionnaire was used to record current activity and existing projects for ambulatory surgery. The questionnaire also collected opinions concerning the analysis of difficulties encountered and possibilities offered by ambulatory surgery.

RESULTS

Overall participation rate was 59%. Ambulatory surgery was practised in 81% of the hospitals. Sixty-six percent had a projects under consideration, including several at the decision making stage (17%). 1550 ambulatory surgery clinics could be created by the year 2000. In 66% of the cases, the future facility would be integrated into the traditional surgery unit. There was favorable opinion concerning the development of ambulatory surgery clinics in public hospitals in 83% of the cases. Inconveniences suggested generally involved organizational aspects, particularly concerning medical organization. Foreseen obstacles to the development of ambulatory surgery clinics were regulatory procedures, unfavorable exchange rate, insufficient investment funds and the lack of a policy favoring their development.

CONCLUSION

The development of ambulatory surgery clinics in public hospitals in France can be expected in the near future. Budgeting and regulatory procedures must however be adapted to promote implementation of the existing projects.

Gangrene of the perineum

Fournier's gangrene, an anaerobic necrotizing cellulitis of the infradiaphragmatic soft tissues, is a serious pathologic entity with an unpredictable course. From 1978 to 1991, a total of 24 men (mean age, 57 years; range 27 to 90) were treated for this entity at our institution. Diagnosis prompted immediate institution of multimodal treatment combining triple antibiotics, surgical dissection, debridement, and repeated surgical drainage. Fecal diversion (16 patients), hyperbaric oxygenation, and standard intensive care procedures were widely indicated and performed quasi-systematically. The mean interval between initial symptoms and diagnosis was 7.4 days. Lesions were limited to the perineum in 11 patients but extended to the abdomen, thighs, or loins in the remaining 13. The pathogens were identified in 19 patients, and hemoculture results were positive in 5. A coloproctologic origin was identified in 12 patients and a urogenital origin in 4. In 2 patients, perineal gangrene occurred postoperatively, and no etiology was determined for 6. Six patients died, and 18 patients recovered, without any sequelae. The prognosis is better when the patient is young (less than 60 years old), has clinically localized disease, without systemic involvement, and sterile hemocultures and is managed with colostomy. A thorough workup is mandatory to determine the etiology (locoregional lesion, malignancy, hemopathy, arteritis).

[Surgical treatment of gangrene of the perineum]

Acute perineal gangrene due to anaerobic Gram negative bacilli or streptococci rapidly leads to tissue necrosis and death in 50% of the cases despite progress in intensive care. Emergency treatment requires adapted antibiotics, hyperbaric oxygen therapy and repeated surgery. Factors of poor prognosis include age over 60 years, lomboabdominal or crural extension, septic shock, positive blood cultures and lack of fecal derivation. Surgery is performed under general anaesthesia since loco-regional anaesthesia is contraindicated during the septic phase. Repeated operations are needed to make large incisions, evacuate pus, search for foreign bodies and resect damaged tissue in order to expose all the infected areas to air and hyperbaric oxygen. A colostomy must be performed in order to avoid fistulization and contamination of the infected areas. An indwelling urine catheter is usually sufficient although a suprapubic catheter may be needed at the risk of further extension of the gangrene. Surgical treatment is associated with intensive care and hyperbaric oxygen therapy. Three effective antibiotics are recommended. Using this aggressive surgical protocol, we have been able to reduce mortality to 20% in patients under 60 years of age.

[Perineal gangrene. Analysis of 24 cases]

Fournier's syndrome, characterised by anaerobic necrotising cellulitis of the soft tissues situated below the diaphragm, is a serous disease with an unpredictable course. From 1978 to 1991, we treated 24 men with a mean age of 57 years (27 to 90 years). Following the diagnosis of this disease, rigorous treatment was instituted immediately, consisting of a triple antibiotic combination, repeated surgical exposure, debridement and drainage with a frequent, almost systematic indication for faecal diversion (n = 16), hyperbaric oxygen therapy and classical intensive care measures. The mean interval between the first clinical signs and the diagnosis was 7.4 days. The lesions were limited to the perineum in 11 cases and extended to the abdomen, thighs and/or loins in 13 cases. The microorganisms responsible for the infection were identified in 19 cases and blood cultures were positive in 5 cases. This infection was of coloproctological origin in 12 cases, urogenital origin in 4 cases and postoperative in 2 cases, while no aetiology could be identified in 6 patients. There were 6 deaths and 18 cures without sequelae. 1. The prognosis of this disease is better in younger subjects (under the age of 60 years) with a localised clinical form, with no deterioration in the general status, sterile blood cultures and treated by a diversion colostomy. 2. A detailed aetiological work-up must be performed, looking for local or regional infection, cancer, haematological malignancy or arterial disease.

[Pre-deposited autologous blood transfusion in elective surgery: our experience]

The risk of contracting infective diseases, which may be potentially lethal, from transfused blood has led to a necessary critical review of the transfusion practice. Autologous transfusion eliminates such risk and appears as an ideal procedure for a pre-hospital donation program particularly useful in elective surgery. To determine the extent to which predeposited autologous blood is used in patients undergoing elective surgery and to assess whether predonation decreases the use of homologous blood and the demand of blood supply, the Authors studied 261 patients submitted to elective surgery from October 1986 to October 1989. In the Authors' opinion a predeposit autotransfusion program is cost-effective, practical and nondisruptive. Therefore, it should be considered as a necessary and standard medical practice by clinicians and patients.

[Severe adenotonsillar hypertrophy in children: a new modality of surgical treatment]

The hyperplasia of the palatine tonsils, which can be often found in children suffering from the so-called "lymphatism", cannot be considered a pathological state; it simply indicates the attempt of the organism to restore a functional balance between the antigenic shock on one hand and the unitary inadequacy of the lymphatic cells to performs their tasks on the other hand. However, this hyperplasia is sometimes so serious to cause respiratory ailments and predispose several pathologies: in these cases, a surgical operation becomes necessary. Since the tonsillectomy deprives these children of the important defensive barrier represented by the palatine tonsils and the results given by the monotonsillectomy have proved to be not completely satisfactory, both for the phlogosis and for the vicarious hypertrophy of the remaining tonsil, the Authors propose a new surgical technique (never suggested before) in cases of mechanical oropharyngeal obstruction due to hyperplasia of the palatine tonsils. This surgical operation, called bilateral tonsillotomia, consists in removing the tonsillary tissue exceeding the ideal connection line between the borders of the tonsillary pillars.

[Indications of the different routes of inferior vena cava for inserting the clip of Adams De Weese (author's transl)]

Partial occlusion of inferior vena cava with clip of Adams De Weese is now currently performed in cavo-iliac thrombosis. The authors recall technical modalities for inserting clip and they try to bring to light the indications of each modality according to following parameters: upper level thrombosis, state of abdominal cavity, general condition of the patient and researched result: temporary or definitive artial oclusion, with or without associated thrombectomy. In localizations under renal veins, a definitive partial occlusion is indicated by sub-mesocolic way, eventually retro-peritoneal way in case of poor risk; it is a fact that associated thrombectomy will be realized easily, only by transmesenteric and submesocolic way. In localizations above renal veins, the authors think that transpericardiac way which allow temporary occlusion and thrombectomy of retro-hepatic part of vena cava is indicated.

[Pulmonary oedema after late revascularisation of the lower limbs (author's transl)]

In the two cases reported, pulmonary oedema developed immediately following revascularisation of the lower limbs after prolonged ischaemia. Without it being possible to formally exclude the possible role of a haemodynamic factor, the authors suggest the hypothesis of a predominantly lesional mechanism. The "reconnection to the circuit" is the provoking factor in this oedema, the alveolo-capillary membrane being previously altered by the prolonged ischaemia, infection and massive transfusion. The pulmonary manifestations would seem to enter within the classification of somatolysis.

[Study of pressor drops during continuous peridural analgesia in gerontologic surgery]

A statistical study bearing upon othe fall of blood pressure concomitant with the setting of peridural anaesthesia was carried out upon an homogeneous series of patients over 75 belonging to groups III and IV of the A S A classification for interventions seating below the IXth metamere. From this study, it seems to follow that: - for starting maximum arterial tensions over 180 mm/Hg, pressure falls are virtually constant in absolute value; - the most important variations in pressure falls are to be found in abdominal surgery; - the lowest figure in blood pressure which accompanies the achievement of surgical analgesia takes place about the 24 th minute whatever the type of surgery can be; - no significant link can be evidence between the importance of the fall in blood pressure and the consumption of the mixture required for surgical analgesia.