POS0677 CONSISTENCY IN TIME TO RESPONSE WITH UPADACITINIB AS MONOTHERAPY OR COMBINATION THERAPY AND ACROSS PATIENT POPULATIONS WITH RHEUMATOID ARTHRITIS

Background

Upadacitinib (UPA) has demonstrated efficacy in patients with moderate-to-severe rheumatoid arthritis (RA) across various patient populations.1–4

Objectives

This post hoc analysis aimed to evaluate the consistency in time to achieving meaningful clinical response with UPA 15 mg + conventional synthetic (cs) DMARDs in biologic (b) DMARD-inadequate responder (IR) versus csDMARD-IR patients with RA as well as with UPA 15 mg monotherapy versus UPA 15 mg + csDMARDs in csDMARD-IR patients.

Methods

Patients originally randomized to UPA 15 mg once daily from four Phase 3 trials were included in this analysis: SELECT-BEYOND1 and SELECT-CHOICE2 (UPA 15 mg + csDMARDs in bDMARD-IR patients), SELECT-NEXT3 (UPA 15 mg + csDMARDs in csDMARD-IR patients), and SELECT-MONOTHERAPY4 (UPA 15 mg monotherapy in methotrexate-IR patients). Time to response was estimated using the Kaplan–Meier method for clinical outcomes over 24 weeks (26 weeks in SELECT-MONOTHERAPY). Clinical outcomes included achievement of 28-joint Disease Activity Score with C-reactive protein (DAS28[CRP]) ≤3.2; low disease activity (LDA) defined as Clinical Disease Activity Index (CDAI) ≤10 and Simple Disease Activity Index (SDAI) ≤11; and 50% improvement in American College of Rheumatology (ACR) core components and morning stiffness (MS) duration/severity. Data presented were as observed.

Results

Overall, 905 patients were included (SELECT-BEYOND: n=164; SELECT-CHOICE: n=303; SELECT-NEXT: n=221; SELECT-MONOTHERAPY: n=217). csDMARD-IR patients had a mean disease duration of 7.3 (SELECT-NEXT) or 7.5 years (SELECT-MONOTHERAPY); bDMARD-IR patients had a mean disease duration of 12.4 years, with a more refractory population (≥3 prior bDMARDs) in SELECT-BEYOND (23%) than SELECT-CHOICE (10%). In general, the median time to DAS28(CRP) ≤3.2, CDAI LDA, 50% improvement in ACR core components, and 50% improvement in MS duration/severity were consistent across the studies in bDMARD-IR and csDMARD-IR patients. For SELECT-BEYOND, SELECT-CHOICE, SELECT-NEXT, and SELECT-MONOTHERAPY, the median (95% CI) time to achieve DAS28(CRP) ≤3.2 was 12 (12, 16), 12 (8, 12), 12 (8, 12), and 14 (8, 14) weeks, respectively (Figure 1), and the median time to achieve CDAI LDA was 20 (12, 24), 16 (12, 16), 16 (12, 16), and 20 (14, 20) weeks, respectively (Figure 2). A longer median (95% CI) time to achieve SDAI LDA was observed with UPA monotherapy (20 [14, 20] weeks) versus UPA + csDMARDs (12 [12, 16] weeks) in csDMARD-IR patients. Among bDMARD-IR patients, the median (95% CI) time to 50% improvement in pain was longer in SELECT-BEYOND versus SELECT-CHOICE (16 [12, 20] versus 8 [8, 12] weeks).

Conclusion

In diverse patient populations with RA, patients treated with UPA 15 mg, as monotherapy or with csDMARDs, generally demonstrated consistent time to achieving DAS28(CRP) ≤3.2, CDAI LDA, and 50% improvement in clinical outcomes.

References

[1]Genovese MC, et al. Lancet 2018;391:2513–24.

[2]Rubbert-Roth A, et al. N Engl J Med 2020;383:1511–21.

[3]Burmester GR, et al. Lancet 2018;391:2503–12.

[4]Smolen JS, et al. Lancet 2019;393:2303–11.

Acknowledgements

AbbVie funded this study; contributed to its design; participated in data collection, analysis, and interpretation of the data. No honoraria or payments were made for authorship. Medical writing support was provided by Amy Wilson, MSc, of 2 the Nth (Cheshire, UK), and was funded by AbbVie.

Disclosure of Interests

Andrea Rubbert-Roth Consultant of: AbbVie, Amgen, Bristol-Myers Squibb, Chugai, Eli Lilly, Gilead, Janssen, Novartis, Roche, and Sanofi, Bernard Combe Speakers bureau: AbbVie, Bristol-Myers Squibb, Celltrion, Eli Lilly, Gilead/Galapagos, Janssen, Merck, Novartis, Pfizer, Roche/Chugai, and Sanofi, Consultant of: AbbVie, Bristol-Myers Squibb, Celltrion, Eli Lilly, Gilead/Galapagos, Janssen, Merck, Novartis, Pfizer, Roche/Chugai, and Sanofi, Zoltán Szekanecz Speakers bureau: AbbVie, Amgen, Bristol-Myers Squibb, Eli Lilly, Gedeon Richter, MSD, Pfizer, Roche, Sanofi, and UCB, Consultant of: AbbVie, Amgen, Bristol-Myers Squibb, Eli Lilly, Gedeon Richter, MSD, Pfizer, Roche, Sanofi, and UCB, Stephen Hall Speakers bureau: Eli Lilly, Janssen, Merck, Novartis, Pfizer, and UCB; and research grants from AbbVie, Janssen, Merck, and UCB, Consultant of: Eli Lilly, Janssen, Merck, Novartis, Pfizer, and UCB; and research grants from AbbVie, Janssen, Merck, and UCB, Boulos Haraoui Speakers bureau: AbbVie, Amgen, Bristol-Myers Squibb, Celgene, Eli Lilly, Janssen, Merck, Novartis, Pfizer, and UCB, Consultant of: AbbVie, Amgen, Bristol-Myers Squibb, Celgene, Eli Lilly, Janssen, Merck, Novartis, Pfizer, and UCB, Grant/research support from: AbbVie, Amgen, Bristol-Myers Squibb, Celgene, Eli Lilly, Janssen, Merck, Novartis, Pfizer, and UCB, Suzan Attar: None declared, Anna-Karin H Ekwall Consultant of: AbbVie and Pfizer, Yanna Song Shareholder of: AbbVie Inc., Employee of: AbbVie Inc., Tim Shaw Shareholder of: AbbVie Inc., Employee of: AbbVie Inc., Orsolya Nagy Shareholder of: AbbVie Inc., Employee of: AbbVie Inc., Ricardo Xavier Consultant of: AbbVie, Amgen, Bristol-Myers Squibb, Eli Lilly, Janssen, Novartis, Pfizer, and UCB

Multi-route exposure sampling of quaternary ammonium compounds and ethanol surface disinfectants in a K-8 school

The frequency of surface disinfectant use has increased over the last several years in public settings such as schools, especially during the COVID-19 pandemic. Although these products are important for infection control and prevention, their increased use may intensify the exposure to both persons applying the disinfection product as well as bystanders. Safety assessments have demonstrated that these products, when used as intended, are considered safe for use and effective; however, point-of-contact effects (such as respiratory or dermal irritation) may still occur. Additionally, relative exposures may vary significantly due to the wide variation in disinfectant formulation and application methods. Quantitative estimations of exposures to two commonly used active ingredients, quaternary ammonium compounds (QACs) and ethanol, are not well characterized during product use and application scenarios. To assess the potential for health risks attributable to increased use in classroom settings, as well as to quantitatively evaluate the potential exposure to both ethanol and QACs, student and adult bystander surface and air measurements were collected in a K-8 school setting in Ohio, United States, over a three-day period. Direct-reading instruments were utilized to collect real-time air samples that characterized mass fraction concentrations following the use of the QAC- and ethanol-based disinfectants. Furthermore, surface and air sampling of microbial species were conducted to establish the overall bioburden and effectiveness of each disinfectant to inform the comparative risk and health effect impacts from the tested products use scenario. Both tested products were approximately equally effective at reducing bioburdens on desk surfaces. In some classrooms, concentrations of QAC congeners were significantly increased on desk surfaces following the application of the disinfectant spray; however, the magnitude of the change in concentration was small. Ethanol was not measured on surfaces due to its volatility. Airborne concentrations increased immediately following spray of each disinfectant product but rapidly returned to baseline. Each of the QAC congeners listed in the product safety data sheets were detected and measurable on desk surfaces; however, air concentrations were generally below the limit of detection. The 15-min time-weighted averages (TWAs) of both QACs and ethanol in the air were below respective health effects benchmarks, and therefore, the negative impact on health outcomes is considered to be minimal from short-term, repeated use of ethanol- or QAC-based spray products in a school setting when the products are used as directed.

AB0566 CONSENSUS-BASED RECOMMENDATIONS FOR THE MANAGEMENT OF PSORIATIC ARTHRITIS IN THE KINGDOM OF SAUDI ARABIA

Background:

Psoriatic arthritis (PsA) is a chronic inflammatory condition associated with psoriasis. The common clinical features of PsA include peripheral arthritis, dactylitis, enthesitis, spondylitis, skin and nail disease1. Considering the heterogeneous course of disease and the different patient characteristics, there is a need to standardize management of PsA patients. At present, no established guidelines are available on PsA care pathway in Saudi Arabia.

Objectives:

To provide consensus-based guidance to all Saudi health care providers (HCPs) on the management of PsA patients including referral pathway, definition of remission and treat-to-target approach.

Methods:

A Delphi technique was used to understand PsA patient care pathway. In first step, a targeted literature review was conducted and a survey questionnaire including 16 questions was developed to explore PsA patient journey. In second step, this questionnaire was submitted to 127 HCPs and 33 of them provided their response. In third step, a panel of 12 experts including 10 rheumatologists, 1 dermatologist and 1 general physician reviewed the available evidence along with survey results to align on final recommendations.

Results:

The most common management guidelines recommended for PsA were European League against Rheumatism (EULAR, 100% agreed) and American College of Rheumatology (ACR, 100% agreed). Psoriasis Epidemiology Screening Tool (PEST) was recommended by 67% of experts as validated screening tool for PsA in dermatology clinic. The laboratory investigations included were C-reactive protein (CRP, 100%), erythrocyte sedimentation rate (ESR, 100%), complete blood count (92%), urea and creatinine (92%), liver function (92%), rheumatoid factor (56%) and X-ray of affected joints (75%). For patients with additional symptoms of back pain, X-ray of sacroiliac joints and human leukocyte antigen B27 (HLA-B27) test to be included. Only rheumatologists should recommend a magnetic resonance imaging based on the individual clinical picture. The agreement criteria for HCPs for referring patient to a rheumatologist were presence of psoriasis (100%) and one of the following features: dactylitis [100%], joint pain [100%], arthritis [100%], nail dystrophy [91%]. Patient with active arthritis should be referred to rheumatologist within 4 weeks. The referral pathway agreed by the experts for PsA patients is presented in Figure 1. Majority of experts (57%) defined clinical remission as absence of disease activity in all facets of disease assessed using the disease activity in psoriatic arthritis (DAPSA) or minimal disease activity (MDA) index. For treat-to-target, 71% of experts agreed on EULAR recommendations2. For remission and treat-to-target, experts identified a need for more clear definition.

Conclusion:

This expert consensus aimed to provide guidance to Saudi HCPs on standardizing diagnosis and care of PsA patients. Most experts recommended PEST as validated screening tool for PsA along with laboratory investigations such as CRP, ESR, X-ray, etc. Referral to a rheumatologist should be considered for patient with presence of psoriasis and one of the other defining features for PsA. There is a need for more clear definition of remission and treat-to-target.

References:

[1]Ogdie A, et al. Rheum Dis Clin North Am. 2015;41(4):545–568.

[2]Gossec L, et al. Ann Rheum Dis. 2020;79:700–712.

Figure 1.

Referral pathway for psoriatic arthritis patients CRP: C-reactive protein; ESR: Erythrocyte sedimentation rate; CBC: Complete blood count; HLA-B27: Human leukocyte antigen B27; PEST: Psoriasis Epidemiology Screening Tool

Acknowledgements:

This project was supported by Novartis Saudi Ltd., Saudi Arabia and the Saudi Society for Rheumatology. We would also like to thank Dr. Xenofon Baraliakos for his support.

Disclosure of Interests:

Hanan Alrayes: None declared., Mansour Alazmi Speakers bureau: Pfizer, Abbvie, Khaled Alderaan: None declared., Mushabab Alghamdi: None declared., Nayef Alghanim: None declared., Ahmed Alhazmi: None declared., Nadeer Alkhadhrawi: None declared., Mohammad Almohideb Speakers bureau: Novartis, Abbvie, Celgene, Lilly, Jansen and Sanofi, Grant/research support from: Sanofi and Abbvie, Suzan Attar Speakers bureau: Lectures in symposium about different diseases in rheumatology and management, Grant/research support from: Research in recruiting patient, Zyad ahmed Alzahrani Speakers bureau: Pfizer, Novartis, MSD, Janssen, Abbvie, Lilly, Consultant of: Pfizer, Novartis, MSD, Janssen, Abbvie, Lilly, Mohamed Bedaiwi: None declared., Nancy Zakaria Employee of: Novartis, Hussein Halabi: None declared.

AB0465 INDIVIDUAL COMPONENTS CONTRIBUTING TO THE ACHIEVEMENT OF ASAS40 RESPONSE IN BIOLOGIC NAÏVE PATIENTS WITH RADIOGRAPHIC axSpA: RESULTS FROM THE COAST-V TRIAL

Background:

Ixekizumab (IXE), an IL-17A antagonist, is effective in patients with radiographic axial spondyloarthritis (rad-axSpA). Assessment in SpondyloArthritis International Society (ASAS) 40 response – the primary study endpoint – was achieved at week (wk) 16 by 48% of those treated with 80mg subcutaneous IXE every 4 wks (Q4W) in the phase 3 COAST V trial (NCT 02696785) 1. Until now, no information has been available on the efficacy of IXE on the components of ASAS40 composite endpoint.

Objectives:

To describe which individual components of ASAS40 drive achievement of efficacy response.

Methods:

This exploratory post-hoc analysis was based on COAST V data. Patients enrolled in COAST V met ASAS criteria for rad-axSpA and were biological disease-modifying antirheumatic drug (bDMARD)-naïve. Patients were assigned 1:1:1:1 to subcutaneous placebo (PBO), IXE Q4W, IXE Q2W or 40 mg adalimumab (ADA). Only data for approved doses are shown.

To reach ASAS40 response, patients must have an improvement of at least 40% and at least 2 units for at least 3 of 4 individual components which define response (patient global assessment of disease activity, spinal pain, inflammation (defined as the mean of Bath Ankylosing Spondylitis Disease Activity Index (BASDAI) questions 5 and 6), and function (Bath Ankylosing Spondylitis Functional Index - BASFI)), without worsening in the remaining component. We describe the percentage of patients who achieved this change, had an insufficient response, or deteriorated in each component out to wk 16 for IXE Q4W, ADA and PBO. The time course of the change from baseline in individual components of the ASAS response is depicted descriptively per treatment arm by use of the mean and standard deviation. Observed data have been utilised.

Results:

IXE Q4W response at 16 wks was driven by all 4 individual components of the ASAS40 with the largest improvements for patients treated with IXE Q4W seen in inflammation and spinal pain (Figure 1).

At wk 16, at least 50% of all patients treated with IXE Q4W achieved response on spinal pain (60.3%), inflammation (60.3%) and patient global assessment (50%), with 43.6% of patients meeting the response criteria for function (Table 1). The corresponding results for ADA were 43.2%, 47.7% 39.8%, and 35.2%.

Conclusion:

Our findings show that meeting ASAS40 response criterion for an individual component at 16 wks by patients treated with IXE Q4W was broadly similar between individual components. However, a clinically relevant improvement was more frequently observed for the spinal pain and inflammation components.

References:

[1]Dougados, M., et al. (2020). Ann Rheum Dis79(2): 176-185.

Table 1.

Observed changes from baseline (CFB), percentage improvements and response status of patients enrolled in COAST V trial at wk 16

MeasureObserved CFB(SD)Observed % improvement (SD)Improvement >=40% and >=2 unitsn (%)Insufficient responsen (%)Deterioratedn (%)IXE Q4W (N=78) Patient global assessment-2.6 (2.9)32.3 (51.1)39 (50.0)30 (38.5)9 (11.5) Spinal pain-3.3 (2.7)43.4 (34.4)47 (60.3)27 (34.6) 4 (5.1) Inflammation*-3.2 (2.5)46.8 (32.8)47 (60.3)25 (32.0)6 (7.7) Function-2.5 (2.3)39.6 (31.0)34 (43.6)37 (47.4)7 (9.0)ADA (N=88) Patient global assessment-2.6 (2.4)35.2 (33.4)35 (39.8)48 (54.5)5 (5.7) Spinal pain-2.6 (2.4)36.8 (34.7)38 (43.2)44 (50.0)6 (6.8) Inflammation*-2.6 (2.4)38.4 (36.9)42 (47.7)37 (42.0)9 (10.2)Function-2.1 (2.2)35.2 (34.3)31 (35.2)48 (54.6)9 (10.2)PBO (N=86) Patient global assessment-1.5 (2.0)18.0 (37.9)21 (24.4)54(62.8)11(12.8) Spinal pain-1.9 (1.9)25.8 (26.7)23 (26.8)55(64.0)8(9.3) Inflammation*-1.4 (1.9)20.9 (33.9)19 (22.1)53 (61.6)14 (16.3) Function-1.3 (1.8)19.1 (31.6)16 (18.6)51 (59.3)19 (22.1)

*Inflammation is the mean of BASDAI 5 (Morning stiffness severity) and BASDAI 6 (Morning stiffness duration)

Mean baseline values for PBO, ADA and IXE Q4W respectively: Patient global assessment (7.1, 7.1, 6.9), spinal pain (7.4, 7.0, 7.2), inflammation (Q5/6) (6.7, 6.6, 6.5), function (6.3, 6.1, 6.1)

Acknowledgements:

Alan Ó Céilleachair, an employee of Eli Lilly and Company, provided editorial and writing support.

Disclosure of Interests:

Denis Poddubnyy Speakers bureau: AbbVie, Bristol-Myers Squibb, Eli Lilly and Company, MSD, Novartis, Pfizer, and UCB, Consultant of: AbbVie, Biocad, Gilead, GlaxoSmithKline, Eli Lilly and Company, MSD, Novartis, Pfizer, Samsung Bioepis, and UCB, Grant/research support from: AbbVie, Eli Lilly and Company, MSD, Novartis, and Pfizer, Suzan Attar: None declared., Michael J. Nissen Speakers bureau: AbbVie, Celgene, Eli Lilly and Company, Janssen, Novartis and Pfizer., Consultant of: AbbVie, Celgene, Eli Lilly and Company, Janssen, Novartis and Pfizer., Grant/research support from: AbbVie, Erica Filippi Shareholder of: Eli Lilly and Company, Employee of: Eli Lilly and Company, Hagen Russ Shareholder of: Eli Lilly and Company, Employee of: Eli Lilly and Company, Alper Erdogan Shareholder of: Eli Lilly and Company, Employee of: Eli Lilly and Company, Yves Schymura Employee of: Eli Lilly and Company, Soyi Liu Leage Shareholder of: Eli Lilly and Company, Employee of: Eli Lilly and Company, Eduardo Collantes Estevez Speakers bureau: Novartis, Janssen, Eli Lilly and Company, AbbVie, Paid instructor for: Novartis, Grant/research support from: Eli Lilly and Company, francesco ciccia Speakers bureau: AbbVie, Celgene, UCB, Pfizer, MSD, Amgen, Eli Lilly and Company, Novartis, Sobi, Roche, BMS, Paid instructor for: Novartis, UCB, Pfizer, Consultant of: Novartis, UCB, Pfizer, Grant/research support from: Pfizer, Roche, UCB.

AB0366 DIFFUSE ALVEOLAR HEMORRHAGE IN LUPUS NEPHRITIS PATIENTS: MULTICENTER RECTROSPECTIVE STUDY

Background:

Diffuse alveolar hemorrhage (DAH) is a rare and potentially lethal complication of systemic lupus erythematosus (SLE) with a high mortality rate. It occurs more frequently in patients with lupus nephritis (LN).

Objectives:

The aim of our study is to explore the characteristics of patients that develop DAH with lupus nephritis, risk factors that predispose DAH, treatment response and outcomes.

Methods:

Multicenter retrospective cohort study was undertaken including 6 centers in Saudi Arabia from 2002 to 2018. Systemic lupus erythematosus patients meeting the SLICC criteria with lupus nephritis (biopsy proven or proteinuria or renal impairment due to lupus) presenting with diffuse alveolar hemorrhage (fulfilling a predefined criteria) were included in the study. An identical number of control group with lupus nephritis was also studied. Data was obtained from medical records by using a data sheet: demographics including age, gender, diagnosis, date of diagnosis of lupus, date of presentation of alveolar hemorrhage, clinical presentation, detection of alveolar hemorrhage proved by radiology, lavage or biopsy and laboratory parameters: including level of hemoglobin before and during DAH, sign of activity, treatment and outcome of DAH. Identification of risk factors predisposing to DAH in lupus nephritis patients was analyzed.

Results:

We identified 23 cases of DAH with lupus nephritis, all fulfilling the criteria. Mean age at presentation of DAH was 31.09 ± 12.6 years ranging from 14-57 years, of which 87 % were females. 13 patients 56.5% had Class 4 LN and 21.7% had Class 4 and 5 LN on renal pathology. DAH occurred at a mean of 6.5 years ±3.8 in 13/23 patients with LN. Shortness of breath 95%, new chest x ray finding 95.7% and mean drop of haemoglobin of 2.72 gm/dl ±0.97 were more frequent at presentation of DAH with LN patients. High SLE disease activity - SELENA SLEDAI 2K was 38.56 ±19.3 was present at the onset of DAH. All were treated with methyprednisone,15/23 (65.2%) underwent mechanical ventilation and plasmapheresis was done in 21/23 patients (91.3%). Cyclophosphamide was given in 14/21 patients (60.9%), Intravenous immunoglobulins were given in 14/23 patients (65.2%) and dialysis was done in 12/23 patients (52.2%). Mortality occurred 8 patients 34.8 %. In comparison with the LN group, a mean haemoglobin of 7.56 ± 1.3, CNS involvement, vasculitis and fever>38% were of statistically significance P value: <0.001,0.02,0.03 and 0.03 respectively.

Conclusion:

In this multicenter cohort series with DAH in LN patients CNS involvement, vasculitis and fever>38 were associated in the occurrence of DAH. Mortality was low in our cohort in comparison to previous series which may be explained by early diagnosis and use of aggressive management.Well designed prospective studies are required to identify high risk patients for preventing this serious complication.

References:

[1]Eagen JW, Memoli VA, Roberts JL, et al. Pulmonary hemorrhage in systemic lupus erythematosus. Medicine (Baltimore) 1978; 57:545.

[2]Badsha H, Teh CL, Kong KO, et al. Pulmonary hemorrhage in systemic lupus erythematosus. Semin Arthritis Rheum 2004; 33:414.

[3]Zamora MR, Warner ML, Tuder R, Schwarz MI. Diffuse alveolar hemorrhage and systemic lupus erythematosus. Clinical presentation, histology, survival, and outcome. Medicine (Baltimore) 1997; 76:192.

[4]Hsu BY, Edwards DK 3rd, Trambert MA. Pulmonary hemorrhage complicating systemic lupus erythematosus: role of MR imaging in diagnosis. AJR Am J Roentgenol 1992; 158:519.

Disclosure of Interests:

None declared

Surgical intervention of nonvertebral osseous metastasis

BACKGROUND

Nonvertebral osseous metastases can result in pain and disability. The goals of surgical intervention are to reduce pain and to improve function if nonsurgical treatment fails. The indications for proceeding with surgical intervention depend on anatomic location, amount of local destruction, extent of skeletal and visceral disease and, most important, the patient's performance status and life expectancy.

METHODS

This article reviews the evaluation and treatment of metastatic nonvertebral osseous lesions from the perspective of the orthopedic surgeon, based mainly on an assessment of the surgical literature.

RESULTS

This article summarizes the approaches to preoperative evaluation, patient selection, and medical optimization. Guidelines for estimating osseous stability and fracture risk are discussed, and surgical implants and their relation to postoperative outcomes are examined. This review also describes less invasive ablative procedures currently available.

CONCLUSIONS

The surgical management of nonvertebral osseous metastases involves multidisciplinary collaboration. The surgical construct must be a stable, reliable, and durable intervention that is individually tailored and matched to a patient's prognosis and performance status.

Alteration of the aurophilic interactions in trimeric gold(I) compounds through charge transfer. Behavior of solvoluminescent Au(3)(MeN=COMe)(3) in the presence of electron acceptors

The ability of the triangular gold(I) complex, Au(3)(MeN=COMe)(3), which as a solid displays the novel property of solvoluminescence (see: Vickery, J. C.; Olmstead, M. M.; Fung, E. Y.; Balch, A. L. Angew.Chem., Int. Ed. Engl. 1997, 36, 1179) to function as an electron donor has been demonstrated through spectroscopic studies and isolation of crystalline adducts with organic acceptor molecules. Four such adducts with nitro-9-fluorenones have been isolated and subject to single-crystal X-ray diffraction study. These are deep yellow [Au(3)(MeN=COMe)(3)].[2,4,7-trinitro-9-fluorenone], red [Au(3)(MeN=COMe)(3)].[2,4,5,7-tetranitro-9-fluorenone], red [Au(3)(MeN=COEt)(3)](2).[2,7-dinitro-9-fluorenone], and red [Au(3)(MeN=COEt)(3)](2).[2,4,7-trinitro-9-fluorenone]. The solid-state structures of [Au(3)(MeN=COMe)(3)].[2,4,7-trinitro-9-fluorenone] and [Au(3)(MeN=COMe)(3)].[2,4,5,7-tetranitro-9-fluorenone] consist of columns in which the planar gold(I) trimers and the nearly planar nitro-9-fluorenones are interleaved with the gold trimers making face-to-face contact with the nitroaromatic portion of the electron acceptor. Thus the organic acceptors disrupt the aurophilic interactions present in crystalline [Au(3)(MeN=COMe)(3)] itself. However, in [Au(3)(MeN=COEt)(3)](2).[2,7-dinitro-9-fluorenone] and [Au(3)(MeN=COEt)(3)](2).[2,4,7-trinitro-9-fluorenone], aurophilic interactions are found which produce dimers, [Au(3)(MeN=COEt)(3)](2), with nearly trigonal prismatic Au(6) cores. These dimers are interleaved with the nitro-9-fluorenone molecules to again form extended columns in which the components make face-to-face contact. Despite the fact that the gold atoms in [Au(3)(MeN=COMe)(3)] and [Au(3)(MeN=COEt)(3)] are in exposed sites and only two-coordinate, there is no evidence of additional coordination of the nitro-9-fluorenones with gold centers in the crystalline adducts.

Heparinless partial cardiopulmonary bypass for the repair of aortic trauma

OBJECTIVE

We hypothesized that partial cardiopulmonary bypass with a heparin-bonded system would be a technically simple, effective adjunct for reducing paraplegia during repair of traumatic aortic rupture. It avoids the risk of heparin, but, unlike left atrial-arterial bypass, it can heat, cool, oxygenate, and rapidly infuse volume if needed.

METHODS

A retrospective review was conducted of patients admitted for aortic trauma from July 1994 to December 1999. Bypass consisted of femoral venous (right atrial) cannulation, a centrifugal pump, and an oxygenator-heater/cooler. Arterial return was to the femoral artery or distal aorta. The entire system was heparin-bonded and no systemic heparin was given.

RESULTS

Heparin-bonded partial bypass was established in 50 patients (mean age 43 +/- 17 years). Crossclamp time was 32 +/- 11 minutes (range 14-70 minutes), mean flow 3.0 +/- 0.8 L/min, and bypass time 64 +/- 43 minutes. During repair, 58% of patients received volume through the system (mean 1.1 +/- 1.9 L). Core temperature rose slightly (35.9 degrees C +/- 0.7 degrees C to 36.3 degrees C +/- 0.8 degrees C). Three of the 15 patients who underwent percutaneous femoral arterial and venous cannulation concomitant with their angiograms had vessel injury, with one limb loss, and this procedure was discontinued. Thirty-five patients underwent percutaneous femoral vein and direct distal aortic cannulation without event. The mortality rate for patients supported by bypass was 10%, and all deaths were due to other injuries. There were no new cases of paraplegia and no worsening of intracranial or pulmonary injuries.

CONCLUSIONS

Heparin-bonded bypass is technically simple to use and avoids the risk of anticoagulation. Paraplegia was avoided. The ability to correct hypothermia, oxygenate, and rapidly infuse volume may simplify management and improve outcomes.

Traumatic aortic rupture: recent outcome with regard to neurologic deficit

BACKGROUND

Traumatic aortic rupture is highly lethal, and its surgical treatment is complicated by a high rate of paraplegia.

METHODS

The charts of 263 patients with traumatic aortic rupture from vehicular accidents treated between 1971 and 1998 were reviewed. Patients were grouped according to four periods: group 1, 1971 to 1975, (n = 31); group 2, 1976 to 1985, (n = 83); group 3, 1986 to 1994, (n = 82); and group 4, 1994 to 1998 (n = 67). Seventy-one patients died of exsanguination before definitive care. One hundred-ninety two patients had surgical repair with the following techniques: clamp and sew, 6 in group 1, 22 in group 2, 54 in group 3, none in group 4; shunt, 23 in group 1, 39 in group 2, 2 in group 3; cardiopulmonary bypass, 2 in group 1, 1 in group 3. Forty-three patients had partial bypass with the centrifugal pump and heparin-coated circuits in group 4.

RESULTS

Operative mortality was 6 of 31 (19%) in group 1, 22 of 61 (36%) in group 2, 15 of 57 (26%) in group 3, and 7 of 43 (16%) in group 4. There was one case of paraplegia in group 1 (4%), ten in group 2 (18%), 11 in group 3 (26%), and none in group 4. This difference of paraplegia between the groups was significant (p<0.002). Significant factors for paraplegia were intraoperative hypotension (p<0.000002), cross-clamp time longer than 30 minutes (p<0.008), pump versus no pump (p<0.008), and younger age group (28+/-11 versus 39+/-17 years) (p<0.03).

CONCLUSIONS

There were no statistically significant improvements in mortality rate over the four periods, although, the mortality rate was lowest in the last period when partial bypass with the centrifugal pump was used exclusively. Further, the use of the centrifugal pump with heparin-coated circuits, with femoral vein cannulation into the right atrium and distal aortic perfusion, reduced paraplegia significantly.

Superior sulcus (Pancoast) tumor: experience with 105 patients

BACKGROUND

The evolution of therapy in 105 patients with superior sulcus (Pancoast) tumor over the past 42 years was reviewed.

METHODS

There were 82 men and 23 women aged 30 to 75 years. Tumor cell types were: squamous, 41 (39%); adenocarcinoma, 23 (21.9%); anaplastic, 14 (13.3%); undetermined, 12 (11.4%); mixed, 9 (8.7%); and large cell 6 (5.7%). Therapy was based on extent of disease and lymph node involvement. There were 5 treatment groups: I, preoperative radiation and operation (n = 28); II, operation and postoperative radiation (n = 16); III, radiation (n = 37); IV, preoperative chemotherapy, radiation, and operation (n = 11); and V, operation (n = 12).

RESULTS

The median survival for group I was 21.6 months; group II, 6.9 months; group III, 6 months; and group V, 36.7 months. Median survival for group IV has not yet been reached (estimated at 72% at 5 years). On univariate analysis, mediastinal lymph node involvement, Horner syndrome, TNM classification, and method of therapy affected survival. On multivariate regression analysis, only N2 and N3 disease and method of therapy were significant (p < 0.05).

CONCLUSIONS

The optimal treatment for superior sulcus tumor was preoperative radiation and operation. However, triple modality therapy, although promising, requires longer follow-up.

Search for a primary lung neoplasm in patients with brain metastasis: is the chest radiograph sufficient?

OBJECTIVE

We assessed whether chest CT provided an advantage over chest radiography when diagnosing a primary lung neoplasm in a selected group of patients.

MATERIALS AND METHODS

From a retrospective evaluation of 925 patients who had a discharge diagnosis of brain metastasis, we identified 32 patients who presented without a known primary tumor site and who were investigated subsequently with both chest radiography and CT. Reports of chest radiographs were classified as showing a primary lung neoplasm (positive), as abnormal but nonspecific, or as negative. Patients were categorized as having negative chest radiograph, negative CT; positive chest radiograph, positive CT; nonspecific chest radiograph, positive CT; or negative chest radiograph, positive CT. Radiographic technique and clinical and lesion characteristics were compared among these categories.

RESULTS

We found negative chest radiograph and negative CT in one patient who ultimately proved to have breast cancer. The remaining 31 patients (97%) had primary lung carcinoma. In 19 (59%) of the 32 patients, chest radiographs and CT were positive. Twelve patients (38%) had a nonspecific or negative chest radiograph and positive CT. In the 31 patients with lung carcinoma, the mean diameter of lesions in patients with positive chest radiographs was 4.2 cm, compared with 2.5 cm in patients with normal or nonspecific radiographs (p < .01).

CONCLUSION

Lung cancer is by far the most common cause of a de novo presentation with brain metastasis. Chest CT is valuable to supplement chest radiography in patients with metastatic brain disease in whom a primary lesion is sought. Lesion size appears to be the most important determinant of detectability of a primary tumor on chest radiographs.

Combined thoracoscopic/laparoscopic staging of esophageal cancer

Unlike mediastinoscopy in lung cancer, there exists no standard minimally invasive test to stage esophageal cancer. If it were possible to obtain exact preoperative staging in esophageal cancer, patients could be separated prospectively to receive neoadjuvant therapy appropriately. We studied the feasibility and efficacy of thoracoscopic and laparoscopic lymph node staging in esophageal cancer. Thoracoscopic staging was performed in 45 patients with biopsy-proven carcinoma of the esophagus. Laparoscopic staging was done in the last 19 patients. Thoracoscopic staging was aborted in three patients because of adhesions. Thoracic lymph node stage was N0 in 39 patients and N1 in three; celiac lymph nodes were normal in 13 and diseased in six. Esophageal resection was performed in 30 patients after thoracoscopic staging; 17 of these underwent laparoscopic staging. Thoracoscopic staging showed N0 lymph node status in 28 patients and N1 in two patients. Two of the 28 patients (7%) with N0 disease were found at resection to have paraesophageal lymph node involvement (N1); thus the disease was understaged by thoracoscopic staging. Thoracoscopic staging was accurate in detecting the presence of diseased thoracic lymph nodes in 28 of 30 cases (93%). Laparoscopic staging detected normal celiac nodes in 12 patients and diseased lymph nodes in five patients. After esophagectomy, the final pathology report in the 12 patients with N0 disease was N0 in 11 and diseased lymph nodes in one patient. Thus laparoscopic staging was accurate in detecting lymph node metastases in 16 of 17 patients (94%). Thoracoscopic and laparoscopic staging are more accurate than existing staging methods. Six of 19 patients in whom laparoscopic staging was used had unsuspected celiac axis lymph node involvement that had been missed by standard noninvasive techniques. One of three patients with thoracic lymph nodes and three of six with celiac lymph nodes were downstaged after preoperative chemotherapy/radiotherapy. The role of thoracoscopy and laparoscopy in staging esophageal cancer should be further evaluated in a multiinstitutional trial.

Paraplegia after thoracotomy: report of five cases and review of the literature

Paraplegia complicating thoracotomy is rare but catastrophic. This report comprises 40 cases: 5 of our cases and 35 reported cases. Our cases comprised a stab wound of the left chest (1), decortication (1), lobectomy for bronchogenic carcinoma (2), and segmental resection for tuberculosis (1). The reported cases included 25 cases following thoracotomy for thoracic pathology (bronchogenic carcinoma, 12; pulmonary tuberculosis, 7; thoracic trauma, 2; bronchiectasis, 1; peptic esophagitis, 1; neurogenic tumors, 2; and benign lung lesion, 1 and 10 cases following operation for malignant hypertension. The surgical procedures performed on the 25 patients with thoracic pathology were lobectomy (8), bilobectomy (1), pneumonectomy (7), decortication (1), thoracoplasty (1), excision of neurogenic tumors (2), drainage of tuberculous cavity (1), and Nissen procedure (1). The intraoperative factors contributing to the neurologic deficit were bleeding at the costovertebral angle (9), migration of oxidized cellulose into spinal canal (9), thrombosis of anterior spinal artery (4), epidural hematoma (2), epidural narcotic (2), metastatic carcinoma (1), and hypotension (1). This serious complication can be prevented by meticulous operation and careful hemostasis. The immediate use of tomographic scanning or magnetic resonance imaging followed by surgical decompression might avert this serious complication.

Guidelines for blood utilization review

Hospitals are required by accrediting agencies to perform blood utilization review. Specific areas that must be addressed are the ordering, distribution, handling, dispensing, and administration of blood components. Monitoring the effects of transfusion on patients is also required. The format of the review process and the criteria for appropriate blood utilization must be developed by each institution. This article provides examples of areas that can be reviewed and procedures that may be used. However, the suggested laboratory values must not be interpreted as defining indications or criteria for transfusion. Each transfusion committee, or its equivalent, is responsible for developing its own institutional blood utilization procedures and audit criteria. Review and approval by the medical staff prior to implementation are essential. The procedures must also be reviewed and revised on a regular basis.

Esophageal perforation: CT findings

OBJECTIVE

Esophageal perforation is a life-threatening condition that can be quickly diagnosed on the basis of findings on contrast esophagograms when the typical signs and symptoms of vomiting, chest pain, and subcutaneous emphysema occur. If the clinical features are atypical, CT may be performed early in the clinical course. Thus, recognition of the CT findings of esophageal perforation is important.

MATERIALS AND METHODS

We reviewed the CT scans of 12 patients with esophageal perforation. The site of perforation was the cervical esophagus in three and the thoracic esophagus in nine. The causes of the perforations were neoplastic (four patients), idiopathic (three patients), iatrogenic (three patients), and traumatic (two patients).

RESULTS

CT abnormalities included esophageal thickening in nine patients, periesophageal fluid in 11 patients, extraluminal air in 11, and pleural effusion in nine. The site of the perforation was visible on the CT scan in two patients. In four patients (33%), CT findings were the first indication of esophageal perforation.

CONCLUSION

For patients who have atypical signs and symptoms, CT scans optimally define the extraluminal manifestations of esophageal perforation. Extraesophageal air is the most useful finding. The CT findings may be the first indication of the diagnosis.

Penetrating cardiac injuries

One hundred nine penetrating cardiac injuries were reviewed: 49 gunshot wounds and 60 stab wounds. They were classified into four groups: group 1 (lifeless), 38; group 2 (agonal), 16; group 3 (shock), 33; and group 4 (stable), 22. Thirty-six patients in group 1 (94%) and 8 of 16 patients in group 2 (50%) underwent emergency room thoracotomy; 24 of 33 in group 3 (73%) and 20 of 22 (90%) underwent thoracotomy in the operating room. Twenty-one (38%) of 55 patients undergoing emergency room thoracotomy survived, whereas 47 (87%) of 54 patients undergoing operating room thoracotomy survived. Survival was 12 of 38 (31%) in group 1, 11 of 16 (69%) in group 2, 26 of 33 (79%) in group 3, and 18 of 22 (82%) in group 4 with an overall survival of 67 of 109 (61%). Gunshot wounds of the heart portend a worse prognosis than stab wounds. Survival of gunshot wounds was 20 of 49 (40%) compared with 47 survivors of 60 stab wounds (78%). Aggressive treatment, including emergency room thoracotomy, is justified for lifeless and deteriorating cardiac injury victims.

Rupture of thoracic aorta caused by blunt trauma. A fifteen-year experience

During the 15 years from 1971 through 1985, 114 patients with rupture of the thoracic aorta caused by blunt trauma were admitted to the Shock Trauma Center of the Maryland Institute for Emergency Medical Services Systems. Mean age was 31.3 years (range, 15 to 80). Ninety were male and 24 were female, a 3.75:1 ratio. Of the 114, 89 (78.1%) survived initial resuscitation in the admitting area. Twenty five of the 89 initial survivors (28.1%) died during or after surgical repair. Paraplegia occurred in 11 of the 78 operating room survivors (14.1%). Further analysis was done of the 83 patients admitted in the 10-year period from 1976 through 1985. Mean Injury Severity Score, excluding aortic injury, was 18.2. Twenty-five of the 83 (30.1%) died during resuscitation in the admitting area or operating room. Seven others died during surgical repair and 12 died postoperatively, leaving 39 survivors (39/83 [47%] of total admissions and 39/58 [67.2%] of survivors of resuscitation). Paraplegia/paresis developed postoperatively in six of 34 (17.6%) cases involving shunt and four of 17 (23.5%) without shunt. Other major complications occurred in 21 of the operating room survivors. Statistically significant risk of death or major complication was associated with female sex, higher Injury Severity Score, lower admission blood pressure, larger hemothorax on admission, less qualified surgeon, major operation before aortic repair, use of shunt, and transfer directly from scene of injury. There was no advantage in this series to using or not using a shunt in preventing paraplegia. Mortality rates are realistic for a highly developed trauma system. Better techniques are needed to manage exsanguination and prevent paraplegia.

Esophageal perforation: a therapeutic challenge

The records of 64 patients with esophageal perforation treated since 1958 were reviewed. There were 19 cervical perforations, 44 thoracic perforations, and one abdominal perforation. Thirty-one perforations (48%) were due to injury from intraluminal causes. Twenty (31%) resulted from extraluminal causes: penetrating wounds, 11; blunt trauma, 3; and paraesophageal operations, 6. Eleven (17%) were spontaneous perforations, and two (3%) were caused by perforation of an esophageal malignancy. Ten (91%) of 11 patients with cervical perforations treated less than 24 hours after injury survived compared with 6 (75%) of 8 patients treated more than 24 hours after injury; hence 16 (84%) of the 19 patients in the cervical group survived. In the thoracic group, 19 patients were treated within 24 hours with 16 survivors (84%) compared with 25 patients treated beyond 24 hours with 12 survivors (48%); hence 28 (64%) of the 44 patients in the thoracic group survived. The patient with an abdominal perforation survived. Thirty patients underwent primary suture closure of the perforation, and 25 (83%) lived. Seventeen patients had drainage, and 10 (59%) lived. Total esophagectomy was performed in 9 patients, 7 (78%) of whom survived. Exclusion-diversion procedures were performed in 5 patients, and 1 (20%) survived.

Carcinoma of the esophagus: a comparison of the results of transhiatal versus transthoracic resection

The cases of 78 patients with primary esophageal carcinoma treated from 1977 to mid-1987 were retrospectively analyzed. Fifty-two of the patients underwent transthoracic esophagogastrectomy (TTE) and 26, transhiatal esophagectomy (THE). The two groups were statistically similar in preoperative characteristics except that more of the THE group had received chemotherapy; this group had relatively more tumors of the upper esophagus; and 20 (77%) of the THE group, compared with 50 (96%) of the TTE group, had tumors in stages III and IV. The incidence of major postoperative complications did not differ significantly between the two groups. There were five (19%) anastomotic leaks in the THE group, but only one led to a prolongation of hospital stay by more than 14 days, whereas all three (6%) of the leaks in the TTE group caused hospital stay to be prolonged several weeks. Overall morbidity was high: 75% (39/52) for the TTE patients and 85% (22/26) for the THE patients (p greater than 0.10). Hospital mortality was 6% (3/52) in the TTE group and 8% (2/26) in the THE patients (p greater than 0.10). There was no significant difference in actuarial survival either between the two groups as a whole or between those patients in each group who had stage III or IV tumors. We conclude that THE, among the types of patients for whom we used the procedure, provides long-term survival comparable with that provided by TTE without causing a significant increase in hospital mortality or morbidity.(ABSTRACT TRUNCATED AT 250 WORDS)

Surgical management of lung cancer with solitary cerebral metastasis

Between 1964 and 1986, 19 patients underwent resection of both a primary lung cancer and the associated brain metastasis. One patient underwent resection of 2 separate primary lung cancers and the associated metastases. The 12 men and 7 women ranged in age from 42 to 67 years (mean, 54.6 years). The cell type was adenocarcinoma in 12 tumors, squamous or adenosquamous cell in 5, large cell undifferentiated or anaplastic in 2, and malignant carcinoid in 1 tumor. The types of resection were as follows: lobectomy for 12 neoplasms, pneumonectomy for 5, bilobectomy for 2, and wedge resection for 1 neoplasm. Radiotherapy to the brain was given in connection with sixteen of the twenty craniotomies. The patient with 2 separate primary neoplasms survived 19 years before dying 5 months after the second craniotomy. The mean survival is 8.0 +/- 2.1 years (+/- the standard error), and the median survival is 1.67 years. Survival at 1 year was 65 +/- 10.7% and at 5 years, 45 +/- 11.1%. On univariate analysis, the following factors were found to correlate significantly with longer survival: a lung tumor in Stage I or II; negative mediastinal nodes; curative rather than palliative resection of the lung tumor; and age younger than 55 years. However, on multivariate analysis, only curative resection was a significant factor (p less than 0.01). We believe these results justify continued application of this combined surgical approach to patients having limited-stage lung cancer with a solitary brain metastasis.

Transhiatal esophagectomy for carcinoma of the esophagus: experience with 26 patients

Transhiatal esophagectomy was performed in 26 patients with esophageal carcinoma. The patients were selected for this procedure by means of transhiatal palpation of the tumor at laparotomy. Twenty had squamous cell carcinoma and 6, adenocarcinoma. The tumor locations were the upper third in 8, middle third in 12, and lower third in 6. On postoperative staging, 15 patients had Stage III and 6, Stage IV neoplasms. Among 25 elective resections there was 1 hospital death, which was due to severe coronary artery disease. One patient who had an urgent resection for a perforated carcinoma died of multisystem failure 32 days postoperatively. Complications included splenic injury requiring splenectomy in 5 patients; tracheal laceration in 2 patients (only 1 requiring a thoracotomy); azygos vein laceration requiring sternotomy for repair in 1 patient; chylothorax in 1; recurrent laryngeal nerve paralysis in 3 (temporary in 2); and transient anastomotic leaks in 3. Five patients had pneumonia with transient respiratory failure. Twelve of the operative survivors died of cancer 3.2 to 32 months postoperatively, and 12 are alive 3 to 28 months after operation. The actuarial survival is 53 +/- 11% (+/- standard error) at one year and 46 +/- 12% at two years. Transhiatal esophagectomy is a reasonable, safe operation that should be considered for tumors at all levels of the esophagus.

Bronchial adenoma: a review of 51 patients

The cases of 51 patients with bronchial adenomas were reviewed. There were 43 bronchial carcinoids, 5 adenoid cystic carcinomas, 2 mixed tumors, and 1 mucoepidermoid carcinoma. The carcinoid group was divided into typical (31, 72%) and atypical (12, 28%) subgroups. Nine carcinoids (20%) were categorized as metastasizing adenomas; in this group, 7 lesions were atypical and 2 were typical. Thirty-two lobectomies, 7 bilobectomies, 8 pneumonectomies, 2 sleeve resections, and 2 tracheal resections were performed. Ten-year survival was 88% for patients with typical carcinoids and 59% for those with atypical carcinoids. In the group with adenoid cystic carcinoma, 1 patient died postoperatively, 1 had recurrence of the tumor, 2 were alive and free from disease 16 and 23 years later, and 1 died of heart disease at 11 years. The patient with mucoepidermoid carcinoma was alive without recurrence 15 years after operation. In conclusion, bronchial adenomas of the carcinoid type are potentially malignant. Their prognosis depends on the histology of the tumor, and on the presence of metastasis to the regional lymph nodes and distant organs.

Thymectomy for myasthenia gravis: 14-year experience

Forty-eight consecutive patients with myasthenia gravis (MG) attended by generalized weakness were treated by complete thymectomy, performed transsternally in 46 patients and through a left thoracotomy in two with thymomas. There were no operative deaths. A 12-year-old child with fulminating MG died of acute pneumonia shortly after hospital discharge. Of the remaining 47 evaluable patients, thymectomy resulted in complete remission in six, marked improvement with a reduced need for medication in 20, and mild improvement on the same dosage of medication in 18. Neither the age of the patient, nor the histopathology of the excised thymus, nor the postoperative change in acetylcholine receptor antibody titer were found to have a significant influence on the response to thymectomy. If the ten patients who were 20 years of age or younger were excluded, the patients with a shorter duration of MG achieved a better response to operation. The authors conclude that thymectomy is effective treatment for MG, regardless of the age of the patient or the type of thymic pathology.

Management of penetrating cardiac injuries: the role of emergency room thoracotomy

Sixty-four consecutive patients with penetrating cardiac injuries were treated between January, 1977, and January, 1983, at the University of Maryland Hospital. Twenty-eight patients had major associated injuries of other organs. The patients were divided into groups according to their clinical status on arrival. An aggressive approach was utilized including early emergency room (ER) thoracotomy for "lifeless" or deteriorating patients. Three patients required immediate cardiopulmonary bypass for repair of their injuries. Twenty-one (57%) of the 37 patients undergoing ER thoracotomy survived; most of the deaths occurred in patients arriving "lifeless" from gunshot wounds. Twenty-four (89%) of the 27 patients who were in stable enough condition to undergo initial repair in the operating room (OR) survived. Overall survival was 45 patients (70%). Though superficial wound infections developed in 18 patients, there were no deep or systemic infections. None of the survivors sustained severe neurological sequelae. Five patients underwent late reoperations for closure of a ventricular septal defect (2), mitral valve replacement (1), and pericardiectomy (2) with no deaths. Though repair of penetrating cardiac injuries should preferably be carried out in the OR, immediate thoracotomy for "lifeless" or deteriorating patients can be performed in the ER with a low incidence of direct surgical complications and with high patient survival.

Migration of Kim-Ray Greenfield umbrella to the heart

We have described a case of migration of a Kim-Ray Greenfield umbrella from the inferior vena cava to the heart for unknown reason. The umbrella was surgically removed and the patient recovered fully. This complication has not been previously reported. Despite this complication, we believe that the Kim-Ray Greenfield umbrella, when placed with particular attention to technique, effectively prevents pulmonary emboli and offers minimal associated morbidity.

Carcinoma of the esophagus: twelve years' experience with a philosophy for palliation

Twelve years of experience have now been gained with a new therapeutic approach to carcinoma of the esophagus. In this approach, the primary goal of treatment is palliation, with cure an important but secondary objective. Carcinomas in the upper third of the esophagus are treated by radiation therapy unless there is severe obstruction or tracheal invasion, in which case colon interposition is performed. Limited resection with esophagogastrostomy is performed through a right thoracotomy and midline laparotomy for neoplasms in the middle third of the esophagus and through a left thoracotomy for carcinomas in the lower third. Since 1969, 161 patients have been evaluated, of whom 107 (66%) have been managed according to the new protocol. Twenty patients with carcinomas of the upper third of the esophagus were treated primarily by radiotherapy and 7 by colon interposition. Resection was performed in 78 of the 80 patients with carcinomas of the middle and lower thirds. There were 9 operative deaths (10%). Palliation, of superior quality to that obtained by previous methods, was provided to 95 of the 107 patients. Survival also is at least on a par with that obtained before.

Cardiac myxoma

Ten patients with cardiac myxoma were reviewed. The ranged from 23 months to 60 years old. Echocardiography was the most helpful noninvasive diagnostic technique. The tumor was demonstrated by angiocardiography, left atrial myxomas frequently migrating to the left ventricle in diastole. Hemodynamically, left atrial myxomas were associated with moderately severe pulmonary hypertension and simulated mitral stenosis or insufficiency and right atrial myxomas, with right atrial hypertension. There were 7 myxomas in the left atrium, 2 in the right atrium, and 1 in the right ventricle. Eight patients underwent open-heart operation with removal of the myxoma, 1 had concomitant tricuspid valve replacement, and 1 had biopsy of the right ventricle only. The other patient was a Jehovah's Witness and refused operation. One patient died of cardiac arrest intraoperatively, and another died of a bilateral cerebral infarct. One patient had recurrence requiring reoperation. Postoperative hemodynamic and clinical improvement was more striking in patients with a left atrial myxoma presumably due to a normal mitral valve in contradistinction to the tricuspid valve.

Pancoast's tumor: irradiation or surgery?

Seventy-three patients with Pancoast's tumor treated at the University of Maryland Hospital between 1955 and 1978 were reviewed. Three were 34 squamous cell carcinomas, 13 undifferentiated, 10 adenocarcinomas, 4 mixed adenosquamous, 1 alveolar cell, and 11 undetermined. Twenty-nine patients received irradiation, with 7% survival at 3 years; 19 patients underwent preoperative irradiation followed by en bloc resection of chest wall, with 23% survival at 3 years; 5 patients underwent extended resection, with 60% survival at 3 years; and 18 patients underwent operation followed by irradiation, with 7% survival at 3 years. Retrospective staging of 42 patients undergoing operation indicated that 22 (52%) were inoperable. Prognosis was related to staging of the disease, the extent of local invasion, nodal involvement, cell type, and adequacy of operation.

Palliation of esophageal carcinoma with intraluminal tubes: experience with 30 patients

Between 1968 and 1978, 26 patients with carcinomas of the thoracic esophagus and 4 with adenocarcinomas involving the esophagogastric junction were treated by the insertion of indwelling intraluminal (endoesophageal) tubes. Four different types of tube were inserted by the pull-through technique. Thirteen of the 30 patients died in the hospital within 30 days. However, among the 20 patients who did not have neoplasms of the upper third of the thoracic esophagus or who had not had a prior resection, only 5 died. The principal cause of death was aspiration pneumonia. Survival averaged 2.5 months. Four patients survived 5 to 7 months. Deglutition was adequate in most patients but was not as satisfactory as after esophagogastrectomy. Our best results were obtained in patients with carcinoma of the middle or lower third of the esophagus, with or without an esophagorespiratory fistula, who had not had a previous resection.

Bronchopleural fistula. Thirteen-year experience with 77 cases

Bronchopleural fistula, although reduced in incidence in recent years, remains a grave complication of pulmonary disease and of pulmonary resection. In a series of 77 patients treated for bronchopleural fistula over a 13 year period, 49 of whom had postresection fistulas, only 44 (57.1 percent) were cured of the fistula and 15 (19.5 percent) died. Prevention assumes great importance. Key factors in prevention are avoidance of pulmonary resection in tuberculous patients with positive sputum; overzealous dissection of the bronchus; a long bronchial stump; tumor in the bronchial stump; contamination of the pleural cavity; and too little tissue left behind to fill the pleural space. Treatment should be surgical. In none of the six patients treated conservatively was the fistula obliterated. Seventy-one patients were treated surgically, and 133 operations were needed to effect fistula obliteration in the 44 patients (62 percent) in whom this was achieved. Adequate surgical drainage has always been the sine qua non of effective treatment, and yet this alone brought about closure of the fistula in only nine patients. Early resuture of the bronchial stump succeeded in only two of five patients. Thoracoplasty combined with drainage effected closure in seven of 11 patients. The highest rate of fistula closure with the lowest mortality occurred among the 20 patients who underwent myoplasty, usually combined with a limited thoracoplasty. In this group, the fistula was obliterated in 16 patients, with one death.

Bronchial adenoma--benign or malignant?

Bronchial adenomas grow slowly and are potentially malignant. Of the 45 cases reviewed, 36 were carcinoids, six were adenocystic carcinomas, two were mixed tumors, and one was mucoepidermoid carcinoma. The carcinoid group is subdivided into histologically typical 27(75%), atypical 9 (25%), and metastasizing 9 (25%) adenomas. There were 32 lobectomies, seven pneumonectomies, one sleeve resection, and two tracheal resections for adenocystic carcinoma. Ten-year survival rate was 88% for typical carcinoids, 66% for atypical carcinoids, and 44% for metastasizing carcinoids. In the cylindroma group, one patient was lost to follow-up, one died postoperatively, and one developed recurrence of the tumor eight years later. The only patient with mucoepidermoid carcinoma is alive without evidence of recurrence nine years after operation.

Carcinoma of the esophagus: experience with a philosophy for palliation

The preliminary results of a new therapeutic approach to carcinoma of the esophagus were reported in 1972. The primary objective of treatment should be palliation, with cure an important but secondary goal. Lesions in the upper third of the esophagus are treated by irradiation unless there is severe obstruction or tracheal involvement, in which case colon bypass is carried out. Limited resection and esophagogastrostomy is performed through a right thoractomy and midline laparotomy for middle-third lesions and through a left thoracotomy for lower-third carcinomas. Since 1969, 85 patients have been evaluated, of whom 65 (76%) have been treated according to the new protocol. Thirteen patients with upper-third carcinomas were treated primarily by radiation therapy and 6 by colon bypass. Resection was performed in 45 of the 46 patients with middle- and lower-third lesions. There were 5 operative deaths (9.8%). The quality and duration of palliation have been far superior to that achieved by previous methods of treatment and, perhaps surprisingly, survival rates have improved.

Traumatic rupture of the aorta. A five-year experience

In the five-year period ending in October, 1975, 31 consecutive patients with traumatic rupture of the thoracic aorta underwent surgery at the University of Maryland Hospital or the Maryland Institute for Emergency Medicine. All cases were confirmed by preoperative aortogram. Rupture was confined to one or more sites in the descending thoracic aorta at or distal to the origin of the left subclavian artery. The age was a mean of 26 years. Operation was done within an average of 18 hours after injury. Significant nonthoracic injuries were present in every case. Six patients with positive findings on peritoneal lavage underwent exploratory laparotomy prior to thoracotomy because of shock. Surgical repair was done by use of left heart bypass in 2 cases (one death), a passive aorta-aorta shunt in 23 cases (5 deaths), and without shunt or bypass in 6 cases (no deaths). An end-to-end tubular Dacron graft was used to reconstruct the aorta in all but one patient. Over-all survival rate was 25 of 31 patients (81 per cent). Paraplegia developed in one patient and renal failure in 3 patients (2 deaths) in the aorta-aorta shunt group. Hypertension was present in 18 (72 per cent) of the survivors. Palsy of the left recurrent laryngeal nerve persisted in 8 (32 per cent) of the survivors. Two of the deaths were related to technical problems of the shunting procedure and 2 to intrapleural exsanguination before proximal aortic control could be achieved. Complications and blood loss were reduced in the group with no shunt. The series lends support to the rigorous aortographic search for ruptured thoracic aortas in trauma patients with widened mediastinum. Once experience has been gained with shunting techniques, tears of the descending thoracic aorta may be safely repaired without shunt if done expeditiously.

Pulmonary aspergillosis: an analysis of 41 patients

During the period 1969 to 1974, 41 patients having cultures positive for aspergillus were seen on the thoracic surgical services of the University of Maryland and Mt. Wilson State Hospitals. Intracavitary mycetoma was present in 36 patients. In 32 the underlying disease was chronic cavitary tuberculosis, 5 had decreased immunity due to other diseases, and in 3 no underlying disease was noted. One final patient developed a mycetoma following repair of tetralogy of Fallot. Hemoptysis, the predominant symptom, occurred in 23 patients, all of whom were from the group with intracavitary mycetoma. Hemoptysis was life-threatening in 8 patients, severe but not life-threatening in 12, and minimal in 3. Fifteen patients underwent pulmonary resection with 2 deaths. Both patients who died had undergone emergency resection for life-threatening hemoptysis; the fungus ball had developed following a previous resection for tuberculosis, and both had poor pulmonary reserve. Of 10 patients with hemoptysis who were not treated surgically, chiefly because they were poor operative risks, 4 died. This study suggests that pulmonary aspergillosis, particularly of the intracavitary type, is a potentially life-threatening disease. Because of the suddenness with which massive hemoptysis may occur, pulmonary resection is recommended for all patients with intracavitary mycetoma who do not constitute prohibitive operative risks.