Metastatic carcinoma of the distal ulna from an occult pancreatic carcinoma

A case of pancreatic carcinoma presenting as a pathologic fracture of the distal ulna is reported. To the best of our knowledge, metastatic pancreatic carcinoma distal to the elbow has never been reported. An attempt to stabilize the fracture with intramedullary fixation and methacrylate augmentation was unsuccessful. Because of the dismal prognosis of pancreatic carcinoma, therapy should be directed toward pain control and maintenance of function in these patients.     

Parietal cell autoantibodies and hypergastrinemia in achlorhydria and the Zollinger-Ellison syndrome.

Parietal cell autoantibody (PCA), basal gastrin, and calcium-stimulated gastrin were measured in twenty patients with achlorhydria, in eight patients with the Zollinger-Ellison syndrome, and in fifty control subjects. In twelve patients with achlorhydria with a spared antrum, PCA was positive and basal gastrin was elevated. In contrast, eight achlorhydric patients with antral gastritis had negative PCA and significantly lower basal gastrin levels. Patients with the Zollinger-Ellison syndrome did not demonstrate positive PCA despite elevated levels of basal gastrin, nor was PCA present in normal controls. This study suggests that certain achlorhydric states are caused by an autoimmune response, particularly if antral function is spared.     

Surgical alteration of intestinal motility

Small Teflon-coated stainless steel wire electrodes were used to monitor the electrical changes associated with “artificial sphincters” produced by ablation of segments of longitudinal muscle. In the area of muscle ablation there were disorganized slow waves of low amplitude compared to adjacent normal intestine. There also was a definite increase in action potentials at the “sphincter” site. The “sphincter” appeared to be more sensitive than normal to stimulation with small doses of cholinergic drugs. Inhibition was produced by stroking the bowel, by intravenous adrenalin, and by balloon distention. Intraluminal pressure studies using small balloon-tipped catheters demonstrated higher pressures at the “sphincter” than at sites either oral or aboral to it.We believe that the attenuated slow-wave activity in the “sphincter” is transmitted to the circular layer from the residual intact neuromuscular elements at the mesenteric border of the intestine. Apparently the loss of ganglion cells renders the residual circular muscle more sensitive to stimulation and produces a segment having increased contractile activity.     

Surgical correction of aganglionic megacolon

Standard procedures for the treatment of aganglionic megacolon include resection of abnormal colon. A procedure has been developed in dogs which obviates resection by insertion of a jejunal pedicle graft along the entire length of the narrowed segment. Results were evaluated by intraluminal pressure recordings, barium enema studies, and clinical observation.     

Effect of paired ventricular pacing upon myocardial infarction size

Although paired ventricular pacing may improve cardiodynamics following acute myocardial infarction, its effect on myocardial infarct size is not known. In 22 dogs, acute myocardial infarction was produced by selective coronary artery ligation. High fidelity left ventricular pressure, $\text{dp}\text{dt}\text{max}$, acceleration of aortic flow ($\text{dQ}\text{dt}$), coronary flow and epicardial mapping were recorded before and at 15-min intervals following acute myocardial infarction for a total of 90 min. Coronary sinus CPK was measured before coronary occlusion and then every 30 min for a period of 150 min. In Group A (n = 10) animals had an acute myocardial infarction only, while in Group B (n = 12), paired ventricular pacing was initiated 30 min postinfarction and continued throughout the study.Two dogs from Group A and six from Group B developed ventricular fibrillation and were excluded from the study.In Group A $\text{dp}\text{dt}\text{p}\text{,}\text{dQ}\text{dt}$ and heart rate did not change, while in Group B $\text{dp}\text{dt}\text{p}$ increased from 20.0 ± 1.5 to 30.2 ± 1.5 (P < 0.05) and $\text{dQ}\text{dt}$ increased from 19.0 ± 1.7 to 27.1 ± 2.5 (P < 0.05). Coronary flow, arterial and coronary sinus blood gases were similar in both groups. CPK increased more in Group B than in Group A (P < 0.05). ΣST was unchanged in Group a between 30 and 90 min post-infarction while in Group B ΣST increased at the same period from 36.0 ± 2.8 to 62.5 ± 8.6 (P < 0.05).These data indicate that paired ventricular pacing increased ischemic injury in acute myocardial infarction, due to increased oxygen consumption resulting from the positive inotropic effect exceeding the influence of a decreased heart rate.     

Endoscopic pancreatography: its value in preoperative and postoperative assessment of pancreatic disease.

Examples of the use of endoscopic pancreatography in the preoperative evaluation and postoperative follow-up study of patients with pancreatic disease are presented and discussed. Six cases selected from a total experience of forty-eight patients have been summarized. The direct role of pancreatography in the management of these cases is cited. There is a small but definite risk to the procedure. With increased use of endoscopic pancreatography, it is hoped that earlier diagnoses of a variety of pancreatic diseases will be obtained which will permit more accurate medical and surgical therapy.     

Easy insertion of a feeding tube

A small bore feeding tube may be readily introduced into the stomach by splinting it internally, before insertion, with a flexible arteriographic guide wire, which is removed when the tube is in place. Gentle placement of the tube is recommmended.     

Symptomatic histoplasmosis in children

Symptomatic histoplasmosis in children is rare and presents difficulties both in differentiation from neoplasm and in the mode of therapy. Thirty-two children with an average age of 8.3 years were studied over a 10-year period for this disease. The most frequent symptoms were chronic fever (25 of the 32 patients), malaise (18 patients), significant weight loss (9 patients), and chest pain (6 patients). While physical evidence of a pneumonic process was present in 11 children, 19 had lymphadenopathy and 10 had hepatic or splenic enlargement or both. Chest roentgenograms demonstrated noncalcified masses and infiltrates in 29 children. Nine patients required operation, primarily for a presumptive diagnosis of neoplasm, including six thoracotomies, one liver abscess drainage, and two pericardiectomies. No operative deaths or morbidity occurred. Six children suffered significant morbidity from the disease.Unlike the chronic process in adults, histoplasmosis in children may strongly mimic neoplasm. Skin and serological testing, while beneficial, are of limited usefulness in endemic regions. Operative intervention is justified when careful patient evaluation cannot confirm the diagnosis.     

A retrospective and prospective study of serial CEA determinations in the early detection of recurrent colon cancer.

The results of the present study emphasize the importance of minimizing the time delay between a significant elevation in CEA and a second-look operation. Equally important are the frequency of serial determinations, a thorough understanding of the limitations of the assay, and careful evaluation of the clinical condition of the patient.     

Changes in the pathogenesis and detection of intrahepatic abscess.

A comparison of two distinct 11 year time periods at our institution demonstrated a change not only in the cause of intrahepatic abscess but also in the procedures used to diagnose this condition. Significant improvement in the methods of detection of intrahepatic abscess permits earlier diagnosis and therapy and thus a significantly improved prognosis.     

Experimental hyperbilirubinemia: effect on glomerular filtration

The hyperbilirubinemia state, as shown in a canine shunt model producing bilirubin levels comparable to those high levels seen in clinical practice, was associated with a 54% decrease in renal creatinine clearance. The amount of deterioration in glomerular function was proportional to the extent of hyperbilirubinemia obtained. Plasma volume in the jaundiced animal was decreased 21% from control values. Decreased renal perfusion may have been responsible for the descreased glomerular filtration rate observed.     

Studies of paralytic ileus. Effects of intraperitoneal injury on motility of the canine small intestine.

This study is significant in demonstrating that the small intestine of the dog is extremely resistant to paralytic ileus. The various types of intra-abdominal irritation studied were quite severe. After a transient period of inhibition, however, in most instances motility of the small intestine returned and continued until near the time of death. Various types of intra-abdominal irritation were used to study paralytic ileus in dogs, including intraperitoneal injection of gastric juice, gastroperitoneal fistula, appendiceal ligation, intraperitoneal injection of Lugol's iodine solution, retroperitoneal injection of blood, and mechanical and thermal irritation of the intestine and peritoneum. The electrical and mechanical activity of the small intestine was observed by means of a Thomas cannula implanted in the jejunum. The presence or absence of fluid accumulation within the intestinal lumen or peritoneal cavity was noted at autopsy. Intra-abdominal chemical irritation caused a transient inhibition of intestinal motility, which was reversed when the irritation was stopped. Repeated irritation did not appear to cause progressive, irreversible inhibition of intestinal motility. When intestinal motility was depressed, spike potentials were absent in the recordings of electrical activity of the intestine. The "slow" electrical waves were distinguishable at all times. With the exception of the gastroperitoneal fistulas, the procedures were tolerated with only transient inhibition of intestinal motility. Accumulation of intraperitoneal fluid occurred in dogs subjected to gastroperitoneal fistulas. A small amount of intraluminal fluid accumulated in dogs subjected to repeated thermal and mechanical irritation of the intestines and peritoneum. In the other groups of dogs no significant increase in intestinal or intraperitoneal fluid was observed.     

Suppression by heparin of injury-induced myointimal thickening

To ascertain the effect of heparin upon intimal smooth muscle cell proliferation after arterial endothelial injury, we subjected young male Sprague-Dawley rats to right carotid air injury and infused them with heparin intravenously for 5, 10, and 14 days after surgery. Control animals received lactated Ringer's solution. Marked inhibition of intimal smooth muscle cell proliferation was observed in the heparinized rats as compared to controls. This profound heparin effect may be due to the enhancement by heparin of antithrombin III inhibition of thrombin and suggests a hitherto unsuspected role of the clotting system in an injury-induced smooth muscle cell proliferation.     

Food-choking and drowning deaths prevented by external subdiaphragmatic compression. Physiological basis.

Applying subdiaphragmatic compression has been successful in saving victims of food-choking and drowning by expelling the asphyxiating bolus or aspirated water. Sudden elevation of the diaphragm compresses the lungs, which explosively forces air out through the trachea, ejecting the obstructing object. The flow rate, pressure, and volume of air expelled were determined in 10 subjects and found to be substantial, providing confirmation of the effectiveness of the procedure.     

Demonstration and characterization of the hemoconcentrating effect of ascitic fluid that accumulates during hemorrhagic pancreatitis

Plasma volume deficit and hemoconcentration in hemorrhagic pancreatitis may be induced by vasoactive factors released by the inflamed pancreas. The ability of intraperitoneally injected pancreatic ascitic fluid (human and experimental) to produce hemoconcentration was examined in 210 female Sprague-Dawley rats (200–250 g) randomly assigned to five groups: 56 (control); 10 (5 cc dog plasma); 20 (5 cc normal saline); 10 (5 cc human pancreatic exudate (HPA)); 124 (5 cc ascites from dogs (10) with bile salt-trypsin pancreatitis (EPA)). Pancreatic exudate was passed through a 0.2-μm filter, injected, and after 2 hr tail vein hematocrits were determined and rats autopsied. Statistical significance was determined by Student's unpaired t test. Control hematocrit (HCT) was 45.1 ± 0.55 (SEM), not different from plasma- or saline-treated animals. Rats receiving HPA had a mean HCT higher than that of controls (52.9 ± 0.0, P < 0.001). Ten subgroups receiving EPA had a mean HCT from 46.5 ± 0.6 to 52.2 ± 0.9, and 7 of the 10 demonstrated significant hemoconcentration. Active trypsin and osmolality of EPA were excluded as causative. Hemoconcentrating effect of EPA remained after freezing at ?20°C for up to 7 months, heating at 56°C for 10 min, treatment with 10% trichloroacetic acid (TCA), and extraction with equal volumes of anydrous ether. Ultrafiltered (1000-dalton Amicon) TCA-treated EPA showed persistence of hemoconcentrating effect. A biologically active factor (likely a peptide with molecular weight below 1000 daltons in the pancreatic exudate may cause hemoconcentration, and may be responsible for continued plasma loss in acute pancreatitis.