Survival after first recurrence of breast cancer. The Miami experience.

BACKGROUND. Four hundred thirty-three patients with recurrent breast cancer were treated by the authors at a large medical breast oncology facility from 1976-1982. The median survival time from first relapse (MSFR) for the 193 patients whose survival experience was not confounded by lead-time bias was 26 months. This MSFR is similar to that of most series published in the 1970s and 1980s and is approximately double that of series published in the 1960s. METHODS. In this series, regression analysis identified disease-free interval (DFI), estrogen receptor (ER) status, and dominant disease site as significant prognostic variables, similar to other published series. RESULTS. In 113 patients with known ER values, DFI, and dominant metastatic sites, a prognostic spectrum of MSFR patterns was identified among combinations of these three variables. The MSFR ranged from 15 months for poor risk patients with negative ER values, visceral dominant sites, and DFI of less than 24 months, to more than 90 months for good risk patients with positive ER values, soft tissue dominant sites, and DFI of more than 24 months. Although menopausal status alone was not a significant prognostic variable in regression analysis, 66% of premenopausal patients had a constellation of "poor" prognostic variables. CONCLUSIONS. This type of prognostic factor analysis at first relapse could help identify subsets of patients who might be considered for aggressive investigational therapies such as high-dose chemotherapy with autologous bone marrow reconstitution.     

Side effects during continuous epidural infusion of morphine and fentanyl

Respiratory effects, nausea, somnolence, and pruritus were compared during a 48-hr period of continuous epidural morphine (n = 34) and fentanyl (n = 32) infusion in 66 patients following elective total replacement of the hip or knee joint. Respiratory effects were assessed by PaCO2. Side effects were assessed by visual analogue scale and considered to be present when the score was above 30. Assessment was made at preoperative visits then 3, 6, 12, 24, 36, and 48 hr after the epidural injection. The bolus dose and subsequent infusion rate were 3,900 +/- 1,300 micrograms and 427 +/- 213 micrograms.hr-1 for morphine, and 85 +/- 46 micrograms and 56 +/- 27 micrograms.hr-1 for fentanyl. Pain relief was similar in both groups. In the morphine group, PaCO2 elevation and nausea occurred over a period of more than 12 hr (P less than 0.05). In the fentanyl group, there was no PaCO2 change, and nausea was confined to the first few hours. Nausea was more severe (P less than 0.01 at six hours and more frequent (24 hr cumulative incidence, 53 vs 28%, P less than 0.05) in the morphine group. Somnolence was prominent within several hours in two-thirds of patients in both groups. Somnolence continued to decline thereafter in the morphine group, but it was demonstrable in approximately half of the patients throughout the second day in the fentanyl group. The incidence was higher in the fentanyl group at the 48th hr (P less than 0.05).(ABSTRACT TRUNCATED AT 250 WORDS)     

Unsere Erfahrungen mit der Infektionsprophylaxe und -therapie nach 53 Lebertransplantationen

Summary An attempt was made to reduce the risk of infection following liver transplantation by means of selective bowel decontamination with tobramycin, polymyxin E and amphotericin B, as well as short-term systemic antibiotics with cephotaxim and tobramycin. After 53 consecutive orthotopec hepatic transplants performed in 51 patients between 1985 and 1987, a total of eight pneumonias occurred as the clinically most significant infection. Two pneumonias were caused by cytomegalovirus, one by Pneumocystis carinii, one by Candida and the remaining four by various bacteria. In 6 patients, bacteria were cultured from the blood, but only in one case was an indwelling catheter identified as the source of the septicemia. Taking all samples together, Streptococcus faecalis was the bacterium most frequently cultured, which was not covered by the prophylactic antimicrobial regime applied. Pseudomonas, however, and gram-negative bacteria were demonstrated much less frequently. Vaginal and oral Candida infections, as well as oral and genital herpes simplex infections, responded well to topical therapy with fungicide and aciclovir, respectively. Three patients developed cytomegalovirus (CMV) hepatitis. All five CMV infections were successfully treated with ganciclovir and hyperimmunoglobulin, as well as reduction of prophylactic immunosuppression. Out of 15 patients transplanted for posthepatitic cirrhosis, 7 developed a recurrence of the infection (5 hepatitis B virus) 2 hepatitis C virus) in the graft. Two died of the cirrhosis, three are still alive with cirrhosis but sufficient graft function, and one patient is suffering from chronic active hepatitis. One patient grafted for acute hepatic failure was able to clear the delta virus within 1 year post-transplant. During the perioperative phase, however, we never lost a single patient to infectious complications. Therefore, bowel decontamination and antibiotic prophylaxis, including Streptococcus faecalis, are recommended.

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Unsere Erfahrungen mit der Infektionsprophylaxe und -therapie nach 53 Lebertransplantationen

Zusammenfassung Durch selektive Darmdekontamination mit Tobramycin, Polymyxin E and Amphotericin B über 8 Tage and kurzzeitige Antibiotikatherapie mit Cefotaxim und Tobramycin wurde versucht, die hohe Infektionsrate nach Lebertransplantation zu reduzieren. Nach 53 konsekutiven orthotopen Leberverpflanzungen bei 51 Patienten zwischen 1985 and 1987 traten als klinisch bedeutsamste Infekte 8 Pneumonien auf. Bei 4 Patienten waren these bakterieller Natur, 2 durch Cytomegalovirus verursacht, 1 durch Pneumocystis carnii and 1 durch Candida. 6 Patienten hatten eine Septikämie, wobei nur in 1 Fall ein Venenkatheter als Ausgangspunkt identifiziert werden konnte. Alle Proben zusammengenommen wurde am häufigsten Streptokokkus faecalis kultiviert, ein Keim, der durch das angewendete antimikrobielle Regime nicht erfaßt wird. Pseudomonaden hingegen und gramnegative Stäbchen wurden in einem wesentlich geringeren Prozentsatz nachgewiesen. Vaginale and orale Candidainfektionen erlangten ebenso wie orale and genitale Herpes simplex-Infektionen kaum Krankheitswert und wurden jeweils topisch mit einem Antimykotikum bzw. Acyclovir behandelt. Neben den 2 CMV-Pneumonien wurden auch 3 durch CMV verursachte Hepatitiden beobachtet. Alle CMV-Infekte konnten mit Gancyclovir und Hyperimmunglobulin bei gleichzeitiger Reduktion der Basisimmunosuppression beherrscht werden. Von 15 Patienten, die wegen posthepatitischer Zirrhose transplantiert wurden waren, entwickelten 7 eine Reinfektion des Transplantates (5 HBV, 2 HCV), wovon 2 an der Zirrhose verstarben, 3 mit einer Zirrhose and noch ausreichender Transplantatfunktion leben, wie auch der Patient, der eine chronisch aktive Hepatitis entwickelt hatte. Eine im akuten Leberversagen transplantierte Patientin hat das Deltavirus innerhalb eines Jahres eliminiert. In der perioperativen Phase wurde jedoch kein einziger Patient an einer infektiösen Komplikation verloren, so da auch bei fehlender Kontrollgruppe die Darmdekontamination sowie die antibiotische Kurzzeitprophylaxe empfohlen werden können.

     

A variant of guided exposure to mourning for use with treatment resistant patients.

We report a variant of "guided exposure to mourning," designed for use with patients who have proved resistant to other treatments for unresolved, morbid grief. The work provides some indication as to when such behavioral techniques for resolution of morbid grief are likely to prove successful, and when not.     

Exceptional diabetic arthropathy of the foot (author's transl)]

The osteopathy of the foot is a rare complication of diabetes mellitus. It is seen in the distal parts mostly. The arthropathy ("Charcot-joint") is even more rare, and is regularly combined with a neuropathy. The roentgen signs of the "diabetic foot" are demonstrated, as there are osteoporosis, iuxta-articular cortical defects, osteolysis of the bone ends, bone destruction and reconstruction, periost reaction and sklerosis of the bone shafts.     

Radiographic findings after duodenal surgery (author's transl)]

A gastroduodenostomy as part of partial gastric resection may change function and morphology of the duodenum in a typical fashion. End to side anastomosis may produce a blind pouch. An end to end anastomosis may lead to postanastomotic dilatation, which may mimick a duodenal bulb (a so called "neo -- or pseudobulb"). Abnormal duodenal peristalsis with atony may follow vagotomy, pyloroplasty, gastroduodenostomy or excisional duodenal biopsy and may thus result in functional obstruction. A blind loop syndrome may develop after bypass procedures for duodenal stenosis.     

Influence of age and of desmotropic drugs on the step phenomenon observed in rat skin

Summary Comprehensive analysis of the mechanical properties of rat skin revealed the step phenomenon. This particular observation was made after constant strain rate (analysis of stress strain curves) as well as after constant load (creep experiments). Relative low extensions or low loads were necessary to provoke the steps. In most cases two, sometimes three steps were observed. The step phenomenon was found mainly in skin strips punched out perpendicularly to the body axis. Probably some bonds in the fibrous network are broken giving way to additional elongation whereafter stronger links take over the stress. Since earlier studies demonstrated a pronounced influence of age and of desmotropic drugs on mechanical properties at ultimate load, e.g., tensile strength, ultimate modulus of elasticity, and ultimate strain, also the step phenomenon was studied under these conditions. In stress-strain experiments most of the steps were found at the ages of 2 and 4 months. Total stress loss and total work loss due to the steps were the highest at the age of 4 months. If, however, these values were calculated as percentage of ultimate values, the highest figures were found in young animals. Elongation gain due to the steps also showed a maximum at time of maturation, e.g., 4 months. Similar findings were achieved in creep experiments at medium load (200 g). After treatment with prednisolone acetate more steps and after treatment with d-penicillamine fewer steps were observed. In stress-strain experiments total stress loss and total work loss due to steps were more than twice as high than controls after prednisolone treatment and only one half after d-penicillamine. If calculated as percentage of ultimate stress or percentage of work input, these changes disappeared because of similar changes at ultimate load. However, elongation gain due to steps, which was not significantly influenced by prednisolone acetate but significantly decreased by d-penicillamine, showed the same changes when calculated as percentage of ultimate strain. Under all conditions the step phenomenon mainly influenced the extension parameters. The data presented here confirm earlier observations that mechanical properties at low loads or low and medium extensions show at least to some extent a different pattern under the influence of maturation and age and after treatment with desmotropic drugs compared to the mechanical parameters at ultimate load.     

MAO inhibition and the effects of centrally administered LSD,serotonin, and 5-methoxytryptamine on the conditioned avoidance response in rats

Pretreatment with the MAO-inhibitors iproniazid, clorgyline, or deprenyl abolishes the effects of LSD on the conditioned avoidance response (CAR) in rats. The effects of serotonin (5-HT) and 5-methoxytryptamine (5-MT) are greatly potentiated by these substances. Brain levels of LSD are not affected by MAO inhibition whereas levels of 5-HT and 5-MT are significantly elevated. It is postulated that the decreased behavioral response to LSD is the result of MAO inhibitor-induced changes whereas the increased response of 5-HT and 5-MT results from increased brain levels of these compounds.     

Cystic lesions of the pineal region – MRI and pathology

Pineal lesions are rare. Tumours in this location comprise 0.4–1 % of intracranial tumours. They grow mainly as solid-mass lesions, and cystic tumours are not common. On MRI, a cystic configuration is associated usually with non-neoplastic pineal lesions rather than with a tumour, but analysis does not allow cystic pineal tumours to be distinguished from glial cysts with certainty. We compared neuroradiological and pathological data from 13 cystic pineal lesions, analysing preoperative MRI. Formalin-fixed, paraffin-embedded surgical specimens were stained routinely and immunocytochemically, using the streptavidin-biotin-complex method. Histology revealed six pineocytomas, four glial cysts, an arachnoid cyst, a low-grade astrocytoma and a teratoma. Signal characteristics of pineocytomas were similar in many respects to those of glial pineal cysts. Histomorphological analysis allowed unambiguous discrimination between pineocytomas and glial pineal cysts. Received: 19 July 1999/Accepted: 3 September 1999