Tumor volume as a prognostic factor for sarcomatosis

BACKGROUND: The appropriate therapeutic interventions for sarcomatosis, or sarcoma characterized by intraabdominal dissemination, remain unclear. The authors performed a retrospective analysis of their recent experience with patients diagnosed with sarcomatosis to determine the overall survival and the effects of clinicopathologic features on survival rates at two and four years. METHODS: A query of the authors' prospective soft tissue sarcoma database identified 51 patients with a diagnosis of sarcomatosis who were evaluated at the authors' institution between June 1996 and June 1999. Clinical and pathologic factors were evaluated, and survival was calculated using a Kaplan-Meier survival analysis. Disease was categorized as low or high volume based on findings at surgical exploration or computed tomography scan evaluation. Disease was classified as low/intermediate grade or high grade based upon histologic examination. RESULTS: Twenty five patients were male and 26 were female. The median time from the initial diagnosis of sarcoma to the development of sarcomatosis was 0.9 years (range, 0-26 years). Thirty nine patients were treated with surgery, whereas 32 received primarily nonsurgical treatment. Histology revealed gastrointestinal stromal tumor (GIST) in 33 patients and other histologies in 18 patients. The two year overall survival rate of patients with GIST was similar to that of patients with other types of sarcoma (38% versus 42%, respectively, P = 0.77). Patients with low volume disease had an overall two year survival rate of 82%, compared with only 24% for patients with high volume disease (P = 0.008). There was no difference in the overall survival rates of patients with low grade (n = 18) versus high grade tumors (n = 33, P = 0.29). With a median followup of 2.7 years (range, 0.5-26.4 years), the median time from sarcomatosis to death was 13 months (range, 4-42 months). CONCLUSIONS: Evaluating volume of disease at the time of diagnosis permits stratification of patients into prognosis based subsets. We found no significant difference in two or four year survival rates in patients with GIST and those with non-GIST sarcomatosis.     

Assessment of mortality rates for congenital heart defects and surgeons' performance

BACKGROUND: In the absence of reliable national data, we have collected results of all operations for congenital heart defects from five departments to assess mortality rates and compare them among surgeons and departments. METHODS: Data relating to all operations (2,718) carried out at the five centers during a period from April 1, 1997 through March 31, 1999. Clearly defined criteria were agreed for the classification of patients into various subgroups. RESULTS: The overall hospital mortality was 4.4% (95% confidence intervals 3.7%-5.3%). Mortality for open-operations was 12.6% in neonates, 5.1% in infants, and 3.5% in children. Mortality rates were 1.1% for coarctation, 0.4% ventricular septal defect, 4.1% atrioventricular septal defect, 2.9% Fallot, 0.9% switch, and 15.6% truncus arteriosus. Although individual surgeons' mortality rates ranged from 1.8% to 7.5%, none of the 12 surgeons' data were above 95% confidence intervals. For individual surgeons, the change in mortality rates between the 2 years ranged between -3.3% and +3.8%. CONCLUSIONS: With 2 years' data available, estimates of mortality rates are more precise as reflected by tighter confidence intervals. There were relatively small data sets for individual hospitals and surgeons, which made statistical evaluation difficult. For setting standards, data from more departments for a longer period will be required. Statistical methods alone cannot be used as a sole arbiter of what is considered acceptable performance.     

Adenocarcinoma arising in a retained esophageal remnant

Fistulation between the trachea and an infected mucocele arising from an excluded retained esophageal segment is an interesting and unusual complication of esophageal bypass surgery. We present such a case in which there was also malignant transformation in the cyst wall, manifested by invasive adenocarcinoma and widespread high-grade glandular dysplasia.     

Adverse operative events in neurosurgical training: incidence, trends and proposals for prevention

We prospectively studied the adverse operative events encountered during the first 4.5 years of a single neurosurgeon's career (JP). We investigated the incidence of these events and their distribution over time, and recorded risk factors in causation. Twenty-three adverse events were identified in 728 cases studied. These all occurred in one of four categories of operation: craniotomy, shunt placement, spinal surgery and stereotactic biopsy. The incidence of adverse operative events varied between 5.8% for spinal operations to 9.5% for stereotactic biopsy. There was evidence of a reducing incidence of adverse operative events over time in some operative groups. The two categories with the highest incidence of adverse operative events were the same two categories with the lowest number of assisted cases per 100 operations performed.     

Expression of voltage-dependent potassium channels in the developing visual system of Xenopus laevis

Accumulating evidence suggests that voltage-dependent potassium (Kv) channels have important and varied roles in the development of neuronal and non-neuronal cell types. They have been implicated in processes such as proliferation, cell adhesion, migration, neurite outgrowth, and axon guidance. In this study, we used antibodies against several electrically active Kv channel alpha-subunits (Kv1-4) to describe the spatial and temporal expression patterns of Kv channel subunits in Xenopus laevis retinal ganglion cell (RGC) somata, axons, and growth cones. We found that RGCs express Kv1.3-, Kv1.5-, Kv3.4-, and Kv4.2-like subunits. Each subunit displayed unique cellular and subcellular distributions. Moreover, the expression patterns changed considerably over the major period of Xenopus retinal cell genesis and differentiation. Weak or no immunoreactivity was observed with antibodies against Kv1.1, Kv1.2, Kv1.4, Kv1.6, and Kv3.2 subunits in RGCs or other retinal cell types. In support of our previous pharmacologic evidence implicating Kv channels in RGC axon outgrowth, we found that Kv1.5-, Kv3.4-, and Kv4.2-like proteins, but not Kv1.3-like subunits, are abundantly expressed in RGC growth cones.     

Risperidone and 9-hydroxyrisperidone concentrations are not dependent on age or creatinine clearance among elderly subjects

Risperidone is extensively metabolized to an active metabolite, 9-hydroxyrisperidone (9-OH), which is dependent on renal clearance. Risperidone and 9-OH clearances are reduced in the elderly when compared to young subjects. The objective of this study was to determine whether among elderly subjects, risperidone and 9-OH clearance would further decline with increasing age and decreasing creatinine clearance (CrCl). Twenty geriatric inpatients were evaluated in a naturalistic setting with regard to total daily risperidone dose and dosing interval. Creatinine clearance was determined using an 8-hour urine collection. Risperidone and 9-OH concentrations were determined by radioimmunoassay. Spearman's correlation coefficients were used to examine the impact of age and CrCl on concentrations of risperidone, 9-OH, their sum, and the quotient of 9-OH/risperidone. Mean age was 76.4 +/- 9 years (range 56-91). Mean CrCl was 55.4 +/- 32.8 mL/min/1.73 m2 (range 17-142 mL/min/1.73 m2). Mean risperidone daily dose was 1.3 +/- 0.7 mg. Steady-state risperidone and 9-OH concentrations were 4.1 +/- 5.3 ng/mL and 9.1 +/- 6.2 ng/mL, respectively. Mean 9-OH/risperidone was 6.2 +/- 6.1. Concentrations of risperidone, 9-OH, their sum, and 9-OH/risperidone were not significantly correlated with age or CrCl. These results were unchanged when concentrations were corrected for total daily risperidone dose. Among elderly subjects, risperidone and 9-OH clearance do not decline with increasing age or declining CrCl.     

Effect of artificial food colours on childhood behaviour.

We performed an objective evaluation of 39 children whose behaviour was observed by their parents to improve on an artificial food additive free diet and to deteriorate with dietary lapses. Only 19 children completed a double blind placebo controlled challenge study with artificial food colours. In these children food colours were shown to have an adverse effect on a daily Conners'' rating of behaviour, but most parents could not detect these changes. A pharmacological mechanism of food additive intolerance is proposed to explain these effects.     

Transplacental fetal hemorrhage after amniocentesis

A retrospective survey of Winnipeg Rh laboratory data from January 1, 1981 to December 31, 1984 determined that, despite placental localization, 2.6% of 974 women having amniocenteses performed at 16 to 18 weeks' gestation for genetic reasons and 2.3% of 1215 women having amniocenteses performed between 32 and 38 weeks' gestation had fetal-maternal transplacental hemorrhages greater than or equal to 0.1 mL of fetal red cells due to placental trauma. In 1.6 and 1.8%, respectively, the fetal transplacental hemorrhages were greater than or equal to 1 mL. Four of 99 alloimmunized women undergoing 257 amniocenteses for determination of severity of fetal erythroblastosis had fetal transplacental hemorrhages all greater than 5 mL of fetal red cells. The 1.9% incidence of fetal transplacental hemorrhages after amniocentesis in alloimmunized women is 83% less than the 11.2% incidence that occurred in the authors' institution from February 1963 to December 1966. However, in three of the four women, there was a very rapid rise in Rh antibody titer and increased severity of Rh fetal disease. Only the alloimmunized woman who meets strict criteria, indicating that her fetus is at risk of fetal death, should be subjected to amniocentesis, and then only after careful placental localization by ultrasound. Because fetal transplacental hemorrhages occur after amniocentesis despite ultrasound placental localization, 300 micrograms of Rh immune globulin should be administered to all unimmunized Rh negative women after amniocentesis.