Readmissions after pancreaticoduodenectomy: efforts need to focus on patient expectations and nonhospital medical care

Readmissions after operations are a burden. This study was undertaken to determine factors predicting readmissions after pancreaticoduodenectomy. Since 1991, patients undergoing pancreaticoduodenectomy have been prospectively followed. Nineteen per cent of 913 patients were readmitted within 30 days after discharge from pancreaticoduodenectomy. The causes for readmissions were reviewed. Median data are presented. All patients had preoperative comorbidities; most common were cardiovascular (26%), gastrointestinal (23%), or endocrine (15%). Twenty-nine per cent had extended pancreaticoduodenectomy, including major vascular resections. The most common reasons for readmission were: nausea/vomiting (26%), wound infection (15%), and abdominal pain (18%). Gender, body mass index, duration of operation, blood loss, length of stay, pathology, American Joint Committee on Cancer? stage, and margin status did not predict readmission. Patients being readmitted were younger (65 vs 69 years, P < 0.001) and had more comorbidities (P < 0.001). Readmission did not curtail long-term survival. Pancreaticoduodenectomy is a complex operation undertaken in patients with notable comorbidities. Readmissions occur frequently after pancreaticoduodenectomy and patients with more comorbidities are at particular risk. Readmissions are not generally the result of complications specific to pancreaticoduodenectomy, but seem more related to ill health, inaccessible nonhospital medical care, and poor expectations. Efforts must focus on patient expectations, intermediate care, home health care, and improving medical care after discharge.     

Modulation of the Functions of Dengue Virus-Specific Human CD8+ Cytotoxic T Cell Clone by IL-2, IL-7 and IFNγ

Lymphokines play an important role in immune responses to viruses by modulating functions of T lymphocytes. In the present study, we examined the effects of interleukin-2 (IL-2), interleukin-4 (IL-4), interleukin-6 (IL-6), interleukin-7 (IL-7), and interferon gamma (IFNγ) on proliferation, cytotoxic activity and lymphokine production of a dengue virus-specific CD8⁺ human cytotoxic T lymphocyte (CTL) clone. IL-2 and IL-7 induced proliferation of the CD8+ CTL clone in the presence or absence of specific antigen, while IFNγ suppressed proliferation of the clone. IL-7 and IFNγ augmented dengue virus-specific cytotoxic activity without inducing non-specific cytotoxic activity, and IL-2 induced non-specific cytotoxic activity. IL-2 induced IFNγ production by the CD8+ CTL clone. IL-4 and IL-6 did not modulate the functions of the CD8+ CTL clone in these experimental conditions.

These results suggest that functions of dengue virus-specific CD8+ CTL are modulated by IL-2, IL-7 and IFNγ, and that IL-7 is a lymphokine useful to induce growth and to maintain specific cytotoxic activity of CD8+ CTL clones in vitro.     

Behavior modification and haloperidol in chronic facial pain.

Neuralgiform pain and migrainous pain, both of which are amenable to drug therapy, comprise a relatively small percentage of the group of patients with facial pain who come to the practitioner's office. The largest group of facial pain patients are those with myofascial connective tissue disorders. A second group includes patients with neuropathic pain due to trauma such as oral surgery. A third group is made up of those without any identifiable focus of pain in the extracranial tissue. In these three nonneuralgiform and nonmigrainous groups, it is thought that personality factors affecting psychophysiologic mechanisms are of great importance. These patients are generally difficult to treat. A variety of modalities of therapy, such as behavior modification, hypnosis, and biofeedback, has been reported as helpful in some of these patients. In this report we focus on 12 subjects who failed with all these forms of therapy. We found that they responded to relaxation therapy (after Jacobson) along with haloperidol. We describe further characteristics of these patients and details of our method of treatment.     

Epitope localization of anti-factor VIII monoclonal antibodies determined by recombinant peptides

In order to define the epitopes recognized by anti-coagulation factor VIII (FVIII) monoclonal antibodies, we have constructed a recombinant DNA epitope library from random fragments of the FVIII cDNA. The characterization of 33 different clones producing recombinant antigens in the expression vector, lambda gt11, has identified the epitopes for six different anti-FVIII monoclonal antibodies. The antigenic determinant for each antibody was defined by the overlapping or shared DNA sequence of multiple-immunoreactive clones. One weak inhibitor of FVIII coagulant activity binds within the gly701-ser750 sequence of the FVIII sequence. An antibody which recognizes the amino-terminus of FVIII heavy-chain (within trp14-tyr46) does not inhibit FVIII activity. Two non-neutralizing antibodies both map within residues asp807-ser817, while two other non-neutralizing antibodies bind within lys1673-pro1688. The general usefulness of this strategy for mapping FVIII antigenic determinants is discussed.     

Some factors involved in the skin flap delay phenomenon

The use of skin flaps for reconstruction following extensive ablative surgery in the head and neck area has played a major role in the improvement of the results being attained. Using the pig as an experimental animal various factors of flap orientation, skin incisions and flap undermining were investigated. Results confirmed the ineffectiveness of incision alone as a delay maneurver and suggested that anatomical orientation of cutaneous skin flaps was not of crucial significance. The complete mechanism of the positive effects of delay remains undefined.