Minimally invasive endoscopic repair of pectus excavatum.

OBJECTIVE: We report our initial 3 years 4 months' single institution experience in 31 consecutive patients with pectus excavatum treated with minimally invasive endoscopic pectus excavatum repair utilizing a modification of the 'Nuss' technique. METHODS: Under general anesthesia, a curved steel bar is individually shaped for each patient to match the ideal chest wall shape and is placed through an endoscopically created retrosternal tunnel between two bilateral midaxillary line 2-cm incisions. The tunnels initially go along the outside of the rib cage, under the pectoral muscles. At the level of the sternum, these tunnels go retrosternal and communicate with each other. The steel bar is passed with the convexity facing posteriorly, within a protective flat silastic drain. Under endoscopic guidance, the curved steel bar is passed through one tunnel, under the sternum, and out the other tunnel. Once positioned, the bar is turned over, thereby correcting the deformity. An epidural catheter provides perioperative pain relief. RESULTS: Minimally invasive endoscopic pectus excavatum repair has been performed on 31 patients (age: range 4.4-31.0 years, median 15.0 years, mean 14.5 years). Median hospital length of stay is 4 days (range 3-10 days, mean 4.6 days). Pneumothorax occurred in five patients requiring tube thoracostomy in three. One patient developed delayed bilateral pleural effusions requiring drainage. Two patients developed evidence of sterile seroma formation at the skin incision several months after minimally invasive repair of pectus excavatum. These seromas resolved with non-interventional conservative medical treatment. No other complications occurred. CONCLUSION: The minimally invasive endoscopic pectus repair is safe and effective and currently our procedure of choice for primary pectus excavatum in all ages. Endoscopic visualization facilitates the safe creation of the retrosternal tunnel. Short-term results have been excellent. Further follow-up will be necessary to determine long-term results.     

5-Fluorouracil with oral leucovorin and hydroxyurea and concomitant radiotherapy for stage III non-small cell lung cancer

Twenty-three patients with regionally advanced non-small cell lung cancer (NSCLC) (Stage III) were treated with continuous infusion 5-fluorouracil (5-FU) augmented by high-dose oral leucovorin and hydroxyurea and concomitant radiotherapy. This chemoradiotherapy regimen was administered during 5 days of every other week for six cycles (total radiation dose, 6000 cGy). Three patients (13%) had stable disease, 13 patients (57%) had a partial response (PR), and 1 patient (4%) had a complete response (CR). The overall response rate was 61% (95% confidence interval, 41% to 81%). At a median follow-up time of 19 months, the median survival time for all 23 patients was 12 months. The median time to disease progression was 6 months. Twelve patients have had disease progression outside of the chest, and only 3 patients have had intrathoracic disease progression as the site of first failure. The toxicities of this regimen consisted of mild to moderate myelosuppression and moderate degree dermatitis and mucositis. It was concluded that concomitant chemoradiotherapy with this regimen results in high local activity at acceptable toxicity. However, the systemic activity of this regimen was low, resulting in a high distant recurrence rate and a median survival time that was not different from that achieved with standard therapy. Therefore, its use, as defined in this study, cannot be recommended.     

Septic shock in children: bacterial etiologies and temporal relationships

In a retrospective analysis of 2110 admissions to the pediatric intensive care unit, 564 cases of septic shock were identified (26.7% of the total admissions). Septic shock was defined in patients with: (1) clinical evidence of sepsis; (2) fever (greater than 38.3 degrees C) or hypothermia (less than 35.6 degrees C); (3) tachycardia; (4) tachypnea; and (5) inadequate organ perfusion. Inadequate perfusion was defined as hypotension or evidence of peripheral hypoperfusion (poor capillary refill or cyanosis with hypoxemia, oliguria, acidosis or altered mentation). Inotropic support was required to maintain an adequate blood pressure and perfusion in 268 of 564 patients (47.5%). Septic shock with confirmed bacterial infection occurred in 143 patients (143 of 564, 25.2%); these cases were caused by Haemophilus influenzae, type b (59 of 143, 41.3%), Neisseria meningitidis (26 of 143, 18.2%) and Streptococcus pneumoniae (16 of 143, 11.2%). Eight of 564 (1.4%) cases of septic shock were not clinically apparent on initial evaluation and were diagnosed within 24 hours after admission to the hospital. We conclude that septic shock occurs more frequently in children than previously appreciated and may develop after admission to the hospital.     

Characteristics of psychiatric patients who engage in assaultive or other fear-inducing behaviors

The hospital records of 1687 psychiatric patients were rated for the presence of assaultive or other fear-inducing behaviors associated with the reasons for their hospital admissions. Data analyses indicated that significant associations existed between these behaviors and sex, race/ethnicity, diagnosis, previous admissions, referral source for hospitalization, legal status at admission, and legal status at discharge. No associations were found for age, education, marital status, employment status, number of days hospitalized during the index hospitalization, and referral at discharge. A comparison of these results with the results of studies by other investigators led to the conclusion that clinical variables appear to have a more consistent relation to violent behavior than demographic variables. Future research examining for the correlates of violent behavior in psychiatric patients may be more productive by focusing on the type and degree of patients' psychopathologies rather than on patients' demographic characteristics.     

Renal effects of S10036 in man

The renal hemodynamic and tubular effects of S10036 (fotemustine) were evaluated in seven patients with advanced malignancy. Initial evaluation carried out prior to treatment and repeated 1 day after the first fotemustine infusion and 7 days after the second included clinical, haematological parameters, liver-function tests, and determination of the glomerular filtration rate, renal blood flow and enzymuria. The glomerular filtration rate was 108 +/- 3.7 ml/min before treatment and remained stable after the first (117 +/- 5 ml/min) and second (124 +/- 6 ml/min) fotemustine infusions. Renal blood flow and urinary beta 2-microglobulin and N'-acetylglucosaminidase excretion were also not modified by fotemustine administration. We conclude that fotemustine does not acutely alter renal haemodynamics, nor does it have direct tubular toxicity.     

Effect of ketanserin on macrocirculatory and microcirculatory blood flow in patients with intermittent claudication. A prospective randomized study

The effect of ketanserin on macrocirculatory and microcirculatory blood flow was investigated in a placebo-controlled, double-blind trial in 11 patients suffering from intermittent claudication using Doppler velocimetry and intravital skin capillary microscopy, respectively. After 1 year of treatment no significant change was observed either in the ketanserin or the placebo group. It appears that ketanserin has no significant effect on macrocirculatory blood flow and microcirculatory nutritional skin blood flow in patients with intermittent claudication.     

Miniplate fixation of zygomatic fractures

The availability and application of miniplate systems for the repair of displaced zygomatic fractures may effect commonly accepted guidelines for fixation of these injuries. A retrospective review of 20 patients at New York University-Bellevue Medical Center was conducted to further delineate issues concerning surgical repair and fixation. Our experience with one- and two-point fixation is evaluated and guidelines are presented.     

Nonmedical management of late luteal phase dysphoric disorder : a preliminary report

The authors report the results of an open trial of group behavioral treatment for women with a prospectively confirmed premenstrual syndrome. Treatment consisted of five weekly group behavioral sessions outlining and supporting lifestyle changes in diet, exercise level, and stress management. Patients monitored symptoms and adherence to dietary and exercise recommendations daily. Results are discussed for the first 48 women to complete the trial. Eighty-three percent of patients demonstrated either a remission (n= 28) or 50% reduction in symptoms (n = 12) at one month following the group treatment. Improvements in physical and emotional symptoms were significantly associated with an increase in exercise.