Laryngopharyngoesophagectomy for advanced hypopharyngeal and esophageal squamous cell carcinoma: The yale experience

The 5-year survival rate for patients with hypopharyngeal squamous cell carcinoma invading the upper esophagus is below 25% regardless of therapy. Most patients with advanced disease—unable to eat or breathe—die within 18 months of diagnosis. Because these patients, on average, have a limited time to live, surgical treatment should aim to maximize the quality of remaining life. Essential to this goal are complete tumor removal and rapid return to oral feeding. Furthermore, short hospital stay and low perioperative morbidity are especially important in these patients. We performed total laryngopharyngoesophagectomy (LPE) with gastric transposition in 34 patients with hypopharyngeal and cervical esophageal squamous cell carcinoma. There has been one perioperative death (3%) and 1 temporary fistula (3%). No major mediastinal or intrathoracic complication occurred. On average, patients began oral feeding by postoperative day 10, with return to a full diet and discharge home within 16 days, maximizing both quality and quantity of time remaining outside the hospital.     

Pulmonary dysfunction is common during a cytomegalovirus infection after renal transplantation even in asymptomatic patients. Possible relationship with complement activation

In 24 patients with a cadaveric renal allograft, serial measurements after transplantation were made of the diffusing capacity for carbon monoxide (DLCO) together with serial measurements of C3d, the stable conversion product of the complement factor C3, and determinations of the anaphylatoxin C3a. Twelve patients were studied during an active cytomegalovirus (CMV) infection, and 12 patients were studied during allograft rejection or during a stable phase after renal transplantation (control subjects). No patients had pulmonary symptoms nor abnormal chest radiographs or arterial blood gas determinations. During an active CMV infection, DLCO was significantly reduced compared with the measurements made during allograft rejection or during a stable phase after renal transplantation. This was true both with (p less than 0.01) and without (p less than 0.01) correction for the hemoglobin concentration. Serum C3d levels were increased in 8 of the 12 patients with a CMV infection, but not in any of the patients in the control group. In 8 patients with a CMV infection, measurements were made of the anaphylatoxin C3a, and were found to be significantly higher than the levels in the control population (p less than 0.01). We conclude that our data are consistent with pulmonary dysfunction in every patient with an active CMV infection. The concomitant findings of complement activation and formation of anaphylatoxins suggest a causal relationship of the complement activation and a decreased DLCO, although further studies are warranted to determine the exact role of complement in the pulmonary events during an active CMV infection after renal transplantation.(ABSTRACT TRUNCATED AT 250 WORDS)     

Current developments in the diagnosis and therapy of cytomegalovirus infections

We describe the case history of a 40-year-old, negroid woman with systemic lupus erythematosus who acquired a severe cytomegalovirus infection on immunosuppression; this infection was successfully treated with ganciclovir. New ideas in the management of CMV infections in immuno-compromised hosts are discussed. The traditional diagnostics are unsatisfactory, antibody detection being very insensitive and culture techniques too slow. A new diagnostic approach by detection of the immediate early antigens of the cytomegalovirus (CMV-IEA) using monoclonal antibodies is fast and reliable (sensitivity 93%, specificity 92%), even in case of immuno-deficiency. Finally we discuss the efficacy of the antiviral agent ganciclovir in the management of severe CMV infections.     

Screening for urinary tract infection using Bac-T-Screen bacteriuria device

The Bac-T-Screen was used to process 795 urine specimens. Tests for urine specimens took slightly more than two minutes. The Bac-T-Screen predicted with 99 per cent accuracy if a specimen was negative for bacteriuria or pyuria. Thus, approximately one half of all carefully collected urine specimens need no further laboratory culture. In addition, the Bac-T-Screen detected bacteriuria with a sensitivity of 96 per cent at the 10(5) CFU/ml level of probability. Pyuria (1 +) was detected with a sensitivity of 98 per cent. The Bac-T-Screen can be used in an office practice as well as in the clinical laboratory.     

Metabolic Syndrome Is Associated with Impaired Long-term Renal Allograft Function; Not All Component criteria Contribute Equally

Chronic renal transplant dysfunction (CRTD) remains a leading cause of renal allograft loss. Evidence suggests that immunological and ischemic insults are mainly associated with CRTD occurring within the first year after transplantation, whereas nonimmunological insults are predominantly associated with CRTD beyond the first year. Several cardiovascular risk factors, such as obesity, dyslipidemia, hypertension, and diabetes mellitus have been identified as important nonimmunological risk factors for CRTD. These risk factors constitute the metabolic syndrome (MS). As renal allograft function is a surrogate marker of renal allograft loss, we investigated the association of MS with impairment of renal allograft function beyond the first year after transplantation in a cross-sectional study of 606 renal transplant outpatients. Metabolic syndrome was defined using the definition of the National Cholesterol Education Program. Renal allograft function was assessed as the 24-h urinary creatinine clearance. A total of 383 out of 606 patients (63%) suffered from MS at a median time of 6 years (2.6-11.4) post-transplant. Presence of MS was associated with impaired renal allograft function beyond 1 year post-transplant [-4.1 mL/min, 95%CI (-7.1, -1.1)]. The impact of MS did not change appreciably after adjustment for established risk factors for CRTD [-3.1 mL/min, 95%CI (-6.0, -0.2)]. However, not all component criteria of MS contributed equally. Only systolic blood pressure and hypertriglyceridemia were independently associated with impaired renal allograft function beyond 1 year post-transplant in multivariate analyses.     

Complement activation associated with active cytomegalovirus infection in renal transplant patients, and its absence in transplant rejection episodes

In 20 patients with a cadaveric renal allograft, serial measurements were made of the serum complement factors C3, C4, factor B (FB), and C3d, the stable conversion product of C3. Measurements were started immediately before transplantation and continued thereafter once a week to investigate whether these assays help to differentiate between acute allograft rejection (R) and an active cytomegalovirus (CMV) infection. Fifteen patients had one or more R episodes, and 9 patients suffered from an active CMV infection. Six patients had an R episode and subsequently a CMV infection 13-64 days after R. No significant changes were found in the levels of C3, C4, and FB during R or CMV infection. C3d levels remained unchanged or decreased slightly during R. However, there was a 43-500% increase in the C3d level during CMV infection. This difference in the behavior of levels of C3d during R and CMV infection is significant (P less than 0.01), and suggests that serial measurements of C3d may be useful in differentiating CMV infection from R after renal transplantation.     

Isolation of handelin fromChrysanthemum boreale

The flowers ofChrysanthemum boreale afforded handelin, a unique guaianolide dimer and a mixture ofn-hydrocarbons andn-hydrocarbon alcohols in addition to β-sitosterol and β-sitosterol glucoside. Detailed analysis of the¹H-and¹¹C-NMR spectra of handelin was carried out by the application of two-dimensional¹H-¹H-COSY and¹H-¹¹C multiple-bond, multiplequantum sepctroscopic correlation techniques. Handelin was inactive in thein vitro anti-tumor activity.