Radical Resection of Periampullary Tumors in the Elderly: Evaluation of Long-term Results

Increasingly, patients of advanced age are coming for evaluation of periampullary tumors. Although several studies have demonstrated the safety of resecting periampullary tumors in older patients, few long-term survival data have been reported. Between 1983 and 1992 various periampullary masses were resected in 70 patients over age 65 (range 65–87 years). Total pancreatectomy was performed in 11 patients, and 59 patients underwent pancreaticoduodenectomy. The mean duration of hospitalization was 17 ± 15 days. Major complications occurred in 27 patients (39%), and operative mortality rate was 8.5%. Overall median survival was 24 months; and 5-year survival was 25%. Perioperative outcome was compared in patients aged 65 to 74 years and in patients ≥75 years old. The older age group required longer periods in the surgical intensive care unit postoperatively, but the long-term survival was similar in the two age groups. Radical resection with the intent to cure periampullary tumors is safe in selected patients of advanced age, and long-term survival is in the range of expected survival for younger patients with the same tumors.     

Right heart function in impaired left ventricular diastolic function: 2D speckle tracking echocardiography–based and Doppler tissue imaging–based analysis of right atrial and ventricular function

Aim

The aim of our study was to describe right atrial (RA) and right ventricular (RV) function, assessed by Doppler tissue imaging and 2D speckle tracking echocardiography (2DSTE), in women with signs of early impaired left ventricular diastolic function (DD).

Methods and Results

In a cross‐sectional trial, standard parameters of diastolic and right heart function were investigated in 438 women of the Berlin Female Risk Evaluation (BEFRI) study. In a subset of women, average peak systolic RA strain (RAS), as well as the average peak systolic RV strain of the free wall (RVS free wall) and of all RV segments (average RV strain; RVS Avg), was analyzed using 2DSTE. Compared to women with normal diastolic function (DD0), RAS, RVS free wall and RVS Avg were significantly reduced in DD (43.1% ± 11.9%, ?26.7% ± 5.6%, and ?23.3% ± 3.5% in DD0; vs 35.1% ± 10.4%, ?23.9% ± 5.5%, and ?20.6% ± 3.8% in DD; P < .01). Peak RV myocardial velocity (RV‐IVV) and acceleration during isovolumetric contraction (RV‐IVA) were markedly higher in DD (15.0 ± 3.9 cm/s and 3.1 ± 1.0 m/s² in DD vs 11.9 ± 3.2 cm/s and 2.8 ± 0.8 m/s² in DD0; P < .05). RAS and RV‐IVV were significantly associated with DD after adjustment to age, BMI, and left atrial strain in multivariate regression analysis.

Conclusion

Systolic right heart function is significantly altered in DD. DTI as well as 2DSTE constitute sensitive echocardiographic tools that enable the diagnosis of impaired right heart mechanics in early‐staged DD.     

Coronary cardiac allograft vasculopathy versus native atherosclerosis: difficulties in classification

Cardiac allograft vasculopathy is regarded as a progressive and diffuse intimal hyperplastic lesion of arteries and veins that leads to insidious vessel narrowing and to allograft ischemic disease, such as acute myocardial infarction or sudden cardiac death. The coronary lesions in transplanted hearts are considered as a particular type of arteriosclerosis with many similarities but also significant differences compared to native coronary atherosclerosis. It is particularly difficult for pathologists to systematically classify the lesions and to elucidate their origins, since over time, the allograft immune responses cause vascular pathology characterized by not only the onset of de novo fibrocellular lesions but also remodeling of already-existing native atherosclerotic lesions in the donor heart. Intraplaque hemorrhages, which result from newly formed leaky microvessels, may cause rapid increase of stenosis and generate a substrate for plaque destabilization. Comparing cardiac allograft vasculopathy from explanted hearts at autopsy with native coronary atherosclerosis from hearts removed at transplantation has revealed that ongoing intraplaque hemorrhages are also an important feature of cardiac allograft vasculopathy and may be important factors in the rapid progression of cardiac allograft vasculopathy.     

Effect of the stage of lactation in humans on carotenoid levels in milk,blood plasma and plasma lipoprotein fractions

Summary. In mammals the composition of milk changes during early lactation, with a rapid decline of fat-soluble vitamins and a continuous increase in total lipids. The mechanisms underlying this phenomenon are not well understood, but might involve selective mechanisms related to mammary uptake or secretion into the milk. Since carotenoids are specifically distributed among the lipoprotein fractions in plasma, the simultaneous determination of carotenoids in plasma, lipoprotein fractions and milk might offer an opportunity to gain insight into this phenomenon. In 21 healthy mothers carotenoids in plasma and lipoprotein fractions were investigated at day 2 and 19 and milk on day 4 and 19 after delivery. Plasma levels of -tocopherol and cholesterol as well as lutein, zeaxanthin and cryptoxanthin were significantly lower later in lactation (day 19) than shortly after birth (P < 0.01). The stage of lactation had no effect on the distribution of carotenoids and -tocopherol among the plasma lipoprotein fractions. In milk, triacylglycerol increased (P < 0.01). In contrast, levels of carotenoids, -tocopherol and vitamin A were highest in colostrum and declined (P < 0.01). Because the magnitude of decrease was not the same in all carotenoids, the carotenoid pattern changed substantially. In colostrum the carotenoid pattern resembled those of plasma and the low-density lipoprotein fraction. In mature milk it was similar to the pattern found in the high density lipoprotein fraction. Based on these observations a selective mechanism might be responsible for the transfer of these components in milk involving different lipoprotein fractions at specific times of lactation.     

Expression of receptors for estrogen and progesterone in malignant colonic mucosa as a prognostic factor for patient survival

BACKGROUND AND OBJECTIVES: Estrogen receptors (ER) and progesterone receptors (PR) have been detected in both normal and malignant colonic mucosa, but the prognostic value of this observation is unknown. We aimed to define the prognostic significance of the presence of ER and PR in malignant cells from colorectal adenocarcinoma specimens. METHODS: An immunohistochemical assay for ER and PR was performed on paraffinized sections from 65 colorectal adenocarcinoma specimens. Survival curves were analyzed to define the prognostic implications of ER and PR. RESULTS: Twenty nine (45%) tumors tested receptor positive (32% for ER and 23% for PR). Tumors of advanced stage were more likely to express receptors than early stage tumors (56% vs. 32%; P = 0.01). Median survival of patients with neoplasms expressing PR was 30 months. For patients whose tumors did not express any receptors, median survival had not been reached at the time of follow-up (P = 0.04). Similarly, patients with tumors expressing both receptors had significantly reduced survival (median survival = 20 months; P = 0.003). CONCLUSIONS: Expression of receptors for sex steroids correlates with advanced stage disease. Expression of PR by the tumor cells is associated with a shorter patient survival. The results suggest that sex steroids may play a role in carcinogenesis and tumor progression.     

Acetylenchemie, 5. Mitt. PTC-Umsetzung von 4-Hydroxychinolin-2-on und Indolin-2-on mit 3-Bromprop-1-in

Acetylenic Chemistry, Part 5.: PTC Reaction of 4-Hydroxyquinolin-2-one and Indolin-2-one with 3-Bromoprop-1-yne PTC propynylations of the titel compounds yield an oxazoloquinolinone and five propynylquinolinones; furthermore, three propynylindolinones and a propynylanthranilic acid ester were obtained. Possible reaction pathways are discussed. The results are compared with those reported earlier.     

Personal Preferences Regarding Family Member Presence during Resuscitation

OBJECTIVES: Previous studies have shown that family members wish to be present during the resuscitation of a family member. No studies have addressed whether the patient would want family members present if he or she required resuscitation. The authors wanted to determine patients' preferences regarding family member presence during their own resuscitation. METHODS: A seven-item survey was administered to a sample of patients and their family members older than 17 years of age on six randomly chosen shifts in an academic community hospital emergency department. Responses were analyzed using chi-square and t-tests. Subjective comments were also recorded. RESULTS: A total of 266 subjects were asked to participate in the study; 200 subjects agreed to complete the survey. Most (72%) wanted a family member present. However, 21% did not wish any family member to be present. Positive responders (family present) tended to be younger (mean, 39.4 years; 95% confidence interval = 36.7 to 42.2) than negative responders (mean, 50.5 years; 95% confidence interval = 42.9 to 55.7; p < 0.001). Positive responders were also more likely to be nonwhite (chi2 = 6.29, p < 0.05). Gender, education, or health status was not associated with responder type. Of positive responders, 56% stated they wanted only certain members present, and these preferences were variable. CONCLUSIONS: Patients preferred to have family members present during their resuscitation. However, most of the positive responders wanted only certain members present, and approximately one in five patients, who tended to be older and white, did not want any family present. This study does not support an open policy of allowing family members into a resuscitation without prior knowledge of the patient's preferences.