Alan Morgan

Early recognition of neonatal abdominal wall necrotizing fasciitis

Necrotizing fasciitis (NF) of the abdominal wall occurring in newborns is associated with a 50% mortality rate. Improved survival requires early diagnosis followed by aggressive surgical débridement. During a 10-year period, we treated 7 infants who developed NF. During the same period, 32 infants were admitted with omphalitis that did not progress to NF. The patients with omphalitis and those with NF were compared. Tachycardia, abnormal white blood cell counts, induration, and violaceous skin discoloration were seen exclusively in the NF patients. Polymicrobial infections were documented in 28% of the omphalitis patients and 86% of the NF patients. All omphalitis patients survived, whereas 5 of 7 (71%) NF patients died. Adjuvant hyperbaric oxygen therapy was used for 4 infants with NF, 2 of whom survived (50%). NF is a highly morbid disease, that can be distinguished from other infant abdominal wall infections by the skin changes, white blood cell counts, heart rate, and microbiologic results. Prompt diagnosis of NF improves survival when combined with aggressive surgical débridement.

Improved survival in children with osteosarcoma following resection of pulmonary metastases

Despite the effectiveness of improved chemotherapy and radiotherapy, surgical resection of all gross metatastic disease from the lung appears to improve the survival of children with osteosarcoma. At Childrens Orthopedic Hospital and Medical Center (COHMC), from 1952 through 1980, 55 patients were treated for osteosarcoma. Twenty-eight of these patients (4 with active disease) were surviving in January 1981. Six patients had pulmonary metastases at diagnosis and 28 patients developed pulmonary metastases after diagnosis. From 1964 through 1980, 17 patients had 34 thoracotomies for resection of metastases. Seven of these 17 patients (41%) are surviving and remain free of disease. The disease was often bilateral, and in most patients more than one thoracotomy was required to erradicate recurrent disease. No patient who developed pulmonary metastases from osteosarcoma survived without surgical resection of all gross disease. An aggressive surgical approach to the treatment of osteosarcoma metastatic to the lung in children appears worthwhile.

Initial experience in a community hospital with sentinel lymph node mapping and biopsy for evaluation of axillary lymph node status in palpable invasive breast cancer.

To determine the sentinel node detection rate and the accuracy with which the sentinel node histology reflects that of the axilla in a series of patients with palpable invasive breast cancer.

A comparison of medicare reimbursement and results for various imaging-guided breast biopsy techniques

BACKGROUND The Medicare population makes up a large proportion of the patients who undergo evaluation and treatment of mammographically detected breast lesions. In the past, the standard approach for obtaining a histological specimen for definitive diagnosis has been wire localization followed by open surgical excision (WL-OSE). In recent years, however, imaging-guided large core needle biopsy (LCNB) has been investigated as a more cost effective and less invasive alternative. METHODS The authors examined accuracy and reimbursement of ultrasound-guided LCNB, stereotactic-guided LCNB, and WL-OSE in 139 Medicare patients who demonstrated abnormalities on screening mammograms in 1994 and 1995. RESULTS Ultrasound-guided LCNB was used to diagnose 20% of these cases, sterotactic LCNB was used to diagnose 68% of the cases, and the remaining 12% were diagnosed using WL-OSE. Histological diagnoses for 54 LCNBs (20 ultrasound-guided and 34 stereotactic-guided) were 98% accurate when compared with a subsequent surgical excision specimen. Ultrasound-guided LCNB was the most cost-effective approach, showing an average savings of

Multiple intestinal atresia and amyoplasia congenita in four unrelated infants: A new association

1,960 per procedure over WL-OSE and

Three- to six-year followup for 379 benign image-guided large-core needle biopsies of nonpalpable breast abnormalities.

211 over stereotactic-guided LCNB. Stereotactic-guided LCNB was significantly more cost effective than WL-OSE, showing an average savings of

Postoperative changes in the trypsin inhibitor activities of human pancreatic juice and the influence of infusion of trasylol on the inhibitor activity

1,750 per procedure. CONCLUSIONS These data indicate imaging-guided LCNB to be a reasonable alternative to WL-OSE for definitive histological diagnosis of nonpalpable breast lesions. Ultrasound-guided imaging was shown to be applicable in 20% of the cases and is the least expensive to the Medicare system. The stereotactic approach can be used for a much larger percentage of these patients and although not as cost effective as ultrasound, it is considerably more cost effective than open excisional biopsy. Both core biopsy techniques provided accurate histological diagnoses.

Juvenile polyps of the colon and their relationship to allergy

Four unrelated infants with multiple segments of nonduodenal intestinal atresia and amyoplasia congenita are described. The extreme rarity of each of these conditions as a single entity indicates that their concurrent incidence in four separate unrelated patients is of significance with respect to pathogenesis. The nature of the relationship between the two conditions is unknown.

Pyloric stenosis—A report of triplet females and notes on its inheritance

BACKGROUND Determining the negative predictive value of benign large-core needle biopsy of nonpalpable mammographically detected breast abnormalities has been difficult because benign results generally preclude surgical excision. Longterm followup of these patients is important to ensure timely diagnosis of new abnormalities and to identify false negatives. STUDY DESIGN This cohort study comprised 379 patients, all with benign diagnoses following imaging-guided large-core needle biopsy of nonpalpable mammographically detected abnormalities. Mammographic, clinical, and laboratory records (when appropriate) were reviewed for all patients followed at our institution. For patients followed elsewhere, these data were provided by each patients current primary-care physician after obtaining written informed consent from the patient. RESULTS We obtained followup for 312 patients (82.3% of 379), for whom the mean followup period was 55 months; 67 patients were either lost to followup (44, 11.6%), had no followup by patient choice (18, 4.7%), or died of causes other than breast cancer (5, 1.3%). Of these 312 patients, we found only 1 (0.3%) false negative in which a 4-mm lesion was observed to have grown to approximately 11 mm eight months later, and was found to be an infiltrating ductal cancer at rebiopsy. The negative predictive value was calculated as 0.997 (311/312). Analysis of core histologies indicated the followup group was a representative sample. CONCLUSIONS These data suggest that benign mammographically detected abnormalities can be diagnosed with a high level of confidence using image-guided large-core needle biopsy, and that mammographic or ultrasonographic screening or both at 6 and 12 months might be sufficient before returning the patient to routine screening mammography.

Histologic Correlation of Image-Guided Core Biopsy With Excisional Biopsy of Nonpalpable Breast Lesions

Abstract The pancreatic trypsin inhibitor activity in juice obtained from the pancreatic duct by a transduodenal drain after operations on the pancreas and its sphincter mechanisms has been studied in the early postoperative stage. Using a pH stat technic with BAEE as the specific enzyme substrate, it was possible to significantly lower the inhibitor activity on the first postoperative day in nine patients who were also able to regain a normal level by the fourth postoperative day. It is considered that this finding may be significant in the etiology of postoperative pancreatitis and it is believed that the fall may be explained as a metabolic response to surgical trauma. Trasylol, a protease inhibitor, has been infused in the postoperative period with a resulting significant rise in the inhibitory effect of the pancreatic juice. In one patient this rise was accompanied by a marked clinical improvement and clearing of the previously blood-stained pancreatic juice.