Anthony L. Imbembo

Laparoscopic Splenectomy in Patients with Hematologic Diseases

OBJECTIVE The authors review their initial experience with laparoscopic splenectomy in patients with hematologic diseases. Efficacy, morbidity, and mortality of the technique are presented, and other patient recovery parameters are discussed. SUMMARY BACKGROUND DATA Laparoscopic splenectomy is performed infrequently and data regarding its safety and efficacy are scarce. Factors such as a high level of technical difficulty, the potential for sudden, severe hemorrhage, and slow accrual of operative experience due to a relatively limited number of procedures are responsible. The potential patient benefits from the development of a minimally invasive form of splenectomy are significant. METHODS Clinical follow-up, a prospective longitudinal database, and review of medical records were analyzed for all patients referred for elective splenectomy for hematologic disease from March 1992 to March 1995. RESULTS Laparoscopic splenectomy was attempted in 43 patients and successfully completed in 35 (81%). Therapeutic platelet response to splenectomy occurred in 82% of patients with immune thrombocytopenic purpura and hematocrit level increased in 60% of patients with autoimmune hemolytic anemia undergoing successful laparoscopic splenectomy. The morbidity rate was 11.6% (5 of 43 patients), and the mortality rate was 4.7% (2 of 43 patients). Return of gastrointestinal function occurred in patients 23.1 hours after laparoscopic splenectomy and 76 hours after conversion to open splenectomy (p < 0.05). Mean length of stay was 2.7 days after laparoscopic splenectomy and 6.8 days after conversion to open splenectomy (p < 0.05). CONCLUSION Laparoscopic splenectomy may be performed with efficacy, morbidity, and mortality rates comparable to those of open splenectomy for hematologic diseases, and it appears to retain other patient benefits of laparoscopic surgery.

Outpatient management of partial-thickness burns : Biobrane® versus 1% silver sulfadiazine

A randomized, prospective study comparing the use of Biobrane (group 1) with the use of 1% silver sulfadiazine (group 2) in treating 56 partial-thickness burn wounds was carried out in 52 outpatients with burns that comprised less than 10% of their total body surface area. The two groups were similar in age, gender, race, and extent of burn. Wounds of patients in group 1 (30) were compared with those of group 2 (26) for healing time, pain, compliance with scheduled visits, and costs. Infected and skin-grafted wounds were excluded from healing time analysis. Infection rates of the two groups were similar (three of 30 vs two of 26). One patient in each group underwent skin grafting. Healing times of group 1 wounds were significantly less than those of group 2 (10.6 +/- 0.8 vs 15.0 +/- 1.2 days, P less than .01). Using a pain scale of 1 to 5, Biobrane-treated patients averaged lower pain scores at 24 hours after the burn (1.6 +/- 0.8 vs 3.6 +/- 1.3 P less than .001) and used less pain medication. Compliance with scheduled outpatient visits was also improved in the Biobrane-treated group (88.6% vs 63.2% attendance, P less than .001). Idealized total treatment costs averaged

Urinary interleukins in patients receiving intravesical Bacillus Calmette-Guerin therapy for superficial bladder cancer.

434 for patients in group 1 compared with

Biosynthetic Skin Substitute vs. 1% Silver Sulfadiazine for Treatment of Inpatient Partial-thickness Thermal Burns

504 for patients in group 2. We conclude that when used on properly selected wounds, Biobrane therapy can significantly decrease pain and total healing time without increasing the cost of outpatient burn care. Improved patient compliance may be an added benefit.

Flexible endoscopy for the diagnosis of esophageal trauma

Intravesical administration of Bacillus Calmette‐Guerin (BCG) causes a localized cell‐mediated immune response. The intensity of this inflammatory response may be gauged by measuring the levels of both interleukin‐2 (IL‐2) and an inhibitor of interleukin‐2 (IL‐2‐IN) activity in the urine during the hours after a BCG instillation. The levels of urinary IL‐2 and IL‐2‐IN in the sixth week of BCG therapy predicted the subsequent clinical course in a group of 25 patients (P < 0.01). Measurement of urinary IL‐2 and IL‐2‐IN activity may be used to identify accurately those patients likely to develop a tumor recurrence, thereby sparing them the risk associated with inadequately treated bladder cancer. Since IL‐2 and IL‐2‐IN are competitive with respect to biologic activity, and since relatively high urinary levels of either IL‐2 or IL‐2‐IN activity correlated with a favorable clinical course, the authors conclude that the presence of bioactive IL‐2 in urine is not required for the prevention of recurrent superficial bladder cancer.

Biodistribution of the photosensitizer dihaematoporphyrin ether

When used appropriately on superficial or moderate-depth partial-thickness burns, Biobrane significantly decreased total healing time to complete reepithelialization, reduced pain, and was associated with decreased nursing time and costs when compared to 1% silver sulfadiazine cream. Care must be used in selecting wounds for Biobrane therapy. They must be fresh, noninfected, and free of eschar and debris with a moist, sensate surface that demonstrates capillary blanching and refill. Wounds must be inspected regularly for nonadherence and signs of infection. Early fluid accumulation requires prompt aspiration. Biobrane should be removed if fluid reaccumulates or the Biobrane becomes nonadherent at any time after 48 hours. When used appropriately, Biobrane offers significant advantages over conventional therapy of acute partial-thickness burns.

Urinary interleukin-2 inhibition in patients with cystitis

The role of flexible endoscopy in the diagnosis of esophageal trauma remains undefined. This study evaluates the use of immediate flexible fiberoptic esophagogastroduodenoscopy (EGD) as the primary diagnostic tool for detection of esophageal injury in trauma patients. Flexible EGD was performed on 31 patients for this purpose from August 1991 through January 1994. There were 28 males and 3 females with a mean age of 24.3 years (range, 16-54 years). Twenty-four of 31 patients (77%) were intubated at the time of the examination. Mechanism of injury was penetrating in 24 patients (20 gunshot wounds, four stab wounds) and blunt (motor vehicle crash) in seven patients. Penetrating injuries were located in the neck in 5 of 24 patients, in the chest in 15 of 24 patients, and in both the neck and chest in 4 of 24 patients. Upper gastrointestinal contrast studies were performed for 3 of 31 patients (10%), computed tomography was performed for eight patients (26%), bronchoscopy was performed for 13 patients (42%), angiography was performed for 17 patients (55%), and rigid esophagoscopy and laryngoscopy were each performed for one patient (3%). Evidence of esophageal trauma during EGD was seen in 5 of 31 patients. True-positive studies occurred for four patients, false-positive results occurred for one patient, true-negative results occurred for 26 patients (as demonstrated by exploration in five and clinical follow-up in 21), and no false-negative examinations occurred. Sensitivity of flexible EGD was 100%, specificity was 96%, and accuracy was 97%. No complications occurred related to the performance of EGD. Flexible fiberoptic endoscopy seems to be a safe and effective method for both detection and exclusion of esophageal trauma.

Effect of estradiol on low density lipoprotein uptake by bovine aortic endothelial cells

Prior investigations describing the biodistribution of haematoporphyrin derivative (HpD) failed to substantiate a tumour-specific localization. Earlier optimism that dihaematoporphyrin ether (DHE), the active component of HpD, would demonstrate tumour specificity has also failed to be substantiated. The major sites of deposition for DHE are the same as those for HpD (liver, kidney and spleen) while the remaining organs show varying accumulation of DHE, depending on the dose given. Smaller doses of DHE, however, result in biodistribution patterns similar to those for HpD. The pharmacokinetics suggest that DHE binds to plasma proteins and, to some extent, to tissue. The optimal time for photodynamic therapy appears to be between 48 and 72 hours since the greatest mean tumour:muscle concentrations are found during this period.

DIHEMATOPORPHYRIN ETHER‐PHOSPHOLIPID INTERACTIONS. THE ROLES OF SURFACE CHARGE and LATERAL PHASE SEPARATIONS

An inhibitor of interleukin-2 activity (IL-2-IN) is present in the urine of most patients during the acute phase of untreated bacterial cystitis (UTI). We measured urinary IL-2-IN activity in 30 adults with uncomplicated UTIs and followed the patients for an additional 6 months. Urinary IL-2-IN activity ranged between 0 and 1.97 units/mg urine creatinine (U/mg u.c.). Relatively low levels of IL-2-IN (less than 0.5 U/mg u.c.) correlated with a prior history of recurrent UTIs (p less than 0.01), and also were predictive of a subsequent UTI during the 6 month follow-up, regardless of the prior medical history (p less than 0.01). Measurement of urinary IL-2-IN during the untreated phase of a UTI may prove helpful for directing antibiotic prophylaxis against subsequent UTIs.

Percutaneous peritoneal lavage using the veress needle: a preliminary report

The means by which estrogen retards atherosclerosis cannot be explained solely by changes in circulating lipoprotein levels. We studied the effects of 17 beta-estradiol on the binding, incorporation, and degradation of low density lipoprotein (LDL) by cultured bovine aortic endothelial cells (BAEC). Estrogen receptors in the cytoplasm and nucleus of BAEC could be demonstrated by immunofluorescent staining. Estradiol was found not to affect surface binding of LDL to BAEC. However, at physiologic concentrations (50 pg/ml), estradiol did enhance LDL uptake by the BAEC (P less than 0.005). This enhancement was present but somewhat reduced at higher concentrations of estrogen (P less than 0.05). Only approximately 10% of incorporated LDL was trichloroacetic acid soluble, indicating a low rate of LDL degradation. The relative rate of LDL breakdown within the BAEC was not altered by estrogen. These results, showing estrogen stimulation of LDL uptake by the BAEC, do not clarify the protective effect of this hormone. It is speculated that estrogen may augment the cellular clearance of LDL.