Nicholas A. Halasz

Recent trends in the management of desmoid tumors: summary of 19 cases and review of the literature

Recent advances in the understanding of desmoid tumor biology affect therapeutic choices. This series of 19 patients and review of the literature outlines historic perspectives and discusses the options in the management of these locally aggressive tumors. Desmoid tumors tend to grow steadily, regardless of tumor location. However differences in the aggressive nature of these tumors are seen when age and sex distributions are scrutinized. Although recurrence rates are high, excisional therapy is the best first approach. An exception is the case in which tumor excision is either particularly dangerous or likely to result in significant physical handicap. Radiation or drug therapy are most often used with recurrent disease or as an alternative to mutilating surgery. Although many pharmacologic approaches have been advocated, (including antiestrogen therapy, cyclic-AMP, and prostaglandin inhibition), results are anecdotal at best.

Bronchial and Arterial Anomalies with Drainage of the Right Lung into the Inferior Vena Cava

Three cases of anomalous pulmonary venous return to the inferior vena cava are presented and 18 previously reported cases are also analyzed. The clinical, radiographic, circulatory and pulmonary function, and anatomic features are carefully detailed. In particular, associated vascular and bronchial anomalies in the lungs were found by preparation of vinylite casts of the pulmonary vessels and bronchial casts; they are of great significance in planning and executing surgical therapy.

Effect of daily oral vitamin D and calcium therapy, hypophosphatemia, and endogenous 1-25 dihydroxycholecalciferol on parathyroid hormone and phosphate wasting in renal transplant recipients.

Ten stable, normocalcemic renal transplant patients with good allograft function, hyperparathyroidism, and variable hypophosphatemia were treated for 2 to 9 months with oral calcium carbonate and replacement doses of vitamin D analogues. Parathyroid hormone levels (PTH) and renal phosphate wasting were not autonomous or fixed but decreased with therapy. Although serum 1–25(OH)2D3 levels could be shown to rise appropriately during oral vitamin D therapy and fall afterwards, a separate study in a larger group of patients showed no effect of elevated parathyroid hormone or hypophosphatemia to increase endogenous 1–25(OH)2D3 levels. Some 42% of patients with elevated carboxyterminal PTH, had elevated N-terminal PTH, which was closely associated with more severe phosphate wasting. Aggressive oral calcium and vitamin D supplementation in certain normocalcemic renal transplant patients may decrease endogenous PTH levels, improve hypophosphatemia, and provide a physiologic increase in levels of 1–25(OH)2D3.

Abdominal Catastrophes and Other Unusual Events in Continuous Ambulatory Peritoneal Dialysis Patients

Primary bacterial peritonitis and catheter-associated infections compose the large majority of abdominal events in continuous ambulatory peritoneal dialysis (CAPD) patients. Yet occasionally primary pathology involving the abdominal viscera develops, and surgery is frequently considered. The early manifestations of intraabdominal inflammation or bleeding in patients undergoing CAPD depend on the pathological process, its access to the peritoneal cavity, and whether generalized bacterial peritonitis supervenes to obscure helpful physical findings. Clear dialysate is not a reliable sign that major pathology is absent, nor does initial stabilization of the clinical course with antibiotic therapy uniformly indicate that surgery will not be necessary. Polymicrobial peritonitis may develop in cholecystitis, pancreatitis, or from a colonic source, the latter featuring more bacterial species and more gram-negative and anaerobic organisms. A history directed at progression of symptoms and sites of abdominal discomfort and an examination for deep local tenderness and bowel incarcerated in an abdominal wall hernia are essential. Measurement of dialysate amylase and Gram stain of dialysate for food fibers may be helpful. Imaging techniques such as abdominal radiographs for dilated bowel or free subdiaphragmatic air, ultrasonography of the gallbladder or pancreas, computed tomographic (CT) scanning of the lower abdomen, and water-soluble contrast colonic studies may help identify the pathologic process. Special studies such as these should be considered early in the course of suspected unusual abdominal events in patients on CAPD.

The Complications of Cirrhosis of the Liver

Excerpt Dr. Marshall J. Orloff: This conference will review the natural history of cirrhosis of the liver and the treatment of the disease and its complications. A case to be presented by Dr. Lipma...

Medicine and ethics : how to allocate transplantable organs

Organ transplantation has made tremendous strides in the last decade. The demand for transplantable organs has far outstripped the supply; waiting lists have grown long and patients are dying for want of vital organs. Therefore policies and criteria that guide the allocation of transplantable organs become ever more important. Over the years, allocation policies have evolved by including both medical and ethical considerations, and much work has gone into defining and analyzing components of such policies. However, they have often grown by accretion, and a parallel analysis of both sets of approaches did not occur. This article attempts to integrate medical and ethical considerations, and to develop a schema that will permit review, redefinition, and—it is hoped—development of a fairer, more equitable and responsive allocation system.

Improved function of perfused rabbit kidneys by prevention of oxidative injury.

This study explored the effect of adding small amounts of the reducing agents ascorbic acid and glutathione to a Ringers-albumin perfusate used for 24-hr hypothermic perfusion of rabbit kidneys. Maintenance of function during preservation was evaluated with a shunt perfusion model and by measuring the ability of cortical slices to restore normal K/Na ratios after incubation in a electrolyte medium. When placed in contact with the unmodified perfusate, an electrode of pyrolytic carbon registered a potential of +190 mV relative to the silversilver chloride couple. This reading fell rapidly by 100–125 mv when kidneys were placed on the circuit. The mean creatinine clearance after 24-hr perfusion was significantly improved from 162 ± 56 ml/hr in controls to 284 ± 92 ml/hr when the potential indicated by this electrode was preadjusted to 43–54 mv with reducing agents, and to 237 ± 62 ml/hr when this adjustment was made after 2 hr. These creatinine clearances were similar to those of kidneys stored on ice for only 1 hr. These findings indicate minimal injury occurred in the chemically reduced groups and emphasize the importance of preventing oxidative damage to kidneys during hypothermic organ perfusion. The time course of the changes in potential registered by this electrode was consistent with our previous finding that much of the damage to perfused kidneys occurs very early in the course of perfusion. The tissue slice studies showed no detectable damage to the renal parenchyma of the kidneys in the control group despite diminished creatinine clearance. This suggests that the site of oxidation injury is the vascular compartment.

Studies of the ideal [H+] for perfusional preservation.

The neutral point of water, being a function of its dissociation constant, is temperature dependent. This is also true of protein-buffered solutions such as perfusates. In organ preservation these facts have been long ignored and, as a result, perfusions have been carried out in a relatively acidotic environment. These studies evaluated the effects of correcting the pH partially or completely for the level of hypothermia involved in perfusional presevation. The findings both in rabbits and dogs were that a pH of 7.4 (measured at 7 C) is dangerously close to the pH below which there is rapid deterioration of function. On the other hand, perfusate pHs up to 7.75 in dogs and 8.25 in rabbits were tolerated at no detriment. As a result, the recommendation is made to carry out hypothermic organ perfusion at a pH well above 7.4; 7.60 or 7.65 seems reasonable.