Seymour I. Schwartz

Chronic carotid sinus nerve stimulation in the treatment of essential hypertension

Abstract Electrical stimulation of the carotid nerve has effected reversal of systemic arterial hypertension. The physiologic basis for this new therapeutic approach and the laboratory experiences with acute and prolonged stimulation are reviewed. The engineering specifications of electrical devices employed to date are outlined, and the clinical experience with eleven patients treated with chronic stimulation of the carotid sinus nerves is presented.

Hepatic resection for noncolorectal nonneuroendocrine metastases

The experience with hepatic resection for metastatic lesions, exclusive of colorectal and neuroendocrine tumors, is anecdotal. The reduction in operative mortality leads to a reconsideration of the subject. A review of the literature suggests a selective approach. These is little improvement to be anticipated for resection of metastases from tumors of the esophagus, stomach, small intestine, or pancreas. Resection of metastases from primary renal cell carcinoma, Wilms tumor, and adrenocortical carcinoma is indicated. There is little to recommend resection of metastases from gynecologic or breast primary carcinomas. Resection as palliation is to be considered for all lesions, particularly bulky metastases from ocular melanomas.RésuméLexpérience acquise en matière de résection hépatique pour des lésions métastatiques en dehors des métastases dorigine colorectale ou endocrine, est tout à fait anecdotique. En raison de la réduction de la mortalité après chirurgie hépatique, cette situation mérite réflexion. Une revue de la littérature suggère une approche élective. On peut nespérer que peu damélioration après la résection de métastases provenant des tumeurs de loesophage, de lestomac, de lintestin grêle, du pancréas, des cancers gynécologiques ou du sein. La résection de métastases provenant de cancers rénaux, des tumeurs de Wilms et des cancers de la corticosurrénale est, par contre, indiquée. La résection palliative est également à recommander surtout en cas de métastases volumineuses provenant des mélanomes oculaires.ResumenLa experiencia con la resección hepática para lesiones metastásicas, excluyendo los tumores colo-rectales y neuroendorinos, es de tipo anecdótico. La reducción en la mortalidad operatoria lleva a la reconsideración del tema. Una revisión de la literatura pertinente sugiere un enfoque selectivo. Se puede anticipar que hay escaso progreso en lo referente a tumores del esófago, estómago, intestino delgado o páncreas. La resección de metástasis de carcinoma de células renales, tumor de Wilms y carcinoma adrenocortical está ìndicada. Hay poco que recomendar en cuanto a la resección de metástasis de carcinomas ginecológicos o mamarios. La resección como forma de paliación debe ser considerada en todo tipo de lesiones, particularmente metástasis voluminosas de melanomas oculares.

Splenectomy for thrombocytopenia

The effects of splenectomy in 49 thrombocytopenic patients managed since 1979 were assessed and compared with our previous experience of 174 patients. Idiopathic thrombocytopenic purpura (ITP) constitutes a common indication for splenectomy, which effects a cure in 86% of these patients. The platelet count rises above 100,000/mm3 by the eighth postoperative day in 88% of responders. Urgent splenectomy is indicated for patients with thrombotic thrombocytopenic purpura (TTP) because it is associated with the highest cure rate. Splenectomy in patients with myeloproliferative disorders causing thrombocytopenia effectively raises the platelet count but has been followed by the greatest incidence of complications among the hematologic disorders studied. In patients with chronic lymphatic or hairy cell leukemia, splenectomy almost always returns platelet counts to normal levels and there is an impressive improvement in the quality of life. A wide variety of disorders characterized by thrombocytopenia is responsive to splenectomy. Accessory spleens have been removed in 17% of ITP patients and are often present in patients with myeloproliferative disease, but only rarely noted in other patients with thrombocytopenia.RésuméLes conséquences de la splénectomie chez 49 malades présentant un état thrombocytopénique opérés depuis 1979 ont été définies et comparées à celles dune expérience antérieure concernant 174 sujets. Le purpura thrombocytopénique idiopathique représente lindication majeure de la splénectomie qui assure la guérison chez 86% des malades. Le nombre des plaquettes dépasse 10,000/mm3 vers le 8ème jour postopératoire dans 88% des cas. La splénectomie durgence est indiquée en cas de purpura thrombocytopénique thrombotique en raison du taux important des succès enregistrés. La splénectomie chez les malades qui présentent un syndrome myeloprolifératif provoquant une thrombocytopénie entraîne une élévation du nombre des plaquettes mais elle saccompagne du taux le plus élevé de complications constatées. En cas de leucémie lymphoïde chronique ou de leucémie à tricholeucocytes la splénectomie entraîne presque toujours le retour au taux normal des plaquettes et une amélioration marquée de la qualité de la vie. En fait de nombreuses affections caractérisées par une thrombocytopénie réagissent favorablement à la splénectomie.En cas de purpura thrombocytopénique idiopathique des rates accessoires ont été découvertes dans 17% des cas. Leur présence est fréquente en cas de syndromes myeloprolifératifs. Elle est rare dans les autres affections saccompagnant de thrombocytopénie.ResumenLos efectos de la esplenectomía en 49 pacientes trombocitopénicos manejados a partir de 1979 fueron evaluados y comparados con nuestra experiencia previa con otros 174 pacientes. La púrpura trombocitopénica idiopática (PTI) constituye la más importante indicación para esplenectomía y la operación conlleva una tasa de curación de 86% en estos pacientes. El recuento de plaquetas asciende por encima de 100,000/mm3 hacia el octavo día postoperatorio en el 88% de los casos que responden a la operación. La esplenectomía de urgencia está indicada en patientes con PTI en virtud de que el procedimiento se asocia con las más altas tasas de curación. La esplenectomía en pacientes con alteraciones mieloproliferativas causantes de trombocitopenia logra elevar efectivamente el recuento de plaquetas, pero se acompaña de la mayor incidencia de complicaciones en el grupo de desórdenes hematológicos estudiado. En los pacientes con leucemia linfática crónica o con leucemia de células peludas, la esplectomía casi siempre retorna el recuento de plaquetas al nivel normal y se logra una impresionante mejoría en la calidad de la vida. Una amplia variedad de condiciones caracterizadas por trombocitopenia responde a la esplenectomía. Bazos accesorios fueron resecados en el 17% de los pacientes con PTI y se encuentran con frecuencia en pacientes con enfermedades mieloproliferativas, pero han sido raramente hallados en otros pacientes con trombocitopenia.

Insulin inhibits apolipoprotein B secretion in isolated human hepatocytes

The effect of insulin on apolipoprotein (apo) B secretion was investigated in human hepatocytes. Freshly isolated hepatocytes, prepared by collagenase dispersion of liver specimens, were incubated in serum-free media in the absence and presence of 100 nmol/L insulin for 2 hours. The media was then assayed for apo B content by radioimmunoassay. In hepatocytes incubated without insulin, the secretion of apo B (relative to human low-density lipoprotein [LDL]) was 125 +/- 37 ng/10(6) cells/2 hours. In the presence of insulin, apo B secretion was reduced to 83 +/- 29 ng/10(6) cells/2 hours (34% inhibition, P less than .05). These results using human hepatocytes are consistent with previous data from our laboratory describing insulin-dependent inhibition of apo B secretion in primary cultures of rat hepatocytes and studies by others employing the human-derived hepatoma cell line, Hep G2. We conclude that human hepatic apo B secretion is under insulin control. The role of more chronic insulin exposure requires further investigation.

ROLE OF SPLENECTOMY IN HEMATOLOGIC DISORDERS

Abstract. There has been an increase in the indications for splenectomy for hematologic diseases. It is a consequence of expanding the list of disorders and liberalizing the indications for splenectomy for many diseases. Hereditary spherocytosis is the most frequently encountered congenital anemia for which splenectomy is curative. Splenectomy is generally advised for warm antibody acquired hemolytic anemia if conventional medical therapy fails. Idiopathic thrombocytopenic purpura (ITP) remains the most common hematologic disorder for which splenectomy is therapeutic. A variety of thrombocytopenias are improved by splenectomy. The myeloproliferative disorders constitute a spectrum of disease potentially improved by splenectomy, but preoperative management should be modified in this group. Splenectomy in patients with chronic leukemias and lymphomas are often palliative and facilitate chemotherapy. There are no specific requirements preoperatively other than the administration of pneumoccocal andHemophilus influenzae vaccines. Platelets are not administered to patients with ITP. An integral part of the procedure is the search for accessory spleens. The postoperative complication of overwhelming postsplenectomy sepsis must be considered; it occurs more frequently in association with specific basic diseases and can be obviated by appropriate treatment.

Splenectomy for Hematologic Disease

The author discusses the indications for splenectomy in various hematologic diseases, including anemias, thrombocytopenia, hypersplenism, and myelofibrosis. Preoperative and postoperative management are also considered.

Primary Sclerosing Cholangitis: A Disease Revisited

Review of the more recent literature suggests a less sanguine prognosis than that originally reported. Although some patients have prolonged favorable responses to treatment, in others the chronicity of the disorder results in cirrhosis and hepatic failure despite early palliation.

Vascularity of gastrointestinal staple lines demonstrated with silicone rubber injection.

Gastrointestinal stapling devices were applied across canine small intestine, and then the blood supply of the stapled segments was immediately filled with silicone rubber. After tissue clearing and microdissection, the outstanding vascularity of the staple lines was clearly demonstrated. The B configuration of the closed staple allows blood vessels of substantial size to pass through it. This might make staple technique especially advantageous whenever vascularity is critical.

Detection of Preformed Venous Thrombi in Dogs by Means of I 131 -Labeled Antibodies to Dog Fibrinogen

Dogs with thrombin-induced thrombi received I131 rabbit antibody to dog fibrinogen and a day later were given antiserum to the rabbit gamma globulin. Scintillation scanning techniques successfully detected the site of thrombosis. Excision of the thrombi and surrounding blood vessels demonstrated deposition of radioactivity in the lesion. The immunologic removal of the gamma globulin from the circulating blood increased the difference between the radioactivity deposited in the lesion and that present in the blood. This accentuates the lesion and offers potential diagnostic advantage.

Comparison of platelet adherence and aggregation in modified human umbilical vein and autogenous vein grafts.

The use of glutaraldehyde-tanned human umbilical vein as a vascular conduit has recently become popular. In previous studies in our laboratory, neointimal fibrous hyperplasia was responsible for poor long-term patency of this material in a canine model. The present study was undertaken to compare the platelet-adhering characteristics of autogenous vein and modified human umbilical vein. After platelets were labelled with chromium-51, 10 mongrel dogs underwent bilateral end-to-side femoral artery bypass grafts. Human umbilical vein and autogenous jugular vein were placed in opposing groins of each dog. Two hours after graft implantation, the animals were killed and the grafts retrieved along with 1 cm of the host artery at each anastomosis. These specimens and an aliquot of blood were placed in a scintillation counter and radioactivity levels were determined. The human umbilical vein had significantly more platelet adherence than the autogenous veins as determined by counts per gram per 10 minutes. The handling characteristics of human umbilical vein were also suboptimal. Separation of the graft layers was occasionally observed, sometimes resulting in intramural hematomas and graft dissection. The previously reported poor performance of human umbilical vein in the canine model is most likely a result of its platelet-adhering surface and poor handling characteristics.