Pressure-controlled Vascular Clamp: A Novel Device for Atraumatic Vessel Occlusion

Morphological vessel injury after clamping has been an important problem in vascular surgery. Although various techniques have been employed to occlude a vessel during a surgical procedure, a complete, atraumatic occlusion method has not yet been developed. In the present study, we describe use of a novel pressure-controlled and balloon-jawed vessel clamp to provide atraumatic vessel occlusion. We compared its traumatic effect on femoral arteries with that resulting from use of a conventional De Bakey vascular clamp in a canine model. During surgical application, our clamp provided complete vessel occlusion with no oozing in distal arteriotomy. On histological examination of the clamped vessel segments, we observed no destruction of the vessel wall, compared to widespread injury of the De Bakey vascular clamp. Despite some difficulties in application, we think this technique could be a promising method for vascular procedures.

Brain death and donor management in the intensive care unit: experiences over the last 3 years

We sought to examine the frequency of brain death in the ICU, the donation rate, and the problems encountered during donor management between the years of January 2000, the date we began treating patients with neurologic pathologies and traumatic brain injury, and March 2003. Between January 2000 and March 2003, 134 patients diagnosed with brain death in our ICU were studied prospectively for the reason of brain death, the time between admission to ICU, and the diagnosis of brain death, the frequency of diabetes insipidus, the inotrope requirement, hypothermia, electrolyte imbalance, arrhythmia, and cardiac arrest. Among the approximately 2600 patients admitted to the general 24-bed ICU, 940 had cerebral injuries. In this group, the mortality rate was 33.5% (315 out of 940 patients) including brain-dead patients. Donor care was performed in 94 patients with organs suitable for transplantation out of 134 brain-dead patients. Fifty (53.2%) out of 94 patients became organ donors. The donor ratio was 12 per million-population per year as a mean value of the study period, which was approximately 10 times higher than the average ratio in Turkey. Although we observed many life-threatening problems during donor management, none of these patients died or had acute organ dysfunction.

Salvage Ifosfamide–Doxorubicin Chemotherapy in Patients with Recurrent Nasopharyngeal Carcinoma Pretreated with Cisplatin-Based Chemotherapy

This study evaluated the efficacy and toxicity of ifosfamide and doxorubicin chemotherapy regimen in Turkish patients with recurrent or metastatic nasopharyngeal carcinoma (NPC) previously treated with platinum-based chemotherapy. Twenty-one patients with recurrent or metastatic NPC previously treated with platinum-based chemotherapy as adjuvant or palliative treatments who received ifosfamide 2500 mg/m(2) d 1-3, mesna 2500 mg/m(2) d 1-3, doxorubicin 60 mg/m(2) d 1, repeated every 21 d was retrospectively analyzed. Patients received a median number of three cycles of ifosfamide-doxorubicin (range: 1-6). Seven patients (33.3%) achieved partial response and no patient achieved complete response. Six (28.5%) had stable disease, whereas three (18.75%) had progressive disease. The median time to progression was 7.0 mo. Ifosfamide-doxorubicin regimen is an effective salvage regimen in patients with recurrent and metastatic NPC.

Induction chemotherapy with cisplatin and 5-fluorouracil followed by chemoradiotherapy or radiotherapy alone in the treatment of locoregionally advanced resectable cancers of the larynx and hypopharynx: Results of single-center study of 45 patients

BACKGROUND

Induction chemotherapy with cisplatin and fluorouracil and radiotherapy is an effective alternative to surgery in patients with carcinoma of the larynx and hypopharynx who are treated for organ preservation.

METHODS

We designed a protocol to evaluate the possibility of organ preservation in patients with advanced, resectable carcinoma of the larynx and hypopharynx. Forty-five eligible patients who were followed up between April 1999 and May 2001 were enrolled. Initially, these patients were treated with two cycles of induction chemotherapy consisting of cisplatin, 20 mg/m2/day on days 1 to 5, and 5-fluorouracil, 600 mg/m2/day by continuous infusion on days 1 to 5. Patients who had a complete response to chemotherapy were treated with definitive radiotherapy; patients who had a partial response to chemotherapy were treated with chemoradiotherapy. Cisplatin, 35 mg/m2/week, was introduced throughout the duration of radiotherapy. Patients who had no response or progressive disease underwent surgery with postoperative radiotherapy. Patients with N2 or N3 positive lymph nodes underwent neck dissection after the treatment.

RESULTS

The mean age was 56.6 years (range, 34-75 years). The overall response rate to induction chemotherapy was 71.1%, with a 17.8% complete response rate and 53.3% partial response rate. With a median follow-up of 13.7 months, 23 (51.1%) of all patients and 63.3% of surviving patients have had a preservation of the larynx or hypopharynx and remain disease free. The most common toxicities were nausea and vomiting and mucositis.

CONCLUSION

Organ preservation, with multimodality treatment, may be achievable in some of the patients with resectable, advanced larynx or hypopharynx cancers without apparent compromise of survival.

Remifentanil vs alfentanil in the total intravenous anaesthesia for paediatric abdominal surgery

BACKGROUND

Our aim was to investigate whether total intravenous anaesthesia (TIVA) with remifentanil and alfentanil would ensure appropriate analgesia and recovery conditions in anaesthesia for children undergoing abdominal surgery.

METHODS

Sixty children, scheduled for abdominal operations were randomized to receive, in a double-blind manner, either remifentanil (loading dose 1 microg x kg(-1); maintenance infusion, 0.25 microg x kg(-1) min(-1)) or alfentanil (loading dose 50 microg x kg(-1); maintenance infusion, 1 microg x kg(-1) min(-1)) as the analgesic component of TIVA. They were combined with propofol (loading dose, 2 mg x kg(-1); step 1 maintenance infusion, 10 mg x kg(-1) h(-1); step 2 maintenance infusion, 8 mg x kg(-1) h(-1); step 3 maintenance infusion, 6 mg x kg(-1) h(-1)) neuromuscular blockade was with mivacurium. Dose changes of the drugs, the times from cessation of anaesthesia to extubation, verbal responses, recovery of ventilation, orientation, and qualification for discharge from the postanaesthetic care unit (PACU) were recorded.

RESULTS

Demographics, duration of surgery and anaesthesia were similar between the two groups. Times to extubation and stay in the PACU were significantly shorter in the remifentanil group compared with the alfentanil group. Quality of emergence (QE) from anaesthesia scale scores were higher in the remifentanil group compared with the alfentanil group.

CONCLUSIONS

Remifentanil provides a more rapid recovery and adequate postoperative analgesia after TIVA for paediatric abdominal surgery, compared with alfentanil.

Waldeyer’s Ring Lymphomas

Optimal management of patients with localized Waldeyer's ring (WR) lymphoma remains controversial due to the lack of randomized studies and heterogenous grouping of most reported series. In this retrospective study, we have evaluated the possible prognostic factors and treatment outcome of WR non-Hodgkin's lymphoma. Between December 1993 and February 2000, 32 patients with WR lymphoma, stage I (11 patients) and stage II (21 patients) were treated. There were 17 male patients and 15 female patients with a median age of 47 years. The distribution among different anatomical sites were as follows: tonsils in 16 (50%), nasopharynx in 10 (31%), base of tongue in 6 (19%). According to Working Formulation, 10 had high-grade, 17 intermediate grade, 3 low-grade, and 2 had unclassified lymphomas. Combined chemotherapy and radiotherapy was the primary modality of therapy for intermediate or high-grade lymphoma. Radiotherapy alone was employed only in low-grade WR lymphomas. Chemotherapy was median 6 courses of CHOP (cyclophosphamide, doxorubicin (Adriamycin), vincristine, and prednisolone) in 26 patients and CEOP (cyclophosphamide, doxorubicin, etoposide, and prednisone). Radiotherapy volume was involved field and the median dose was 40 Gy. Median follow-up is 40 months (ranged from 6-82 months). Overall survival and disease-free survival (DFS) rates at 3 years are 100% and 92%, respectively. Two patients developed recurrence, both salvaged with further chemotherapy. Only one patient died because of other reasons. International Prognostic Index score (<or=2 vs. >2) is found to be an important prognostic factor for DFS. The other significant prognostic factors for DFS are performance status and serum levels of alkaline phosphatase and lactate dehydrogenase. Our results suggest that combined chemotherapy and involved field radiotherapy is appropriate treatment for stage I-II WR lymphoma. International Prognostic Index is the strongest predictor for DFS.

Tissue trace element change after total body irradiation

PURPOSE

In this study, we examined the changes of tissue contents of trace elements and iron after total body irradiation (TBI) and their possible impact on late toxicities.

MATERIAL AND METHODS

20 female Wistar rats were randomly assigned to two groups - either radiation (n = 10) or control (n = 10). Rats in the radiation group received TBI of 5 Gy in a single fraction. Rats were sacrificed and tissue samples of heart, lung and kidney were taken 8 weeks after radiation. Tissue levels of zinc, copper, magnesium, manganese and iron analysis were performed with an atomic absorption spectrophotometer and suprapure grade standard solutions. One kidney of each animal was taken for electron microscopic analysis. Blood samples were collected from all animals and the blood chemistry related to kidney function was studied.

RESULTS

The kidney levels of Fe and Cu significantly increased 8 weeks after irradiation (p < 0.05). The Cu/Zn ratio did not reach statistical significance in any tissue, however in kidney, there was a tendency to rise (p = 0.08). Myocardium and lung content of trace elements and iron did not show any significant change 8 weeks after irradiation. Electron microscopic analysis showed significant injury in glomerular endothelial cells, renal tubules and thickening of basement membrane. Blood chemistry showed a significant rise in serum creatinine (p = 0.008) and calcium (p = 0.01) in the TBI group. Serum creatinine levels were 0.73 and 0.84 mg/dl, and serum calcium levels were 10.1 and 11.3 mg/dl in control and TBI groups, respectively.

CONCLUSION

A sublethal dose of TBI causes deposition of Cu and Fe within the kidney after TBI. Deposition of these elements may have some additional role on the toxicity caused by direct radiation on the kidney.

Antioxidant system in Down syndrome: a possible role in cataractogenesis

Recent studies show a relationship between oxidants, antioxidants, and degenerative disease of aging like cataract formation. Focal lens cortical changes and cortical liquification have been reported in patients with Down syndrome (DS) over 14 years. There is evidence supporting the hypothesis that trisomy 21 patients have an increase in free radical reactions. These changes in antioxidant system may play a role in cataractogenesis in Down syndrome. We screened serum samples from 12 patients with DS and cataract: and 12 healthy age and sex-matched persons. We evaluated the antioxidant enzyme activities of superoxide dismutase (SOD), glutathione peroxidase (GSHPx), glutathione-S-transferase (GST) and reduced glutathione (GSH) in erythrocytes. SOD and GSHPx levels of patients with DS were significantly higher than the control group. No significant changes were observed in GST and GSH levels between the DS and control groups. These findings suggest impairment in antioxidant system, which may be a possible mechanism for early cataract formation in DS.

Patterns of failure in patients receiving definitive and postoperative IMRT for head-and-neck cancer

PURPOSE

To analyze the patterns of locoregional failure in patients with head-and-neck cancer treated with inverse planning intensity-modulated radiotherapy (IMRT).

METHODS AND MATERIALS

Between February 1997 and December 2000, 165 patients with histologically confirmed head-and-neck cancer were treated using a parotid-sparing inverse planning IMRT protocol. Thirty-nine patients who received either palliative repeat irradiation or IMRT as a boost were excluded from this analysis, leaving 126 patients for this analysis. Of the 126 patients, 30 were women and 96 were men (median age 56 years, range 13-84). Fifty-two patients (41%) received definitive IMRT. Of the 52 patients, 17 were treated with RT alone and 35 with concurrent cisplatin-based chemotherapy regimens. Seventy-four patients (59%) received postoperative IMRT. The median follow-up was 26 months (range 12-55). IMRT was used only in the upper neck for salivary sparing. The lower neck was treated with a conventional AP low-neck port abutted to the inferior IMRT dose distribution border. The radiation dose was prescribed to the two clinical target volumes (CTVs) according to the assumed risk of containing disease. The mean dose for definitive IMRT patients was 72.64 +/- 4.83 Gy to CTV1 and 64.34 +/- 5.15 Gy to CTV2. The mean dose to CTV1 and CTV2 in postoperative cases was 68.53 +/- 4.71 Gy and 60.95 +/- 5.33 Gy, respectively. The locations of failure were analyzed.

RESULTS

Seventeen locoregional failures (persistent or recurrent disease) were found. Of these 17 failures, 9 (53%) were inside CTV1. One failure (6%) was marginal to CTV1 but inside CTV2. One failure (6%) occurred outside CTV1 but inside CTV2. Another failure was marginal to CTV2. Of the 17 failures, 5 (28%) were found outside of the IMRT field and in the lower neck. Dose-volume histogram analysis revealed that for all but 1 patient, the recurrent/persistent disease within the CTVs received comparable or superior dose coverage relative to the CTV. The 2-year actuarial locoregional control rate was 85%, and the ultimate locoregional control rate after surgical salvage was 89%. We observed no dermal failure and only one marginal failure in the region adjacent to the spared parotid glands.

CONCLUSION

We have shown that the target definition and coverage for patients treated with IMRT for parotid sparing is adequate. The predominant tumor failure within CTV1 may imply the need to identify patients with radioresistant tumor subvolumes (such as hypoxic regions) within the CTV. This information would assist in discriminating a subgroup of tumors for a more aggressive and target-specific therapeutic approach.

Malignancy in Behçet's disease: a report of 13 cases and a review of the literature

Behçet's disease (BD) has rarely been reported in association with malignant diseases. In most cases the autoimmune nature of the disease itself or immunosuppressive drug use has been blamed for malignant transformation. We report 13 cases of BD concurrent with neoplastic disease as well as treatment-related morbidities in this particular patient group. Between 1986 and 1999, 400 patients were diagnosed as having BD in Hacettepe University Hospitals. Of these 13 patients, 3.25% developed malignant diseases within a median follow-up time of 9.8 years. Solid tumors were diagnosed in 10 patients and haematological or lymphoid malignancies in three. Surgery was performed in seven patients, whereas radiotherapy was applied in six and chemotherapy in eight. A literature review revealed 27 cases of BD associated with malignancies, mostly lymphoid or haematological. Ten of our cases were solid tumors, and to our knowledge most of these are the first reported cases of specific malignancies concurrent with BD. Treatment-related morbidities were wound infection as surgical morbidity in one patient (1/7) and radiotherapy-related morbidity in three (3/6) patients in a median follow-up time of 2 years. Solid tumors in addition to lymphoid and haematological malignancies are also seen during the course of BD. Radiation therapy may cause severe late toxicities in the presence of BD. Chemotherapy and surgery are fairly safe for the treatment of malignancies in BD patients.

Plasma carnitine levels in children with Down syndrome

Carnitine is responsible for several chemical processes, including lipid metabolism, nerve cell conduction, reduction in muscle hypotonia, and limitation in oxidative damage to cells. In patients with Down syndrome (DS), the process of growth is behind that of normal children and neuromuscular control is attained somewhat later. The purpose of this study was to assess variation in levels of carnitine in normal and DS children and the relationship between the amount of carnitine and age. The study involved 30 (15 girls, 15 boys) normal children and 40 (20 girls, 20 boys) DS patients of Turkish ancestry, 6 months to 13 years of age. Carnitine level was determined using Deufel's enzymatic method. Carnitine level was significantly lower in DS patients compared with normal children between 6 months to 5 years of age. Between 5 and 13 years of age, the level of carnitine was about the same in both the normal and DS groups. The results suggest that carnitine level shows a different pattern of age related increase in DS compared to normal children.

Radiotherapy in the management of Kasabach-Merritt syndrome: a case report

A 21-day-old infant with hemangioma was brought to the hospital with enlargement of the hemangioma of the left thigh and purple discoloration around umbilicus. This led to the diagnosis of Kasabach-Merrill syndrome. Initial treatment with corticosteroid failed. The patient underwent radiotherapy that led successfully to improvement of both hemangioma and thrombocytopenia. After 2 years of follow-up, the patient has experienced long-term complications, including atrophy and growth retardation of the irradiated leg.

Changes in the antioxidant system in epileptic children receiving antiepileptic drugs: two-year prospective studies

The aim of this study was to measure changes in the antioxidant systems of epileptic children who had been receiving either valproate or carbamazepine monotherapy for 2 years. For this purpose, levels of erythrocyte glutathione, glutathione peroxidase, superoxide dismutase, and serum lipid peroxidation in 25 healthy children and 27 children who had previously been diagnosed as having epilepsy but who had not, prior to the study, received antiepileptic drugs were tested. Of the 27 epileptic children, 14 were given valproate, and the remaining 13 were given carbamazepine; these tests were repeated in the 13th and 24th months of treatment. The results showed that, during valproate therapy, the lipid peroxidation levels of the epileptic children increased and the glutathione peroxidase levels decreased in comparison with those levels recorded in the control and pretreatment groups. In addition, the superoxide dismutase levels were found to be increased during the first year of valproate therapy when compared with those of the pretreatment group. However, during carbamazepine therapy, lipid peroxidation levels increased when compared with the control group only, not the pretreatment group. Furthermore, the results showed that during the second year of treatment, the superoxide dismutase levels of the children receiving carbamazapine monotherapy were found to be higher than those of both the control and pretreatment groups. From these results, it can be concluded that the antioxidant systems of the children who had been receiving valproate therapy during the 2 years were more significantly affected than those of the children who had been receiving carbamazepine.

Acute phase response during radiotherapy

PURPOSE

The acute phase response is characterized by changes in the plasma concentrations of a number of liver-synthesized proteins, one of which is C-reactive protein (CRP). The existence of these changes in the plasma profile underlies the change in erythrocyte sedimentation rate (ESR). Acute phase response itself is an illness and may result from immunologic reactions and inflammatory processes. This study is designed to determine whether the CRP level and ESR increase during radiotherapy and whether their rise correlates with acute and late radiation morbidity.

METHODS AND MATERIALS

Between April 1997 and October 1998, 51 patients with the diagnosis of endometrium and cervical cancer were treated with surgery and postoperative radiotherapy. Median age at the time of radiotherapy was 52 (range, 26-73) years. Thirty patients received pelvic radiotherapy, and 21 patients were treated by pelvic-paraaortic irradiation. A total dose of 50.4 Gy to the pelvis and 45 Gy to the paraaortic field were delivered in conventional fraction. Erythrocyte sedimentation rates and CRP levels were studied before, during, and at the end of radiotherapy.

RESULTS

The mean ESR measurements before and after radiotherapy were 40 (8-100) and 52 (10-120), and mean CRP levels were 1.4 (0.12-9.8) and 2.7 (0.12-32.2), respectively. The statistical analysis yielded significant rise in ESR and CRP levels at the end of radiotherapy (p < 0.001). The increase was more prominent in patients who were irradiated through pelvic-paraaortic field than in patients with pelvic radiation (p = 0.005 and 0.028 respectively).

CONCLUSION

Acute phase response was present during radiotherapy. Radiotherapy should be considered as a cause of increase in CRP level and ESR especially in clinical conditions where acute phase response is important.

Erythrocyte glutathione, glutathione peroxidase, superoxide dismutase and serum lipid peroxidation in epileptic children with valproate and carbamazepine monotherapy

This prospective study was carried out to determine changes in the antioxidant system in epileptic children receiving long term antiepileptic drugs (AEDs). Levels of erythrocyte glutathione (GSH), glutathione peroxidase (GSH-Px), superoxide dismutase (SOD) and serum lipid peroxidation were determined in 25 healthy children and 30 epileptic children who had not yet received AEDs. Sixteen patients were treated with valproic acid (VPA) and 14 with carbamazepine (CBZ); 13 months later these parameters were retested. The results showed that SOD and lipid peroxidation levels were increased but the GSH-Px levels were decreased in epileptic children on VPA therapy compared with the control group and the results before treatment. No significant differences of these parameters were found in epileptic children on CBZ therapy compared with the control group and the results before treatment, except that lipid peroxidation level was slightly higher in epileptic patients before treatment. We conclude that antioxidant systems in epileptic children on CBZ therapy are better regulated in comparison with epileptic children on VPA therapy.

Effect of verapamil on lenticular calcium, magnesium and iron in radiation exposed rats

PURPOSE

To investigate the effect of verapamil on lenticular calcium, magnesium, iron and on radiation-induced cataract in rats.

METHODS

Thirty-seven, female, Wistar Albino rats, weighing 180-230 g were randomly grouped as follows: control group (10 rats), radiation group (13 rats) and radiation-verapamil group (14 rats). Both radiation and radiation-verapamil groups received 5 Gy radiation to the whole body in a single dose, including both eyes within the irradiation volume; in addition the verapamil group received daily subcutaneous injections of 8 mg/kg verapamil starting on the first day of radiation. At the end of an 8-week experimental period, the animals were killed by decapitation. Lenticular calcium, magnesium, and iron levels were studied.

RESULTS

The mean lens calcium level for the radiation group was significantly higher than that for the control and radiation-verapamil groups and, there was no significant difference between the control and radiation-verapamil groups. The mean lens magnesium value for the radiation group was significantly higher than that for the control group. In the radiation-verapamil group the mean lens magnesium content was significantly lower than that for the radiation group. The iron level in the radiation group was significantly higher than that for the radiation-verapamil group.

CONCLUSIONS

The lens calcium, magnesium and iron contents increased after radiation exposure. Verapamil treatment significantly reduced the increase in the lenticular content of calcium, magnesium and iron, indicating a probable protective effect of verapamil in radiation-induced cataract formation.

The effects of carbamazepine and valproic acid on the erythrocyte glutathione, glutathione peroxidase, superoxide dismutase and serum lipid peroxidation in epileptic children

Some epileptic drugs may change antioxidant enzyme activities in humans and experimental animals. Recent studies suggest that membrane lipid peroxidation may be causally involved in some forms of epilepsy, and the differences are reported in free radical scavenging enzyme levels. GSHpX, SOD, GSH are important parameters of antioxidant defence mechanisms. This study was undertaken to evaluate the effects of valproic acid and carbamazepine (CBZ) therapy on erythrocyte glutathione (GSH), glutathione peroxidase (GSHpX), superoxide dismutase (SOD) and lipid peroxidation. During the treatment with VPA or CBZ, the erythrocyte GSHpX and GSH levels of epileptic children were significantly changed as compared to those of health control subjects. The mean levels of serum lipid peroxidation and erythrocyte superoxide dismutase were not statistically different from controls. The methods used for investigation of glutathione peroxidase, superoxide dismutase, glutathione and serum lipid peroxidation were all based on spectrophotometric measurement.

A possible mechanism of X-ray-induced injury in rat lens

PURPOSE

X-ray and other radiation can cause cataract, but the pathogenic mechanism is largely unknown. The aim of this study was to investigate the accumulation of iron in the x-ray-exposed rat lens and its relationship to lens injury.

METHODS

Fifty male Wistar rats were divided randomly into five groups of 10. Groups 2 and 4 rats were sham-exposed, groups 3 and 5 were x-ray-treated, and group 1 served as control. X-ray radiation and sham exposure were performed in a similar manner. After 10 and 30 days of exposure, a lens from each rat in groups 2 and 3, and 3 and 5, respectively, were analyzed by flame atomic absorption technique for the assessment of metal content.

RESULTS

Significantly decreased zinc and increased iron and calcium concentrations were detected in the lens samples of groups 3 and 5 compared with groups 2 and 4 and controls. Similar results were obtained comparing groups 5 and 3.

CONCLUSIONS

We propose that x-ray exposure may cause toxic cell injury of the rat lens via Fenton metals catalyzed damage. Initial lens membrane damage in the radiolytic phase may permit the access of iron resulting in lens damage.

High-dose-rate mold brachytherapy of early gingival carcinoma: a clinical report

Two elderly edentulous patients with the diagnosis of early stage cancer of the upper gingiva were treated by customized dental mold brachytherapy. Locoregional tumor control was achieved in both patients. One patient is alive without any evidence of disease 36 months after treatment, the other patient died of distant metastasis shortly after brachytherapy. Brachytherapy, being easy to apply with short treatment time and good acute tolerance, is a good choice and effective modality for the management of early stage gingival cancer, particularly in elderly patients.

Effect of low-dose methyl prednisolone on serum cytokine levels following extracorporeal circulation

The systemic inflammatory response to cardiopulmonary bypass (CPB) is associated with increased production of cytokines. This systemic inflammatory response characterized by the activation of interleukin-6 (IL-6) and interleukin-8 (IL-8) during and after CPB is well documented. A prospective, randomized, double-blind study was performed so as to understand the effects of low-dose methyl prednisolone sodium succinate (MPSS) on the circulating levels of serum cytokines and clinical outcome. Twenty patients were randomly divided into two groups on the basis of the administration of low-dose (1 mg/kg) MPSS (n = 10) and placebo (n = 10) into the pump prime solution. All patients were scheduled to undergo a primary elective coronary artery bypass grafting operation. Patients receiving concurrent corticosteroids, salicylates, dipyridamol or anticoagulants were excluded from the study. Other exclusion criteria were concurrent chronic obstructive pulmonary disease, chronic renal failure, insulin-dependent diabetes, congestive cardiac failure, peptic ulcer history, prior cardiac operations, recent (in a one-month period) myocardial infarction and steroid dependency. Mild systemic hypothermia (30-32 degrees C, rectal) was assured during the CPB. Four blood samples were drawn from the radial artery catheter immediately before starting CPB (T1), following protamine administration (T2) and at 24 (T3) and 48 h (T4) after completion of CPB. In each sample, creatine kinase-myocardial band (CK-MB), white blood cell (WBC), IL-6 and IL-8 levels were measured. IL-6 and IL-8 concentrations were measured by enzyme immunoassay and enzyme-linked immunoabsorbant assay methods. Serum IL-6 T2 and serum IL-6 T3 levels were significantly higher than IL-6 T1 levels in both groups (p < 0.001) and (p < 0.01), and there was no significant elevation in serum IL-8 levels in either group. Serum IL-6 levels were significantly higher in the placebo group than in the MPSS group at T3 (p < 0.009). There was no significant difference in CK-MB T1 levels between the groups. Although there was no significant difference between CK-MB T1 and T2 levels in the MPSS group, the CK-MB T2 and CK-MB T3 levels were significantly higher than T1 levels in the placebo group (p < 0.001) and (p < 0.05). There was significant elevation of WBC levels at T2 and T3 in both groups without notable difference between the groups (p < 0.05). This study has shown that low-dose MPSS suppresses CPB-induced inflammatory response. Further clinical studies (on larger and higher risk groups) may reveal more information on relations between morbidity and cytokine levels which may have some predictive value on clinical outcome following CPB.

The effect of verapamil in the prevention of radiation-induced cataract

PURPOSE

Cataract is an unavoidable complication when radiation therapy includes the lens, even in small doses. Alterations in the ion content of the lens were considered to play an essential role in cataract formation. In this experimental study, the effect of verapamil on ion concentrations within the irradiated lenses was investigated in rats.

METHODS AND MATERIALS

Forty female Wistar albino rats, each weighing 180-250 g, were divided into three groups: (a) radiation treated (n = 10); (b) no treatment (n = 10); (c) or a combination of radiation and verapamil (n = 20). Both the radiation group and verapamil-treated group received 5 Gy radiation to the cranium in a single fraction, including the eyes, within the irradiation volume. All animals were sacrificed by bleeding, 7.5 weeks posttreatment. Calcium, sodium, and potassium levels were measured in blood and in lens homogenates. However, for technical reasons, magnesium levels could only be studied in lens homogenates.

RESULTS

Potassium and sodium concentrations in lens homogenates did not differ in the control and radiation groups, but both were significantly lower in the verapamil-treated group (p = 0.001, p = 0.009, respectively). Calcium levels were higher in the radiation group and lower in the verapamil-treated group compared to the controls (p < 0.0001); magnesium levels did not differ (p = 0.37).

CONCLUSION

Verapamil effectively decreased the lens calcium concentration, which is accepted as the key element in radiation cataractogenesis. It is therefore concluded that verapamil may reduce the risk of radiation-induced cataract formation.

Sucralfate in the prevention of radiation-induced oral mucositis

Radiotherapy-induced mucositis decreases the quality of life by impairing eating, swallowing, and talking and by disturbing sleep. Mucositis may also predispose to local and systemic infections and may cause interruption of radiotherapy course. We studied the efficacy of sucralfate suspension in the prevention and management of oral mucositis and pain during radiotherapy in a double-blind, placebo-controlled, randomized, prospective trial. Twenty-eight patients with head and neck cancer were included in the study. The patients were randomized to use either sucralfate mouth washing (n = 18) or placebo washing (n = 10) during irradiation. Oral mucositis and symptoms were assessed by the same physician using Radiation Therapy Oncology Group Acute Radiation Morbidity Scoring criteria. All patients developed varying degrees of radiation-induced mucositis. Grade 4 mucositis was not encountered in any patient. One patient had grade 1, seven patients grade 2, and two patients grade 3 mucositis in placebo group. In sucralfate group, nine patients each had grade 1 and grade 2 with no grade 3 mucositis. Patients in the sucralfate group experienced significantly lower degree of mucositis than placebo group (p < 0.05). Sucralfate mouth washing is beneficial in decreasing the intensity of radiation-induced mucositis and oral discomfort. It is cheap, easy to administer with no serious side effect, and may be routinely used in patients receiving head and neck radiotherapy.

N-acetyl-beta-glucosaminidase and beta-galactosidase activity in children receiving antiepileptic drugs

To evaluate renal tubular function in children receiving antiepileptic drugs the urinary activity of two lysosomal enzymes, N-acetyl-beta-glucosaminidase and beta-galactosidase, were measured. The enzyme levels were determined before the administration of antiepileptic drugs and 8 months after. Fourteen epileptic children received valproate, and 17 received carbamazepine. The urinary activity of these enzymes in 25 healthy control patients also was examined. Increased N-acetyl-beta-glucosaminidase activity was found in 50% of patients taking valproate and in 17.6% of patients taking carbamazepine. Increased beta-galactosidase activity was found in 28.5% of patients taking valproate and 11.7% of patients taking carbamazepine compared with the results before treatment. On the basis of these results, it is suggested that patients taking antiepileptic drugs, especially valproate, may demonstrate minor signs of tubular dysfunction. In those patients who use these drugs at increased dosage levels or for long periods, the possibility of tubular dysfunction may be increased, and these dysfunctions may manifest in clinical symptoms.

Management of foreign body aspiration in infancy and childhood. A life-threatening problem

It is well known that young children have tendency to place objects in their mouths, frequently leading to aspiration of foreign bodies (FBs) into the tracheobronchial tree (TBT). The patient group comprised 596 patients with a history of suspected aspiration of FBs into the TBT who were bronchoscoped for diagnosis and treatment. There were 306 male (51.3%) and 290 female (48.7%) patients, with a mean age of 2.4 years (range 3 months-13 years). Sunflower seeds and hazelnuts were the most common FBs that were extracted using an open-tube rigid bronchoscope (Storz, Germany) and suitable coaxial forceps (Storz, Germany). Patients admitted within 48 hours following the aspiration numbered 341 (57.2%). The distribution of FBs between the right and left lung and trachea was 53, 37 and five percent, respectively. The aspirated material was visible on the chest x-ray in only 10 percent cases, which facilitated in making the diagnosis. Despite a history of aspiration, bronchoscopy was negative in 21 (3.4%) of the cases. Thoracotomy and subsequent bronchotomy was the treatment of choice in seven (1.5%) and lobectomy in two (0.3%) cases. Cardiorespiratory arrest was observed in five (0.8%) cases, three of whom (0.5%) died during bronchoscopy (2 cases) or thoracotomy (1 case). In conclusion, patients with FB aspiration are rapidly recognized from their histories and easily treated by bronchoscopy and extraction of the aspirated foreign body. A high index of suspicion is crucial for early diagnosis. However, education is the best preventive measure for decreasing the incidence of this problem.

Venous lesions in Behçet's disease

OBJECTIVES

Review of venous lesions in Behçet's disease (BD).

DESIGN

Retrospective study.

SETTING

University Hospital, Turkey.

MATERIALS AND METHODS

One hundred and twenty nine patients with BD diagnosed and treated in our hospital during the last 10 years were reviewed. Fifty-two patients with 54 vascular lesions of Behçet's disease were identified.

MAIN RESULTS

The incidence of isolated venous lesions in BD was 26%. Venous lesions developed after the initial diagnosis of BD in all patients within 10 years. Thirty-four (63%) of the 54 vascular lesions were venous and 15 (28%) were arterial. In 5 (9%) patients, both arterial and venous lesions were present. Deep vein thrombosis was the most frequent lesion (76%), followed by superficial thrombophlebitis (10%), superior vena cava thrombosis (10%) and inferior vena cava thrombosis (2%) and varicose veins (2%).

CONCLUSIONS

Venous lesions are not rare and affect the prognosis of BD. For this reason, venous lesions of BD should always be sought at follow-up of patients with BD.

Glutathione and related enzymes in rat liver treated with methyl nitrosourea

In vivo effects of methyl nitrosourea (MNU) on rat liver glutathione, glutathione S transferase and glutathione reductase have been studied. MNU was injected (20 mg per kg i.r.) weekly for 10 weeks. The animals were killed by decapitation 6 months later, livers were removed, homogenized and the enzymes were studied. Twenty-five animals were treated with MNU. Physiological salt solution was given to ten control animals. It was shown that the cytotoxic effects of MNU cause a decrease of glutathione levels. There was no difference in activity of glutathione reductase in the MNU treated group when compared to control, but glutathione S-transferase activity of the MNU treated group was found to be increased. Glutathione protects the cells against alkylating agents, which may cause cell damage due to depletion of glutathione levels. Increased levels of glutathione S-transferase may be a reaction of the organism to the alkylating agents. Because of depletion of glutathione levels, glutathione reductase levels may be unaffected.

Effects of compliance alteration on healing of a porous dacron prosthesis in the thoracic aorta of the dog

In our study, the results reveal that a marked reduction in the compliance of an external-velour, weft-knit Dacron prosthesis did not impair healing of either the graft wall or of the anastomoses when these grafts were implanted in the upper part of the descending thoracic aorta of the dog for 56 days. These observations are clinically relevant, since they are important to the design of noncrimped fabric prostheses which are resistant to kink and compression when used for axillofemoral, femoropopliteal and femorotibial bypass. However, experimental studies of the influence of compliance disparity should be extended to such grafts implanted for several years.

The effect of ventilation on the accuracy of pulmonary artery and wedge pressure measurements

A comparison was made of automated versus manual measurement of pulmonary artery (PA) and wedge (WP) pressures. The manual pressure measurements were taken at end-expiration whereas the automated measurements were taken using existing monitor and computer algorithms. A total of 40 critical care patients were divided into groups according to the ventilatory mode used (spontaneous, intermittent mandatory ventilation [IMV], or assist/control). In patients who were breathing spontaneously, the automated method underestimated mean PA pressure (MPAP) (p less than 0.01), WP (p less than 0.001), and PA diastolic (p less than 0.001) pressure but not PA systolic pressure. In patients on IMV, the automated method underestimated MPAP (p less than 0.05), WP (p less than 0.001), and PA diastolic (p less than 0.001) pressure and overestimated PA systolic pressure (p less than 0.05). In patients on assist/control, the automated method overestimated WP (p less than 0.001) and PA systolic (p less than 0.005) pressure pressure, underestimated PA diastolic (p less than 0.001) pressure and did not affect MPAP. The error was not affected by respiratory rate, thoracic compliance, or level of PEEP. The errors in automated pressure measurements believed to be clinically important varied with the ventilatory mode used. Patients breathing spontaneously had the largest measurement error, with 42% of these patients having a clinically important error in WP and 99% having a clinically important error in PA diastolic pressure. Patients on assist/control had the fewest errors in automated pressure measurements. In all ventilatory modes used, automated measurement of PA diastolic pressure had the largest amount of error.

Prolonged mechanical ventilation for respiratory failure: a cost-benefit analysis

To define the costs and benefits associated with prolonged mechanical ventilation, we studied retrospectively the records of 137 consecutive patients who required at least 48 h of ventilator support. The patients were physiologically unstable and required intensive care. Causes of respiratory failure included pulmonary diseases, post-operative complications, neuromuscular diseases, cardiac dysfunction, and GI disease. Forty-nine (36%) patients survived the hospitalization, and 38 (28%) patients were alive 3 yr after receiving prolonged mechanical ventilation. The mean total hospital cost was +16,930/patient (U.S. dollars, 1976-1977). The cost-benefit averaged +1826/yr of extended life. These costs varied from +460/yr of extended life for patients with respiratory failure complicating asthma to +8026/yr for patients with cardiac dysfunction. The cost-benefit ratio increased sharply for men older than 56 yr and for women older than 75 yr. These data document the importance of the basic disease process and the patient's age in the cost-benefit relationship.

Cardiovascular alterations in the adult respiratory distress syndrome

We reviewed the hemodynamic data of 27 patients with severe adult respiratory distress syndrome (ARDS) and found significant elevations in heart rate, pulmonary artery pressure, and pulmonary vascular resistance and depressions of stroke index and left ventricular stroke work index. Altered left ventricular performance was suggested by a left ventricular stroke work index lower than expected for the level of wedge pressure in 19 patients and decreased slopes in nine of 11 ventricular function curves. Hemodynamic values in a subgroup receiving 0 to 5 cm H2O of positive end expiratory pressure (PEEP) were similar to those in the overall group (mean PEEP 12.5 +/- 7.9 cm H2O). Improvement in pulmonary and systemic hemodynamics occurred in survivors. Eight of 11 patients who underwent postmortem examination had cardiac abnormalities. The findings in this study suggest that changes in cardiovascular performance commonly occur in severe ARDS and that several mechanisms may contribute to the alterations.