Pectoralis major myocutaneous flap: analysis of complications in difficult patients

The purpose of this study was to assess and discuss the effects of old age and systemic diseases on complications related to the use of a pectoralis major myocutaneous flap (PMMF) for reconstruction in head and neck surgery. Eighty-four consecutive patients, operated on between January 1992 and December 1998, were included in the study. Of these patients, 47 were in relatively good condition, while 37were old and frail or affected by systemic diseases. Patients were monitored for complications during a follow-up of 2 years. All patients included in the study had very advanced squamous cell carcinomas (T3-T4) and reconstruction with PMMF was performed after a commando procedure, a total laryngectomy with partial pharyngectomy, or a composite resection. Necrosis of skin island was the most frequently encountered complication, but no surgical intervention was needed. Overall, complications occurred more frequently in patients with underlying pathologies, the risk ratio adjusted for age and sex being 2.94, but 95% confidence intervals were 0.99-8.65 and all complications were minor. In summary, we recommend the use of PMMF for immediate repair in difficult patients who have large oropharyngo-laryngeal excisions and radical neck dissections and who suffer concomitantly with various medical problems known to increase complication rates. PMMF proved to be suitable to give these patients good chances of a quick recovery with satisfactory aesthetic and functional results.

Polystyrene-Natural-Rubber Mixtures: Preparation and Properties

Thermoplastic elastomers were prepared from mixtures of polystyrene and natural-rubber latexes. The mechanical measurements, thermally stimulated depolarization current measurements, and NMR spin-spin relaxation measurements have shown that the properties of prepared thermoplastic elastomers depend on the composition and the interface created by changing the size of the accessible polystyrene surface.

Effects of a new long-acting form of bromocriptine on tumorous hyperprolactinemia

Recently, a new long-acting form of bromocriptine (Parlodel LA, Sandoz) has been developed and it has already been found to be effective in lowering plasma PRL levels in normal volunteers and postpartum women. This work reports the clinical, hormonal and radiological effects of a single 50 mg dose of long-acting bromocriptine in 10 patients with tumorous hyperprolactinemia (2 microprolactinomas, 6 macroprolactinomas, 1 acromegaly and 1 nonsecreting macroadenoma). A rapid and long-lasting (28 days) normalization of PRL levels was observed in patients with microprolactinoma, acromegaly and nonsecreting adenoma. None of the 6 patients with macroprolactinoma underwent normalization of plasma PRL, but the latter was markedly reduced (61-80% of basal levels). A second injection of the drug in 5 macroprolactinoma patients induced a further reduction of plasma PRL levels in 2 of them. No changes in the tumor size were observed either after the first or the second injection of long-acting bromocriptine in any of the patients. This injectable form of bromocriptine induced nausea and/or mild hypotension lasting a few h in 4 of the 10 patients and was better tolerated than the oral form as regards both the duration and intensity of the side effects. Thus, as this drug has proved to be efficacious and well tolerated by the patients, this long-acting form of bromocriptine may be a valid therapeutical approach for initiating medical treatment of patients with prolactinoma.

[Adrenal tuberculosis in 13 patients with Addison's disease. CT findings]

A series of thirteen cases of adrenal tuberculosis with Addison's disease is presented. At the onset of disease, CT findings consisted of an enlargement of both glands, with peripheral enhancement after contrast medium was injected. The CT differential diagnosis among tubercular, metastatic and amyloidotic etiology was not possible. When the course of the illness was favourable, CT showed a generalized glandular atrophy with calcifications. In two fatal cases, the diagnosis could be made only at post-mortem examination.

[Computed tomography of non-functioning adrenal masses]

Incidental finding of non-functioning adrenal masses is not uncommon in patients undergoing abdominal CT. In a 4-year period, adrenal masses were detected as an accessory finding in 38 patients. The diagnosis was confirmed either histologically or in follow-up studies. This global series consists of 6 adenomas, 4 carcinomas, 1 pheochromocytoma, 1 ganglioneuroma, 23 metastases, 1 lymphoma, 1 histiocytoma, 1 myelolipoma. The Authors point out the parameters for the pathologic assessment of adrenal masses: size, contours and fine-needle biopsy appear to be the most reliable features.

[The role of computed tomography of the adrenal glands in endocrine diseases: pheochromocytoma]

The diagnostic reliability of CT in pheochromocytoma was evaluated in 12 symptomatic and 2 asymptomatic patients with a total of 1 bladder and 15 adrenal histologically confirmed tumours. Particular attention is drawn to two cases with bilateral sites (one male child, one woman with Sipple's syndrome) and the detection of possible local and distant malignancy. CT is thus an examination of the first order, since it is noninvasive, specific (no false positives) and able to reveal even small tumours.

[The role of adrenal computerized tomography in endocrinopathies. Cushing's syndrome]

A comparison was made between the adrenal or hypophyseal histology and the CT finding of adrenal glands in 18 Cushing patients in an assessment of CT as a preliminary screening measure prior to hormone studies for the detection of subjects with adrenal tumours, and hence candidates for adrenalectomy. The CT finding were: 8 tumours (7 adenomas and 1 carcinoma), 5 hyperplasia, 5 NAD. All the adrenal tumours (diameter 18-69 mm) were correctly identified. The only distinctive feature of the carcinoma was its size. A CT diagnosis of adrenal tumour can be regarded as conclusive. Pictures indicative of hyperplasia or absence of alterations, however, must be supplemented by hormone tests and (if necessary) CT of the hypophysis.

[The role of adrenal computerized tomography in endocrinopathies. Primary hyperaldosteronism]

A review was made of the CT findings in a series of 15 patients with a clinical diagnosis of primary hyperaldosteronism. An adrenal tumour (diameter 11-68 mm) was observed in 13 cases. No adrenal involvement was noted in the other two. The initial diagnosis was confirmed either histologically or by means of a thorough clinical and instrumental follow-up in all 15 cases. High-resolution CT may thus be proposed as an initial examination in the diagnosis of primary aldosteronism. Its efficiency is such that venous sampling can be restricted to doubtful or negative cases.

[Pancreatic needle biopsy guided by ultrasound or CT]

24 patients suspected to have a pancreatic expansive lesion underwent a biopsy with Chiba needle: 15 biopsies were guided by US and 9 by CT. Such series regards lesions having a diameter between 2.5 and 5.5 cm with average values of 4 cm. The results showed high specificity (100%) and satisfactory accuracy (66.6%); complications never set in. The authors prove the clinical utility of this procedure instead of the laparotomy and stress the importance of a strict collaboration between radiologist and cytologist in order to achieve the best results.

[Tomodensitometric evaluation of retroperitoneal damage caused by translumbar aortography]

23 patients were scanned over the abdomen following translumbar aortography. Retroperitoneal bleeding was smaller than expected and never serious for the patients. The use of computed tomography is considered helpful in the follow-up of patients after translumbar aortography; however it must be restricted only to patients with a previous difficult or traumatic procedure.

[Computerized tomography of bladder neoplasms]

A comparison was made between the pelvic CT picture and clinical and instrumental findings in 89 patients with bladder neoplasm. A close critical assessment was also made of CT as a reliable way of determining the TNM stage, and its effective aid in the choice of a therapeutic strategy. The advantages and limits of CT are discussed. The conclusion is drawn that it is of assistance in overall TNM rating, and may sometimes provide useful informations concerning the involvement of surrounding structures. Particularly as far as the choice of radical management is concerned, however, it is prone to by no means negligible staging errors, though these are open to correction in the light of non-radiological criteria.

Comparison of the presence of immune complexes in Felty's syndrome and rheumatoid arthritis

Evidence has been found to document the presence of circulating immune complexes in all patients with Felty's syndrome. The sera of all 12 patients studied showed intermediate complexes by analytical ultracentrifugation. The sera of 9 of 12 patients (75%) showed precipitin lines upon immunodiffusion against IgM rheumatoid factor. Both findings were statistically increased above those in a matched group of patients with classic rheumatoid arthritis. The presence of circulating immune complexes in the sera of the Felty patients was consistent with the observation that large inclusions containing IgG, IgM, and complement were phagocytized by normal polymorphonuclear cells when incubated with sera of Felty patients. Normal polymorphonuclear cells phagocytosed inclusions from 77% of Felty sera, compared with 27% classic rheumatoid arthritis sera. It is suggested that the uptake of immune complexes by polymorphonuclear cells plays a role in the neutropenia of Felty's syndrome.

Phagocytosis of immune complexes by polymorphonuclear leucocytes in patients with Felty's syndrome

The possible role of phagocytosis of circulating immune complexes by neutrophils in the production of the neutropenia of Felty's syndrome has been investigated. Normal neutrophils phagocytosed massive inclusions from the sera from twelve of fifteen patients with Felty's syndrome when incubated with these sera. Such inclusions were phagocytosed from only three of fifteen patients with seropositive RA who did not have Felty's syndrome. Normal neutrophils were more effective than patient neutrophils with regard to phagocytosis of inclusions from the patients' serum suggesting a defect in phagocytic function of Felty's neutrophils. The titre of granulocyte-reactive antinuclear antibodies did not appear to be related to the degree of neutropenia. The data suggest that phagocytosis of circulating immune complexes by neutrophils may interfere with the function of these cells in combating infection and also render them susceptible to removal from the circulation thus leading to the development of neutropenia.

Macrophage migration inhibitory factor in rheumatoid pericarditis

The pericardial effusion in a case of rheumatoid pericarditis was studied to determine whether immune complexes and mediators of cellular immunity, represented by migration inhibitory factor (MIF), were present. MIF-like activity was detected in the pericardial fluid, but only traces of immune complexes were revealed by ultracentrifugation. The MIF-like activity was partially characterized by column fractionation and sugar inhibition tests. The role of lymphokines in the pathogenesis of this case of rheumatoid pericarditis is strongly suggested.

Lymphokines in rheumatoid synovitis

In antigen-induced experimental arthritis of rabbits, a macrophage migration inhibitory factor was released from the inflamed synovial tissues. A migration inhibitory factor, blastogenic factor, and B-cell-stimulating factor were also found in human rheumatoid synovial fluids and culture supernatants of rheumatoid tissue explants. Joint fluids from patients with inflammatory conditions other than RA sometimes also displayed these activities. OA fluids were usually inactive. At present, little is known of the origin or role in vivo of the lymphokine-like activities observed in the joints of rheumatoid patients. In related experiments, injection of lymphokine-rich antigen-free lymphocyte supernatants into normal rabbit knee joints produced a synovitis characterized by lining layer hyperplasia and infiltration of the sublining layer by macrophages. The lymphocytic and plasmacytic components seen in active antigen-induced synovitis were absent. It seems likely that some of the changes observed in active chronic synovitis are mediated by soluble factors of the lymphokine variety.

Lymphokines in the rheumatoid joint

Joint fluids and culture supernatants of synovial tissue were examined for the presence of two lymphokines. Migration inhibitory activity was found in 16 of 22 rheumatoid fluids (73%), in 3 of 15 osteoarthritis fluids (20%), and in 3 of 11 fluids from patients with various inflammatory arthritides (27%). Blastogenic activity was present in 14 of 15 rheumatoid fluids and in 1 of 7 nonrheumatoid effusions. The active materials eluted with the third peak from Sephadex G-200 and were therefore smaller than immunoglobulin or immune complexes. These findings suggest that lymphokine-like substances were present in effusions and synovial tissue of most patients with rheumatoid arthritis and some patients with other forms of chronic synovitis.