Biomedical subjects
Publications and source records attributed to J M Siminovitch.
The finding of Torulopsis glabrata fungal cystitis has become increasingly evident. The presence of indwelling urinary catheters, diabetes mellitus, and prior antibiotic therapy are significant risk factors in its development. Three cases are presented exemplifying the presentation of this disease. A discussion of its diagnosis and a protocol for its management are outlined.
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From 1968 to 1978, 246 patients underwent surgical exploration for renal adenocarcinoma at our clinic. Of these patients 241 had complete tumor excision and 5 had biopsy only. Correlation of the clinical and pathological data of these patients with the clinical course identified prognostic parameters. Disease progression was uncommon when the tumor was contained within the capsule of the kidney (9 of 80 patients). Perinephric tumor extension indicated a worse prognosis (11 of 40 patients with progression) that was not altered significantly by the presence of renal vein involvement (17 of 35 patients with progression). Inferior vena caval involvement or regional lymph node metastases worsened the prognosis markedly, with 8 of 11 and 8 of 9 patients demonstrating progressive disease, respectively. The worst prognosis was seen in patients with metastatic disease at operation (66 of the 71 patients dying of the disease by the end of followup). The disease was classified according to the tumor, node and metastasis system of the American Joint Committee and a stage grouping system has been suggested.
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Although inferior venacavography has been suggested as a routine test for patients with renal adenocarcinoma we have used urographic criteria of a large and/or medially placed tumor, and/or decreased visualization of the affected kidney to select patients for inferior venacavography. Of 235 patients with renal adenocarcinoma undergoing excretory urograms 64 of 76 (84 per cent) with gross renal vein involvement and 72 of 151 (47 per cent) without renal vein involvement had at least 1 criterion. All 20 patients with inferior vena caval thrombi and excretory urograms had at least 1 criterion. High dose selective renal angiography identified successfully a renal vein thrombus in 11 patients, 4 with inferior vena caval thrombi, while the renal vein was not visualized in 7 with renal vein involvement and 1 with an inferior vena caval thrombus. Inferior venacavography identified correctly an inferior vena caval thrombus in 16 patients. With the correct preoperative identification in 19 of 22 patients with inferior vena caval thrombi our criteria for inferior venacavography are outlined.
From 1969 to 1979, 448 patients underwent parathyroid exploration for presumed hyperparathyroidism. Of these patients 184 had associated renal calculus disease, 72 of whom (16 per cent) had metabolically active stone disease. Of these 72 patients 48 had adenomas, 18 had hyperplasia and 6 had normal glands. Of those patients with assessable disease none with adenomas has had recurrent calculi, whereas calculi continued to form in 45 per cent of the patients with hyperplastic glands and in 50 per cent of those with normal glands. Although most patients with adenomas had persistent calcium elevations 13 were identified with only intermittent hypercalcemia. Serum parathormone calcium elevations 13 were identified with only intermittent hypercalcemia. Serum parathormone served to confirm the presence of parathyroid pathology. Urinary calcium levels were of no diagnostic benefit.
From a review of the literature and detailed study of 16 cases, the authors believe that ureteral obstruction in diverticulitis is more common than is apparent from the literature. They suggest that urograms be performed preoperatively in patients destined to undergo intestinal surgery. Management of the intestinal disease need not be altered from that initially planned for treatment of diverticulitis except with the proviso that the retroperitoneum be examined for the presence of a fibrotic inflammatory reaction. If this is found, they suggest that ureterolysis of the involved ureter be performed to allow relief of this obstruction.
A review of 2,368 patients with Crohn's disease identified 45 patients with hydroureteronephrosis treated with various medical and surgical regimens. Twenty-six of 30 patients undergoing both pre- and post-treatment intravenous pyelography showed resolution of the obstructed ureter, even though ureterolysis was rarely used.
With the entity of normocalcemic primary hyperparathyroidism increasingly prevalent in the literature the treatment of parathyroidectomy has been advocated. A total of 21 patients with recurrent calcium-containing calculi and normocalcemia underwent parathyroidectomy. Of the 21 patients 1 had an adenoma, 9 had hyperplasia and 11 had normal glands. Of the 19 patients followed stones ceased forming in 32 per cent, while in 42 per cent calculi continued to form. Of 5 patients with multiple unassessable calculi 1 ceased passing stones. We conclude that the entity of normocalcemic hyperparathyroidism is rare and repeated serum calcium determinations to identify true hypercalcemic hyperparathyroidism are necessary.
Since few cases of exophytic malignant melanoma have been reported, their nature, history, and prognosis have been uncertain and controversial. We report 26 cases followed at the Cleveland Clinic from 1969 to 1975. Twenty men and 6 women ranging in age from 19 to 65 years were followed. There were 16 deaths, 3 patients are alive with lymph node metastases, and 3 patients are alive with distant metastases, for a 2-year disease-free survival of 15% and 5-year survival of 33%. All patients had lesions of either Clark level III, IV, or V with no correlation to survival. All lesions were 2 mm or more in thickness. A 44% disease-free survival was found for lesions 2 to 3 mm in thickness and no disease-free survival for lesions thicker than 3 mm. Our findings support the concept that exophytic malignant melanomas have increased malignant potential. We believe all malignant melanomas should be classified according to both Clark levels and Breslow's micrometer thickness measurements.
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