Biomedical subjects
Publications and source records attributed to S L Wangensteen.
Drastic changes have occurred in medicine in the last few years. Overproduction of medical students has led to increased competition for surgical residency positions, with consequent changing prospects for the surgical resident. Despite the perceived overproduction of trained surgeons, little has been done to curtail the output of surgeons from training programs.
We examined and surgically restaged (using posttreatment laparotomy) 26 patients with stage III and IV Hodgkin's disease treated with combination chemotherapy and in apparent remission to determine the status of their clinical remission. Eleven patients had normal clinical restaging and surgical restaging. Fifteen patients had abnormal clinical restaging, mainly consisting of abnormal lymphangiograms or abdominal CT scans. Ten lymphangiograms were abnormal and could not exclude persistent lymphoma. Two of the 15 patients proved to have Hodgkin's disease involving the para-aortic nodes and the spleen. With a median follow-up of 24 months, two patients had relapses in supradiaphragmatic sites and no patient with a negative laparotomy had a recurrence abdominal sites. Restaging laparotomy in selected patients with Hodgkin's disease with abnormal lymphangiograms or CT scans may identify additional patients with residual lymphoma who require further therapy and, more importantly, may identify those patients who have no residual disease and, therefore, may be spared additional therapy. Mortality and morbidity were nil.
Open-chest dog preparations were used to determine divalent cation transport following acute myocardial infarction. Cardiac lymph flow, lymph and plasma protein, zinc, calcium, and magnesium content and hemodynamic measurements were recorded every 20 min before and after coronary artery occlusion in sham operated (N = 4), infarcted (N = 6), and lymph-ablated animals (N = 4). During the 4-hr occlusion period, with constant blood pressure, lymph flow increased from 1.53 +/- 0.25 to 2.15 +/- 0.44 mg/hr (SEM), P less than 0.01. Zinc decreased in plasma from 0.69 +/- 0.10 to 0.41 +/- 0.08 micrograms/ml, P less than 0.01, and in lymph from 0.69 +/- 0.08 to 0.40 +/- 0.02 micrograms/ml, P less than 0.01. Zinc to protein ratio decreased similarly to total zinc in plasma and lymph. Changes in calcium and magnesium were insignificant. Lymph to plasma concentration ratios increased for protein from 0.57 +/- 0.05 to 0.62 +/- 0.02, P less than 0.05, and for zinc from 1.10 +/- 0.26 to 1.21 +/- 0.14, P less than 0.05. Heart lymph clearance (lymph:plasma ratio X lymph flow) steadily rose for protein from 0.31 to 0.06 to 0.50 +/- 0.08, P less than 0.05, and for zinc from 0.59 +/- 0.18 to 0.92 +/- 0.15, P less than 0.05. Lymph and plasma measurements did not change significantly in sham-operated animals. Plasma zinc remained unchanged from baseline after coronary occlusion in all lymph-ablated animals. The increased clearance of protein and zinc suggests that plasma proteins are zinc carriers after acute myocardial infarction and that the reduction of plasma zinc is dependent upon an intact cardiac lymphatic circulation.
The utility of fine-needle aspiration biopsy to detect carcinoma in thyroid nodules was evaluated by a decision-analysis approach in 102 patients. The procedure caused no morbidity. Cytologic diagnoses were categorized as unsatisfactory (4), no abnormality detected (61), atypical (13), suspicious for malignancy (14), malignancy (2), and inflammation (8). The duration of follow-up averaged 13 months. Of 21 thyroidectomy patients, 10 (48%) had carcinoma. Half of the ten patients operated upon for suspicious cytologic findings were found to have malignancy. Assuming criterion I, that atypical, suspicious, or malignancy results indicated cancer, sensitivity was 90%, specificity 77%, false positive fraction 23%, positive predictive value 31%, negative predictive value 99%, and accuracy 79%. Assuming criterion II, that only suspicious or malignancy cytologic findings represented carcinoma, sensitivity was 70%, specificity 90%, false positive fraction 10%, positive predictive value 44%, negative predictive value 96%, and accuracy 88%. We conclude that sensitivity and specificity of fine-needle aspiration biopsy vary depending upon the use of criterion I or II. Accuracy is highest if atypical results are not considered to represent carcinoma. Positive predictive values remain low and negative predictive values are high in either case. The utility of fine-needle aspiration biopsy when interpreted in relation to clinical criteria is supported by these results.
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Surgical procedures involving the parathyroid glands pose special problems. Careful attention to preoperative rehydration, control of hypercalcemia, and evaluation of renal function are mandatory. Intraoperative management is usually uncomplicated. Severe hypocalcemia may complicate the postoperative period, especially if severe bone disease is present.
Neither histologic nor clinical staging reliably correlates with patient survival or the time course of tumor metastatic spread. There is no general biologic tumor marker which is able to distinguish those patients with microscopic residual cancer who may benefit from adjuvant anticancer treatment from those patients cured by their primary treatment who do not require additional anticancer therapy. Our data suggest that tumor activation and inhibition of fibrinolysis are related to the likelihood of tumor spread. Calculation of mean activation/inhibition ratios (A/I ratios) in groups of tumors with and without metastatic spread demonstrated a statistically significant difference between their respective A/I ratios (p less than 0.001). In addition, the mean activation/inhibition ratios for secondary or "metastatic" lesions were significantly different from the mean activation/inhibition ratios of the original tumors from which they metastasized (p less than 0.001). Therefore, tumor activation/inhibition ratios would appear to have clinical reliability as biologic markers for the presence or absence of tumor metastases. These data may have important therapeutic implications that would permit the use of activation/inhibition ratios as a biologic marker for the presence or absence of tumor spread at the time of primary surgical excision of the tumor. These observations warrant further investigation into the mechanisms of tumor interaction with the fibrinolytic system.
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Cathepsin D, a potent acid proteinase, has been implicated in the pathogenesis of circulatory shock. The infusion of purified preparations of cathepsin D into intact animals resulted in significant depressions in core body temperature but failed to reproduce the cardiovascular disturbances seen in shock states.
In the majority of patients in this series of 1,000, acute abdominal pain was due to conditions that required neither surgical intervention nor hospitalization. Eleven of the 1,000 patients had an early missed diagnosis in the emergency clinic for which a subsequent operation was needed, and twenty underwent an operation which subsequent diagnosis showed was not required. All false-negative evaluations occurred in patients with early appendicitis or small bowel obstruction. Most false-positive results were due to acute infections of the female genitourinary tract in patients operated on to exclude appendicitis or a tubo-ovarian abscess. The following factors help identify the high risk patient with an acute surgical abdomen: (1) pain for less than 48 hours; (2) pain followed by vomiting; (3) guarding and rebound tenderness on physical examination; (4) advanced age; (5) a prior surgical procedure. The presence of these features demands careful evaluation and a liberal policy of admission and observation. White blood cell counts, body temperature, and abnormal abdominal roentgenograms may add confirmatory evidence but are not particularly helpful as screening devices.
Massive doses of methylprednisolone were given to dogs prior to severe, lethal, hemorrhagic shock. An untreated group of dogs subjected to hemorrhagic shock served as controls. No persistent significant differences were seen in cardiac output, mean arterial blood pressure, superior mesenteric artery flow, and survival. Calculated total peripheral resistance tended to be lower in the treated dogs and was significantly lower after reinfusion of shed blood. Pretreatment with methylprednisolone did not prevent plasma elevations of the lysosomal enzymes, cathepsin D and beta-glucuronidase. Stabilization of hepatic lysosomes in treated dogs subjected to hemorrhagic shock was not evident. The results failed to indicate significant salutary effects of methylprednisolone sodium succinate in this lethal hemorrhagic shock model.
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