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Background: The International Duration Evaluation of Adjuvant therapy (IDEA) pooled analysis compared 3 to 6 months of adjuvant chemotherapy for stage III colon cancer. The overarching goal was to reduce chemotherapy-related toxicity, mainly oxaliplatin-induced neuropathy. Patients were classified into low-risk and high-risk groups, suggesting that low-risk patients may be offered only 3 months of treatment. We aimed to evaluate the benefit of monotherapy versus doublet chemotherapy in low and high IDEA risk groups., Methods: Using the National Cancer Database (2004-2014), we identified 56,728 low-risk and 47,557 high-risk individuals with stage III colon cancer, according to the IDEA classification. We used multivariate Cox regression to evaluate the magnitude of survival differences between IDEA risk groups, according to treatment intensity (doublet versus monotherapy). In a secondary analysis, we examined the prognostic and predictive value of subgroups of age, tumour sidedness and lymph node ratio (LNR)., Results: Low and high IDEA risk groups derived similar benefit from doublet adjuvant chemotherapy as compared with monotherapy, with hazard ratios (HRs) of 0.83 (95% confidence interval [CI] 0.79-0.86) and 0.80 (95% CI 0.78-0.83), respectively. The only subpopulations that did not benefit from doublet chemotherapy were low-risk patients older than 72 years (HR = 0.95, 95% CI 0.90-1.01) and high-risk patients older than 85 years (HR = 0.90, 95% CI 0.77-1.05). LNR and tumour sidedness were shown as additional prognostic, but not predictive, factors within the IDEA risk groups., Conclusions: IDEA risk classification per se does not predict for treatment benefit from doublet chemotherapy in stage III colon cancer. However, omission of oxaliplatin can be considered in IDEA low-risk patients older than 72 years., (Copyright © 2018 Elsevier Ltd. All rights reserved.)

Background: Previous studies have shown that elevated preoperative carcinoembryonic antigen (CEA) levels are associated with worse prognosis in patients with colon cancer. These studies compared the prognosis of patients with elevated versus normal CEA levels. We sought to assess the prognostic role of increasing levels of CEA in stage I and II patients who did not receive adjuvant chemotherapy., Methods: Using the National Cancer Database (2004-2014), we identified 45,449 individuals with stage I and II colon cancer who did not receive adjuvant chemotherapy and had preoperative CEA levels available. We estimated the optimal cut-point of CEA levels to predict survival using the Youden Index. Cox proportional hazards were used to compare individuals with CEA levels above and below the defined cut-point. In a secondary analysis, we examined the prognostic value of stage, age and tumour location., Results: The optimal preoperative CEA cut-point to predict survival was 2.35 ng/mL. The adjusted HR for overall survival among individuals with preoperative CEA levels at or above compared with below 2.35 ng/mL was 1.56 (95% CI, 1.49-1.64). Individuals with CEA levels below 2.35 ng/mL had higher 3-year survival rates compared with those with CEA levels above 2.35 ng/mL (79.7% vs 64.5%, respectively)., Conclusions: Preoperative CEA levels at or above 2.35 ng/mL, found within the normal range, may be used to identify stage I and II colon cancer patients harbouring worse prognosis., (Copyright © 2018 Elsevier Ltd. All rights reserved.)

Thermodynamics describes large-scale, slowly evolving systems. Two modern approaches generalize thermodynamics: fluctuation theorems, which concern finite-time nonequilibrium processes, and one-shot statistical mechanics, which concerns small scales and finite numbers of trials. Combining these approaches, we calculate a one-shot analog of the average dissipated work defined in fluctuation contexts: the cost of performing a protocol in finite time instead of quasistatically. The average dissipated work has been shown to be proportional to a relative entropy between phase-space densities, to a relative entropy between quantum states, and to a relative entropy between probability distributions over possible values of work. We derive one-shot analogs of all three equations, demonstrating that the order-infinity Rényi divergence is proportional to the maximum possible dissipated work in each case. These one-shot analogs of fluctuation-theorem results contribute to the unification of these two toolkits for small-scale, nonequilibrium statistical physics.

Mutations in the BRCA1/2 genes were recently shown to be associated with an increased risk for colorectal cancer. We characterized the largest cohort available of BRCA1/2 mutation carriers with colorectal cancer. We analyzed 32 patients with lower gastrointestinal cancers and germline BRCA1/2 mutations from two large academic hospital registries; 91% of patients were of Ashkenazi ancestry, 78% were women, and 62.5% were carriers of BRCA1 gene mutations. A high percentage of colorectal tumors (34.5%) had a mucinous histology and were located atypically in the left colon. Two patients had anal cancer with unusual histology and an additional patient had mucinous small bowel carcinoma. Gene expression analysis showed significant correlation between the gene signatures of left mucinous colorectal cancer and basal-like breast cancer. Our results imply that Ashkenazi BRCA1/2 mutation carriers with colorectal cancer might have unique characteristics with a high rate of left-sided, mucinous histology colorectal cancer, and possibly anal carcinoma. This report suggests a phenotypic influence of defects in DNA repair genes on colorectal tumors.

Background: During the past 2 decades, numerous clinical trials have focused on improving outcomes in patients with metastatic pancreatic cancer (mPDAC). The efficacy of new treatments has been demonstrated among highly selected patients in randomized phase III trials; hence, it is not clear to what extent these advances are reflected within the broader mPDAC population. Materials and Methods: Survival statistics were extracted from the SEER database for patients diagnosed with mPDAC between 1993 and 2013. Survival was analyzed using the Kaplan-Meier method and proportional hazard models. Results: The study population consisted of 57,263 patients diagnosed with mPDAC between 1993 and 2013; 52% were male, with a median age of 69 years (range, 15-104). Superior prognosis correlated with younger age, being married, tumor located within the head of the pancreas, lower grade disease, and more recent year of diagnosis. Median overall survival (OS) remained stable at 2 months between 1993 and 2013. Improvements in OS were seen for younger patients (age <50 years) and those with a more recent year of diagnosis (2009-2013). The percentage of patients who died within 2 months of initial diagnosis decreased between 1993 and 2013 (from 63.5% to 50.6%; P <.0001). The percentage of patients surviving ≥12 months improved from 4.9% in 1993 to 12.7% in 2013 ( P <.0001). Conclusions: In recent years a modest improvement in OS has been seen among younger patients with mPDAC. The percentage of patients living beyond 1 year has significantly increased over time; however, the percentage of those dying within 2 months remains substantial., (Copyright © 2017 by the National Comprehensive Cancer Network.)

Gene expression assays are widely used to predict risk of recurrence in early breast cancer (BC). We report the 21-gene expression assay (Oncotype Dx) recurrence score (RS) distribution of 27 BRCA carriers with estrogen receptor (ER) positive BCs, identified at Hadassah Medical Center, combined with 2 previous studies. Treatment decision and outcomes of the 27 BRCA carriers were compared with an Israeli cohort of 1594 patients published recently. We found Oncotype Dx RS low (<18), intermediate (18-30) and high (>30) among 12 (21.4%), 23 (41.1%) and 21 (37.5%) of 56 BRCA1 carriers compared with 15 (17.2%), 49 (56.3%) and 23 (26.4%) of 87 BRCA2 carriers (p = 0.2). The corresponding distribution in a population of 82,434 women published by Genomic Health was 53.4%, 36.3% and 10.3% for low, intermediate and high RS (p < 0.001 for BRCA1 and BRCA2). Treatment decision regarding chemotherapy according to RS was similar in BRCA1, BRCA2 and the control group. Two of 27 carriers had distant recurrence: a BRCA1 carrier with RS of 18 and a BRCA2 carrier with RS of 22; both have an excellent response to chemotherapy. We found an approximately ∼3 fold increased rate of high RS among BRCA1 and 2 carriers with ER positive BC compared with the general BC population. These data might indicate that hormone positive BC in BRCA carriers are molecularly unique. The surprisingly good response to chemotherapy in the metastatic setting in 2 patients may suggest that the predictive value of low-intermediate RS in carriers merits further studies., (© 2017 UICC.)

The grand canonical ensemble lies at the core of quantum and classical statistical mechanics. A small system thermalizes to this ensemble while exchanging heat and particles with a bath. A quantum system may exchange quantities represented by operators that fail to commute. Whether such a system thermalizes and what form the thermal state has are questions about truly quantum thermodynamics. Here we investigate this thermal state from three perspectives. First, we introduce an approximate microcanonical ensemble. If this ensemble characterizes the system-and-bath composite, tracing out the bath yields the system's thermal state. This state is expected to be the equilibrium point, we argue, of typical dynamics. Finally, we define a resource-theory model for thermodynamic exchanges of noncommuting observables. Complete passivity-the inability to extract work from equilibrium states-implies the thermal state's form, too. Our work opens new avenues into equilibrium in the presence of quantum noncommutation.

The difference ΔF between free energies has applications in biology, chemistry, and pharmacology. The value of ΔF can be estimated from experiments or simulations, via fluctuation theorems developed in statistical mechanics. Calculating the error in a ΔF estimate is difficult. Worse, atypical trials dominate estimates. How many trials one should perform was estimated roughly by Jarzynski [Phys. Rev. E 73, 046105 (2006)PLEEE81539-375510.1103/PhysRevE.73.046105]. We enhance the approximation with the following information-theoretic strategies. We quantify "dominance" with a tolerance parameter chosen by the experimenter or simulator. We bound the number of trials one should expect to perform, using the order-∞ Rényi entropy. The bound can be estimated if one implements the "good practice" of bidirectionality, known to improve estimates of ΔF. Estimating ΔF from this number of trials leads to an error that we bound approximately. Numerical experiments on a weakly interacting dilute classical gas support our analytical calculations.

Thermodynamics has recently been extended to small scales with resource theories that model heat exchanges. Real physical systems exchange diverse quantities: heat, particles, angular momentum, etc. We generalize thermodynamic resource theories to exchanges of observables other than heat, to baths other than heat baths, and to free energies other than the Helmholtz free energy. These generalizations are illustrated with "grand-potential" theories that model movements of heat and particles. Free operations include unitaries that conserve energy and particle number. From this conservation law and from resource-theory principles, the grand-canonical form of the free states is derived. States are shown to form a quasiorder characterized by free operations, d majorization, the hypothesis-testing entropy, and rescaled Lorenz curves. We calculate the work distillable from-and we bound the work cost of creating-a state. These work quantities can differ but converge to the grand potential in the thermodynamic limit. Extending thermodynamic resource theories beyond heat baths, we open diverse realistic systems to modeling with one-shot statistical mechanics. Prospective applications such as electrochemical batteries are hoped to bridge one-shot theory to experiments.

Mutations in MCM9, which encodes DNA helicase, were recently shown to cause a clinical phenotype of primary ovarian failure and chromosomal instability. MCM9 plays an essential role in homologous recombination-mediated double-strand break repair. We describe a multiplex family with early colorectal carcinoma and mixed polyposis associated with primary hypergonadotropic hypogonadism. A combination of whole genome homozygosity mapping as well as exome sequencing and targeted gene sequencing identified a homozygous c.672&#95;673delGGinsC mutation that predicts a truncated protein, p.Glu225Lysfs*4. Our data expand the phenotypic spectrum of MCM9 mutations and suggest a link between MCM9 and inherited predisposition to mixed polyposis and early-onset colorectal cancer., (Copyright © 2015 Elsevier Inc. All rights reserved.)

Lynch Syndrome is caused by mutations in DNA mismatch repair genes. Diagnosis is not always trivial and may be costly. Information regarding incidence, genotype-phenotype correlation, spectrum of mutations and genes involved in specific populations facilitate the diagnostic process and contribute to clinical work-up. To report gene distribution, mutations detected and co-occurrence of related syndromes in a cohort of Ashkenazi Jews in Israel. Patients were identified in dedicated high risk clinics in 3 medical centers in Israel. Diagnostic process followed a multi-step scheme. It included testing for founder mutations, tumor testing, gene sequencing and MLPA. Lynch Syndrome was defined either by positive mutation testing, or by clinical criteria and positive tumor analysis. We report a cohort of 75 Ashkenazi families suspected of Lynch Syndrome. Mutations were identified in 51/75 (68%) families: 38 in MSH2, 9 in MSH6, and 4 in MLH1. 37/51 (73%) of these families carried one of the 3 'Ashkenazi' founder mutations in MSH2 or MSH6. Each of the other 14 families carried a private mutation. 3 (6%) were large deletions. Only 20/51 (39%) families were Amsterdam Criteria positive; 42 (82%) were positive for the Bethesda guidelines and 9 (18%) did not fulfill any Lynch Syndrome criteria. We report C-MMRD and co-occurrence of BRCA and Lynch Syndrome in our cohort. Mutation spectra and gene distribution among Ashkenazi Jews are unique. Three founder Lynch Syndrome mutations are found in 73% families with known mutations. Among the three, MSH2 and MSH6 are the most common. These features affect the phenotype, the diagnostic process, risk estimation, and genetic counseling.

Objectives: Increases in the number, size, and occupancy rates of ICUs have not been accompanied by a commensurate growth in the number of critical care physicians leading to a workforce shortage. Due to concern that understaffing may exist, the Society of Critical Care Medicine created a taskforce to generate guidelines on maximum intensivists/patient ratios., Data Sources: A multidisciplinary taskforce conducted a review of published literature on intensivist staffing and related topics, a survey of pulmonary/Critical Care physicians, and held an expert roundtable conference., Data Extraction: A statement was generated and revised by the taskforce members using an iterative consensus process and submitted for review to the leadership council of the Society of Critical Care Medicine. For the purposes of this statement, the taskforce limited its recommendations to ICUs that use a "closed" model where the intensivists control triage and patient care., Data Synthesis and Conclusions: The taskforce concluded that while advocating a specific maximum number of patients cared for is unrealistic, an approach that uses the following principles is essential: 1) proper staffing impacts patient care; 2) large caseloads should not preclude rounding in a timely fashion; 3) staffing decisions should factor surge capacity and nondirect patient care activities; 4) institutions should regularly reassess their staffing; 5) high staff turnover or decreases in quality-of-care indicators in an ICU may be markers of overload; 6) telemedicine, advanced practice professionals, or nonintensivist medical staff may be useful to alleviate overburdening the intensivist, but should be evaluated using rigorous methods; 7) in teaching institutions, feedback from faculty and trainees should be sought to understand the implications of potential understaffing on medical education; and 8) in academic medical ICUs, there is evidence that intensivist/patient ratios less favorable than 1:14 negatively impact education, staff well-being, and patient care.

Background: A new approach for assessing non-cognitive attributes in medical school candidates was developed and implemented at the Hebrew University Medical School. The non-cognitive tests included a biographical questionnaire, a questionnaire raising theoretical dilemmas and multiple mini-interviews., Objectives: To evaluate the effects of the change in the admission process on students' demographics and future career choices., Methods: A questionnaire including questions on students' background and future residency preferences was administered to first-year students accepted to medical school by the new admission system. Results were compared with previous information collected from students admitted through the old admission process., Results: Students accepted by the new process were significantly older (22.49 vs. 21.54, P < 0.001), and more had attended other academic studies before medical school, considered other professions besides medicine, and majored in humanities combined with sciences in high school. Significantly more students from small communities were admitted by the new system. Differences were found in preferences for future residencies; compared with the old admission process (N = 41), students admitted by the new system (N = 85) had a more positive attitude towards a career in obstetrics/gynecology (41% vs. 22%, P < 0.001) and hematology/oncology (11.7% vs. 4.8%, P < 0.001), while the popularity of surgery and pediatrics had decreased (34.5% vs. 61%, P < 0.001 and 68.7% vs. 82.5%, P < 0.001 respectively)., Conclusions: Assessment of non-cognitive parameters as part of the admission criteria to medical school was associated with an older and more heterogenic group of students and different preferences for future residency. Whether these preferences in first-year students persist through medical school is a question for further research.

Technological advances in critical care will undoubtedly find their way into the ICU of the 21st century. The challenge for critical care practitioners is to meticulously assess these innovations and adopt the most appropriate and efficient technologies that will improve unit function and staff efficiencies, support educational programs, and most importantly, enhance patient outcome at a reasonable cost. Hospital-based intensivists have excellent opportunities to establish leadership roles in the technology evaluation process by cultivating relationships with administrators, and through active participation in the hospital-based Technology Committee and the ICU-based multidisciplinary committee. The authors' experience has left them with the lasting impression that the evaluation and introduction of new technology is time consuming and requires perseverance and patience. Ultimately, it is hoped that technological breakthroughs coupled with a standardized approach to delivery of ICU services in the coming decades will ensure better and more efficient care to critically ill patients.

The current strategy to the treatment of SIRS and MODS uses a multidisciplinary approach that emphasizes supportive therapy. Herein, we have presented a futuristic approach that focuses on replacing the function of failed organs using bioartificial technology (Table 1). Bioartificial organ technology may allow the intensivist to provide physiologic organ replacement either as a bridge to transplantation or as a "time-buying" element until native organs that have become acutely dysfunctional or nonfunctional in a variety of clinical settings, can recover their function or regenerate their mass. As bioartificial organ technology matures, it is conceivable as an ultimate goal that non-immunogenic bioartificial organs would be miniaturized or redesigned and acutely placed within the intracorporeal space as replacement organs.

The new paradigm of POCT as integrated into the ICU will allow for an improved and more efficient critical care workplace and possibly improvements in outcome and costs. Technologic advances in POCT will focus on enhancements of current devices, connectivity, and data management and on the introduction of novel diagnostic and therapeutic approaches. It is hoped that in the future the regulatory, laboratory, and L/HIS communities will recognize the need to accept, integrate, accommodate, and expand POCT, thereby promoting bedside diagnostics. For ongoing follow-up of the myriad of POCT projects, refer to the POCT websites listed in Table 1.

Endogenous carbon monoxide (CO) is produced in the degradation of heme by heme oxygenase. Studies have shown that hypoxia induces heme oxygenase production of CO in vascular tissue. Because elevated plasma lactate levels are associated with tissue hypoxia, we determined if there was any correlation between lactate and carboxyhemoglobin (COHb) levels in a group of critically ill patients with a high likelihood of hypoxia. In a 7.5-month period, 5322 simultaneous arterial COHb and lactate measurements were performed routinely on 183 patients with a blood gas analyzer in the Department of Veterans Affairs Medical Center, Bronx, New York, Surgical Intensive Care Unit. Sixty-one percent of the patients had elevated lactate levels (> 2.5mmol/L), and 46% had elevated COHb levels (> 1.5%). Lactate levels ranged from 0.12 to 22.7 mmol/L and COHb levels from 0% to 4.8%. There was no correlation between lactate and COHb levels (r = .07 with P < .0001). Levels of endogenous CO do not increase in situations in which lactate production is increased. It is possible that changes in endogenous production of CO may not significantly affect the circulating level of COHb. Although readily available, COHb levels do not seem to be clinically useful as markers of critical illness.

Point of care testing (POCT), a new paradigm in laboratory testing, has recently been introduced to the critical care setting. In this model, laboratory testing is performed in the critical care vicinity by local bedside personnel. POCT devices perform user selected critical care tests on whole blood in a timely and accurate fashion. The POCT data, while used immediately at the bedside, must still be managed in accordance with regulatory guidelines and incorporated into the laboratory or hospital information system. Currently, critical care physicians are not educated and trained in the intricacies of laboratory data management and device interfacing. This article addresses the technical, political, and implementation issues surrounding POCT data management and interfacing as well as the philosophical and practical differences in laboratory data management between the central laboratory and POCT sites.

Sarcotoxin IA is a cecropin-type antibacterial protein produced by the flesh fly, Sarcophaga peregrina. Similar to other bactericidal small proteins produced by insects, sarcotoxin IA is released into the hemolymph of larvae and nymphs upon mechanical injury or bacterial infection. The gene (sarco) that encodes this toxin was introduced into Saccharomyces cerevisiae yeast cells and was expressed under a constitutive yeast promoter. The transformed yeast cells were grown in a liquid medium, and a peptide with a similar molecular size to that of the mature sarcotoxin IA was detected in the medium by Western blot analysis. The secreted sarcotoxin-like peptide (SLP) had a potent cytotoxic effect against several bacteria, including plant pathogenic bacteria, similar to the toxic effects of the authentic sarcotoxin IA. Erwinia carotovora was more susceptible to the toxic medium than Pseudomonas solanacearum and Pseudomonas syringae pv. lachrymans. Thus, yeast may be used in the production of such proteins for employment against various bacterial pathogens., (Copyright 1999 Academic Press.)

Although operative resection of metastatic lesions to the liver, lung, and brain has proved to be useful, only recently have there been a few reports of pancreaticoduodenectomies in selected cases of metastases to the periampullary region. In this report we present four cases of proven metastatic disease to the periampullary region in which the lesions were treated by pancreaticoduodenectomy. Metastatic tumors corresponded to a melanoma of unknown primary site, choriocarcinoma, high-grade liposarcoma of the leg, and a small cell cancer of the lung. All four patients survived the operation and had no major complications. Two patients died of recurrence of their tumors, 6 and 63 months, respectively, after operation; the other two patients are alive 21 and 12 months, respectively, after operation. It can be inferred from this small but documented experience, as well as a review of the literature, that pancreaticoduodenectomy for metastatic disease can be considered in selected patients, as long as this operation is performed by experienced surgeons who have achieved minimal or no morbidity and mortality with it.

Objectives: The objectives of this article are to review the physiology of hearing; identify acute pathologic and perceived causes of hearing loss in the adult critically ill patient; and to discuss its evaluation, treatment, and prevention., Data Sources: Computerized bibliographic search of MEDLINE from 1966 to the present of all relevant articles in all languages on acute hearing loss in the adult population., Data Extraction: Data gathered from studies and reports of acute hearing loss as relates or potentially relates to the peri-intensive care unit (ICU) period., Data Synthesis: Hearing loss is an infrequent but potentially serious complication associated with critical illness. The causes of hearing loss in the ICU patient include mechanical or accidental trauma, administration of ototoxic medications, local or systemic infections, vascular and hematologic disorders, autoimmune diseases, and environmental noise. Patients who are elderly, have coexisting liver or renal failure, or who are receiving concomitantly administered ototoxic drugs are particularly at risk for developing hearing loss. A thorough assessment of potential causes of hearing loss and audiological examination should be undertaken on all ICU patients suspected of hearing loss. Mechanical, pharmacologic, and environmental strategies are available to decrease the incidence of hearing loss in this patient population., Conclusions: Hearing loss should be recognized as a potential clinical problem by intensivists. Its causes should be identified and appropriate evaluation and therapy initiated. High risk populations should be identified for preventive measures.

Objectives: The purpose of this study is to compare normal saline with Isolyte S as the wash solutions during high-volume cell saver autologous blood transfusion. Normal saline, the standard wash solution in cell saver autologous blood transfusion, is associated with acid-base and electrolyte derangements. Isolyte S is a physiologic, balanced multielectrolyte crystalloid solution that approximates the electrolyte content of plasma., Design: Open-label, prospective, randomized study., Setting: Research laboratory in a Department of Veterans Affairs medical center., Subjects: Fourteen mongrel dogs, weighing 22 to 23 kg each., Interventions: Fourteen mongrel dogs were prospectively randomized to receive normal saline (n = 7) or Isolyte S (n = 7). Animals were anesthetized, received heparin for anticoagulation, and underwent 18 cycles of cell saver autotransfusion. In each cycle, 125 mL of blood was arterially withdrawn, and washed with either normal saline (mEq/L) (sodium 154, chloride 154) or Isolyte S (mEq/L) (sodium 141, potassium 5, magnesium 3, chloride 98, phosphate 1, acetate 28, and gluconate 23). The washed blood was retransfused., Measurements and Main Results: Acid-base and electrolyte analyses were performed throughout the study on the systemic blood of each group and compared. By the end of the study, the Isolyte S group had a normal pH and an increased bicarbonate concentration (mEq/L: normal values 24 to 32; normal saline 9.0 +/- 1.9 vs. Isolyte S 13.2 +/- 3.0 [p < .01]) and an increased magnesium concentration (mg/dL: normal values 1.6 to 2.4; normal saline 1.6 +/- 0.2 vs. Isolyte S 2.2 +/- 0.2 [p < .0001]). Additionally, the Isolyte S group had a lower chloride concentration (mEq/L: normal values 95 to 110; normal saline 130 +/- 9 vs. Isolyte S 117 +/- 7 [p < .02]) and a lower potassium concentration (mEq/L: normal values 3.5 to 5.0; normal saline 4.4 +/- 0.5 vs. Isolyte S 3.7 +/- 0.3 [p < .01]). There were no significant differences between normal saline or Isolyte S in the values of PCO2, lactic acid, sodium, total and ionized calcium, inorganic phosphorus, total protein, albumin, hemoglobin, and hematocrit., Conclusions: Fewer systemic acid-base and electrolyte derangements were observed when blood was washed with Isolyte S. Differences between the normal saline and Isolyte S groups are ascribed primarily to the constituents of the wash solution. We conclude that Isolyte S, a physiologic, balanced, multielectrolyte solution, should be considered as the wash solution in high-volume autologous cell saver blood processing and transfusion.

Study Objective: To compare therapeutic outcome and perform a cost-benefit analysis of inpatients with community-acquired pneumonia (CAP) treated with a shortened course of i.v. antibiotic therapy., Design: A prospective, randomized, parallel group study with a follow-up period of 28 days., Setting: Bronx Veterans Affairs Medical Center (VAMC) and the Castle Point VAMC; university-affiliated VAMC general medical wards from September 1993 to March 1995., Patients: Seventy-two male veterans and 1 female veteran with 75 episodes of CAP defined by a new infiltrate on chest radiograph and either history or physical findings consistent with pneumonia. Study population was 42%(31) black, 33%(24) white, and 25%(18) Hispanic., Interventions: Patients were randomized (1:1:1) to 1 of 3 treatment groups: group 1 received 2 days of i.v. and 8 days of oral therapy; group 2 received 5 days of i.v. and 5 days of oral therapy; and group 3 received 10 days of i.v. therapy. Antibiotics consisted of cefuroxime, 750 mg every 8 h for the i.v. course, and cefuroxime axetil, 500 mg every 12 h for the oral therapy., Measurements and Results: No differences were found in the clinical course, cure rates, or resolution of chest radiograph abnormalities among the three groups. A significant difference was found in the length of stay (LOS) among the three groups. The mean +/- SD LOS was 6 +/- 3 days in group 1, 8 +/- 2 days in group 2, and 11 +/- 1 days in group 3. The shortened LOS could potentially save $95.5 million for the Department of Veterans Affairs and $2.9 billion for the US private sector., Conclusions: Adult patients hospitalized for CAP who are not severely ill can be successfully treated with an abbreviated (2-day) course of i.v. antibiotics and then switched to oral therapy. A longer course of i.v. therapy prolongs hospital stay and cost, without improving the therapeutic cure rate.

Background: Managed care and the increasing percentage of surgical procedures performed in the elderly have renewed the focus on hospital charges and expenditures. The objective of this study was to determine whether septuagenarians and octogenarians accrue more hospital charges or have a higher risk of morbidity and death., Methods: We retrospectively reviewed the charges and pertinent clinical outcomes data that were available on 70 of the last 100 pancreatoduodenectomies performed at our institution (1989 to 1994). Charges from four cost centers were analyzed and normalized to 1995 dollars by using the Consumer Price Index and Wilcoxon rank sum test. Patients were divided into two groups: group 1, 70 years of age or older (n = 21); group 2, younger than 70 years of age (n = 49)., Results: Anesthetic charges were $2657 +/- $835 for group 1 versus $2815 +/- $826 for group 2, which was not a statistically significant difference. Laboratory charges were $4650 +/- $3284 for group 1 versus $5969 +/- $5169 for group 2, which was not a significant difference. Pharmaceutical charges were $5424 +/- $4435 for group 1 versus $9243 +/- $9695 for group 2, which was not a significant difference. Charges for operative units were $6198 +/- $1671 for group 1 versus $7469 +/- $2116 for group 2, p < 0.02. Total charges were $41,180 +/- $20,635 for group 1 versus $50,968 +/- $33,783 for group 2, which was not a significant difference. No difference was noted in morbidity, mortality, length of stay, or survival., Conclusions: Pancreatoduodenectomy in the elderly can be performed safely without accruing higher cost, increased morbidity, or increased mortality.

Objective: To evaluate acid-base and electrolyte changes in high volume cell saver autologous blood transfusion when normal saline (0.9% NaCl) is used as the wash solution., Design: Open-label study., Materials and Methods: Nine anesthetized and anticoagulated mongrel dogs underwent 15 cycles of cell saver autologous blood transfusion. Eight percent of the circulating blood volume (125 mL) was withdrawn, washed with normal saline, and retransfused for each cycle., Measurements and Main Results: Analyses of acid-base, electrolyte, and hematologic parameters were performed on both systemic and the washed blood. The washed blood had increased levels of sodium and chloride. There were decreased levels in pH, Pco2, total CO2 (bicarbonate), lactic acid, potassium, total and ionized calcium, magnesium, inorganic phosphorus, total protein, and albumin. Systemically, in the animals, by the end of the study, there were significant increases in the levels of chloride, inorganic phosphorus, hemoglobin, and hematocrit and significant decreases in the levels of pH, total CO2, total and ionized calcium, magnesium, total protein, and albumin., Conclusions: Acid-base, electrolyte, and hematologic changes occur when normal saline is used as the wash solution in high volume cell saver autologous blood transfusion. The washed blood with its elevation of sodium and chloride appears to reflect the constituents of the wash solution, normal saline. The depletion in the washed blood of PCO2, total CO2, potassium, total calcium, ionized calcium, magnesium, phosphorus, total protein, and albumin we feel is because of the absence of these electrolytes in the wash solution and their physical removal during salvaged blood separation and washing. The systemic acid-base and electrolyte changes primarily reflect the electrolyte pattern of the reinfused washed blood except for inorganic phosphorus. Inorganic phosphorus was maintained systemically, despite its wash out in the cell salvage process. This paradoxical finding may be caused by intracellular to extracellular inorganic phosphorus flux caused by the progressive systemic metabolic acidosis.

As others have emphasized, a progressive and structured training process is necessary to understand and avoid the potential pitfalls of laparoscopy. A surgeon who is poorly trained or has minimal skills and experience finds that many cases are "difficult." Nevertheless, even those with appropriate skill and experience encounter intellectual and technical challenges in laparoscopy. It is also very important to realize that some procedures simply should not be done laparoscopically. A review of 77,604 laparoscopic cholecystectomies documented that more than half the deaths were from technical complications occurring during the procedure. Traditional methods of surgery may have their own characteristics of limitations and morbidity, but in most cases, the old operation might still be a very good one in the face of unfavorable laparoscopic conditions.

Acute arteriolar vasoconstriction is considered to be the common physiologic pathway for hypertensive crises. Calcium plays a critical role in this process as a required element in the generation of vascular smooth muscle contraction. Within the vascular smooth muscle cell, calcium homeostasis is maintained through a complex set of mechanisms that control cellular calcium influx and efflux as well as intracellular calcium storage. Extracellular calcium enters the intracellular free space of the vascular smooth muscle cell through four portals: a passive slow leak, voltage-gated channels, hormone-mediated receptor-operated channels, and stretch-activated channels. The myofilaments actin and myosin contract upon the increase in cytosolic calcium. Calcium-channel blockers are commonly used as vasodilators for the treatment of hypertensive crises. There are three families of commercially available calcium-channel blockers: 1,4 dihydropyridines, phenylalkylamines, and benzothiazepines. These drugs block extracellular calcium entry through the L-type voltage-gated channel. Systemic vasodilation is produced as the cytosolic calcium level is lowered and myosin-actin contraction cannot be maintained. The precise mechanism of blockade and the tissue site selectivity varies among the three drug families. The 1,4 dihydropyridines are selective for the arteriolar beds, while the phenylalkylamines and benzothiazepines are selective for the atrioventricular node. Of the calcium-channel blockers, the dihydropyridines nifedipine and nicardipine are recommended as first-line agents for hypertensive emergencies and urgencies because of their peripheral arteriolar bed selectivity and their pharmacologic and kinetic profiles.

Objectives: To develop and implement a fully mobile computer terminal that interfaces with our computerized intensive care unit (ICU) local area network and order management system. This system can provide access to the entire network and to order review and entry and during ICU bedside rounds., Design: Descriptive report., Setting: Surgical ICU in Department of Veterans Affairs Medical Center. SYSTEM CONFIGURATION: A parallel local area network was configured for the remote mobile computer system. A proprietary remote transmission system (Altair II, Motorola) was used. This high-throughput system minimizes interference and errors by using licensed, nonshared, radiofrequency spectra., Conclusion: The resulting mobile system is an economical and time-efficient adjunct to an established ICU computerized network and order management system. Clinical working bedside rounds are now routinely conducted with the mobile terminal, providing immediate access to full network resources.

Technological advancements have, for the first time, made the entire laboratory testing process feasible at the bedside. Physicians working in the intensive care unit have always had immediate access to patients' medical history, physical examination, and physiologic monitoring data, but had to wait for laboratory results. Using point-of-care testing, laboratory parameters targeted to critical illnesses can now be integrated into initial diagnostic assessments, on patient rounds, and during therapeutic maneuvers. The concept of point-of-care testing in the intensive care unit is relatively new, but as technology progresses, physicians will undoubtedly become aware and use it in the intensive care unit. This article focuses on the intensive care physician's perspective on laboratory testing, the evolution of the intensive care unit laboratory, advantages of point-of-care testing in that setting, new developments in arterial blood gas analyzers and monitors, and cost-effectiveness and incorporation of point-of-care testing.

Postoperative hypertension, though transient, requires immediate attention. Clinical variables include the patient's preoperative blood pressure, medications, and acute medical status; the surgical procedure performed; and the physiologic changes induced by surgery. Evaluate and treat any reversible causes of hypertension. Initiate drug therapy when organ failure or dysfunction is present or when the patient is at high risk for such complications. In choosing an agent, look for ease of administration, titratability of blood pressure response, rapid onset and cessation of action, and a low incidence of adverse effects. Options are nitrovasodilators, calcium channel blockers, ACE inhibitors, direct-acting vasodilators, adrenergic blockers, and neuromodulators (narcotics and anesthetics).

OBJECTIVE: To compare computerized ICU order writing with handwritten ICU physician orders. DESIGN: Prospective study. SETTING: Medical and surgical Intensive Care Units and pharmacy of a Department of Veterans Affairs Medical Center. PATIENTS: Two hundred sixty-four individual sets of orders. INTERVENTIONS: A time study and problem analysis were performed in the pharmacy as orders were received and processed. MEASUREMENTS AND MAIN RESULTS: Two hundred sixty-four sets of orders were evaluated; MICU (handwritten; n = 133) and SICU (computerized; n = 131). Physician length of training are similar in both units. The patient age and number of major diagnoses per patient in the two ICU groups were similar. Significantly less time (min) (MICU 2.5 ± 0.3 versus SICU 1.84 ± 0.1, p < 0.05) is required to review SICU orders. The SICU had significantly fewer order problems (MICU 45 versus SICU 12, p < 0.05). Computerized SICU orders were corrected more rapidly. The majority of order problems in both groups were resolved by telephone. CONCLUSIONS: ICU orders by computer program are processed more rapidly, have fewer errors, and are corrected more rapidly than standard handwritten orders. We conclude that a dedicated ICU computerized order-writing system permits orders to be written with fewer errors and the pharmacy to process them more efficiently than handwritten orders.

Objectives: To establish Department of Veterans Affairs' intensive care unit (ICU) costs from a database and to use this information to validate the Russell equation, the most commonly used method of calculating ICU costs. To compare and trend Department of Veterans Affairs' and nationwide (USA) ICU and healthcare costs., Design: Comparison study., Setting: Database analysis of Department of Veterans Affairs' and nationwide ICUs over a 6-yr period (1986-1992), with biennial evaluations., Main Measures: Costs and bed occupancies of Department of Veterans Affairs' and nationwide hospitals and ICUs, as well as United States national health expenditures and gross domestic product., Results: Fifty percent to Department of Veterans Affairs' ICU funds were used for nurse and physician salaries. Department of Veterans Affairs' ICU direct and indirect cost ratios have remained constant (2:1). The Russell equation is valid, providing that the "inpatient only" cost variable is used. ICU costs were consistently lower in the Department of Veterans Affairs' than nationwide, as compared by the Russell equation. A smaller fraction of the hospital budget was allocated to the ICU in the Department of Veterans Affairs than in nationwide institutions. Despite an increasing nationwide ICU patient workload, the percentage of ICU fund allocations has not increased. Health care in the United States increases at a rate greater than the increase in gross domestic product. Healthcare delivery costs are increasing at a greater rate nationwide than in the Department of Veterans Affairs. The percentage increase in ICU cost per day, both in the Department of Veterans Affairs and nationwide, was less than the increase in healthcare costs. The percent of the gross domestic product, national health expenditure, and hospital cost used by the ICU has increased minimally during the course of this study., Conclusions: The Department of Veterans Affairs has the only national ICU line item cost database available. For the Russell equation calculation to be accurate, inpatient only costs should be used. Until customized Health Care Financing Administration analyses become available, nationwide ICU costs are best determined by the Russell equation. Department of Veterans Affairs' ICUs have a consistent cost advantage over nationwide ICUs. Increases in United States healthcare delivery costs continue to exceed the increase in gross domestic product. Cost containment is already occurring in critical care.

Objectives: To study the critical care medicine programs of the Department of Veterans Affairs., Design: Survey study., Setting: Data were obtained from 85% (113/133) of the acute care hospitals of the Department of Veterans Affairs., Main Measures: Intensive care unit (ICU) administrative and patient demographics, physician training and certification, participation in critical care medicine programs and research., Results: Analyses were performed on 78% (2021) of Department of Veterans Affairs' ICU beds. Mortality (%) was highest in medical ICUs (11.7 +/- 0.8) and lowest in coronary care units (5.0 +/- 0.5) and surgical ICUs (5.5 +/- 0.5). The average length of stay (days) was highest in medical ICUs (5.6 +/- 0.6) and lowest in combined medical-coronary care units (4.2 +/- 0.4) and coronary care units (4.3 +/- 0.5). The majority of ICU directors have internal medicine training. A minority of ICU directors are formally trained in critical care medicine or are board eligible or certified in critical care medicine. The majority of fellows in the ICU are pulmonary or cardiac fellows; a minority are critical care medicine fellows. Accredited critical care medicine fellowship training programs were found in only 17% (19/113) of responding Department of Veterans Affairs' institutions. Seventy-three percent (82/113) of ICUs in responding hospitals had published fewer than five publications between 1987 and 1990., Conclusions: The results of this study suggest that the Department of Veterans Affairs would benefit from increasing the number of critical care medicine board eligible/certified directors, and increasing the program's participation in accredited critical care medicine fellowship training programs and research endeavors. Overall, however, we conclude that the Department of Veterans Affairs' critical care medicine program is at least comparable to nationwide ICUs in the parameters evaluated.

A patient who developed a mixed neuroendocrine carcinoma and adenocarcinoma at the site of a previous long-standing ileostomy is reported. The neuroendocrine features are documented by both ultrastructural and immunocytochemical findings. Carcinoma arising in an ileostomy site is rare but has been recorded in patients with long-standing ileostomies after colectomy for chronic inflammatory bowel disease, as in this patient. Neuroendocrine carcinoma developing in this setting apparently has not been described before, however.

Objective: To gather data about occupancy, admission characteristics, patients' ages, and types of therapy utilized in ICUs in the United States., Design and Setting: Survey instruments were mailed to the administrators of 4,233 hospitals to gather information from the medical director of the institutions' respective ICUs for the purpose of developing a database on ICUs in the United States. The sampling frame for this study was based on all American Hospital Association (AHA) hospitals stating they had ICUs., Measurements: Census questionnaires solicited information on occupancy, where the patients were admitted from, length of stay, therapies rendered, intensive care diagnoses, and resuscitation status, as well as other information., Main Results: Data were obtained regarding 32,850 ICU beds, with 25,871 patients from 2,876 separate ICUs in 1,706 hospitals in the United States. The census response rate was 40% of the AHA hospitals that stated they had ICUs, with specific ICU data on 38.7% of the nation's ICUs. Overall, the responding units reported a mean occupancy rate of 84% of total bed capacity and 87% of available beds. As hospital size increased, so did ICU occupancy. Nearly 17% of all of the critical care patients had been in the units for > 14 days. More precisely, 49% of all responding units indicated that they had one or more "chronic" (> 14-day length of stay) patients. Most patients were admitted to the units from the emergency room (38%), operating room/postanesthesia care unit (22%), and the general hospital floor (16%). Neonatal units were exceptions to this observation, where most patients came from the delivery room (60%). Admission from other hospitals represented a significantly larger group of patients in the cardiac care, pediatric, and neonatal units. Respondents indicated that many of their current patients were elderly, with 43% of these patients aged 65 to 84 yrs and with 4% being > or = 85 yrs of age. The 47% of patients > or = 65 yrs of age increased to 58% when the neonatal and pediatric units were eliminated from the analyses. For all units responding to the survey, the leading primary admitting intensive care diagnoses were postoperative management, ischemic heart disorder, respiratory insufficiency/failure, and prematurity. Elimination of units predominantly treating children (pediatric and neonatal) from the analysis left "adult" units with three primary admitting diagnoses: ischemic heart disease, postoperative management, and respiratory insufficiency/failure with variation according to specific unit type. The leading diagnoses in pediatric units were respiratory insufficiency/failure, postoperative management, and congenital abnormalities. For neonatal units, prematurity was the primary admitting diagnosis, accounting for 59% of these units' patients. Respondents reported 5.3 +/- 10.9% of patients had received cardiopulmonary resuscitation (CPR) before admission into the critical care unit. Only 6.0 +/- 11.9% of patients in these critical care units had instructions that CPR not be performed while in the unit., Conclusions: This report should be viewed as the beginning step of an effort to improve both the information base available on critical care medicine and the performance of ICUs. Our survey findings provide an introduction into the everyday workings of critical care units throughout the United States. Research is required to determine which patients will benefit from intensive care and how to efficiently utilize the vast technology we have available for them in a world with limited financial resources, an aging population, and a multiplicity of societal and ethical concerns.

Objective: To compare the efficacy and safety of iv nicardipine with sodium nitroprusside in the treatment of postoperative hypertension after both cardiac and noncardiac surgery., Design: Multicenter, prospective, randomized, open-label study., Setting: Six tertiary referral medical centers (recovery rooms and surgical ICUs)., Patients: A total of 139 patients with postoperative hypertension: i.v. nicardipine (n = 71), sodium nitroprusside (n = 68)., Intervention: Administration of i.v. nicardipine or sodium nitroprusside., Measurements: Vital signs (BP, heart rate), hemodynamic variables, medication dosage, total number of dose changes, and time to achieve BP control were recorded., Main Results: Both medications were equally effective in reducing BP in both the cardiac and noncardiac surgical groups. Under the conditions of the study, i.v. nicardipine controlled hypertension more rapidly than sodium nitroprusside (i.v. nicardipine 14.0 +/- 1.0 mins and sodium nitroprusside 30.4 +/- 3.5 mins, p = .0029). The total number of dose changes required to achieve therapeutic BP response was significantly less in the i.v. nicardipine-treated patients (i.v. nicardipine 1.5 +/- 0.2 vs. sodium nitroprusside 5.1 +/- 1.4, p < .05). Adverse effects were observed with both drugs (i.v. nicardipine 7% [5/71] and sodium nitroprusside 18% [12/68] [NS])., Conclusions: Intravenous nicardipine is as effective as sodium nitroprusside in the therapy of postoperative hypertension. Specific advantages have been identified. The use of i.v. nicardipine should be considered in the therapy of postoperative hypertension.

Objective: To report our ICU experience with patients noted to have a left-sided superior vena cava after central venous and pulmonary artery catheterization., Design: Retrospective review., Setting: Surgical ICUs in a University and Veterans Administration Medical Center., Patients: Five patients who had insertion of central venous or pulmonary artery catheters were noted to have abnormal placement., Results: Five patients were noted to have a left-sided superior vena cava that was not appreciated on preinsertion radiography after central venous (two patients) or pulmonary artery catheterization (three patients). The finding of left-sided superior vena cava was confirmed by computed tomography scan (one patient), transesophageal echocardiography (one patient), bolus contrast injection (two patients), and intraoperative inspection (one patient)., Conclusions: Left-sided superior vena cava occurs infrequently, most often in association with a right-sided superior vena cava. It is often associated with cardiac septal defects. The intensivist should be aware of its occurrence in order to not mistake catheters placed in it as being present in the arterial circulation or malpositioned outside of the venous circulation.

Objective: To gather data about available technology, staffing, administrative policies, and bed capacities of ICUs in the United States., Design and Setting: On January 15, 1991, survey instruments were mailed to the administrators of 4,233 hospitals to gather information from the medical director of the institutions' respective ICUs for the purpose of developing a database on ICUs in the United States. The sampling frame for this study was based on all American Hospital Association (AHA) hospitals that stated they have ICUs., Measurements: Census questionnaires solicited information on types of hospitals, types of ICUs, number of ICU beds open and closed, technology available to the unit, organizational structure and management of the ICU, as well as the staffing and certification of unit personnel., Main Results: Data were obtained on 32,850 ICU beds with 25,871 patients from 2,876 separate ICUs in 1,706 hospitals in the United States. Census responses came from units in all sizes of hospitals within all ten census regions in the country, all states, and all types of hospital sponsorship (federal, state, and local government, private nonprofit and private for profit). The census response rate was 40% of the AHA hospitals that stated that they have ICUs, with specific ICU data on 38.7% of the nation's ICUs. The number of ICUs per hospital increases with overall hospital size. The smallest hospitals (less than 100 beds) usually had only one ICU. As hospital size increased, the single, all inclusive medical/surgical/coronary care units diminished, and in hospitals with greater than 300 beds, specialization of units became prevalent. In absolute terms, hospitals had the following number of ICUs: 1.04 +/- 0.20 (less than or equal to 100 beds); 1.30 +/- 0.65 (101 to 300 beds); 2.37 +/- 1.58 (301 to 500 beds); and 3.34 +/- 2.21 (greater than 500 beds). ICU beds averaged, nationally, 8.09% of hospital-licensed beds with a median of 6.98%. Generally, medical units, pediatric units, coronary care units (CCUs), and medical/surgical/CCUs reported an average of 10 beds per unit. Neonatal units averaged 21 beds, and surgical units averaged 12 beds. The average ICU size, nationally, was 11.7 +/- 7.8 beds per unit. Available technology within hospitals and individual units was increased as hospital size increased; surgical units tended to have more available technology than other unit types. A wide range of organizational arrangements within hospitals determines where the ICU appears in an organizational chart and to whom unit management is accountable. Thirty-six percent of the units were located organizationally within the hospital's department of medicine, while 23% were considered "free standing," having no departmental affiliation. Although units must have a medical director, the perception as to whether this director supervises the day-to-day operation was different in larger vs. smaller hospitals. In hospitals with less than or equal to 100 beds, 72% of the units were perceived to be supervised by the medical director, whereas in larger hospitals (greater than 500 beds), 81% of units were supervised. Study results indicated that medical directors in pediatric, neonatal, and burn units most often were perceived to supervise the unit. Presently, 63% of all ICUs responding are directed by an internist. The next largest group to direct ICUs were surgeons, followed by pediatricians. Pediatrician involvement tended to be exclusive in pediatric and neonatal units. Surgeons directed most surgical and neurologic units and were involved in 21% of mixed medical/surgical units. Internists predominated in medical units and in CCUs, as well as in combined medical/surgical/CCUs. Direction by anesthesiologists, although relatively infrequent, predominated in the surgical unit. Critical care medicine certification of the medical director and attending staff of the ICU increased as hospital size increased, although only 44% of all units stated that thei

Objective: To present a computerized intensive care unit order-writing protocol., Design: Descriptive report., Setting: Eight-bed surgical intensive care unit, Department of Surgery, Department of Veterans Affairs Medical Center, Bronx, NY., Methods: IBM-based, computer network program that provides user-friendly, logical, and comprehensive organ-system order sequences for patient management., Results: Since July 1988, an order program that stresses (1) improved and more efficient patient care, (2) the use of program-integrated automatic safety features, (3) the substitution of computer entry for handwriting, and (4) the assurance that physicians deliver obligatory care in a logical organ-system-based progression has been implemented., Conclusions: The order protocol system presented is simple to introduce and operate, has minimal training and technical requirements, and is demonstrably reliable.

Objective: To determine if postoperative diagnostic abdominal paracentesis is a useful clinical tool in the abdominal evaluation of the critically ill septic patient., Design: Retrospective review., Setting: Surgical ICU patients in a Veterans Administration medical center., Patients: Ten patients were studied from a total of 1,053 patients admitted to the surgical ICU between September 1985 and May 1989., Interventions: Diagnostic abdominal paracentesis performed by the open or closed approaches., Measurements and Main Results: Results are presented in three patient groups (A, B, and C): Group A (n = 4) had positive diagnostic abdominal paracentesis. Abdominal causes for the sepsis were found at reexploration. One of these four patients survived. Group B (n = 3) had negative diagnostic abdominal paracentesis. No abdominal septic source was found at reexploration; all three patients died. In group C (n = 3), diagnostic abdominal paracentesis was negative, patients were not reexplored, and all survived. Diagnostic accuracy correlated with three variables: a) the gross appearance and smell of the fluid, b) WBC count greater than 5000 or less than 500/mm3, and c) Gram stain demonstrating bacterial organisms., Conclusions: Diagnostic abdominal paracentesis proved accurate, reliable, simple, safe, and rapid in evaluating the abdomen in the postoperative septic patient. The use of this procedure should be considered in postoperative septic patients in whom an abdominal source for the sepsis needs to be excluded.

To investigate the long-term effectiveness of choledochoduodenostomy (CDD), the experience with 71 patients followed for 5 or more years after CDD was analyzed retrospectively. From 1968 to 1984, 134 patients underwent CDD. Eight patients (6%) died in the immediate postoperative period, 55 left the hospital, 8 of them were lost to follow-up, and 47 were followed but died before 5 years elapsed after CDD. The remaining 71 patients form the data base for this analysis: 38 were followed for more than 5 years, 25 were followed for more than 10 years, and 8 were followed for more than 15 years (mean 12.1 years +/- 1.3 SEM). Choledocholithiasis, chronic pancreatitis, and postoperative stricture were the indications for CDD. Cholangitis was observed in only three patients. The diameter of the common bile duct (CBD) was large in most patients (mean 18 mm +/- 0.9 SEM). These results infer that CDD is effective to treat non-neoplastic obstructing lesions of the distal CBD on a long-term basis and that the presence of a dilated CBD (more than 16 mm) that allows the construction of a CDD more than 14 mm is essential to obtain good results.

Attitudes to autologous blood donation have been surveyed in a group of 38 postoperative bariatric patients. Only two patients (5%) declined to participate. Twenty-eight of 38 ( 70%) successfully predeposited autologous blood. Twenty-five of 28 donors (90%) had done so at the suggestion of their surgeon. Concern about contracting AIDS was the motivating factor in the majority of patients (21 patients = 55%). Lack of infectious complications in general was cited by an additional four (11%). All respondents would donate autologous blood in the future, and would recommend the procedure to others who were about to undergo elective surgery. There was an increase from 29% to 50% who stated that, following their autologous donation experience, they would consider being homologous volunteer blood donors in the future.

From 1976 to 1988, 35 patients were treated for Stage IE and Stage IIE primary gastric lymphoma (non-Hodgkin's). Pain and weight loss were the predominant symptoms, physical findings were usually absent and 20 per cent of the patients were anemic. The results of gastrointestinal contrast studies suggested a malignant condition in 75 per cent, but findings were not specific for lymphoma. Endoscopic findings suggested a malignant process in 85 per cent, but the yield for biopsy was only 60 per cent. Of 28 patients undergoing operative exploration, 75 per cent were resectable. Nine patients received postresectional adjuvant therapy. Five had chemotherapy; three, radiotherapy, and one patient, a combination of the two. Primary nonsurgical treatment consisted of chemotherapy in 11, radiotherapy in two and combined therapy in one instance. Three of five recurrences were successfully treated. The five year survival rate was 65 per cent without significant differences between surgical and nonsurgical regimens. Those with tumors smaller than 7 centimeters had a five year survival rate of 100 per cent versus 50 per cent for larger neoplasms. Patients more than 60 years of age appeared to have a more favorable course after surgical therapy compared with those who had nonsurgical treatment. We concluded that endoscopy is a most useful, although limited diagnostic study and since no treatment program is obviously superior, the choice of therapy can be individualized accordingly.

Nicardipine hydrochloride, a new calcium channel blocker for intravenous use, has been compared with placebo in a prospective, randomized, double-blind trial on postoperative hypertension. Of 175 patients who signed preoperative consent, 24 (13.7%) met entry criteria. Hypertension was significantly better controlled in nicardipine-treated patients compared with those receiving placebo (93% versus 30%, p less than 0.05). All the placebo failures were subsequently successfully treated with nicardipine. There were no significant complications in either group. The authors conclude that nicardipine HC1 is an effective, safe therapy for postoperative hypertension. Further studies are now indicated comparing it with other drugs currently used to treat this condition.

The therapy of postoperative hypertension (POH) after head and neck surgery was evaluated in a prospective, randomized, double-blind trial. Nicardipine hydrochloride, a Ca channel-blocker for iv use, was compared with placebo. Patients were initially randomized to receive nicardipine infusion or placebo. Those not responding to placebo were given nicardipine infusion on an open basis. Hypertension was significantly better controlled in patients treated with nicardipine infusion compared with placebo (83% vs. 22%, p less than .002). Subsequently, six (86%) of seven of the placebo failures were successfully treated with nicardipine. There were no significant complications in either group. We conclude that the titratable infusion of nicardipine is an effective and safe method for the control of POH after surgery of the head and neck. Further studies are now warranted comparing nicardipine with other drugs currently used to treat this condition.

The absorption of ranitidine from different segments of the intestinal tract was studied in a subject who had an anatomically divided small intestine. The results indicate that the drug is maximally absorbed from the small bowel rather than the stomach. Subsequent animal studies have shown that absorption of ranitidine in dogs is primarily duodenal followed by jejunal and ileal. The lack of gastric absorption, with predominantly small bowel absorption, may have investigational and therapeutic implications in a variety of gastrointestinal diseases.