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Chronic massive pancreatic pleural effusion is an uncommon and often unrecognized clinical syndrome which results from an internal pancreatic fistula and usually presents as an exudative effusion of unknown cause. The effusion frequently occurs without clinical evidence of pancreatitis, but occasionally it may be associated with a pseudocyst of the pancreas. Chronic massive pancreatic pleural effusion is usually recurrent and characterized by very high levels of amylase in the pleural fluid. Morbidity and mortality are reduced when a definite diagnosis is established and appropriate therapy rendered. In this report, three cases of chronic massive pancreatic pleural effusions are presented. Two of the three had no demonstrable pancreatic disease, and the condition responded to conservative therapy. The third patient had a pancreatic pseudocyst and an internal pancreatic fistula which was corrected only after multiple surgical procedures.

A series of 38 patients 65 years of age or older who underwent Wertheim hysterectomy for primary treatment of stages IB and IIA (FIGO) carcinoma of the cervix is reported. There were no ureteral fistulas and no perioperative mortality, but 4 of the patients required reoperation. A control population of 320 patients less than age 65 was identified who had been treated in the same fashion and who resembled the older group in regard to stage, histologic features, grade, and incidence of pelvic nodal metastasis. Transfusion requirements and incidence of postoperative lower extremity edema were similar between groups. Febrile morbidity was less frequent in the geriatric group (P = 0.03) but postoperative small bowel obstruction (P = 0.01), bladder dysfunction (P = 0.06), and pulmonary emboli were more frequent (P = 0.11). Five-year cancer-specific Kaplan-Meier survival estimates were 84 and 85% for the geriatric and younger patient populations, respectively.

In a retrospective study conducted at the University of Alabama at Birmingham, the University of Michigan, and the Mayo Clinic, 185 patients with previously untreated FIGO stage IB and IIA squamous cell carcinoma of the cervix were found to have nodal metastasis at the time of radical hysterectomy and pelvic lymphadenectomy. Of these patients, 103 received adjuvant pelvic irradiation. Cancer recurred in 76 patients; the median time to recurrence was 3.1 years. The prognostic significance of patient age, clinical stage, lesion diameter, number and location of nodal metastases, and use of adjuvant radiation therapy was determined by multivariate analysis. Only patient age (P = 0.0006), lesion diameter (P less than 0.0001), and number of nodal metastases (P = 0.0004) were noted to be significant factors in determining overall survival. Rates of recurrence were also related to these factors. Employment of these significant variables led to identification of four risk groups. In general, patients with small cervical lesions (diameter less than 1 cm) and no more than two nodes with metastases fell into the low-risk category; those patients with large cervical lesions (diameter greater than 4 cm) and more than two involved nodes fell into the high-risk category. All other patients were categorized into intermediate-risk groups. Ten-year survival was 92% in the low-risk group (n = 13), 70% in the low-intermediate-risk group (n = 66), 56% in the high-intermediate-risk group (n = 66), and 13% in the high-risk group (n = 20). This risk group classification identifies subgroups of early-stage cervical carcinoma patients found to have nodal metastasis at the time of radical hysterectomy that warrant appropriately selected adjuvant therapy.

Therapeutic Recreation is being increasingly recognized as a valuable element of a total rehabilitation approach. In order to be effectively utilized as a treatment tool however, recreation must be approached in a scientific manner which gears activities to individual skills, interests and rehabilitation goals. Many programs in the past have been based primarily on what the therapeutic recreation specialist thought was best, rather than relying on objective analysis of client needs. In actuality this should not be the case. A more scientific approach is evolving as professionals learn more about the physical and psychological ramifications of recreation participation. Analysis of activity demands and outcomes can be used to match participation with client needs and interests to provide a recreation program that is truly rehabilitative as well as enjoyable. This manuscript provides a review of the benefits of Therapeutic Recreation and describes why it is important to utilize scientific and objective criteria in program planning. A number of models are identified that have developed systems approaches to Therapeutic Recreation programming. A recent model, developed at New York University, is described in detail and some projections for the future are made.

In a retrospective study, 185 patients with previously untreated stage IB or IIA (International Federation of Gynecology and Obstetrics) squamous cell carcinoma of the cervix were found to have pelvic nodal metastasis at the time of Wertheim hysterectomy and bilateral pelvic lymphadenectomy. Of these patients, 103 received adjuvant whole-pelvis irradiation and 82 received no adjuvant therapy. Median dose of pelvic irradiation was 5000 cGy. Among the irradiated patients, in 75% the dose was 5000 cGy or greater. Matching irradiated and nonirradiated patients according to stage, tumor size, and number and location of positive nodes yielded 60 pairs. Mean length of follow-up was 3.9 years for the 60 irradiated patients and 5.8 years for the non-irradiated patients. Kaplan-Meier overall and cancer-specific survival estimates for the two groups were not significantly different (P greater than 0.30). During the follow-up period, 21 surgery-only patients and 22 patients treated with adjuvant radiotherapy had recurrence, but adjuvant radiotherapy decreased the proportion of recurrences occurring in the pelvis alone--27% compared with 67% in the surgery-only group (P = 0.01).