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The antileukemic reactivity of transplanted immunocompetent cells from a panel of 10 donor strains was bioassayed in AKR mice. Donors were syngeneic or allogeneic, and matched or mismatched with AKR at H-2. The most important finding was that cells from matched donors had no detectable antileukemic effect against a long passage AKR leukemia; cells from mismatched donors had excellent antileukemic reactivity. This difference in antileukemic effect occurred, although in several instances cells from matched and mismatched donors produced graft-versus-host disease in nonleukemic AKR mice of similar severity. Despite the ineffectiveness of cells from H-2-matched donors in adoptive immunotherapy experiments, most mice of these same strains failed to develop leukemia following administration of 105AKR leukemic blast cells.

• Twenty consecutive patients undergoing gastric bypass for morbid obesity were evaluated psychologically preoperatively and postoperatively by Minnesota Multiphasic Personality inventory (MMPI) assessment, a Problem Index designed for the study, and semistructured interviews. Patients were classified into categories based on the extent of psychopathology demonstrated preoperatively, and into categories based on the presence or absence of postoperative complications. Eighty percent of the patients continue to do well or improve psychologically. Patients with postoperative complications showed no significant change in psychological status. Patients who did not experience postoperative complications showed significant improvement in depression, hysteria, poor morale, psychoticism, phobias, and health concerns. Psychological changes with surgery did not correlate with weight loss. All patients with complications were unmarried and more likely to be moderately or severely disturbed on preoperative MMPI assessment.(Arch Surg 115:21-28, 1980)

Hospitalization costs are the prime reason for increasing health care delivery costs. The initial 15-month experience (633 patients) with an ambulatory surgical unit in an urban teaching hospital was evaluated as an alternative to hospitalization.A progressive increase in utilization of the unit was not accompanied by a decrease in hospital admissions. Gynecological, urological, and orthopedic procedures lend themselves to performance on outpatients. A wide variety of surgical procedures were performed.Analysis of hospital billing to patients undergoing therapeutic abortion, laparoscopic tubal ligation, breast biopsy, and cystoscopy indicated that charges range from 47% to 70% higher for inpatients than for outpatients undergoing similar procedures. Screening tests and room charges to inpatients accounted for this significant cost differential.Patients preferred ambulatory surgery to hospitalization. Patients and physicians indicated a highly satisfactory experience in all aspects of high quality medical care.

Hospital charges for inpatients undergoing breast biopsy were 1.9 times higher than for outpatients. Outpatient biopsy reduced length of stay from 2.7 days to 6.3 hours, provided psychological benefits, minimally disrupted family life, and did not compromise medical care.Substantial unnecessary hospital costs resulted from extensive preoperative medical evaluation and preparation for possible mastectomy plus screening for metastases in patients admitted with benign disease.Screening studies to detect metastases (bone survey, bone scan, liver scan) were performed in 45% of patients with carcinoma. No metastases were demonstrated when not suspected clinically. These data suggest that time-consuming and expensive screening studies for metastatic disease are not warranted.A treatment strategy, which includes outpatient biopsy only for undiagnosed breast lesions and a specified preoperative assessment prior to admission for biopsy-proven breast carcinoma, has been defined.

• To study the influence of bacterial culture data on the clinical management of gangrenous or perforated appendicitis, we reviewed records of 104 patients who had been treated empirically with aminoglycoside antibiotics. Culture results appeared to influence antibiotic therapy in only 7 patients (7%). The routine cultures obtained at appendectomy affected therapy in only 2 patients. Discriminant analysis identified postoperative infectious complications and related factors as the principal determinants of culture utility. We conclude that, in patients with perforated appendicitis treated empirically with aminoglycoside combination regimens, culture results were seldom used for clinical management except in instances of postoperative infectious complication. Routine cultures and Gram's stains of perforated appendicitis, however, should still be obtained (1) to allow epidemiologic tracking in the hospital; (2) to identify organisms that are recovered infrequently but may cause serious disease (eg, Clostridium); and (3) because newer antibiotics are replacing aminoglycosides in the treatment of perforated appendicitis.(Arch Surg. 1989;124:1280-1283)

Femoral bone marrow cellulari–ty, CFU concentration, and CFU content were markedly subnormal in allogeneic radiation chimeras that had been produced with bone marrow cells from adult donors.2. Marrow cellularity was restored to normal within 3 weeks when liver or liver plus thymus from fetal donors was the tissue transplanted.3. In chimeras produced with fetal cell transplants, marrow CFU increased at a slower rate than did differentiated marrow cells. However, at 77 ± 7 days, chimeras produced with fetal liver plus fetal thymus cells had normal numbers of femoral CFU and this level was significantly higher than in chimeras produced with fetal liver without thymus cells.4. Hematopoietic repopulation of allogeneic radiation chimeras using combined fetal liver and thymus cell transplants was equal or superior to that achieved with fetal liver alone or adult bone marrow despite the fact that with the latter tissues 2 to 5 times as many hematopoietic stem cells had been transplanted.Expert technical assistance was provided by Miss Brigid M. Finnegan, Mrs. Alice C. Grady, and Mrs. Evangeline R. Reynolds.

Transcystic duct operative cholangiography was performed in 423 of 506 consecutive cholecystectomies. Patients were classified prospectively as having or not having a preoperative clinical indication for common duct exploration on the basis of jaundice, pancreatitis, or an elevated alkaline phosphatase level. Cholangiography avoids consideration of classical intraoperative indications for common duct exploration.Thirty-nine of 79 patients, or 50%, with positive preoperative clinical indications for common duct exploration had normal cholangiograms, and were spared exploration of the common duct by operative cholangiography. Of 427 patients without clinical indications for duct exploration, unsuspected common duct stones were demonstrated in eight, or 1.8%. Routine operative cholangiography reduced the number of common duct explorations to 11.1% of cholecystectomies, and reduced negative common duct explorations to 3.2%. This experience suggests that the indication for operative cholangiography is "cholecystectomy."

SINCE hemodialysis has become a routine treatment for patients with end-stage renal disease, the surgically created arteriovenous (AV) fistula, first described by Brescia and Cimino in 1966, has become the vascular access of choice in most patients. In general, it is relatively simple and safe; but with an increasing number of these procedures being performed, one might anticipate an increasing prevalence of complications.We report ipsilateral breast enlargement developing with the maturation of such a fistula and finally necessitating surgical closure of the fistula.Report of a CaseA 71-year-old woman was found to have chronic renal failure in 1970 thought to be secondary to chronic pyelonephritis. An AV fistula (end of cephalic vein to side of radial artery) was created in her left forearm in March 1975, when her creatinine clearance was 8 ml/min; serum creatinine level, 5.1 mg/100 ml; and blood urea nitrogen level, 45 mg/100 ml. In