Epidemiology, clinical aspects, and biology of IDDM patients under age 40 years. Comparison of data from Antwerp with complete ascertainment with data from Belgium with 40% ascertainment. The Belgian Diabetes Registry

OBJECTIVE: To compare the incidence rate of IDDM in the age-groups 0-14 and 15-39 years in Antwerp, Belgium, and to compare demographic, clinical, and biological data from Antwerp IDDM patients with 92% ascertainment with those from a larger Belgian patient group with 40% ascertainment. RESEARCH DESIGN AND METHODS: Incident cases of IDDM were reported by physicians of the Belgian Diabetes Registry and in Antwerp by several other sources. In Antwerp, completeness of ascertainment was calculated by the capture-recapture method. Demographic and clinical data were collected by questionnaire. Blood was sampled for HLA-DQ genotyping and, in new-inset patients, for autoantibodies. RESULTS: In Antwerp, the age- and sex-standardized IDDM incidence rates were similar in both age-groups (0-14 years: 11.8/100,000; 15-39 years: 8.9/100,000). The incidence rate decreased in girls above age 15 years (6.9/100,000; P = 0.003) but not in boys (11.0/100,000). Both in Antwerp and Belgium, IDDM was diagnosed more frequently in the 15-39 years age-group (60% of all cases) than under age 15 years, with a lower prevalence of acute symptoms, ketonuria, high-risk HLA-DQ genotype, and autoantibodies against insulin, islet cells, and IA-2, but with a higher prevalence of GAD65 autoantibodies. CONCLUSIONS: In Antwerp, the incidence rate of IDDM under age 15 years is intermediately high compared with the rates in other European regions. It is similar in the 15-39 years age-group, but with a marked male predominance. Demographic, clinical, and biological data show the same age-dependent heterogeneity as the data collected nationwide, with 40% ascertainment indicating the representativeness of the latter.     

The learning curve for laparoscopic colorectal surgery. Preliminary results from a prospective analysis of 1194 laparoscopic-assisted colectomies

BACKGROUND: Laparoscopic-assisted colectomy is an emerging technology for patients with cancer, polyps, inflammation, and other types of pathologic conditions. While previous studies have shown better outcomes for laparoscopic cholecystectomies when surgeons perform more procedures, there is no information on the relationship between surgeon volume and outcomes for laparoscopic-assisted colectomy. OBJECTIVE: To evaluate whether better clinical outcomes are found for surgeons who perform higher numbers of laparoscopic-assisted colectomies and whether such a relationship, if it exists, applies to both intraoperative and postoperative outcomes. DESIGN: Analysis of a data set of 1194 patients, operated on by 114 surgeons, from a prospective registry sponsored by the American Society of Colon and Rectal Surgeons, from May 1991 to October 1994. MAIN OUTCOME MEASURES: Completion rate, intraoperative and postoperative complications, and length of hospital stay. RESULTS: In 75% of cases, surgery was completed laparoscopically, with no difference between high-volume surgeons (> or = 40 cases) and low-volume surgeons. Length of stay (average, 6 days) did not vary according to surgeon volume. Postoperative complications occurred in 15% of cases, with a significantly lower rate for high-volume surgeons (10% vs 19%; P < .001). Intraoperative complications occurred in 5% of cases, with a nonsignificant trend toward a lower rate for high-volume surgeons (3.7% vs 6.3%). A multivariate regression analysis, adjusting for type of disease (cancer vs inflammation vs polyps) and for level of difficulty of the procedure (high vs low) showed that for high-volume surgeons there is a lower probability of both intraoperative complications (adjusted odds ratio, 0.56; 95% confidence interval, 0.32-0.97; P = .04) and postoperative complications (adjusted odds ratio, 0.48; 95% confidence interval, 0.34-0.68; P < .001). CONCLUSIONS: There is a learning curve for laparoscopic-assisted colectomy with respect to intraoperative and postoperative outcomes. As with other laparoscopic procedures, surgeons who perform higher volumes of laparoscopic-assisted colectomy have lower rates of intraoperative and postoperative complications.     

Complete remission of refractory gestational trophoblastic disease with brain metastases treated with multicycle ifosfamide, carboplatin, and etoposide (ICE) and stem cell rescue

Patients with chemotherapy-refractory gestational trophoblastic disease and brain metastasis are considered to have a very poor prognosis. We present the case of a patient who had failed several chemotherapeutic regimens. Despite transient responses to chemotherapy, she had not achieved a complete remission in 3 years, and had developed systemic disease and recurrent brain metastasis. She was treated with four cycles of high-dose ifosfamide, carboplatin, and etoposide with blood progenitor cell support. She tolerated this regimen well and has obtained a complete remission that is ongoing for 12 months.     

Malignancy associated with hepatolithiasis

BACKGROUND/AIMS: Malignancy is known to be associated with hepatolithiasis. The present report summarizes the results of our management of patients with cholangiocarcinoma associated with hepatolithiasis. MATERIALS AND METHODS: Twenty patients with cholangiocarcinoma and associated hepatolithiasis were analyzed retrospectively. There were 12 males and 8 females, with a mean age of 59.3 years. The clinical records of these patients were reviewed to determine demographic characteristics, clinical features, laboratory findings, diagnostic tests, operative management and results of therapy. RESULTS: One patient was moribund on presentation and was treated conservatively. Fourteen patients underwent hepatic resection. Three of them had palliative resection. Hepatic resection was less likely to be performed in patients having right lobe disease (50%) as compared to patients having left lobe disease (90%) (p = NS). The overall operative morbidity and mortality rates after hepatic resection were 36% and 7%, respectively. Non-resective operations were performed in five patients. The overall operative morbidity and mortality rates after non-resective operations were 20% and 0%, respectively. After curative hepatic resection (11 patients), the 1- and 2-year survival rates were 81% and 51%, respectively. CONCLUSIONS: A suspicion of malignancy is necessary in managing patients with hepatolithiasis. Hepatic resection is the treatment of choice for cholangiocarcinoma when it is resectable.     

Thyroid peroxidase as toxicity target for dithiocarbamates

In vivo ethylenebisdithiocarbamates and ETU are toxic to the thyroid gland. Since the molecular target of these compounds is thought to be thyroid peroxidase (TPO) which catalyzes the transfer of iodine to thyroglobulin, we examined the effect of these compounds on peroxidative activity in Chinese hamster ovary (CHO) cells transfected with the human TPO gene. The activity was inhibited by 50 microM ETU, 5 microM ziram and 5 microM zineb, the last-mentioned effect being irreversible in the absence of iodide. Thiram had no effect. By contrast, the iodinating activity of TPO was blocked only by 5 microM ETU and 50 microM zineb but not by the other compounds. The effect on TPO-catalysed iodination could explain the differences in thyrotoxicity of these compounds in vivo.     

Prolonged survival in selected patients following surgical resection for pulmonary metastasis from hepatocellular carcinoma

BACKGROUND: Pulmonary metastasis is the commonest site of extrahepatic spread from hepatocellular carcinoma (HCC). The aim of the present study was to evaluate the efficacy of surgical management in patients with solitary pulmonary metastases from HCC. METHODS: This was a retrospective study of patients with HCC admitted for hepatectomy from July 1972 to June 1995. The records of patients who had a pulmonary resection for histologically proven pulmonary recurrence after curative hepatectomy were selected for analysis. RESULTS: In the study interval, 380 patients with HCC underwent hepatectomy. Some 48 patients (12.6 per cent) developed pulmonary metastases documented pathologically or radiologically. Nine (seven men and two women) were suitable for curative pulmonary resection. The median disease-free survival between hepatectomy and appearance of the lung metastasis was 21 months. The median survival after pulmonary resection was 42 months, and the 1-, 2- and 5-year survival rates were 100, 78 and 67 per cent respectively. CONCLUSION: Pulmonary resection for metastases from HCC resulted in long-term survival in these highly selected patients.     

Warfarin sodium (Coumadin) anticoagulant therapy for vascular access patency

The increase of geriatric and diabetic patients with poor vasculature brings about a corresponding increase in the use of synthetic vascular access grafts. Synthetic vascular accesses are plagued with numerous problems in maintaining patency. As a result, many practitioners use warfarin sodium. Coumadin, because of its predictability and bioavailability to interrupt the coagulation cascade to prevent thrombus formation. This article includes actions, interactions, monitoring, and adverse effects of this drug.