Fifty-three (3.6%; actuarially 4.1% at 48 months) of 1465 consecutive in-hospital survivors of valve replacement from 1975 to July 1979 (aortic, mitral, or aortic and mitral, only one untraced) developed prosthetic valve endocarditis (PVE). Incremental risk factors for developing PVE were native valve endocarditis (p < .0001), black race (p = .0001), mechanical prosthesis (vs bioprosthesis) (p = .005), male sex (p = .04), and longer cardiopulmonary bypass time (p = .09). In general, the hazard function for developing PVE was greatest at 3 weeks after valve replacement. Patients with native valve endocarditis had a tendency to develop PVE early after valve replacement, as did patients in whom mechanical prostheses were used. PVE associated with Staphylococcus epidermidis tended to appear within 6 months of valve replacement, whereas streptococcal PVE tended to appear later after valve replacement. PVE took an atypical form in some patients, but patients with possible PVE (n = 6) had the same findings as those with certain PVE (n = 47). In 11 patients bacteriologic confirmation of PVE was not obtained. The typical prosthetic and periprosthetic characteristics of PVE were present in 30 of the 40 cases in which observations were possible. PVE is a serious condition; 34 (64%) of our 53 patients died. Most deaths occurred within 3 months of the first evidence of PVE. Recovery of some patients is possible with appropriate medical and surgical treatment, but more intense preventive measures are indicated.

Primary adenocarcinoma of the appendix is rare and less than 200 cases are on record. The present material consisted of 20 cases collected from different hospitals. The cases are described in respect of sex and age-distribution, symptoms, treatment and prognosis. Of 7 patients with malignant mucocele, 6 subjected to appendectomy only, were still alive 5 years after the operation. Of 12 patients with colonic type of adenocarcinoma, 3 had been treated with appendectomy only. Of these, 2 were still alive 5 years after the operation. The remaining 9 patients had undergone right hemicolectomy. Only one of them was alive 5 years after the operation. A compilation of a further 39 cases garnered from the literature, however, showed that 60% had survived at least 5 years after right hemicolectomy, compared with 46% after appendectomy alone. Appendectomy alone is probably a sufficiently radical operation for malignant mucocele provided the tumor has not grown through the submucosa and that it is confined to the tip of the appendix. Right hemicolectomy is indicated for the colonic type of adenocarcinoma.

No abstract

The patients who survive gallbladder carcinomas more than five years are usually those in whom the carcinoma was first diagnosed at microscopic examination of gallbladders removed for presumed benign disease. A group of 32 such patients (from a series of 120 cases) was studied. The prognosis was very bad (longest survival 2.5 years) in 21 of the patients where the cancer involved all the layers of the gallbladder wall. The prognosis was far better in the 11 patients in which the cancer was confined to the mucosa or submucosa. Sixty-four per cent of the patients were alive after 5 years and 44% after 10 years. Five of the 11 patients died because of recurrence. Simple cholecystectomy had been performed in all the patients except one who underwent a right hepatic lobectomy. Radical cholecystectomy including a wedge resection of liver tissue and dissection of the regional lymph nodes is recommended in all patients with inapparent gallbladder carcinomas.

SummaryAmong l0 patients with primary malignant melanoma of the CNS, the turnout was localized to the brain in 7 cases (group I) and to the spinal cord in the remaining 3 cases (group II). A mean age of about 50 years and a male preponderance were found. In group I there were various neurological symptoms, and cerebral ar~eriography disclosed either vaseular or non-vascular lesions. Diagnosis was made at light microscopic examination of material obtained at operation or autopsy. The tumour was either diffuse or localized and involved both the leptomeninges and cerebral parenchyma. After operation the patients survived for between 2 weeks and 7 months. In group II there were compression symptoms and pathological gas myelography. At operation tumours were found that involved the leptomeninges and medulla. Light microscopic examination showed malignant melanoma. The postoperative survival was longer (12 months-2 years and 9 months) than in group I.