In 1971, the National Surgical Adjuvant Breast Project (NSABP) implemented a prospective randomized clinical trial to compare the worth of alternative treatments with radical mastectomy in women with primary operable breast cancer. Information has been obtained from 1,665 patients eligible for follow-up from 34 NSABP member institutions in Canada and the United States. Results from that trial, at present in its sixth year with patients on study for an average of 36 months, (26 to 62 months), fail to demonstrate an advantage for those who had a radical mastectomy. No significant difference in the treatment failure or survival has as yet been observed in clinically negative node patients who have been randomly managed by conventional radical mastectomy, total mastectomy with postoperative regional radiation or total mastectomy followed by axillary dissection of those patients who subsequently develop positive nodes. Similarly, there presently exists no difference between patients with clinically positive nodes treated by radical mastectomy o r by total mastectomy followed by radiation. Of particular interest is the observation that based upon findings from radical mastectomy patients, there may be as many as 40% of patients having a total mastectomy who had histologically positive nodes unremoved, to date only 15% have developed positive nodes requiring a n axillary dissection. The persistence of such a difference in incidence would have profound biological significance. The discovery that leaving behind positive axillary nodes has as yet not been influential in enhancing the incidence of distant metastases o r the overall proportion of treatment failures and that a disproportionate number of treatment failures in the total mastectomy group occurred in those patients who subsequently required axillary dissection provides reinforcement to the view that positive axillary lymph nodes are not the predecessor of distant tumor spread but are a manifestation of disseminated disease.comer 39:2827-2839,1977. HERE HAS EXISTED GREAT CONTROVERSYtional Surgical Adjuvant Breast Project T concerning the treatment of primary breast (NSABP), after almost a decade of planning cancer. Prompted by that uncertainty, the Na-initiated in August of 1971, a prospective ran-
A B S T R A C T The effect of intra-aortic counterpulsation (IACP, 22-94 hr) on hemodynamics and cardiac energetics was evaluated in 10 patients in shock after acute myocardial infarction. The data clearly indicate that IACP improves myocardial oxygenation, enhances peripheral perfusion, and probably improves myocardial contractility in the severely diseased heart.Before treatment, decreases in cardiac index (mean value, 1.22 liter/min per m'), systolic ejection rate (67 ml/sec), and time-tension index per minute (1280 mm Hg -sec/min) were observed. Systemic vascular resistance varied widely. Low coronary blood flow (68 ml/min per 100 g) was associated with increased myocardial oxygen extraction (79%), low coronary sinus oxygen tension (20 mm Hg), and abnormal myocardial lactate-pyruvate metabolism.During 4-6 hr of IACP, systolic pressure and left ventricular outflow resistance decreased by 18% and 24%, respectively, while cardiac index improved by 38%. Diastolic arterial pressure rose 98%. Increase in coronary blood flow from an average of 68 to 91 ml/100 g per min (P < 0.001) was significantly correlated with rise in mean arterial pressure (r = 0.685). This correlation was best expressed in a third-order curve, which intercepts the point of no flow at a mean aortic pressure of 30 mm Hg. The flow-pressure curve is relatively flat above 65-70 mm Hg, but becomes steeper as mean aortic pressure falls below this point. Myocardial oxygen consumption remained essentially unchanged during early IACP and tended to rise during the later stages.However, the relationship of cardiac work performed to oxygen availability was markedly improved. Myocardial
We have documented a highly significant increment in hepatic arterial flow following a portacaval shunt in patients with cirrhosis of the liver and portal hypertension. In contrast with other hemodynamic variables, the increment in arterial flow was directly related to morbidity, hospital mortality, and long term survival. Patients with increments smaller than 100 ml/min had the worst clinical results. They accounted for all of the hospital mortality, the largest incidence of encephalopathy, and the worst long term cumulative survival rates. The extent of the increment was not related directly to the type of shunt but, rather, to some intrinsic capability of the cirrhotic liver to increase its arterial flow in response to the relief of sinusoidal hypertension produced by the shunt. This capablilty appears related to the degree of entrapment of the hepatic arterioles by the fibrous tissues of cirrhosis. This encasement of arterioles should change the elastic properties of the hepatic arterial bed and we propose to measure these properties by determining the characteristic input impedance of the arterial bed.
A series comprised of 28 patients (five with perforations of the recto-sigmoid colon and 23 with lodged rectal foreign bodies) is presented. The symptomatology, physical, laboratory and x-ray findings are described. Methods of management are discussed, with emphasis on the operative management of perforations and the conservative approach to retained foreign bodies. It is felt that these protocols will be useful to physicians who see this practice less frequently. X-rays of two more unusual cases are depicted. A thorough review of the literature is also presented. This is the largest reported series of patients with retained rectal foreign bodies and/or perforations. The series includes two female patients, a heretofore unreported occurrence.
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