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Patients with prostate cancer are commonly treated medically or undergo radical prostatectomy and/or radiation therapy. Radiation therapy is usually selected for patients with local or regional disease and patients for whom traditional surgery has failed. The local recurrence of cancer in patients treated with radiation therapy presents a difficult challenge regarding the selection of further treatment options. A commonly applied treatment is salvage prostatectomy, but it can be difficult and complicated, with positive surgical margins occurring in as many as 50 percent of patients and with significant postoperative morbidity. Hormonal therapy, which is not curative, has served as an alternative to surgery in patients who have failed to respond to radiation therapy. Cryosurgery, the destruction of diseased tissue by freezing, is increasingly used both as a first-line therapy and as a second-line therapy (salvage therapy) in patients for whom radiation therapy has failed. Recent reports suggest that cryosurgery may be a useful alternative procedure for treating some of these patients with recurrent cancers. Outcomes of cryosurgery are improving through better instrumentation, surgical technique, and experience. The available data suggest that some patients with radioresistant cancer appear to benefit from the use of cryosurgery as a salvage therapy. Use of this technique has resulted in biochemical disease-free survival for varying periods of some patients who had recurrent prostate carcinoma following radiation therapy; however, morbidity remains high and relatively few patients have had adequate followup. Salvage cryosurgery prospective clinical trials are warranted and would help determine long-term survival benefits and make possible the comparison of cryotherapy patient survival rates with those of untreated biopsy-positive patients.

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The localization of epileptogenic foci that are amenable to curative epilepsy surgery may be accomplished by noninvasive surface electroencephalogram (EEG) recordings, clinical observations, computed tomography (CT), magnetic resonance imaging (MRI), and neuropsychologic tests. Other tests, such as invasive EEG, 18F-fluoro-deoxyglucose-positron-emission tomography (FDG-PET or PET) scans, and single-photon-emission computed tomography (SPECT) scans, have also been used at various epilepsy centers to help identify candidates who might benefit from such surgery. Interictal PET scans have demonstrated hypometabolism in areas concordant with the epileptogenic foci indicated by other diagnostic tests such as EEG and MRI. However, PET scans have also shown no abnormality in many patients with EEG-indicated epileptogenic foci; in others, the scans have shown abnormal metabolism in areas that were discordant with the epileptogenic foci. Although substitution of the noninvasive PET scan for the invasive EEG recordings would be desirable, the available data were insufficient to determine whether PET scans might serve as a reliable substitute for EEG. A positive PET scan might contribute independent information for identifying the epileptogenic site but could be noncontributory or confusing when hypometabolism is not seen or is seen in presumably normal brain areas. It is not evident from the data in the literature to what extent confirmatory PET scan findings might contribute to the management of patients with complex partial seizures.

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OBJECTIVE: To discuss the potential role of continuous subcutaneous insulin infusion (CSII) therapy in patients with insulin-dependent diabetes mellitus (IDDM). DATA SOURCES: Published studies describing intensive insulin therapy are reviewed and evaluated. DATA SYNTHESIS: CSII delivers insulin at a preset basal rate and at bolus doses, when needed, throughout the day. Although this technology allows for greater lifestyle flexibility, the risks of hypoglycemia and ketoacidosis are also increased if the pump malfunctions. Studies have shown that CSII therapy may offer some advantages over conventional insulin therapy; however, the full impact of these benefits has yet to be determined. The National Institutes of Health has recommended seven commercially available insulin pumps for patient use. Cost ranges between $2000 and $3500; the average lifespan is about five years. CONCLUSIONS: CSII may be a viable alternative to multiple daily injections for maintaining glycemic control in patients with IDDM who require intensive insulin therapy.

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Cardiac rehabilitation programs are safe and effective in improving the functional activities of patients with cardiac disease, but they may be hazardous to those patients whose life might be in jeopardy if subjected to exercise. It is clear that not all cardiac patients require supervised rehabilitation programs to return to normal pre-cardiac-event activities. Many patients who have suffered cardiac events recover from the events without much functional debilitation, usually because they were normally active prior to the cardiac event. Patients who have had heart transplants, percutaneous transluminal coronary angioplasty, or heart valve surgery have no unique characteristics that differentiate them from cardiac patients who have had a myocardial infarction or coronary artery bypass graft or who have stable angina in terms of the necessity for participating in supervised rehabilitation programs. Therefore, patients who have had these surgical procedures might be selected for enrollment in cardiac rehabilitation programs on the basis of their physical and psychological conditions. Those patients who benefit from rehabilitation programs usually accomplish their goals within the 12-week sessions of the usual programs. Patients with stable cardiac conditions who are at high risk and have minimal functional capacities (3-5 METs) appear to benefit most, while patients who are of low risk and have functional capacities of 7-9 METs have minimal need for the program. High-risk patients have been described as including those who develop ventricular arrhythmias or marked ischemia with exercise. Low-risk patients have been described as including those who have functional capacities at 3 weeks postoperation of 8 METs or more, which allows them to resume most of their vocational and recreational activities. Patients with intermediate risk and functional capacities benefit from the programs, but they may not require the full 12 weeks of participation. The latter group may safely exit the programs when they attain the goals of the cardiac rehabilitation programs, e.g., the resumption of pre-cardiac-event activities and return to a relatively normal life. Accordingly, heart transplant patients and patients who have undergone percutaneous transluminal coronary angioplasty or heart valve surgery could benefit from prescribed cardiac rehabilitation programs if they have the need as described. The available information implies that many heart transplant, PTCA, or heart valve surgery patients are in excellent functional status after the surgical intervention and require minimal or no supervised exercise programs. However, a significant number of patients may lack confidence in their capabilities and may benefit from earlier exercise testing that would demonstrate to them their functional capabilities.(ABSTRACT TRUNCATED AT 400 WORDS)

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Liver transplantation, one of the most technically difficult of all solid organ transplant, is effective in extending the lives of carefully selected adult patients who have end-stage organ failure due to irreversibly damaged livers. Factors that influence the outcome of liver transplantation include the specific liver disease, patient's health status, and the presence or absence of extrahepatic disease or disorder. The outcome of liver transplantation has been improved significantly by the introduction of cyclosporine and continues to be improved by the use of newer immunosuppressants such as OKT3 monoclonal antibody and antithymocyte globulin for the prevention of graft rejection. The quality of life for those who survive one or more years was generally good. Survival rates were good for patients with primary biliary cirrhosis, primary sclerosing cholangitis, hepatitis B (antigen negative), alcoholic cirrhosis, alpha-1-antitrypsin deficiency disease, Wilson's disease, and primary hemochromatosis. Patients with liver malignancies, with the possible exception of those with epithelioid hemangioendoepithelioma, had poor outcomes, while patients presenting with other end-stage liver diseases had variable outcomes.

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Continuous subcutaneous insulin infusion (CSII) therapy using external infusion pumps provides an alternative to multiple daily injections (MDI) for insulin-dependent diabetics who require intensive insulin therapy. CSII allows for the delivery of regular insulin continuously at preset basal rates and at bolus doses, which can be varied in response to insulin needs of the patient. Intensive insulin therapy by CSII or MDI was administered to diabetics to improve control of their blood glucose levels and to assess its effects on the development of complications such as retinopathy and nephropathy. CSII appeared to be as effective as MDI in attaining near-normoglycemia and improving metabolic control in patients with insulin-dependent diabetes mellitus who required intensive insulin therapy. It was not clear, however, whether the improved control of the blood glucose levels resulted in the prevention or progression of the diabetic complications. The risks of having adverse effects, such as diabetic ketoacidosis or hypoglycemia, were higher with CSII as compared with MDI; both methods having higher risks of these complications in comparison to conventional insulin therapy. CSII may be beneficial for patients requiring intensive insulin therapy who may need greater lifestyle flexibility with regard to meal timing, work, and recreational scheduling.

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Adult male rats were surgically provided with a drainage catheter in the left thoracic lymphatic channel and an indwelling duodenal catheter for constant infusion of physiological saline-5% glucose. After an overnight fast, animals were given a single duodenal dose of an aqueous emulsion containing one of the following: oleic acid, corn oil, menhaden oil or a fish oil concentrate (FOC) and [1,2-3H]cholesterol. Digestion and absorption were estimated by recovering the total fatty acids in the thoracic duct lymph over a 24-h collection period (after subtraction of the "baseline" endogenous fatty acids in the lymph). Cholesterol absorption in the thoracic duct lymph was significantly reduced (P less than 0.05) in the presence of menhaden oil or FOC compared to that in the presence of corn oil. With various fat feedings, the major increases in lymph fatty acids were directly related to the dietary fatty acid content. The relative amounts of eicosapentaenoic acid (EPA) and arachidonic acid (AA) in the thoracic lymph were influenced by the lipid content of the emulsion. The EPA/AA ratio in control, oleic acid and corn oil feedings ranged from 0.12 to 0.25. When marine oil was administered, the EPA/AA ratio was 0.78-0.98. The total amount of fatty acids found in the lymph after marine oil feeding was significantly less (P less than 0.01) than that found after corn oil feeding. The results suggested that the digestion and absorption of menhaden oil and FOC were decreased as compared with corn oil. The EPA/AA ratio was increased in the thoracic lymph after dietary fish oil feeding.

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The biosyntheses of cholesterol from acetate and mevalonate were determined in rat liver homogenates that were prepared and incubated in buffers containing varying concentrations of phosphate. Relatively little acetate or mevalonate was incorporated into cholesterol in the absence of added phosphate. When phosphate was added, there was an increase in incorporation of both substrates. The addition of phosphate resulted in an increase in the incorporation of mevalonate to a maximum, whereas phosphate appeared to increase the incorporation of acetate at low phosphate levels and decrease the incorporation at higher phosphate levels. The results appear to be consistent with the possibility that, at low phosphate levels, the biosynthesis of cholesterol is limited by some phosphate-requiring reaction(s) in the pathway after mevalonate, and at higher phosphate levels, the biosynthesis is limited by the 3-hydroxy-3-methylglutaryl coenzyme A reductase-catalyzed step.

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The effect of age on hepatocyte mensuration and mitotic activity 48 h after partial hepatectomy was investigated in rats. Both age and partial hepatectomy had significant effects upon hepatocyte counts per microscopic field. The number of hepatocytes per microscopic field declined with age in the control groups of different advancing ages and in the experimental groups of advancing ages. There was essentially no mitotic activity in the livers of the control groups. However, mitotic counts were greatly increased in livers from those animals that were partially Hepatectomized; the increase in mitotic activity in the 13-month-old animals was double over that observed in both the very young and the very old.

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