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Melanoma is a common malignancy whose prevalence has been increasing, accounting for between 1 to 3 percent of cancers in the United States (USA), and is one of the most common types of cancer that metastasize to the gastrointestinal tract in advanced stages. It is reported that malignant melanoma (MM) either skin or mucous, can metastasize to virtually every organ in the human body. Although these have frequently secondary location in the gastrointestinal tract (GIT), where it is known to have special predilection, gastro intestinal metastasis are rarely found in the follow-up of these patients. Late diagnosis is due to its generally silent evolution. Endoscopy is a valuable tool both to confirm histological diagnosis, and monitoring of systemic therapies and palliative care locally. MM compromising the GIT is generally already spread by the time of diagnosis, in which case survival is only of 6 – 8 months, despite aggressive treatment. Hence the importance of anamnesis, to have a history of melanoma surgery, in addition to diligent physical examination that can reveal a primary skin or mucosal melanoma. All patients diagnosed with malignant melanoma should undergo endoscopic GIT studies.

El melanoma es una neoplasia frecuente, cuya prevalencia ha ido en aumento, representando entre 1 a 3 por ciento de los cánceres en EE.UU. y es una de las neoplasias que con mayor frecuencia presenta metástasis al tracto gastrointestinal en etapas avanzadas. Se ha reportado que el melanoma maligno (MM), ya sea cutáneo o mucoso, es capaz de producir metástasis a prácticamente todos los órganos del cuerpo humano. Aunque es frecuente su ubicación secundaria en el tracto gastrointestinal (TGI) por el cual se sabe que tiene especial predilección, rara vez se pesquisan metástasis gastrointestinales en el seguimiento de estos pacientes. El diagnóstico tardío se debe a que su evolución es generalmente silente. La endoscopia es una valiosa herramienta tanto para confirmar el diagnóstico histológico, como para el seguimiento de terapias sistémicas y tratamiento paliativo local. El MM con compromiso del TGI generalmente se encuentra diseminado al momento del diagnóstico; en cuyo caso la sobrevida es sólo de 6 a 8 meses, pese a un tratamiento agresivo. De ahí la importancia de la anamnesis, para contar con el antecedente de melanoma operado, además del examen físico acucioso que nos pueda dar cuenta de un melanoma primario en piel o mucosas visibles. Todo paciente con diagnóstico de melanoma maligno debería ser sometido a estudios endoscópicos del TGI.

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OBJECTIVE: To determine the effect on risk management of full-time attending physician coverage in a pediatric emergency department. DESIGN: Retrospective, with data collected through a review of malpractice cases from August 1, 1984 through July 31, 1990. SETTING: Large urban teaching hospital's pediatric emergency department. RESULTS: Malpractice cases from August 1, 1984 to July 31, 1987, when there was part-time attending physician coverage, were compared with those of 1987 through 1990, when full-time attending physician coverage was instituted. Medical records from the pediatric emergency department, subsequent hospital records, and abstracts of claims were reviewed. Disbursements and the types of lawsuits were also analyzed. There was a 41.7% decrease in the number of claims filed and a 44.3% reduction in payments with full-time coverage. CONCLUSIONS: Full-time attending physician coverage in a pediatric emergency department was associated with a decrease in the number of malpractice claims and the amounts of disbursements. Further research in this area on a larger study sample is advisable.

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It seems self-evident that the establishment of 24-hour per day attending physician coverage in a teaching hospital's emergency department would enhance risk management. However, prior to this study, little investigation had been done to corroborate the effects of full-time emergency department attending physician coverage. In a retrospective study from a large teaching hospital's emergency department, malpractice claims filed for 1985-1987 (part-time attending physician coverage) were analyzed and compared to those for 1987-1989 (full-time attending physician coverage). A total of 98 claims were filed; these data were derived from 466,862 patient visits. Attending physician presence increased from 6000 hours per year in 1985-1987 to 26,280 hours per year in 1987-1989. There was an 18.5% decrease in claims filed, and a 70.1% decrease in disbursements for the first 2 years after the introduction of full-time attending physician coverage as compared with the preceding 2 years. These findings suggest that full-time attending physician coverage in the emergency department is associated with improved risk management.

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A 19-year-old woman underwent termination of pregnancy by dilatation and evacuation at 19 weeks of gestation. She subsequently developed persistent massive hemorrhage, with laboratory evidence of a consumption coagulopathy. Attempts to control bleeding were unsuccessful, and the patient underwent a hysterectomy. Pathologic evaluation of the uterus revealed embolization of fetal tissues and placental fragments in the uterine and parametrial veins. This is the first reported case of such a finding, and its importance in relation to the patient's clinical presentation is discussed.

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The diagnostic usefulness of an intestinal oxalic acid absorption test was evaluated in nine patients with ileostomy. They received an oral overload of 250 mg sodium oxalate and 4 Ci oxalic acid-C14 and a controlled diet. The urinary levels of cold and radioactive oxalic acid were measured 24 and 48 hours after the overload. Intestinal oxalic acid absorption in the ileostomized patients was found to be normal, with 16.13 +/- 5.1% of the administered dose being eliminated/recovered in the urine 48 hours after the overload (control value = 14.5 +/- 2.8%). The dose of radioactivity excreted on the second day after the overload was smaller in the ileostomy group than in the control group, possibly connected with the absence of colon. The results suggest that in ileostomized patients whose colon has been removed, oxalic acid absorption is normal. Hence there appears to be no risk of oxalic lithiasis in this group.

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A new specific and sensitive method for determination of oxalic acid in plasma by High Performance Liquid Chromatography (HPLC) is described. The plasma sample is deproteinized by ultrafiltration. The oxalic acid in the ultrafiltrate is purified by precipitation with CaCl2, new dilution of calcium oxalate precipitate, oxalic acid extraction with diethyl-ether and total dryness of the sample. The losses of oxalic acid during this process are evaluated by the addition of oxalic acid (U-14C) before the precipitation step. The dried samples are redissolved in mobile phase (o-H3PO4, 0.05 M) and injected into a HPLC chromatograph, with reversed phase column (Lichrosorb RP-8, Merck). Oxalate peak is detected spectrophotometrically at 220 nm with a retention time of 3.20 minutes. The method shows a mean recovery value of 82.11, with an intra-run and between-run CV values of 2.54 and 6.95 respectively. The oxalic acid measured in plasma by this method is 291 +/- 89 micrograms/100 ml plasma ultrafiltrate, in 16 normal subjects.

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A new method for determination of oxalic acid in urine is described. The method encloses sample purification prior to the treatment by High Performance Liquid Chromatography (HPLC). The purification step consists in the passage of acidified urine through Sep-pak C18 cartridge (Waters), followed by the precipitation of the oxalic acid eluted with CaCl2, new dilution of the calcium oxalate precipitate, oxalic acid extraction with diethyl ether and total dryness of the sample. The losses of oxalic acid during this process are evaluated by the addition of oxalic acid (U-14C) before the precipitation step. The dried samples are redissolved in mobile phase (o-H3PO4, 0.05 M) and injected into a HPLC chromatograph, with reversed phase column (Lichrosorb RP-8, Merck). Oxalate peak is detected spectrophotometrically at 220 nm, with a retention time of 3.20 minutes. The method shows a mean recovery value of 98.25%, with an intra-run and between-run values of 5.13 and 8.06 respectively. The oxalic acid measured in urine by this method is 35.52 +/- 9.42 mg/24 h in normal subjects.

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Total content of cobalamins was estimated by an isotopic dilution technique in serum and liver of Yoshida sarcoma-bearing rats and in a group of control rats. Total levels of vitamin B12 were also measured in neoplastic tissue. Hydroxycobalamin, adenosylcobalamin, cyanocobalamin and methylcobalamin, were estimated by a chromato-bioautographic technique in the above mentioned tissues and animals. We found no significant difference between control and tumor-bearing rats with respect to the total content of vitamin B12 in the different tissues. This suggests that vitamin B12 requirements of neoplastic cells do not significantly deplete host cobalamin stores. We have also found no significant differences in the values of the different cobalamin coenzyme forms between the two groups of animals. This suggests that there is not preferential uptake of any host cobalamin fraction by the neoplastic cells. The four coenzyme-forms of cobalamin have been detected in Yoshida sarcoma. Adenosylcobalamin and cyanocobalamin are the major components of the pool of cobalamins of the tissue.

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We have studied the effect of methylene blue on GSH and GSSG levels in rat blood, liver and kidney. Methylene blue treatment increases GSH levels and PBG-synthetase activity in erythrocytes while liver and kidney GSH and GSSG levels remain constant. These results indicate that methylene blue effect on PBG-synthetase activity in rat erythrocytes is mediated by an increase in blood GSH levels.

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Changes in blood glucose in response to glucagon and epinephrine administration, in rats bearing Yoshida solid sarcoma and Walker-256 carcinosarcoma have been studied, and in rats carrying Yoshida tumor which had received previously intraperitoneal glucose. The response to glucagon by tumor-bearing rats follows the control pattern but at a lower level of blood glucose. Rats which had received glucose before glucagon administration responded to this hormone as the control animals. These results indicate that glycogen metabolism in the host liver is not diturbed by the presence of the tumor.

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Drug addiction during pregnancy has been managed in two ways: the detoxification program and the methadone-maintenance treatment program. In the detoxification program, there have been few complications for the mother and child except for low birth weight, meconium-stained amniotic fluid, and an increase in breech presentation. The methadone-maintenance treatment program at this time is the most satisfactory approach to the treatment of heroin addiction. The complications of pregnancy in this program are similar to those of the average obstetric population. Low birth weight at term is still frequent for those on methadone maintenance. The problem of multiple drug abuse, including heroin, cocaine, alcohol, tranquilizers, and amphetamines, requires more attention. The characteristics of the withdrawal syndrome and its treatment in infants are described. Excessive weight loss and irritability are commin in these infants. Of the many drugs available for the treatment of the newborn withdrawal syndrome, diazepam is currently favored. The long-term effects of intrauterine drug exposure, the withdrawal syndrome, and treatment are generally unknown. Schedules for management of adult narcotic, alcohol, and barbiturate abuse and newborn narcotic withdrawal are suggested.

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Data on the concentration of methadone in maternal plasma and urine of pregnant women on methadone in relationship to levels of amniotic fluid, cord blood, fetal urines, and breast milk are presented. These findings do not demonstrate a simple relationship between methadone levels in the neonate and the intensity of the withdrawal syndrome. The effects of multiple drug abuse and other as yet unknown factors may influence the severity of withdrawal signs in the neonate.

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