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Low-dose cyclosporine (CsA) plus prednisone for induction and maintenance immunosuppression were used in 106 consecutive cadaveric renal transplants. Previous reports of lower initial CsA have described its use in combination with other forms of immunosuppression. An oral CsA dose of 3 mg/kg was given 2-4 hr before operation, and maintenance CsA was started 12 hr post-operatively at 1 or 1.5 mg/kg i.v. every 12 hr for non-functioning and functioning kidneys, respectively. Oral CsA was given at 3 times the i.v. dose and started 2-3 days postoperatively. The CsA dose was adjusted to maintain plasma trough levels, as measured by radio-immunoassay, of 150-200 ng/ml for the first two weeks, 125-175 ng/ml 2-4 weeks posttransplant, and 100-150 ng/ml for the second month after transplant. Between two and six months, the CsA dose was gradually reduced by 33%. Maintenance prednisone was rapidly reduced 5 mg/month to a maintenance dose of 10 mg/day. Graft survivals for low and high-risk patients at one year were 91% and 81%, respectively. Patient survivals for low-and high-risk patients at one year were 97% and 90%, respectively. Patient death was caused by: aspiration (1), suicide (1), cardiac failure (1), Mediterranean fever with colon perforation (1), and traumatic renal artery disruption (1). Except for death, grafts were lost to primary nonfunction (2), accelerated rejection at +/- 12 hr (3), medical noncompliance (1), renal artery thrombosis (1), and vascular rejection (1). Of 106 patients, 26 (25% were treated for rejection with 3.5 g of i.v. methylprednisolone over 10 days; 25/26 (96%) rejections were reversed with methylprednisolone alone. OKT-3 failed to reverse the remaining vascular rejection. All 9 conversions from CsA to azathioprine for toxicity were successful. Our definition of toxicity was rising serum creatinine, normal CsA level, and no response to 7-10 days of i.v. methylprednisolone and no change in biopsy. We were not able to distinguish CsA toxicity and rejection in most biopsies. Average serum creatinines at 1, 6, and 12 months were 1.6 mg/dl, 1.55 mg/dl and 1.65 mg/dl, respectively. We conclude that low-dose CsA plus prednisone can be successfully used for all cadaveric renal transplants without other forms of immunosuppression. Steroid-resistant rejection is extremely rare if adequate time is given for i.v. methylprednisolone treatment. Almost all "steroid-resistant rejections" were found to be CsA toxicity, and they were reversed after conversion to azathioprine.

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Mesenteric ischemia is a catastrophic event, which has a mortality due to florid sepsis that approaches 100%. The demography of the bacterial changes has not been documented. After 72 hr of colonic ischemia in the dog, the total number of anaerobic organisms increased while the number of aerobic organisms decreased. After 24 hr of ischemia, anaerobic bacteria appeared only in the portal vein and persisted. Cultures of peritoneal fluid and aortic blood became positive for the same anaerobic organisms after 48 hr. Acute colonic ischemia promotes a relative overgrowth of intraluminal anaerobic bacteria, which progressively invade the portal vein and later the systemic circulation.

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The utility of radionuclide labeled leukocytes in the demonstration of infection within vascular prostheses was examined. The infrarenal aorta was replaced with a 3 cm Dacron graft in 12 dogs. On the third postoperative day, six of the animals received an intravenous injection of 10(8) Staphylococcus aureus. Labeled leukocyte scans were performed at postoperative days one and three, and then weekly for 8 weeks with indium-111 and technetium-99 labeled autologous leukocytes. When scans showed focal uptake of isotope in the area of prosthetic material, the grafts were aseptically excised and cultured on mannitol-salt agar. Both control and infected animals had retroperitoneal isotope activity in the immediate postoperative period that disappeared by the end of the first week. By the eighth postoperative week, all of the animals that received the bacteremic challenge had both radionuclide concentration in the region of the vascular prosthesis and S. aureus cultured subsequently from the perigraft tissues. None of the control animals had either radionuclide or bacteriologic evidence of infection at the eighth postoperative week. The radiolabeled leukocyte scan is a highly sensitive and specific technique, clinically applicable for the diagnosis of vascular prosthetic infections.

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A 64-year-old man presented with a history of four days of lower abdominal pain and 12 hours of cutaneous discoloration, bullae formation, and swelling of the soft tissues of abdominal wall and right thigh. Myonecrosis of abdominal wall and an adenocarcinoma of the cecum were found at operation. Cultures of blood and fluid from the bullae yielded Clostridium septicum. Nontraumatic clostridial myonecrosis is a fulminant, usually fatal disease that is most often the result of bacteremia from an occult gastrointestinal lesion. Ulceration of the colon or terminal ileum is the most common predisposing condition, and is usually due to gastrointestinal or hematological malignancy. Patients often present with nonspecific complaints, including pain at the affected site and fever. The disease progresses rapidly to include bronze discoloration, edema, and hemorrhagic bullous lesions of the skin, subcutaneous emphysema, and myonecrosis. Presumptive diagnosis often can be made by Gram stain of the bullous fluid that reveals gram-positive bacilli and a paucity of leukocytes. Favorable outcome depends on prompt institution of appropriate antimicrobial therapy and surgical debridement of involved soft tissues, as well as correction of the underlying disorder. This disease should be considered to be a medical-surgical emergency.

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During a 25 year period at this medical center and the UCLA Center for Health Science, we identified 34 patients who had jejunal or ileal pseudodiverticula. Seventeen of these were treated for a more significant pathologic condition, the diverticula being an incidental finding. Of the remaining 17 patients, six underwent an operation for complications of these diverticula; two of them had diverticulitis of the jejunum; two, a perforated ileal diverticulum, and two others, severe malabsorption. Another two patients had laboratory evidence of malabsorption attributed to the presence of the diverticula and were treated medically. In the remaining nine persons, four were diagnosed as having a functional bowel syndrome and five had undiagnosed abdominal pain. For the group of six patients undergoing an operation, there was a 50 per cent mortality. Our experience gives weight to the contention that, although jejunal and ileal diverticula are rare, in any collected experience with them, significant morbidity and mortality accompanies the complications.

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A retrospective study of 35 patients with anal cloacogenic carcinomas showed that the histological characteristics of the tumors were correlated with their biological behavior. The basaloid squamous type of cloacogenic carcinoma was more common in women (3.6:1) and had a more favorable course in both men and women, with a mean survival of 5.0 years. Glandular variants of these tumors, with an adenocystic or mucoepidermoid pattern, occurred predominantly in men and had a more aggressive course, manifested by early metastases to inguinal and mesenteric lymph nodes, liver, and lung, with mean survival limited to 2.5 years. Nine of the 11 patients who survived longer than five years had the basaloid squamous histological pattern and were treated by abdominoperineal resection or pelvic exenteration; five of these patients also received postoperative therapy with radiation. The overall actual five-year survival for patients with anal cloacogenic carcinoma was 41% in this study. The histological pattern of anal cloacogenic carcinoma provides useful prognostic information to the clinician.

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