Journal of the American College of Surgeons
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Improved survival with pediatric malignancies has been positively influenced by multidisciplinary cooperative studies using surgery, chemotherapy, and radiation therapy, but one-third of all children with cancer succumb to their condition. The identification of biologic and genetic characteristics as risk factors for the various tumors has led to changes in treatment using risk-based management as the template for care. ⋯ On the basis of these data, children with solid tumors are currently categorized into low-, intermediate-, and high-risk groups. Newer protocols individualize treatment using risk factors as predictors of outcomes. Risk-based management allows the clinician to weigh the risks and benefits of treatment for each patient to maximize survival, minimize longterm morbidity, and improve the quality of life.
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Hypothermia occurs commonly in severely injured patients and is associated with a high mortality rate. It perturbs the normal homeostatic response to injury and affects multiple organ systems and physiologic processes. In trauma patients, hypothermia-induced coagulopathy often leads to marked bleeding diathesis and frequently provides a challenge for the surgeon. ⋯ Efforts to prevent and treat hypothermia in trauma patients should be instituted in the field and continued as an integral part of the resuscitation process. Hospital personnel and physicians at various levels caring for trauma patients from the initial injury and thereafter should bear in mind that a patient's temperature is as important as any other vital sign. Appropriate measures for preventing and treating hypothermia should be instituted promptly and tended to with utmost vigilance.
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Review Comparative Study Clinical Trial
Budd-Chiari syndrome caused by Behçet's disease: treatment by side-to-side portacaval shunt.
Behçet's disease is a chronic multisystem vasculitis of unknown etiology that involves skin, mucous membranes, eyes, blood vessels, joints, central nervous system, digestive system, and occasionally other organs. Budd-Chiari syndrome from occlusion of the major hepatic veins is a rare and serious complication of Behçet's disease. Although the mortality rate of Behçet's disease is only 3% to 4%, development of Budd-Chiari syndrome in patients with Behçet's disease has been associated with a mortality rate of 61%. This report presents the largest reported experience of Behçet's disease-related Budd-Chiari syndrome confined to the hepatic veins, and results of treatment by side-to-side portacaval shunt (SSPCS). These results are compared with those we have obtained in Budd-Chiari syndrome confined to the hepatic veins without Behçet's disease, and with results of treatment of Budd-Chiari syndrome in Behçet's disease reported in the literature. ⋯ SSPCS permanently reduced the mean portal vein-IVC pressure gradient (mm saline) from 205 to 7 in the 5 patients with Behçet's disease, and from 250 to 4 in the 27 without Behçet's disease. There was only one operative death, a patient without Behcet's disease. One patient with Behçet's disease died 2 years postoperatively from diffuse vasculitis, a complication of Behçet's disease, and the other 4 (80%) remain alive. All 26 operative survivors in the group without Behçet's disease (96%) are alive. Only one patient developed occlusion of the SSPCS, a man without Behçet's disease, and he required liver transplantation as a result of hepatic decompensation, PSE, and recurrent ascites. All other patients with or without Behçet's disease remained free of ascites, required no diuretics, were free of PSE, and had reversal of hepatic dysfunction. Serial liver biopsies showed normal architecture in 60% of patients with Behçet's disease and 46% of those without Behçet's disease. Return to fulltime work or housekeeping occurred in 80% of patients with Behçet's disease and 96% without Behçet's disease. Comparison of outcomes of our patients with 42 cases of Behçet's disease with Budd-Chiari syndrome reported in the literature, 79% of whom were treated medically, showed striking differences with an overall mortality rate of 61% in generally shortterm followup. (ABSTRACT TRUNCATED)