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Insomnia is one of the most frequent symptoms and usually generates significant stress in 60% of patients with advanced cancer. Worries from the patients' and relatives' perspective are crucial to improve the patients' quality of life but have received limited attention. The aims were to identify the concerns of patients with insomnia in the terminal illness stage in a palliative care unit and the relatives' perception, and to compare both. Here, 63 patients and 53 relatives answered a questionnaire about worries in the personal, spiritual, family-related and economic area, as well as a quality-of-life uniscale. The results showed that the relatives' most frequent concern was "Having lived life to the fullest" (100%), and the most intense was "The possible suffering during the process" (9.2/10). The patients' most expressed concern was: "Having unfinished business" (100%), and the most intense was "Suffering during the process" (9.3/10). Quality of life showed an average value of 6.95 out of 10. Relatives only coincided significantly in: "Not knowing what happens after death" (r = 0.600; p = 0.000). These results bring visibility to concerns during the final stage of oncological palliative patients with insomnia from the patients' and relatives' perspective. Knowing both is useful for professionals to foster the well-being for a short, yet very important, period for patients, relatives and the caregiving team.

Incidence and mortality from cancer is increasing in most countries in the world, with the highest burden in developing countries. City Cancer Challenge (C/Can), an initiative launched in 2017, aims to improve access to quality cancer care in metropolitan areas (1 million inhabitants or more) in low- and upper-middle income countries by transforming the way stakeholders at the city, regional, and national levels collectively design, plan, and implement local cancer solutions. The approach is built on the core principle that local leaders in cities define their own needs and craft solutions with the support of a network of global, regional, and local partners that reflect an understanding of the unique local context. C/Can aims to build a collective movement of cities that can together deliver quality, equitable, and sustainable cancer control solutions for all.

To date, antegrade intussusception involving a Roux-en-Y reconstruction has been reported only once. We report a case of acute bowel obstruction due to an intussusception involving two Roux-en-Y limbs in a 40-year-old woman with a history of chronic pancreatitis due to pancreas divisum. Four years preceding this event, the patient had undergone a Whipple procedure, and three years prior to that, a Puestow operation. The patient was successfully treated with bowel resection and a side-to-side anastomosis between the most distal aspect of the bowel and the most distal Roux-en-Y reconstruction, which preserved both Roux-en-Y reconstructions.

There are increasing reports of seeding of tumor at the trocar sites following laparoscopic cholecystectomy in patients with unexpected or inapparent gallbladder carcinoma. A patient is reported here whose primary tumor appeared controlled by surgery and radiation, but who died of the disease after developing implant metastases at three untreated trocar sites. The second case report illustrates the difficulty in identifying gallbladder cancer during laparoscopic cholecystectomy, and the importance of a diligent preoperative effort to establish the diagnosis. Current literature suggests that tumor implantation occurring during laparoscopic cholecystectomy for inapparent carcinoma adversely affects prognosis, and, until the effect of laparoscopy on the spread of this tumor is better understood and controlled, open operation should be performed when carcinoma of the gallbladder is suspected. When laparoscopic cholecystectomy is done for inapparent gallbladder cancer, surgical and adjuvant radiotherapy to the trocar sites appears to improve outcome in association with extended treatment to the gallbladder bed and adjacent areas. Recent reports suggest that progress in diagnostic, surgical, and adjuvant techniques could substantially improve survival in carcinoma of the gallbladder.

Background: Previous Commission on Cancer studies have examined time trends in stage of disease, treatment patterns, and survival for special populations. Reported herein are the most current National Cancer Data Base data for Hispanics., Methods: Two Calls for Data have yielded a total of 23,650 cancer reports for Hispanics from hospitals across the country., Results: There were differences in the relative frequency with which different cancer sites were reported among different Hispanic sub-populations. For seven of eight types of cancers studied, Hispanics had a less favorable stage of disease at first diagnosis than non-Hispanic whites., Conclusions: Poverty may be an important factor affecting the outcome of different cancers. Ethnicity may have a different and additional impact on patients with cancer.

Primary gastric lymphoma is a rare tumor in which surgical resection plays a major role in improving the response rate and reducing the incidence of bleeding and perforation after chemotherapy. In 17 consecutive patients, the diagnosis of gastric lymphoma was made by immunophenotyping snap-frozen endoscopic biopsy specimens. All neoplasms were B-cell lymphomas. Pan B surface marker antigens were present in all patients. Levels of Ki-67, a nuclear marker of tumor proliferation, were greater than 45% in two of the four patients who died after progression of their lymphoma. All patients alive had Ki-67 levels of less than 30%. A lower proliferation index, as measured by Ki-67, appears to be associated with better prognosis. Ten of 11 patients treated by resection prior to chemotherapy had no complications. Immunophenotyping is the key in the differential diagnosis when considering malignant lymphoma with gastric carcinoma and benign conditions such as pseudolymphoma.

Cytogenetic analysis of short-term cultures was carried out on 109 lipomas from 92 patients. Clonal chromosomal abnormalities were present in 50% of the tumors analyzed. Based on the results, three main cytogenetic groups were identified and included: (a) tumors with normal karyotypes, (b) tumors with abnormalities involving region q13-15 on chromosome 12, and (c) tumors with other clonal aberrations. Within each of these groups, cytogenetic subgroups could be identified, each characterized by a specific anomaly. Tumors with abnormalities of 12q included specific subgroups with t/ins(1;12)(p32-33;q13-15), t(2;12)(p21-22;q13-14), t(3;12)(q28;q14), t(12;21)(q13;q21), complex, and nonrecurrent aberrations. The group containing heterogeneous clonal aberrations included subgroups with del(13)(q12q22), der(6)(p21-23), der(11)(q13), and nonspecific aberrations. Chromosome bands 1p36, 1p32-33, 2p21-22, 3q27-28, 6p21-23, 11q13, 12q13-15, 13q12, 13q22, 17p13, 17q21, and 21q21-22 were preferentially involved in structural rearrangements in lipomas. The identification of these sites of nonrandom rearrangements may serve to identify genes (at or near the junctions of chromosomal aberrations) involved in normal cellular growth control. Statistical analysis of the data revealed a correlation among karyotypic abnormalities and clinical data, such as age and sex of the patient, and tumor depth, site, and size.

Using a battery of monoclonal antibodies directed at B and T cell antigens, we delineate the immunotopography of the human spleen. The tissue section immunohistochemical methods employed demonstrate the complexity of white pulp reactivity with both light and heavy chain immunoglobulin expression appearing polyclonal. Zonal expression of heavy chains suggests an anatomic basis for the known sequence of heavy chain switching due to immunoglobulin gene rearrangement. Localization of universal B-cell antigen, B1, delineates the entire B-cell zone whereas antibodies directed at universal T antigens (e.g. Leu 1, 4, 9) delineate the T cell zone. Leu 14 demonstrates striking B-zone staining in normal spleen and in hairy cell leukemia, suggesting that leukemic cells in this disease arise from Leu 14+ B cells. Leu 2a staining occurs not only on lymphoid cells but probably also on sinusoidal endothelial lining cells.

Gastric partitioning has been proposed as an alternative to jejunoileal bypass for the control of morbid obesity because of the relative ease of performance and the lack of metabolic complications. From our series of 250 patients who underwent gastric partitioning, one of them developed a neurologic syndrome consistent with Wernicke's disease. The clinical findings were characterized by ataxia, confusion, impaired extra-ocular movements with diplopia, and weakness. A second patient with a similar condition was referred to us for evaluation and treatment. Pretreatment thiamine levels were normal in one case and revealed thiamine deficiency in the second. The study group of 15 patients had thiamine and red cell transketolase levels determined before, 6 wk, and 1 yr after gastric partitioning. A significant drop in values was seen at 6 wk postoperatively. Gastric partitioning is a safe and effective alternative to jejunoileal bypass in the control of morbid obesity. However, severe permanent neurologic deficits, probably related to thiamine deficiency, may occur.

Cytomegalovirus (CMV) causes major morbidity in organ transplant recipients. Gastrointestinal disease was the most prominent manifestation of CMV infection in a population of heart and heart-lung transplant patients, with an incidence of 9.9%, compared with pneumonitis (4.0%) and retinitis (0%), and occurred most frequently in CMV-seronegative recipients of organs from CMV-seropositive donors. Clinical manifestations included gastritis (nine patients), gastric ulceration (four patients), duodenitis (three patients), esophagitis (one patient), pyloric perforation (one patient), and colonic hemorrhage (one patient). Patients with gastrointestinal CMV infection were treated with intravenous ganciclovir sodium therapy, 5 mg/kg twice daily, for 2 to 8 weeks, with positive clinical, endoscopic, histologic, and virologic responses. Relapses occurred in four of nine patients who were followed up for a median period of 18 months. Retreatment resulted in healing of endoscopic lesions and in viral clearing. We conclude that early endoscopic evaluation for CMV is indicated in heart and heart-lung transplant patients with gastrointestinal symptoms. This study further suggests that intravenous ganciclovir therapy is effective for the treatment of gastrointestinal CMV in these patients.

One hundred fifty-three patients underwent 159 heart transplants; 7 of these patients received 8 artificial hearts used as a bridge before implantation. The 1-year survival rate was 81 percent. One hundred forty gastrointestinal complications developed in 70 patients. Thirty-eight operations were required. Twenty-nine were intraabdominal operations. Of these, 22 were elective and 7 were emergency procedures. Five of the seven patients who underwent emergency procedures died, for an overall total mortality rate of 17 percent for major intraabdominal interventions. There were no complications or deaths in patients who underwent elective procedures. Major elective intraabdominal surgical interventions can be safely carried out in heart transplant patients. Repeated physical examination, aggressive use of endoscopy and imaging techniques, sound surgical judgement and a mutual relationship of trust and respect between cardiac and general surgeons are keys to a successful outcome.

The patterns of fundic and antral motility as well as changes in fundic pressure in response to balloon distention were evaluated in 26 patients before and after gastric partitioning (18 patients) or gastric bypass (8 patients). In addition, the rate of gastric emptying, as measured by the ingestion of 99mTc-tagged chicken liver, was determined after gastric partitioning (12 patients) and bypass (7 patients). A striking alteration in the motility of the fundus occurs after both gastric partitioning and bypass. Normal pressure waves of the fundus disappear with both procedures. Fullness after both operations is secondary to distension of the pouch rather than to an increase in pressure. Changes in antral motility, inhibition, and recovery seem to be neurally mediated. The gastric emptying rate was 6.9% +/0 2.9% per minute after gastric bypass and 1.8% +/- 0.4% per minute after partitioning. Delayed emptying could be an additional benefit of gastric partitioning.

Emergency esophagogastroduodenoscopy has been performed in 192 consecutive patients admitted with massive gastrointestinal bleeding. Accurate endoscopic diagnosis was made in 184 or 96%; 58 patients underwent emergency operations to control bleeding with an overall operative mortality of 26%. Excluding 16 patients who underwent emergency portacaval shunting, the operative mortality was 7%. In 6 patients, the bleeding was controlled by endoscopic electrocoagulation. There were no complications. Emergency endoscopy should be done routinely as the primary diagnostic approach in the diagnosis of upper gastrointestinal bleeding.

Twenty-six patients with Hodgkin's disease were restaged both clinically and surgically within 2 months of completing their planned chemotherapy. Six patients (23%) had surgically proven persisting disease. Patients were divided into three groups: group I--eight patients had normal findings at clinical restaging and all were free of disease at surgery; group 2--13 patients had abnormal findings at clinical restaging, but only two (15%) were surgically documented to have persistent disease; and group 3--five patients had incomplete clinical restaging but, because of initial bulky disease, underwent surgical restaging, which showed that four patients had residual disease. The spleen was the site of persisting disease in all six patients with residual disease; four also had para-aortic nodal involvement. All 20 patients in pathologically documented complete remission remain relapse-free, with a mean followup of 26 months. This is significantly better (P less than 0.001) than the 21% relapse rate for 224 comparable patients in complete remission established by clinical but not surgical restaging. It appears that surgical restaging provides useful prognostic and therapeutic information in selected patients with Hodgkin's disease.

Neurological complications consisting of recent memory loss, visuospatial disorientation, and poor concentration disabled three patients years after a jejunoileal bypass for morbid obesity. The metabolic evaluation and computed tomography gave normal results. The neurological dysfunction cleared completely after reconstitution of normal intestinal anatomy. Neurological recovery was documented by formal neuropsychological testing.

We examined and surgically restaged (using posttreatment laparotomy) 26 patients with stage III and IV Hodgkin's disease treated with combination chemotherapy and in apparent remission to determine the status of their clinical remission. Eleven patients had normal clinical restaging and surgical restaging. Fifteen patients had abnormal clinical restaging, mainly consisting of abnormal lymphangiograms or abdominal CT scans. Ten lymphangiograms were abnormal and could not exclude persistent lymphoma. Two of the 15 patients proved to have Hodgkin's disease involving the para-aortic nodes and the spleen. With a median follow-up of 24 months, two patients had relapses in supradiaphragmatic sites and no patient with a negative laparotomy had a recurrence abdominal sites. Restaging laparotomy in selected patients with Hodgkin's disease with abnormal lymphangiograms or CT scans may identify additional patients with residual lymphoma who require further therapy and, more importantly, may identify those patients who have no residual disease and, therefore, may be spared additional therapy. Mortality and morbidity were nil.

Fourteen dogs received varying doses of antigastrin antibody; after a single dose of 0.07 ml/kg, circulating gastrin levels could not be measured for as long as forty-seven days. Gastric secretion in response to food was not diminished by antigastrin antibody doses as high as 0.07 ml/kg daily for ten days. Larger doses, 0.2 and 0.4 ml/kg, were required to produce a temporary reduction in gastric-stimulated gastric acid secretion. Mucosal levels of gastrin in the antrum, fundus, and duodenum were greatly increased ten days after injection of antigastrin antibody. The therapeutic use of antigastrin antibody to control gastric secretion seems at the present time not feasible because of the scarcity of the antigastrin antibody and because large doses aare required to obtain only a temporary effect.

We have developed a sensitive, specific and reproducible radioimmunoassay for cholecystokinin (CCK) with which basal levels of CCK of between 400-800 pg/ml have been measured in normal man, in patients with diabetes and with duodenal ulcer disease, and in normal dogs. After a meal, circulating levels of CCK rose to 1000-1200 pg/ml in human subjects. Release of CCK was more rapid in diabetic and duodenal ulcer patients than in normal subjects, but elevated postprandial levels persisted much longer in normal subjects. Patients with the Zollinger-Ellison syndrome had elevated values of cholecystokinin which rose after a meal. Lack of correlation between elevated basal levels of gastrin and CCK in patients with the Zollinger-Ellison syndrome suggest that the hypercholecystokininemia may be absolute. The disappearance half-time of exogenous CCK was about 21/2 minutes in normal subjects as well as in diabetic and duodenal ulcer patients. Studies in dogs demonstrated no uptake of basal levels of cholecystokinin by the kidney; on infusion of exogenous CCK-33, the kidney extracted 43% of the total CCK presented and 56% of the integrated CCK. We conclude that: 1) circulating basal and postprandial levels of CCK may be measured in a reproducible fashion; 2) postprandial release of CCK is more rapid in diabetic and duodenal ulcer patients than in normal man; 3) the disappearance half-time of exogenous CCK in man and dogs is about 21/2 minutes; 4) the kidney is a major site for uptake of CCK.

In five awake mongrel dogs, endogenous gastrin was released by continuous irrigation of the antrum with acetylcholine. After 60 minutes of antral perfusion, the entire vascular supply of the antrum was suddenly and totally occluded, and serial samples of peripheral blood were taken for measurement of gastrin. The rate of disappearance of endogenous gastrin was caluclated by standard linear regression analysis; the calculated half-life of endogenous gastrin was 8.62 minutes. Analysis of the data suggests that the disappearance rate of endogenous gastrin could be explained by two distinct half-lives: one of 2.8 minutes (which is similar to the half-time in dogs of both 14- and 17 -amino acid gastrin), and another of 15.4 minutes (which is similar to the half-time of 34 -amino acid gastrin). Physiologically released gastrin is a mixture of three or more molecular forms of gastrin and the half-life of 8.62 minutes probably represents the disappearance half-time of this mixture.

In dogs prepared with isolated, innervated antral pouches, intraduodenal perfusion with liver extract at pH 7, with the atrum buffered at pH 7, resulted in a significant release of gastrin selectively from the antrum and from the duodenum. Acidification of the meal to pH 1 abolished both antral and duodenal gastrin release, whereas acidification of the antrum abolished only the antral gastrin response. After antrectomy, liver extract at pH 7 caused a diminished but significant release of duodenal gastrin. These studies provide evidence that an intestinal meal may release (in addition to a specific intestinal phase hormone) gastrin from the intestine, and from antrum, by means of a pH-sensitive mechanism which may involve a humoral agent (enterobombesin?) from the small bowel.

Using a battery of monoclonal antibodies on snap-frozen sections, we delineated the immunoarchitecture of two splenic small cleaved cell lymphomas (SCL). Both cases had light- and heavy-chain restricted immunoglobulin (lg) expression signifying replacement of splenic white pulp by a single B-cell clone. Both the monotypia and aberrant topography of lg expression in SCL contrasted with the usual polyclonal, zonal lg expression in reactive splenic B-cell zones. Pan B antigens (B1, B4, and L14) were constant in expression as expected for B-cell neoplasms, while B-cell maturation antigens (B2, IgD, and CALLA) were variably expressed, suggesting that different SCL may derive from separate phases of B-cell ontogeny. Close association of SCL with dendritic reticulum cells suggests SCL may derive from splenic secondary follicles or home to these sites. The variable T-cell component detected by a T-cell panel (Leu 1-9) indicates the substantial range of T-cell reactivity in splenic SCL. We emphasize the immunologic aberrancy of splenic SCL when compared to normal splenic B-cell immunotopography. Further, we illustrate the utility of serial tissue section immunochemistry in revealing complex neoplastic cell phenotypes and in revealing the relationships of reactive cells to neoplastic cells.

Surgical procedures involving the parathyroid glands pose special problems. Careful attention to preoperative rehydration, control of hypercalcemia, and evaluation of renal function are mandatory. Intraoperative management is usually uncomplicated. Severe hypocalcemia may complicate the postoperative period, especially if severe bone disease is present.

The clinical course of patients with leukemia, specifically after treatment, is complicated by opportunistic infections, often derived from the gastrointestinal tract. Four hundred and thirty-eight patients with leukemia were treated at the Arizona Health Sciences Center from 1976 to 1985. Fifty-five (13 per cent) had 60 major gastrointestinal complications develop. Thirty-seven were treated medically with a mortality rate of 51 per cent, while 18 who were treated surgically had a 17 per cent mortality rate. These infections usually occur during induction or consolidation chemotherapy. Positive blood cultures and white blood cell counts of less than 2,500 per millimeter are a frequent occurrence. The most common complications of the gastrointestinal tract are enterocolitis, perirectal sepsis and bleeding. Because of the combined defects in phagocytosis (neutropenia), antibody production and cell mediated immunity, opportunistic infections (such as viral, fungal, parasitic or bacterial) are frequent and often lethal, despite routine antibiotic coverage. A protocol to identify a subset of patients with septic leukemia who may require emergency surgical treatment is vital since death in this group is most commonly from undiagnosed sepsis or progression of hematologic defects. This protocol should include repeated physical examinations, daily roentgenograms of the abdomen, liberal use of endoscopy, contrast roentgenography and computed tomography (CT) or ultrasound. Extensive surgical procedures can be safely carried out in patients with leukemia. The diagnosis of leukemia should not be a deterrent to emergency surgical exploration.

Twelve patients underwent a takedown of the jejunoileal bypass with restoration of normal continuity of the intestine. Specimens were obtained for biopsy from the excluded proximal jejunum and distal ileum as well as the distal in continuity jejunum. Hypertrophy of the mucosa was observed in the in continuity segment, as previously described. Villi of the bypassed jejunum displayed no evidence of hypertrophy or of atrophy and were identical in size to villous measurements prior to creation of the jejunoileal bypass. At the ultrastructural level, absorptive cells of bypassed jejunal segments exhibited normal morphologic characteristics. There was no indication of cellular immaturity above the level of the intestinal crypts. In contrast, villi of bypassed ileum, near the colonic anastomosis, demonstrated hypertrophy, presumably reflecting reflux of luminal material into this segment of bypassed intestine. The results of this investigation support the concept that significant morphologic alterations of the mucosa do not occur in totally bypassed segments of intestine after the jejunoileal bypass procedures with attainment of weight stabilization.

With better methods of diagnosis, patients will be identified earlier in the course of their disease and will often have atypical and borderline manifestations of the syndrome. Serum gastrin measurements with calcium and especially with secretin challenge will be the most important method of diagnosis. Any patient with acid hypersecretion who has a high serum gastrin level that does higher on secretin infusion should be considered to have the Zollinger-Ellison syndrome. A firm diagnosis of the Zollinger-Ellison syndrome should be made, if at all possible, prior to operation. At operation, a thorough search of the pancreas, duodenum, stomach, greater and lesser omentum and liver should be made for primary and secondary gastrinomas. If the preoperative data firmly establish the diagnosis of the Zollinger-Ellison syndrome, a total gastrectomy should be carried out even if no primary tumor is found. Similarly, a total gastrectomy should be done even if there are massive hepatic metastases. If total gastrectomy is not performed, the patient is apt to die of complications of acid hypersecretion. The only possible exceptions to the rule of always performing a total gastrectomy are in asymptomatic patients with easily excisable tumors or patients with tumors of the duodenum that are easily excisable, providing that in both instances after the excision of the tumor the output of gastric acid as measured at operation is immediately halted. All possible metastatic tumor tissue should be removed. The more tumor tissue removed, the longer the patient will survive. Metastases should be treated aggressively. They do not disappear after total gastrectomy in our experience, and they may kill patients. Patients should be followed after operation with serial measurements of serum gastrin concentrations and by hepatic scintillation scans and hepatic angiography. If hepatic metastases develop, intrahepatic artery infusions of 5-fluorouracil may slow tumor growth.

Gel fractionation of portal, arterial and peripheral plasma glucagon levels was performed before and after the successful removal of a glucagonoma. A 47 year old woman had symptoms of dermatitis, weight loss, anemia and diabetes mellitus over a 16 year period. Removal of the alpha-cell tumor corrected all of her symptoms. Gel filtration of portal, arterial and peripheral blood showed two peaks of glucagon radioimmunoassay activity, a higher molecular weight glucagon with a molecular weight of 9,000 and a 3,500 dalton glucagon. Five minutes after tumor removal, the higher molecular weight glucagon had disappeared completely from the arterial and peripheral blood but not from the portal vein.

We have measured serum gastrin and gastric acid secretion in 66 duodenal ulcer patients before and after vagotomy and pyloroplasty (V + P--15 patients), selective proximal vagotomy without drainage (SPV - D--11 patients), and with drainage (SPV + D--19 patients), and vagotomy, antrectomy, and either gastroduodenostomy (V + BI--15 patients) or gastrojejunostomy (V + BII--6 patients). Basal and peak postprandial gastrin levels were increased in postoperative V + P, SPV - D, and SPV + D patients. Basal and peak postprandial levels of gastrin were unchanged after V + BII, indicative of duodenal release of gastrin. Gastrin response to food was abolished in V + BII patients. Acid output was reliably reduced after all five operations; reduction was greatest in patients after antrectomy and least in patients after SPV. No beneficial results were found with drainage in SPV patients. Acid secretion increased with time in SPV patients, especially those with drainage.

Five dogs prepared with Heidenhain pouches received infusions of saline, GIP and VIP before and after a standard meat meal. Blood samples were obtained under basal conditions and at subsequent intervals for measurement of gastrin, insulin, GIP and VIP by radioimmunoassay. GIP and VIP infusions had no effect on basal levels of gastrin. GIP and VIP (in common with secretin and glucagon) were found to suppress food-stimulated release of gastrin and gastrin-stimulated acid secretion from the Heidenhain pouch. Insulin levels were significantly elevated during GIP and VIP infusions. Food released GIP (and perhaps VIP.

Seven patients with acute and progressive abdominal distension secondary to massive cecal and right colon ileus are analyzed. Five had pseudoobstruction of the colon and two had cecal volvulus. Two of the patients with pseudoobstruction and one with cecal volvulus died from preexisting diseases. Pseudoobstruction of the colon is not a rare complication of elderly, sick, bedridden patients. Differential diagnoses include cecal and sigmoid volvulus and acute gastric dilation. Initial conservative therapy is warranted if no peritoneal signs are present. If the cecal diameter is more than 12 cm, colonoscopic decompression with a fiberscope should be attempted. If unsuccessful, tube cecostomy will provide curative, life-saving therapy even if taenia splitting is present. Perforation or widely scattered areas of necrosis make resection mandatory.