Annals of surgery
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Sixty-four consecutive patients underwent renal homotransplantation 10 1/6 to 11(1/2) years ago, 46 from related and 18 from nonrelated living donors. Thirty-six of these recipients were alive when this series was presented to the American Surgical Assocation in 1965. Now, nine years later, 26 (72%) of the 36 still survive, in 22 instances with function of their original grafts. ⋯ Vascular lesions had a somewhat less serious import. Mononuclear cell infiltration, tubular atrophy, and interstitial fibrosis proved prognostically to be the least significant. Long-term followup of these early cases has shown the durability of chronic renal homografts, particularly if these are from related donors, and has demonstrated the very high degree of rehabilitation that could be achieved even in the early days of renal homotransplantation.
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One-hundred thirty-two renal transplant recipients were systematically screened for viral infections and the findings correlated with the clinical course. One-hundred ten patients showed evidence of infection with herpesviruses and 89 patients showed laboratory evidence of infection with cytomegalovirus (CMV) uncomplicated by bacterial infections or technical complications. Patients without viral infections were usually asymptomatic. ⋯ These patients could be distinguished from those who recovered by a decreased or absent antibody response to the virus, suppressed lymphocyte responses to mitogen in autochthonous blood, and absent histologic evidence of rejection in the renal allografts. Thus, two paradoxical responses to CMV infections are seen in transplant patients: In the relatively immunocompetent patient, the infection is associated with renal allograft rejection, a prompt antibody response to the virus, and recovery. The severely immunosuppressed patient cannot make an antibody response, does not exhibit allograft rejection as a cause of renal malfunction, he may be further immunosuppressed by the viral infection, and is susceptible to sequential opportunistic infections leading to death.
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Hypermetabolism characterizes the metabolic response to thermal injury and the extent of energy production is positively related to the rate of urinary catecholamine excretion. Alpha and beta adrenergic blockade decreased metabolism from 69.6 +/- 5.3 Kcal/m(2)/hr to 57.4 +/- 5.2 (p < 0.01), and infusion of 6 microgm epinephrine/minute in normal man significantly increased metabolic rate. Twenty noninfected burned adults with a mean burn size of 45% total body surface (range 7-84%) and four normal controls were studied in an environmental chamber at two or more temperatures between 19 and 33 C with vapor pressure constant at 11.88 mm Hg. ⋯ Burned patients are internally warm, not externally cold, and catecholamines appear to mediate their increased heat production. Hypermetabolism may be modified by ambient temperature, infection, and pharmacologic means. Alterations in hypothalamic function due to injury, resulting in increased catecholamine elaboration, would explain the metabolic response to thermal injury.
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The development of effective, non-toxic (local and systemic) methods for the rapid chemical (enzymatic and non-enzymatic) debridement of third degree burns would dramatically reduce the morbidity and mortality of severely burned patients. Sepsis is still the major cause of death of patients with extensive deep burns. The removal of the devitalized tissue, without damage to unburned skin or skin only partially injured by burning, and in ways which would permit immediate (or very prompt) skin grafting, would lessen substantially the problems of sepsis, speed convalescence and the return of these individuals to society as effective human beings, and would decrease deaths. ⋯ The authors' work with the chemical debridement of burns, in particular the use of Bromelain, indicates that this approach will likely achieve clinical usefulness. The experimental studies indicate that rapid controlled debridement, with minimal local and systemic toxicity, is possible, and that effective chemotherapeutic agents may be combined with the Bromelain without either interfering with the actions of the other. The authors believe that rapid (hours) debridement accomplished by the combined use of chemical debriding and chemotherapeutic agents will obviate the possibility of any increase in infection, caused by the use of chemical agents for debridement, as reported for Paraenzyme(21) and Travase.(39,48) It is possible that the short term use of systemic antibiotics begun just before and continued during, and for a short time after, the rapid chemical debridement may prove useful for the prevention of infection, as appears to be the case for abdominal operations of the clean-contaminated and contaminated types.