Biomedical subjects
M D Ram
Publications and source records attributed to M D Ram.
Pseudolymphoma of the stomach. A diagnostic and therapeutic dilemma.
Pseudolymphoma is an uncommon benign lesion of the stomach that poses a difficult problem in diagnosis and management. The clinical manifestations and endoscopic, radiologic, and biopsy findings are not generally helpful in making this diagnosis preoperatively. Histologic examination of the lesion is the only reliable method that distinguishes pseudolymphoma from true lymphoma. Distinguishing histologic features of pseudolymphomas are (1) formation of true germinal centers, (2) presence of a polymorphous inflammatory infiltrate, and (3) absence of lymph nodal involvement by lymphoma. We report four cases and review the literature to illustrate the features of pseudolymphoma. Subtotal gastric resection is done for diagnostic as well as for therapeutic purposes. Distinction of these benign lesions from malignant lymphomas is important so that unnecessary radical surgery and postoperative radiation therapy or chemotherapy are avoided.
Evaluation of biliary disease by scintigraphy.
The value of biliary scintigraphy was studied in 180 patients with suspected biliary tract disease. Scintigraphy was performed after intravenous injection of technetium-99m labelled (1) N-substituted iminodiacetic acid derivative (HIDA) in 91 patients, and (2) butyl derivative of iminodiacetic acid (BIDA) in 89 patients. Most of the patients were investigated additionally by conventional techniques such as cholecystography, cholangiography and ultrasonography. It is concluded that biliary scintigraphy is a simple and safe technique for visualization of the biliary tract. It is particularly useful in the evaluation of acute cholecystitis, in patients with iodine sensitivity requiring imaging of biliary tract, and in the differentiation of obstructive from nonobstructive jaundice. Its value in kinetic disturbances of the gallbladder and in quantitative evaluation of hepatobiliary function needs further study.
The value of scintigraphy in the diagnosis of biliary disease.
Scintigraphy was performed on 180 patients with suspected biliary tract disease using technetium-99m-labelled derivatives of iminodiacetic acid. Most of the patients were also evaluated by conventional techniques and the results were correlated with the findings at operation and with histological examination of tissue removed whenever indicated. The technique was very accurate in the diagnosis of acute cholecystitis. In chronic cholecystitis it was useful in the diagnosis only when the cystic duct was obstructed. Scintigraphy has no value in the diagnosis of gallstones. However, it permits visualisation of the biliary tract even in the presence of jaundice and is useful in distinguishing obstructive from non-obstructive types of jaundice.
Management of gastrocolic fistula.
The authors present 13 patients with gastrocolic, gastrojejunocolic, or duodenocolic fistula, the majority of which were complications of peptic ulcer disease or its treatment. In contrast to previous reports, these patients were not severely anemic, dehydrated, or malnourished at time of presentation. Pain, fecal emesis, and diarrhea were the most common presenting symptoms. Half of the patients waited more than two weeks before seeking treatment. Barium enema and upper gastrointestinal series were equally useful in making the diagnosis in this study. When the patient was adequately prepared, one-stage operations could be performed safely in most situations. Operation may not be necessary or advisable in patients with metastatic malignant disease with minimal symptoms relating to fistulization.
Thyroidography in evaluation of thyroid disease.
Thyroidography was performed in 53 patients with various thyroid disorders. In ten patients with hyperthyroidism, the procedure showed the size of the gland and the presence of nodules not suspected clinically or by scanning. It also demonstrated noticeable lymphadenopathy and lymphovenous communications. In nine patients with malignant disease of the thyroid, the pattern of contrast distribution within the gland was distinct from normal and was diagnostic. In addition, involvement of the regional lymph nodes by tumor was identified in three patients. The technique was useful in exclusion of malignant disease in two patients suspected of having cancer of the thyroid. In 26 patients with single thyroid nodules or with multinodular glands studied by this method, 19 were found to have cystic lesions and the other seven solid lesions. These results were compared with scintiscanning and ultrasonography. Based on this data, the technique seems to be useful in evaluation of thyroid disease.
Colonic tumorigenesis in rats with 1,2-dimethylhydrazine.
Subcutaneous injections of the carcinogen dimethylhydrazine in inbred Fischer 344 male rats induced squamous-cell carcinomas in the ear canal, adenocarcinomas in the small bowel and duodenum, and adenomas and adenocarcinomas in the large bowel. The incidences of the tumors induced in the large bowel and ear canal were dose-related. As for tumors of the large bowel, the average size of adenomas was less than that of adenocarcinomas with massive infiltration beyond the muscularis mucosa. The average size of early adenocarcinomas was greater than that of adenomas but less than that of adenocarcinomas with massive infiltration beyond the muscularis mucosa.
Thyroidography as a technique for localization of parathyroid adenomas.
Thyroidography was performed in seven patients with hyperparathyroidism. The technique accurately localized parathyroid adenomas in six patients. It was not useful in the patient with hyperplasia of the glands due to secondary hyperparathyroidism. There were no recognizable complications. Thyroidography is a simple technique, and we feel that it is useful in preoperative evaluation of patients with hyperparathyroidism.
Factors influencing morbidity and mortality in perforated duodenal ulcer.
The overall mortality and morbidity rates in 124 patients with perforated duodenal ulcer from 1968 to 1978 were 9.6 per cent and 28 per cent. The only factors which directly affected the patient's outcome were 1) age of the patient (high mortality in older patients) and 2) the time interval from onset of symptoms caused by perforation to the time of the operation (the longer the interval, the more likely the complications). No improvement in mortality and morbidity figures was seen in the past decade.
The use of staples in surgery.
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Hypercalcitoninemia, pheochromocytoma, and C-cell hyperplasia. A new variant of Sipple's syndrome.
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Myelolipoma of adrenal.
A case of a forty-six-year-old woman with an adrenal myelolipoma on the left side is reported. The presenting complaint was pain, and investigation revealed a large, relatively avascular nonfunctioning tumor of the left adrenal. This rare (ninth reported instance of surgical removal) tumor is briefly reviewed.
Systemic effects of hypernephroma.
In a study of 30 patients with hypernephromas, 23 patients manifested systemic effects of the tumor, and in 5 of these, the systemic effects were the presenting feature that led to the diagnosis. In contrast to this, only 17 patients had urologic complaints, and no single patient in this study had the classic triad of hematurial, loin pain, and mass. Weight loss (52 per cent), pyrexia, and elevated sedimentation rate (36 per cent) were seen most frequently. Anemia was seen in 25 per cent of patients. Other features seen in this group wer abnormalities in liver function, elevated alkaline phosphatase, hypertension, erythrocytosis, and hypercalcemia. In the majority of instances, removal of tumor was associated with remission of these effects. The effects were classified as those of a general toxic nature, those due to normal or abnormal production of hormones, and those due to production of abnormal substances by tumor cells. The evaluation of these effects was useful in making an early diagnosis and in follow-up care.
Health care costs of gunshot wounds.
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Surgical treatment of acute cholecystitis.
A study of the results of surgical treatment of patients with acute cholecystitis showed that cholecystectomy is a safe procedure for the majority of patients during their initial hospitalization and avoids the risk of recurrent attacks and readmissions. Cholecystostomy has a limited place in the treatment of older patients with systemic disease and advanced local disease. Early aggressive management of acute cholecystitis will probably reduce complications of cholecystitis and reduce the need for cholecystostomy.
Biliary excretion and concentration of cefazolin.
The excretion of cefazolin into the human biliary tract in health and disease was investigated in 34 patients undergoing surgical procedures. The patients included: I. Four controls. IIA. Eleven patients with cholelithiasis and/or cholecystitis and a radiological visualized gallbladder. IIB. Nine patients with cholethiasis and cholecystitis and a radiologically nonvisualized gallbladder. III. Five patients with obstructive jaundice. IV. Five patients with a T-tube in the common bile duct. Two dose regimes: 1. A single dose of 500 mg and 2. four doses each of 500 mg. given every six hours, were used. Samples of serum, gallbladder bile, common duct bile and gallbladder tissue were assayed for antibiotic activity by the cylinder plate method with Bacillus subtilis. Following administration of four doses of the antibiotic, the mean level of the drug in the gallbladder bile, in controls was 127.0 mug/ml. In the group with cholelithiasis and cholecystitis and a gallbladder that is visualized, a similar high level was noted (mean = 132.2 mug/ml.). In the presence of a nonvisualized gallbladder or obstructive jaundice, the levels in bile were lower. Two hours following a single injection of the drug, the level in the common duct bile reaches a peak of 10 mug/ml and at eight hours falls to less than one mug/ml. In the absence of obstruction cefazolin reaches a significantly high level in bile and could be valuable in treatment of biliary infections.
Adenomyomatosis of the gallbladder.
Adenomyomatosis of the gallbladder is an entity that is being recognized increasingly, chiefly by radiologists. The pathogenesis, pathology, and indications for surgery are not well understood. This report is a study of 27 patients seen in the last 6 years, all of whom had proved histologic features. Patients ranged from 21 to 72 years of age, with a preponderance of women. Thirteen patients had no gallstones. The disease was confined to the fundus in 15 patients, to the neck in one patient, and was generalized in 11 patients. Bile cultures were obtained in the last six consecutive patients and all were negative. Histologically there was evidence of thickening of the gallbladder wall, glandular elements in the mucosa, and invagination of glands into the muscularis. The clinical, radiological, and pathologic features supported a hyperplastic and degenerative disorder which should be distinguished from cholecystitis. Associated with these morphologic changes is a dyskinesia similar to that seen in diverticular disease of the colon. Follow-up studies after cholecystectomy have shown that over 90 percent of all patients were completely relieved of symptoms. Adenomyomatosis should be identified as a distinct entity, probably of a degenerative nature. Cholecystectomy is indicated and beneficial when the symptoms suggest biliary tract diseases.
Cephalothin levels in human bile.
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