Preoperative White Blood Cell Research Articles

Preoperative white blood cell count and mortality and morbidity after coronary artery bypass grafting

Background Arteriosclerosis is increasingly viewed as an inflammatory disease. The purpose of these analyses was to examine the preoperative white blood cell (WBC) count, a generalized marker of inflammation, and to assess its association with in-hospital mortality and other adverse outcomes after coronary artery bypass grafting. Methods Information was collected prospectively on 11,270 consecutive patients who had isolated coronary artery bypass grafting in northern New England from 1996 through 2000. Patients were divided into five categories based on their preoperative WBC count. Crude and adjusted in-hospital mortality rates and adverse event rates were calculated using logistic regression. Results Increasing WBC count across its entire range was associated with a linear increase in the mortality rate. This finding was highly significant ( p [trend] < 0.001) and persisted after adjustment for patient and disease characteristics. Patients with preoperative WBC of at least 12.0 × 10 9/L had an adjusted mortality rate 2.8 times higher than those with a WBC less than 6.0 × 10 9/L (4.8% versus 1.7%). An increasing preoperative WBC count was also significantly associated with increasing rates of perioperative strokes and the need for an intraaortic balloon pump but was not associated with mediastinitis. Conclusions The preoperative WBC count across its entire observed range is a statistically significant independent predictor of in-hospital death and other adverse outcomes after coronary artery bypass grafting. Although the cause of the association between increased WBC count and increased morbidity and mortality is unknown, the preoperative WBC count, which is objectively measured, inexpensive, and always available, can serve as a useful marker to help predict risk before coronary artery bypass grafting.

Surgical site infections following pediatric liver transplantation: risks and costs.

Infectious complications following orthotopic liver transplantation (OLT) represent a significant cause of morbidity and mortality in both adults and children. In adults, surgical site infections complicating OLT have been shown to significantly increase resource utilization, but their impact in children has not been studied. In this study we identify risk factors for surgical site infections in children undergoing primary OLT for end-stage liver disease and estimate their impact on patient survival, graft survival, length of stay, and charges. All pediatric liver transplants (n = 77) less than 16 years of age from the National Institute of Diabetes and Digestive and Kidney Diseases (NIDDK) Liver Transplantation Database were included in the analysis. Surgical site infections (n = 25) were defined as wound infections, abdominal abscesses, and bacterial or fungal infections of the liver, intestine, or peritoneum during the initial transplant admission. Risk of infection was estimated using logistic regression, survival rates were estimated using the Kaplan-Meier method, and length of stay and charges were compared using Student's t-test. Multivariate analysis of charges was performed using linear regression. Of the 77 patients, 25 (32.5%) developed a surgical site infection. Several factors were associated with increased risk of infections, including a leak at the biliary anastomosis (odds ratio [OR] 115, P = 0.003), preoperative white blood cell count (OR = 1.28, P = 0.009), surgery > 7 h (OR = 15.0, P = 0.011), HLA mismatches (OR = 6.0, P = 0.03), and female gender (OR = 8.0, P = 0.038). Surgical site infections did not significantly decrease either patient survival or graft survival, and increased hospital stay by an average of 21 days (P = 0.14). After controlling for other factors, patients who developed surgical site infections incurred on average $132,507 (P = 0.03) more in charges than patients who did not develop infections. Surgical site infections in pediatric patients following liver transplantation are significantly influenced by surgical technique and endogenous patient characteristics. Though survival outcomes are not different, the development of such infections has significant implications for resource utilization in the care of these patients.

Early and late mortality after pleurodesis for malignant pleural effusion

Background. The purpose of this study is to analyze morbidity and mortality and to determine the relative contribution of each of these potential prognosis variables for predicting morbidity and mortality in patients after pleurodesis by thoracotomy or thoracoscopy. Methods. Between March 1, 1996, and January 31, 2001, a total of 70 patients underwent pleurodesis for recurrent malignant pleural effusion. Thoracoscopy was performed in 54 patients (77%); pleurodesis was achieved by pleural abrasion (n = 15), pleurectomy (n = 5), and talc insufflation (n = 34). Thoracotomy was performed in 16 patients (23%) who also needed pleurectomy and decortication for a trapped lung. Results. Postoperative complications occurred in 24 patients (34%). Factors adversely affecting morbidity with univariate analysis included: three or four metastatic sites ( p = 0.003), and thoracotomy ( p = 0.009). Factors adversely affecting morbidity with multivariate analysis included: thoracotomy ( p = 0.0005) and number of metastatic sites ( p = 0.007). Six patient deaths (8.6%) occurred during hospitalization. Factors adversely affecting in-hospital mortality with univariate analysis included: Eastern Cooperative Oncology Group Performance Status 2 to 3 ( p = 0.001), lower preoperative serum hemoglobin ( p = 0.001), lower preoperative serum albumin ( p = 0.0001), and thoracotomy ( p = 0.03). Factors adversely affecting in-hospital mortality with multivariate analysis included: preoperative serum albumin less than 60 g/L ( p = 0.007) and ECOG Performance Status 2 to 3 ( p = 0.008). Twelve patients (17%) died within 90 days after surgery. Factors adversely affecting 3-month mortality with univariate analysis included: ECOG Performance Status 2 to 3 ( p = 0.001), lower preoperative serum hemoglobin ( p = 0.03), higher preoperative white cells ( p = 0.03), lower preoperative serum albumin ( p = 0.03), and preoperative thoracentesis more than once per month ( p = 0.03). Factors adversely affecting 3-month mortality with multivariate analysis included: ECOG Performance Status 2 to 3 ( p = 0.01), preoperative thoracentesis more than once per month ( p = 0.03), three or four metastatic sites ( p = 0.02), and preoperative white blood cell count ≥ 12,000/mm 3 ( p = 0.03). Conclusions. Thoracotomy is not indicated in patients with a malignant effusion because of poor survival, a high frequency of complications, and prolonged hospital stay. Pleurodesis thoracoscopy is indicated in patients with good performance status coupled with good nutrition.

Short-term complications of central line placement in children with the human immunodeficiency virus

Purpose: The aim of this study was to characterize the perioperative complications of central venous catheter placement in children infected with human immunodeficiency virus (HIV) Methods: A retrospective chart review was conducted of all central venous catheters placed by the surgical service into HIV-infected children from 1988 to 1998 at a large urban children's hospital. Complications occurring within 1 month of catheter placement were analyzed for several host and environmental factors. Results: Forty HIV-positive patients underwent 60 central venous access procedures. Thirty-two of the patients were severely immunosuppressed. Eight catheter placements (13%) resulted in perioperative complications, including hemorrhage (n = 2), site infection (n = 2), catheter sepsis (n = 2), thrombotic occlusion (n = 1), and a pleural effusion secondary to catheter malposition (n = 1). Only 3 patients required catheter removal. There was no significant relationship between either hemophilia or thrombocytopenia and perioperative hemorrhage. No significant relationship was found between infectious complications and preoperative white blood cell count, absolute neutrophil count, CD4% and CD4#, suggesting that a patient's compromised immune status should not be considered a contraindication to central venous catheter placement. Conclusion: The complication rate of central venous catheter placement into HIV-infected children is low (<15%), but is still higher than that of the general pediatric population. With careful preoperative preparation this procedure can be performed safely, even in patients with advanced HIV disease. J Pediatr Surg 36:1777-1780. Copyright © 2001 by W.B. Saunders Company.

Laparoscopic management and clinical outcome of emphysematous cholecystitis.

As opposed to acute, chronic, and acalculus cholecystitis, emphysematous cholecystitis (EC) is associated with significant morbidity and mortality. Only a few studies have specifically reviewed the operative management and clinical outcome of EC. This study documents the operative management and clinical outcome of EC at the Cleveland Clinic Foundation. Between January 1996 and June 1999, 18 consecutive patients underwent cholecystectomy for emphysematous cholecystitis at our institution. All charts were reviewed retrospectively, and patients undergoing concurrent procedures were excluded. Mean values +/- standard deviation (SD) of the mean were calculated for patient demographics, preoperative white blood cell count (WBC), bilirubin, alkaline phosphatase, and length of hospital stay. Operative procedure (laparoscopic, converted, or open), preoperative imaging studies, operative time, ICU stay, morbidity, and mortality were reviewed. Patients presented with a mean age of 53.4 years (range, 18-80) and a male/female ratio of 3.5 (14/4). There were no differences between groups in terms of patient demographics. Mean WBC on admission was 14.2 K/mL (range, 5.4-19.7). Mean alkaline phosphatase and total bilirubin were 115 U/L (range, 45-428) and 1.4 mg/dl (range, 0.5-3.4), respectively. Thirteen patients (72%) were completed laparoscopically, two patients (11%) were converted to an open procedure, and three patients (17%) had open surgery. Overall mean length of hospital stay was 5 days (range, 1-18). Two patients from the open group ultimately died 1 year later due to progression of preexisting illness. One of these patients had congestive heart failure and chronic renal failure; the other had metastatic malignant melanoma. None of the patients died in the immediate perioperative period. There were five complications (27.8%). Two patients presented with bleeding secondary to heparin and coumadin therapy. One developed sepsis, and another developed leakage from the cystic duct stump, necessitating an endoscopic retrograde cholangiopancreatogram (ERCP) with stent decompression. The fifth complication, ileus, required readmission 3 days postoperatively, but the patient responded to conservative management. Complications were evenly distributed between the three groups. There were two complications in the laparoscopic group, two in the open group, and one in the conversion group. All other patients were alive at the time of this publication. Using current techniques, patients with EC can be managed successfully utilizing laparoscopy. Morbidity and mortality appear to be slightly higher than published reports for acute, chronic, and acalculus cholecystitis. Conversion rates are comparable to patients with acute and chronic cholecystitis who undergo laparoscopic cholecystectomy. Based on these data, laparoscopic cholecystectomy should be considered the first-line treatment for patients with known or suspected EC.

Predictors of operative outcome in patients with human immunodeficiency virus infection and acquired immunodeficiency syndrome

Background: Plasma viral load has recently been associated with clinical outcome in patients with human immunodeficiency virus (HIV) infection and acquired immunodeficiency syndrome (AIDS). We hypothetized that, in addition to CD4 lymphocytes, plasma HIV-1 RNA counts are predictive of postoperative outcome. Methods: HIV-infected and AIDS patients admitted to a major teaching hospital requiring invasive or surgical procedures were retrospectively analyzed for postoperative outcome. Preoperative and postoperative immune cell counts including plasma HIV-1 RNA counts were recorded. Chi-square analysis, Fisher’s exact test, and multivariate regression were performed with statistical significance P ≤0.05. Results: Fifty-five consecutive patients between 14 and 62 years of age were admitted in a 1-year period and underwent 64 diagnostic and therapeutic procedures. Fourteen (22%) postoperative infections and 18 (28%) complications other than infection, with an overall mortality of 11%, were documented. Total preoperative white blood cell count ([WBC] P <0.01), preoperative percent lymphocyte count ( P <0.01), absolute postoperative CD4 lymphocyte count ( P <0.01), and postoperative plasma viral load ( P <0.0001) are associated with mortality. Multivariate regression indicated that postoperative percent CD4 lymphocyte count is an independent predictor of both postoperative infection and other complications ( P <0.05, R = 0.848, power = 0.9911), while the decrement in percent CD4 lymphocyte count is an independent predictor of postoperative complications other than infection ( P <0.05, R = 0.596, power = 0.7838). Conclusions: In accordance with the medical literature for clinical outcome in HIV-infected and AIDS patients, both immune cell counts and HIV-1 RNA counts were found to associate with postoperative mortality. However, the postoperative and decrement in percent CD4 lymphocyte proved to be the independent predictors of postoperative complications.

Risk of Venous Access Device Wound Complications in Patients Undergoing Paclitaxel Chemotherapy for Gynecologic Malignancies

Objective.To determine if wound complications after placement of a central venous catheter access device are related to the type of postsurgical cytotoxic chemotherapy administered.Methods.All patients in a 10-year period undergoing placement of central venous access device followed by postsurgical chemotherapy for gynecologic malignancies were included in this retrospective case–control study.Results.Sixty-eight patients underwent 78 placement procedures followed by chemotherapy. Six catheters (7.7%) in five patients developed wound complications. Variables evaluated included the type of gynecologic malignancy, previous use of chemotherapy, patient age and weight, preoperative white blood cell count, type of access device and insertion site, use of prophylactic antibiotics, type of chemotherapy and interval to administration, development of wound complication, and catheter removal. Univariate analysis shows an association between subsequent catheter site wound complication and paclitaxel use (P= 0.02) as well as wound complication and combined paclitaxel and cisplatin use (P= 0.005). Multivariate analysis with stepwise linear regression confirms that a paclitaxel containing regimen is associated with an increase in wound breakdown (P= 0.04).Conclusion.The use of a paclitaxel containing chemotherapeutic regimen administered after placement of an indwelling central venous access device in gynecologic oncology patients is associated with wound complications of the catheter site.

Biliary complications after hepatic resection: risk factors, management, and outcome.

To identify the risk factors for the development of biliary complications after hepatic resection and to evaluate management in relation to the outcomes of these patients. Biliary complications are a common cause of major morbidity after hepatic resection. A survey was made of all patients undergoing hepatic resection at 1 institution. Perioperative risk factors related to the development of biliary complications were identified using multivariate analysis. Management and outcome were analyzed also. A tertiary referral center. From January 1, 1989, to October 31, 1995, 347 consecutive patients underwent 229 major and 118 minor hepatic resections. Development of postoperative biliary complications. Biliary complications developed in 28 (8.1%) of 347 patients; these complications carried high risks for liver failure (35.7%) and operative mortality (39.3%). Stepwise logistic regression analysis identified increasing age, higher preoperative white blood cell count, left-sided hepatectomy, and prolonged operation time as the independent predictors of development of biliary complications. Conservative treatment or nonoperative measures alone, such as percutaneous drainage or endoscopic therapy, were effective in treating the complication in 13 of 19 patients, but those who required reoperation had a high mortality rate (7 [77.8%] of 9 patients). Patients with demonstrable leakage from the common bile duct or its bifurcation tended to have poor outcomes. Biliary complications are a common and serious cause of morbidity after hepatic resection. Preresection cholangiography for finding biliary tract anomaly is recommended before left-sided hepatectomy. Although nonoperative measures are the preferred approach for selected patients with biliary complications, those with demonstrable leakage from the common bile duct or its bifurcation have a grave prognosis and may benefit from early surgical intervention.

Routine preoperative testing: a systematic review of the evidence.

OBJECTIVES. To review the available evidence on the value of routine preoperative testing in healthy or asymptomatic adults. To assess the completeness of existing reviews of preoperative testing and how applicable their conclusions are to the UK. To identify areas for further research. HOW THE RESEARCH WAS CONDUCTED. The databases Medline, Embase, Biological Abstracts, Science Citation Index and HealthSTAR were thoroughly searched for relevant articles which were then classified and appraised. The databases of the Centre for Reviews and Dissemination (DARE and NHS Economic Evaluations Database) and the Cochrane Collaboration (the Cochrane Library) were also used to verify the completeness of the search. In this review, 'routine' tests are defined as those ordered for an asymptomatic, apparently healthy individual in the absence of any specific clinical indication, to identify conditions undetected by clinical history and examination. RESEARCH FINDINGS. No controlled trials of the value of the following routine preoperative tests have been published. All available evidence reports the results of case-series. CHEST X-RAY. Few studies allow the outcome of routine chest X-rays to be distinguished from those of indicated chest X-rays, and fewer have gone beyond abnormality yields to examine the impact on clinical management. Findings from routine preoperative chest X-ray are reported as abnormal in 2.5-37.0% of cases, and lead to a change in clinical management in 0-2.1% of patients. The effect on patient outcomes is unknown. Both abnormality yield and impact on patient management rise with age and poorer American Society of Anesthesiologists (ASA) status. The limited evidence on the value of a chest X-ray as a baseline measure suggests that it will be of value in less than 9% of patients. ELECTROCARDIOGRAPHY. The findings from routine preoperative electrocardiograms (ECGs) are abnormal in 4.6-31.7% of cases, and lead to a change of management in 0-2.2% of patients. The effect on patient outcomes is unknown. The proportion of abnormal tests rises with age and worsening ASA status. The predictive power of preoperative ECGs for postoperative cardiac complications in non-cardiopulmonary surgery is weak. There is no evidence to support the value of recording a preoperative ECG as a 'baseline.' HAEMOGLOBIN MEASUREMENT AND BLOOD COUNTS. Routine preoperative measurement shows that the haemoglobin level may be lower than 10-10.5 g/dl in up to 5% of patients, but that it is rarely lower than 9 g/dl. The routine test leads to a change of management in 0.1% to 2.7% of patients. Routine preoperative measurement shows that the platelet count is abnormally low in less than 1.1% of patients, and that platelet count results rarely if ever lead to change in management of patients. Routine preoperative white blood cell count is abnormal in less than 1% of patients, and rarely if ever leads to change in management of patients. TESTS OF HAEMOSTASIS. Abnormalities of bleeding time, prothrombin time and partial thromboplastin time are found in up to 3.8%, 4.8% and 15.6% of routine preoperative tests, respectively. The results of these tests very rarely lead to change in the clinical management of patients. BIOCHEMISTRY. In routine preoperative tests of serum biochemistry, abnormal levels of sodium or potassium are found in up to 1.4% of patients, and abnormal levels of urea or creatinine are found in up to 2.5% of patients. Abnormal levels of glucose are found in up to 5.2% of patients. These abnormalities rarely lead to change in clinical management of patients. URINE TESTING. Routine preoperative urinalysis finds abnormal results in 1-34.1% of patients, and leads to a change of management in 0.1-2.8% of patients. The only abnormality that leads to a change in management of patients is the finding of white blood cells in the urine. There is no good evidence that preoperative abnormal urinalysis is associated with any postoperative complication in non-urinary tract surgery. (ABSTRACT TRUNCATED)

Laparoscopic cholecystectomy in histologically confirmed acute cholecystitis.

Forty-four patients with histologically confirmed acute cholecystitis (AC) underwent attempted laparoscopic cholecystectomy (LC) from August 1990 to February 1994 and were retrospectively reviewed. During this time frame, LC was attempted in all patients with AC. Twelve of the patients were scheduled for elective LC as they were not thought to have AC preoperatively. Interestingly, eight of these unsuspected cases of acute cholecystitis had both a normal preoperative white blood cell count and were afebrile. The other 32 patients had a clinical presentation consistent with AC. The only diagnostic finding common to all cases of AC was abdominal pain and tenderness. In addition to AC, five patients also had gallstone pancreatitis, and three others were found to have concomitant choledocholithiasis. Fourteen patients required intraoperative conversion to open cholecystectomy for a laparoscopic success rate of 68%. The most common reason for conversion was difficulty in the dissection or unclear anatomy caused by dense adhesions. LC is an appropriate surgical treatment of AC, provided the surgeon abandons the laparoscopic approach if unable to safely proceed. Diagnostic and admission criteria for AC that requires elevated white blood cell count and/or fever may need revision.

White blood cell counts in patients undergoing abdominal surgery.

The role of pre-operative white blood cell counts (WBCC) in patients with an acute abdomen is contentious. This study documents the association between pre-operative WBCC and the extent of intraperitoneal inflammation at the time of surgery in a heterogeneous group of 1166 patients undergoing abdominal surgery. WBCC failed to adequately discriminate between groups of patients with varying degrees of intraperitoneal inflammation. For example, only 31% (37/118) of the patients with either free pus or an abscess within the peritoneal cavity had a WBCC > 15.0 x 10(9)/L. There is a need to replace the WBCC with more powerful predictors of inflammation within the peritoneal cavity.

Preoperative identification of patients at risk for delirium after major head and neck cancer surgery.

This study was performed to determine preoperative criteria for identifying patients at risk for delirium after major head and neck cancer surgery. The authors prospectively evaluated 138 consecutive patients undergoing head and neck cancer surgery lasting more than 2 hours at the Arthur G. James Cancer Hospital and Research Institute, Ohio State University, Columbus, from July 1993 through May 1994. Postoperative delirium developed in 24 of 138 patients (17%; 95% confidence interval 11% to 24%). The strongest univariate predictors of delirium were living alone (P = .005), the American Society of Anesthesiologists class (P = .003), and the preoperative white blood cell count (P < .0001). A predictive model for delirium using five criteria--age of 70 or more years, alcohol abuse, poor cognitive status, poor functional status, and markedly abnormal serum sodium, potassium, or glucose level--stratified the patients into three cohorts with an increasing risk of postoperative delirium (i.e., 9%, 19%, and 25%).

Adjuvant Chemotherapy With Cyclophosphamide, Doxorubicin, and Cisplatin in Patients With Completely Resected Stage I Non-small Cell Lung Cancer: An LCSG Trial

Two recent studies in resectable non-small cell lung cancer by the Lung Cancer Study Group (LCSG) suggested an advantage to adjuvant therapy with cyclophosphamide, doxorubicin (Adriamycin), and cisplatin (CAP). Neither study had a no-treatment control arm. The purpose of this study was to compare the CAP regimen with no treatment in patients with resectable early-stage non-small cell lung cancer. After complete resection, eligible patients with T1N1 or T2N0 non-small cell lung cancer were randomly assigned to receive or not to receive four courses of CAP at 3-week intervals beginning on day 30 after surgery after stratification for histology, preoperative white blood cell count, and Karnofsky performance status before surgery. The CAP regimen consisted of 400 mg/m2 of cyclophosphamide, 40 mg/m2 of doxorubicin, and 60 mg/m2 of cisplatin. Of the 269 eligible patients entered in the study, 101 had recurrence and 127 had died at the time of analysis. The mean time since randomization is 6.4 years; mean follow-up is 3.8 years. There were no differences in time to recurrence or overall survival between the two groups even when analyses were adjusted for prognostic variables. Only 53% of the eligible patients received all four courses of CAP, and only 57% of such patients received all four cycles on time. Among the patients who had recurrences, 74% had their initial recurrence at a distant site. No survival benefit for CAP vs no-treatment control was found in this study. Therefore, adjuvant therapy with CAP should not be recommended for patients with resected early-stage non-small cell lung cancer. Further trials to test adjuvant therapy are indicated, but investigators should use better antiemetics to improve patient compliance as well as more active cisplatin-based chemotherapy regimens.

Preoperative indium-labeled white blood cell scintigraphy in suspected osteomyelitis of the axial skeleton.

The cases of six patients with suspected osteomyelitis of the axial skeleton who underwent preoperative indium-labeled white blood cell scintigraphy (In-WBC) were reviewed retrospectively. Five of these patients had undergone previous spinal surgery, and all six patients complained of back pain. Four of these six patients were proven to have osteomyelitis by culture and histopathology. The sensitivity, specificity, and accuracy of In-WBC scintigraphy in detecting osteomyelitis of the axial skeleton was 25%, 50%, and 33%, respectively. Our preliminary experience in six patients with suspected osteomyelitis of the axial skeleton suggests that In-WBC scintigraphy is neither sensitive nor specific in predicting infection.

Prophylactic topical cefamandole in radical hysterectomy

From July 1, 1978 to June 30, 1984, 45 radical abdominal hysterectomies were performed by the authors at Tripler Army Medical Center. Management was uniform except for the use of prophylactic antibiotics. Three patterns of practice were identified: Group I, no antibiotics were used; Group II, intravenous (i.v.) antibiotics were given in the induction room and for less than 48 h post-surgery; Group III, prophylactic i.v. antibiotics were given and the surgical site was also irrigated with a cefamandole and saline solution. The three groups were found to be similar with regard to age, parity, weight-height index, pre- and postoperative hematocrit, pre-operative white blood cell count, operative and anesthesia times, estimated blood loss, and amount of blood transfused. Groups I and II had a higher surgical site infection rate (87.5% and 63.6%, respectively) than Group III (3.8%). The mean 10-day fever index in degree hours was 109 for Group I, 71 for Group II, and 30 for Group III (P < 0.001). Irrigation of the surgical site with a cefamandole and saline solution in addition to i.v. antibiotics decreases the infectious morbidity of radical hysterectomy.

Acute abdominal conditions in patients with leukemia

Acute abdominal abnormalities are relatively uncommon during the treatment of leukemia. Over a 22 1 2 year period, acute abdominal abnormalities were diagnosed in 22 of 412 patients (5.3 percent) with acute leukemia and in 9 of 343 patients (2.6 percent) with chronic leukemia. Five patients with acute leukemia and two patients with chronic leukemia were treated medically, and all died within 1 week of diagnosis. Operative mortality decreased from 50 percent during the first half of the study period to 12.5 percent during the last half and was not related to the preoperative white blood cell count, platelet count, age of the patient, type of leukemia, or state of relapse or remission. Postoperative survival averaged 23 months in the patients with chronic leukemia and 5 months in those with acute leukemia, approximating the length of survival of patients with uncomplicated acute or chronic leukemia. Indications for operation in patients with leukemia are the same as for other patients and should be based on careful physical examination.

Leukocytosis in Acute Appendicitis

To determine if the relative neutropenia previously reported in healthy American, West Indian, and African blacks might also occur in patients with inflammatory disease, preoperative white blood cell (WBC) counts were compared among 112 cases of histologically proven acute appendicitis. Statistically significant lower WBC and neutrophil counts were found in black patients than in an identical group of whites. ( JAMA 229:1630-1631, 1974)

FLUOROURACIL COLON-RECTUM ADJUVANT CHEMOTHERAPY.

Since the synthesis of the fluorinated pyrimidines in 1957 by Heidelberger and his co-workers, 1 fluorouracil has been extensively used for cancer chemotherapy and has been found to be the most effective agent to date in the treatment of colon and rectum lesions. In the past few years the use of chemotherapy compounds as adjuvant therapy to curative surgical procedures has been practiced and in 1961, fluorouracil was added as a double blind adjuvant to the primary treatment of colon and rectal carcinoma at Roswell Park Memorial Institute. Requirements for the entrance of patients on this study were as follows: (1) the current malignancy could not have been treated with radiation, chemotherapy, or surgery prior to admission, (2) patients with a previous or concomitant malignancy regardless of site, except for basal cell cancers of the skin, were excluded, (3) if the preoperative white blood cell count was below 5,000 cells