Rebound insomnia: a new clinical syndrome. Rebound insomnia followed the withdrawal of three benzodiazepine hypnotic drugs, each of which had been administered in a single nightly dose for only short-term periods. The intense worsening of sleep is attributed to the short duration of the action of these drugs. A hypothesis involving benzodiazepine receptors in the brain is proposed in which there is a delay or lag in replacement of endogenous benzodiazepine-like molecules after the abrupt withdrawal of exogenous drugs.


Prolactin binding sites in the rat brain. The principles of the competitive-binding assay were used in conjunction with light microscopic radioautography to demonstrate specific prolactin binding sites localized on ependyma of the rat choroid plexus, a previously unknown prolactin target tissue.


The fanconi syndrome in Basenji dogs: a new model for renal transport defects. The renal defects resulting in a Fanconi syndrome were seen in eight Basenji dogs by measuring renal clearance and in vitro amino acid and sugar uptake and performing histopathologic evaluations. Renal tubular handling of glucose, phosphate, sodium, potassium, uric acid, and amino acids was abnormal, and in vitro uptake of labeled lysine, glycine, and alpha-methyl-D-glucoside by renal cortical slices was impaired. Histopathology was normal except for enlarged nuclei in some renal tubule cells. These Basenji dogs, which may be genetically affected, represent a likely model for idiopathic Fanconi syndrome in humans.


Molecular conformation of a halogen-free thyroxine analog: 4-Methoxy-3,5,3-trimethyl-L-thyronine N-acetyl ethyl ester. The molecular conformation of the halogen-free thyroxine analog 4-methoxy-3,5,3'-trimethyl-L-thyronine -n-acetyl ethyl ester has been determined by x-ray diffraction techniques. The unsubstituted parent compound, trimethylthyronine, has significant biological activity in rat thymocyte tests when compared with the thyroid hormone 3,5,3'-triiodo-L-thyronine (T3). Although no activity data are available for the analog studied, it is presumed to be inactive because of the 4-methoxy blocking group. The observed conformation of this structure is similar to that found for the natural hormone T(3). The 3'-methyl group is distal, the overall conformation is cisoid, and the diphenyl ether conformation is twist-skewed. The results of this diffraction study show that methyl substituents are capable of maintaining the thyronine conformation required for hormonal activity; they suggest that iodine enhances hormone-protein binding because of the electronic effects it produces either by alteration of molecular charge distributions or by direct charge-transfer interactions with the serum or nuclear binding proteins.


Enhancement of oncogenesis in C3H/10T1/2 mouse embryo cell cultures by saccharin. Impure and pure samples of saccharin (2 milligrams per milliliter) did not produce oncogenic transformation of C3H/10T1/2, clone 8, mouse embryo fibroblasts. However, after treatment of the cells with a nontransforming initiating dose (0.1 microgram per milliliter) of 3-methylcholanthrene, continuous treatment with either sample of saccharin (100 micrograms per milliliter) led to significant transformation. It is concluded that in this system saccharin is a cocarginogen, probably functioning as a promoting agent that is 1000-fold less active than the tumor promoter 12-O-tetradecanoyl-phorbol-13-acetate.


Secretion in mast cells induced by calcium entrapped within phospholipid vesicles. Purified mast cells secreted histamine when fused to phospholipid vesicles containing calcium but not magnesium or potassium. Microscopic observation revealed highly localized exocytotic responses involving punctate extrusion of individual granules. Calcium delivered from the vesicles to the cytoplasm is apparently a sufficient stimulus to initiate exocytosis. The results support the calcium hypothesis of stimulus-secretion coupling.


Infantile stimulation induces brain lateralization in rats. The hypothesis tested was that the effects of early experiences are asymmetrically distributed in the two brain hemispheres. Litters were either handled or not handled between birth and weaning, and the weanlings were reared in either laboratory cages or enriched environments between 21 and 50 days. When approximately 135 days old, animals within each of the four treatment groups had a right neocortical ablation, a left neocortical ablation, a sham operation, or no surgery. About 1 month later, all animals were given the open-field test for emotionality and exploratory behavior. Ablating either the right or left neocortex increased the activity scores of nonhandled controls, but there was no evidence of lateralization. However, the groups handled in infancy did show lateralization. Ablating the left brain did not significantly increase activity, but ablating the right brain caused extreme scores: handled rats without enrichment experience were the most active, and handled rats also placed into the enriched environment had near-zero scores in the open field.


Computers in nuclear medicine: introductory concepts. Computers play an important role in image and data processing in nuclear medicine. Applications extend from relatively simple mathematical processing of in vitro specimen assays to more sophisticated image reconstruction procedures for emission tomography. The basic concepts and terminology associated with computer applications in image and data processing in nuclear medicine are presented here.


Computers and quality control in nuclear medicine. The general topic of computers and nuclear medicine quality control may be approached from two main areas; controlling the quality of computerized studies, and computer applications in general nuclear medicine quality control. Overlap occurs when quality control of computer studies is performed by the computer itself. The uses of computers in record-keeping and in quality control of imaging instrumentation and in vitro studies, including radioimmunoassay, are discussed in this review. Aspects of quality control for computerized clinical cardiovascular, cerebral, and renal studies and emission computed tomography are reviewed, including consideration of difficulties and inaccuracies involved in the studies. Any automatic computer analysis program should incorporate adequate checks and error detection protocols and should illustrate results for verification. Current routine quality control procedures using the computer unfortunately are few. Quality control criteria are needed for camera/computer systems in high count rate clinical applications, and increasing emphasis should be aimed at quality control of those computerized dynamic and function studies in current clinical use. The computer has a valuable potential for nuclear medicine quality control. In vitro and computerized in vivo studies can be analyzed by readily available statistical programs, and variances can be monitored continuously. Computers can calibrate and monitor instrument performance regularly, and can handle managerial and clerical duties such as bookkeeping.


Improvement of scintigrams by computer processing. Computer processing can improve the quality of scintigrams in several ways. It can increase the accuracy with which the image approximates the activity distribution by reversing degradation. It can selectively enhance normal or abnormal structures of interest. It can optimize the use of the display system presenting the image. The usefulness of computer processing must be determined by observer testing and clinical experience. The need to correct distortion in both intensity (nonuniformity) and space can be avoided by attention to calibration and to the setup of the imaging device employed and by use of the sliding energy window technique. Nonuniformity correction, especially for quantitative studies, should not be done using a flood field as this may actually decrease accuracy. Instead, any necessary correction should employ the sensitivity matrix, which measures the variation of sensitivity to a point source with the position of the source. Statistical fluctuations (noise) and degradation of resolution are commonly corrected using linear, stationary techniques [concepts which are defined and developed in the text], but nonstationary techniques appear to be frequently more successful at the expense of increased processing time. Techniques of choice for pure smoothing are nine-point binomial smoothing and variable shape averaging, and those for both sharpening and smoothing (preferred for most modern, high-count scintigrams) are unsharp masking, Metz or Wiener filtering, and bi-regional sharpening. Structures of interest can be enhanced by methods which detect and emphasize changes in local distributions of slope and curvature of intensity. High quality display devices are essential to reap any benefits from degradation correction. Those devices, which must have appropriately high sensitivity and must avoid display artifacts, have become available only recently. Use of the display should be matched to the processing done. Contrast enhancement, e.g. by histogram qualization, for optimal use for each image of the display intensity range, is often helpful. Most scintigram processing is done using computers with about 32K 16-bit words. Floating point hardware is often useful. Most processing methods require 1-30 seconds on such computers and usually under 15 seconds. Processing time tends to be negligible compared to time for user specification of the processing to be done, so the quality of command languages should be of concern. Careful observer studies using phantoms have shown processing to improve detectability of lesions when a single display is used for both processed and unprocessed images, but not when unprocessed images on standard analog displays are compared to processed images on common computer displays...


Application of the computer to rapid dynamic studies. Current trends in nuclear medicine to some degree, at least, reflect the level of sophistication available in the instrumentation. A technologically oriented speciality such as this might be expected to shift emphasis from time to time as stepwise advances are made in instrumentation. In its infancy, nuclear medicine concentrated on studies that could be accomplished with a single-probe system. The introduction of rectilinear scanners made imaging practical and of primary concern. Anger's gamma camera made combined static and dynamic studies possible using a single instrument--a decided advantage over previous methodology. The development of digital acquisition, processing, and display systems has had a profound effect on the recently increased emphasis on rapid dynamic studies. Computers are currently being applied to a broad range of clinical problems. Data preparation routines such as uniformity correction and data bounding often are used preliminary to more rigorous mathematical treatment. The development of reasonably low-cost, TV-type displays has greatly increased the quality of the computer display of the radionuclide imaging process.


Automated data processing and radioassays. Radioassays include (1) radioimmunoassays, (2) competitive protein-binding assays based on competition for limited antibody or specific binding protein, (3) immunoradiometric assay, based on competition for excess labeled antibody, and (4) radioreceptor assays. Most mathematical models describing the relationship between labeled ligand binding and unlabeled ligand concentration have been based on the law of mass action or the isotope dilution principle. These models provide useful data reduction programs, but are theoretically unfactory because competitive radioassay usually is not based on classical dilution principles, labeled and unlabeled ligand do not have to be identical, antibodies (or receptors) are frequently heterogenous, equilibrium usually is not reached, and there is probably steric and cooperative influence on binding. An alternative, more flexible mathematical model based on the probability or binding collisions being restricted by the surface area of reactive divalent sites on antibody and on univalent antigen has been derived. Application of these models to automated data reduction allows standard curves to be fitted by a mathematical expression, and unknown values are calculated from binding data. The vitrues and pitfalls are presented of point-to-point data reduction, linear transformations, and curvilinear fitting approaches. A third-order polynomial using the square root of concentration closely approximates the mathematical model based on probability, and in our experience this method provides the most acceptable results with all varieties of radioassays. With this curvilinear system, linear point connection should be used between the zero standard and the beginning of significant dose response, and also towards saturation. The importance is stressed of limiting the range of reported automated assay results to that portion of the standard curve that delivers optimal sensitivity. Published methods for automated data reduction of Scatchard plots for radioreceptor assay are limited by calculation of a single mean K value. The quality of the input data is generally the limiting factor in achieving good precision with automated as it is with manual data reduction. The major advantages of computerized curve fitting include: (1) handling large amounts of data rapidly and without computational error; (2) providing useful quality-control data; (3) indicating within-batch variance of the test results; (4) providing ongoing quality-control charts and between assay variance.


Multicystic dysplastic kidney: diagnostic considerations and management. A protocolled diagnostic approach for assessing various cystic and solid masses occurring in the neonate and infant, with particular emphasis on renal masses, is described. This protocol uses diagnostic examinations in such a sequence as to establish the diagnosis with acceptable confidence by the least invasive procedure and, therefore, at minimal cost in time, money, and risk to the patient. Early definitive diagnosis permits triage of patients into a group benefiting from immediate surgical intervention versus those with entities that can safely be followed up expectantly. Moreover, certain diagnostic procedures such as antegrade pyelography can be expanded to serve therapeutic purposes as a temporizing percutaneous nephrostomy, thus preserving renal parenchyma and hopefully improving the general condition of the neonate until a definitive surgical procedure can be safely undertaken to correct the underlying deficit.


Pancreatic injury.

Pancreatic injury. During the ten-year period from 1967 to 1977, 50 cases of pancreatic trauma were reviewed. There were 40 gunshot wounds, six stab wounds, and four cases of blunt abdominal trauma. Ten of the patients died, a mortality of 20%. The overall complication rate was 57%, but only 27% had complications attributable to the pancreatic injury. As has been reported by most authors, there is a high incidence of associated injuries. In our series only one patient had isolated pancreatic injury, while 30% had a major vascular injury, and the mortality for this group was 50%. Several methods of treatment were used, but the majority (36 patients) had drainage alone. The others had either resection (five) or Roux-en-Y pancreaticojejunostomy (five). Of particular interest were results of treatment of severe injuries to the head of the pancreas. Early in the series two patients were treated by pancreaticoduodenectomy and both died within 24 hours. During the last year we have treated five similar injuries using a Puestow type of Roux-en-Y pancreaticojejunostomy, with one death and no pancreatic complications. At present we advocate sump tube drainage for most injuries but rely on a Roux-en-Y pancreaticojejunostomy for severe injury to the head of the pancreas rather than resection.


Blunt trauma to the pancreas in children. Sixteen children below the age of 12 were operated on for blunt injury to the pancreas during a ten-year period. Unless there was an associated injury, signs and symptoms did not immediately develop. Common to the delayed manifestation of an injury to the pancreas was history of an impaling force to the upper abdomen, abdominal tenderness, and an elevated serum amylase level. The postoperative morbidity for contusion of the pancreas was unpredictable, and a prolonged period without oral alimentation should be anticipated.


Mental effects of mercury poisoning.

Mental effects of mercury poisoning. Three dentists suffered symptoms of mercury poisoning from the use of this substance in the production of amalgam for dental fillings. The problem of mercury absorption in dental offices has been well documented in the dental literature. The three cases are presented.


Acute acetaminophen intoxication.

Acute acetaminophen intoxication. Acetaminophen is a readily available, widely used drug which has been thought safer than aspirin. Overdosage which may result in fatal hepatic necrosis is commonly seen in the United Kingdom but is rarely reported in the United States. In a two-month period, three patients were admitted to a general hospital because of acetaminophen overdose, suggesting that this problem may occur more commonly than expected. They were successfully treated with N-acetylcysteine. Our experience in management of these three patients is presented and the pertinent literature concerning diagnosis and treatment of acute acetaminophen intoxication in briefly reviewed.


Cytosine arabinoside for varicella zoster: a second look. Herpes zoster and disseminated herpes zoster, or varicella (V-Z), continue to be dreaded complications of patients with immunosuppression. Currently, there is no available therapy for V-Z, except for general supportive measures. Seven cases of V-Z are presented, showing the results of cytosine arabinoside administration when given as an intermittent intravenous infusion. The results compare favorably with previously unsuccessful continuous intravenous infusion. It is suggested that further evaluation of the intermittent administration of cytosine arabinoside for V-Z would be worthwhile.


Nasal polyposis in children.

Nasal polyposis in children. In this study, the cases of patients under age 18 who had been admitted to the hospital over a five-year period for nasal polypectomy were reviewed for evidence of allergy or other possible predisposing conditions. Two of the children had cystic fibrosis and one had Kartagener's syndrome. Of the remaining 21 patients, 12 (57%) had four or more positive criteria for allergic disease, out of eight criteria considered. It is concluded that in the majority of children with nasal polyposis, allergy can be implicated as a causative factor.


PPD-tuberculin and PPD-Battey dual skin testing of hospital employees and medical students. Tuberculin PPD and PPD-Battey skin tests were simultaneously applied to 3,882 employees of Charity Hospital and 408 medical students at Louisiana State University. The PPD was doubtful (5 to 9 mm induration) in 253 of the total 4,290 persons tested (5.9%). In 86 of these 253 persons, the reaction to PDD-Battey was greater than the reaction to PPD, presumably identifying a subpopulation with a falsely positive PPD and therefore at considerably lower risk of developing future tuberculous disease. Of the 408 medical students (average age 24 years), 80 (19.6%) were classified by the skin tests as having atypical mycobacterial sensitization as compared to six (1.45%) who were classified positive or probably positive to Mycobacterium tuberculosis (P less than .001). In the Southeastern United States, where the incidence of atypical mycobacterial infection is relatively high and occurs at a young age, dual skin testing may have its greatest applicability in identifying tuberculous infection when the PPD falls in the "doubtful" 5 to 9 mm range.


Repair of rectal prolapse: experience with the Ripstein sling. Forty-eight patients with rectal prolapse were seen at Ochsner Clinic from 1955 to 1977. The charts of these patients were reviewed to assess the results of treatment and to evaluate a suggested association between rectal prolapse and solitary rectal ulcer syndrome. Since 1970 the Ripstein sling procedure has been used exclusively to treat those patients with rectal prolapse who are able to undergo a transabdominal procedure. We compared the results of this procedure with the ones formerly used: perineal (Altemeer), sigmoidectomy, and Thiersch procedures. Although the earlier operations for rectal prolapse were associated with either a high recurrence or a high complication rate, the Ripstein has both a low recurrence and a low morbidity rate: two patients had recurrence and two had the sling applied too tightly. The Ripstein procedure was shown to be an effective, safe procedure for repair of rectal prolapse, and the result was considered satisfactory by 20 of the 21 patients questioned. Regarding the association of rectal ulcer and rectal prolapse, we found that, although the symptoms of the solitary rectal ulcer syndrome and rectal prolapse are similar, they appear to represent a different response to the same stimulus, and the syndrome is relatively unabated by repair.


Freezing an extremity in preparation for amputation. Patients requiring a major amputation for ischemia are frequently gravely ill. Physiologic amputation obtained by freezing the leg, usually with a tourniquet, will permit delay and intensive preoperative therapy. In an efficient, safe, and convenient method which we have developed and used in 46 patients, a pump circulates antifreeze solution through a specially constructed boot. The last 32 patients so treated have been analyzed as to indications and results. Advantages obtained control of sepsis, correction of diabetic coma, dialysis for chronic renal failure, improvement in congestive heart failure, and improvement in pulmonary function. Four patients had successful below-knee amputations after control of infection that had previously seemed to dictate above-knee amputation. The control of pain and odor, the resultant appreciation of the family, and the lessened demand on nursing staff offer worthwhile benefits in many of the patients, even in some in whom advanced systemic disease prevented survival.


Three-year follow-up study of stroke patients at the Medical College of Virginia. Thirty-two patients with recent stroke were followed up for a three-year period. Correlation of rehabilitation therapy, survival, and life-style integration is discussed. Problems related to physician-patient relationship are emphasized including impact of available facilities upon long-term prognosis.


Epidemic rubella in military recruits.

Epidemic rubella in military recruits. Between Dec 1 and Feb 18, 1976, 320 cases of rubella occurred among recruits and dependent children at two Air Force bases in Illinois and Texas. Only 28 cases (9%) were identified in patients aged 17 and under. Routine serosurveilance before the outbreak revealed protective immunity in 89.1% of trainees. This outbreak emphasizes the changing epidemiology of what was formerly considered a childhood illness, and underscores the failure of herd immunity.


Single coronary artery: recent considerations. Although traditionally regarded as a minor congenital variation, a reconsideration of the single coronary artery anomaly indicates the potentially profound clinical significance of this entity--notably the consequences of coronary artery disease, the risk of sudden death at an early age, and the technical difficulties presented in cardiac surgery. To this point, it has recently been observed that 15% of individuals with isolated single coronary artery present with severe cardiac difficulties before age 40 years.


Radiation-recall enteritis after actinomycin-D and adriamycin therapy. A 22-year-old man developed four episodes of bowel obstruction after radiation therapy for a testicular tumor metastatic to retroperitoneal nodes. Each episode followed a course of chemotherapy with actinomycin-D or adriamycin. On one occasion bowel resection was required and revealed vascular changes compatible with radiation injury. The case appears to be an example of radiation recall injury involving the small bowel. The decision to use actinomycin-D or adriamycin must be weighed against the risk of tissue injury when a predisposition to radiation damage is present.


Tetracycline toxicity presenting as generalized vasculitis. We believe, then, that our patient represents an infrequently reported form of tetracycline toxicity. She developed a picture consistent with multisystem involvement, with a positive ANA test. All of the toxic manifestations were reversed upon withdrawal of the drug.


Massive oral theophylline poisoning.

Massive oral theophylline poisoning. A patient ingested a massive amount of an oral theophylline preparation and recovered. The paucity of central nervous system manifestations may have been related to the presence of fulminant diarrhea with expulsion of the tablets per rectum.


Adrenogenital syndrome: unusual presentation in an adult. A case of bilateral testicular tumors thought secondary to hyperplastic adrenal rest tissue in an adult with the adrenogenital syndrome is presented. The appropriate endocrinologic diagnosis of 21-hydroxylase deficiency was made by extensive hormonal assay of serum and urine. Pathologic investigation suggested Leydig cell hyperplasia or tumor, but clinical and laboratory response to steroid therapy indicated elaboration of androgens from adrenal or adrenal rest sources. We believe initial medical therapy is justified in these particular cases.


Tuberous sclerosis in old age.

Tuberous sclerosis in old age. A case of tuberous sclerosis without seizures in a 64-year-old man has been presented. Typical cutaneous, retinal, and bone lesions were found, along with calcifications in the lateral and third ventricle. Tuberous sclerosis is generally seen in young patients, though its occurrence in elderly patients has been described in the literature. Diagnosis in the present case was delayed. It is hoped that reemphasis of this aspect of tuberous sclerosis will lead to a prompt diagnosis in similar cases.


Otitic hydrocephalus.

Otitic hydrocephalus. This case of otitic hydrocephalus emphasizes a complication of ear disease which is rarely seen in modern otologic practice. The diagnosis and treatment of this entity have been reviewed in detail. Although the mechanism of this hydrocephalus is unknown, several theories have been presented.


Saline lavage: a rapid, safe, effective method of whole-gut irrigation for bowel preparation. The standard preparation for cleansing the colon usually involves dietary restrictions, purgatives, and enemas. This is time-consuming, often uncomfortable, and at times unsuccessful. This study of 37 patients examines the efficacy of saline lavage as an alternative method for cleansing the bowel. Isotonic sodium chloride solution is passed into the gut via a small nasogastric tube. The flush is continued for about four hours, until clear effluent is passed per anus. There were no significant complications or variations in weight or serum electrolyte values. Patient acceptance was generally excellent. In our opinion, this rapid bowel preparation consistently provided a clean bowel so that both bowel preparation and colonscopy were accomplished the same day.


Arthroscopic teaching technics.

Arthroscopic teaching technics. Arthroscopy has benefited greatly by the development of the miniaturized television camera. Not only is televised arthroscopy a valuable teaching aid, but it also promises to shorten and make more efficient many of the necessary operative procedures on the knee. A method for accomplishing this is presented.


Thoracic outlet syndrome: a comprehensive evaluation. Using various modalities, we analyzed 110 patients with thoracic outlet compression syndrome who had extensive evaluation. Nerve conduction velocities and Directional Doppler studies are the most useful adjuncts in diagnosis. Diagnosis and selection of the proper treatment of these patients will be outlined.


Malignant melanoma in children and young adults: effect of diagnostic criteria on staging and end results. Since the entity of "juvenile melanoma" was first described, many pathologists have been reluctant to diagnose malignant melanoma in childhood by pathologic criteria alone. In this series of 125 cases, pathologic criteria are used to distinguish malignant melanoma of childhood from spindle and epithelioid nevus. Among the patients reviewed, 110 cases (86%) occurred between ages 13 and 20 years, and 15 cases (14%) in children under 12. There were 60 males (54%) and 50 females (46%) in the older age group, and six males (41%) and nine females (59%) in the childhood group. In the 13 to 20 age group, there were 24% head and neck primary melanomas, 38% truncal primaries, 30% limb primaries, and 7% indeterminate, as opposed to 35% head and neck, 23% truncal, and 41% limb in the group under 12. In the 13 to 20 year group, 66% were stage I, 11% stage II, 12% stage III, 2% stage IV and 7% indeterminate while in the 12 and under group, 76% were stage I, 12% stage III, and 12% stage IV. Mortality rates were 49% for the 13 to 20 year group and 60% for the 12 and under group.


Small airway disease: comparison of tests in young smokers versus nonsmokers. A number of new tests for detection of small airway disease have been developed in the past several years. It is hoped that these will prove valuable as screening tests to detect those at risk of developing obstructive airway disease. We obtained data on the degree of discrimination of single breath nitrogen studies (CV/VC, CC/TLC, deltaN2/L), air-He studies (Vmax50), and the maximal midexpiratory flow (FEF25-75%) in detecting abnormalities in young smokers. Only the CV/VC and CC/TLC significantly separated smokers from nonsmokers, each revealing 20% abnormal values in smokers.


Value of routine flow studies in nuclide brain scanning. Nuclide brain scanning offers a noninvasive means of obtaining dynamic information about intracranial disease. Lesions which could be missed without the flow study are described, and other instances in which the differential diagnosis is greatly improved by the use of the vascular sequence are demonstrated. We recommend the routine use of the flow study when performing brain scans.


Management of low-velocity gunshot wounds of the hand. Of 41 consecutive patients with low-velocity gunshot wounds to the hand, 28 were treated by superficial debridement of wound edges and 13 were treated by meticulous debridement and exploration under operating room conditions. All patients received antibiotics. All wounds were closed primarily. Some had small drains for 24 to 48 hours. There were no complications of exploration. Of the 28 patients whose wounds were not explored, 16 had complications or residual deficits that required exploration. Hospital stay of the two groups was similar. Surgical exploration of low-velocity gunshot wounds to the hand is recommended.


Annotated contract technic: special adolescent groups. Fifty-six consecutive adolescent inpatients at the Adolescent Center of Houston International Hospital were subjects of a prospective study reviewing the efficacy of the Annotated Contract technic. Three primary diagnostic groups evolved: adjustment reaction of adolescence (ARA); borderline schizophrenia (BL-S); and antisocial personality (A-P). Follow-up of 6 to 20 months showed the technic overall to be extremely useful for ARA group, useful for BL-S group, and of questionable value for A-P group. The contract technic was initially accepted by all groups; it was facilitative in family conferences for 89%, 80%, and 56% of the ARA, BL-S, and A-P groups respectively. Most patients were able to use the contract as a barometer of their own progress; the A-P group used the contract largely to ventilate hostilities and/or limit parental demands. Only 18% of the ARA, compared to 50% of BL-S and 94% of A-P groups, ultimately ignored the contracts altogether. The technic is adaptable for clinical research as well as office practice.


Recent experience with tetanus in Alabama. In recent years, all cases of tetanus reported in the United States have occurred either in unimmunized persons, partially immunized persons, or persons whose immunization history was uncertain. We present our experience with three unimmunized individuals who acquired this disease. One patient became ill after a "clean, minor wound." Present guidelines do not encourage immediate protection with human tetanus immune globulin (TIG) for unimmunized patients with this type of injury. We believe serious consideration should be given to modification of current recommendations to include the more liberal use of TIG, especially in nonimmune persons.


Rational management of alcohol withdrawal seizures. Phenytoin has traditionally been used for both prophylaxis and acute treatment of alcohol withdrawal seizures. With the exception of a well defined subgroup of withdrawing patients, this may not be appropriate. Chronic anticonvulsant therapy is not indicated without evidence of another underlying seizure diathesis.


Combined use of lithium and diuretics.

Combined use of lithium and diuretics. Three cases demonstrating the effects of the combined use of lithium carbonate and a diuretic are reported. In each case, the serum lithium level rose, or the daily dose was decreased, or both. No clinical problems were noted because of careful monitoring and patient education. The renal excretion of lithium is reviewed. It is concluded that lithium and diuretics is a safe drug combination, if it is necessary to give both drugs.


Blood transfusion practices in surgery: an approach to intrahospital analysis. This study presents a two-year experience with the use of methods for the intrahospital analysis of surgical blood transfusion practices. Statistical and graphic methods were used to classify 21 types of operations (comprising 2,261 surgical procedures) by patterns of blood requests and usage. Surgical procedures were separated into three groups based on the frequency of transfusion. The results show that for many procedures careful attention to preoperative diagnoses can be very useful in predicting the amount of blood needed for a given surgical procedure. Methods described in this paper could be very helpful in reducing excess labor and preventing the unnecessary blood wastage which can result from improper ordering of blood for surgical procedures.


Vigorous intrathoracic needle aspiration biopsy: a micropathologic technic. Modification of intrathoracic needle aspiration using a vigorous technic consisting of multiple short, plunging, and rotating movements of the needle tip allows retrieval of a micropathologic rather than a cytologic specimen. This often facilitates more specific diagnosis and allows pathologists not expert in cytology to interpret the results. Increased incidence of transient hemoptysis is the only penalty incurred by this technic. The high diagnostic accuracy and clinical value of this simple short procedure in 31 patients is emphasized.


Serum lysozyme activity in inflammatory bowel disease. Serum lysozyme activity was determined in the sera of 70 patients with inflammatory bowel disease by the lysoplate method. Serum lysozyme levels were significantly elevated only in patients with Crohn's disease of the small bowel. Patients with either granulomatous or ulcerative colitis had serum lysozyme values not different from normals, irrespective of activity of their disease.


Total hip replacement in patients with rheumatoid arthritis. In this prospective study, 50 patients with a confirmed diagnosis of rheumatoid arthritis had total hip replacement. Preoperatively and at regular intervals postoperatively, all patients had evaluation of pain, ambulation, and range of motion according to the scale of d'Aubigne and Postel. Follow-up ranged from three to seven years, with the average being longer than four years. All patients demonstrated significant improvement in these parameters. Specific problems of the rheumatoid patient are discussed in detail.


Spindle cell lipoma: a benign lipoma variant with potential hazards of diagnostic misinterpretation. Spindle cell lipoma is a relatively common, recently described benign lipoma variant. It demonstrates highly characteristic clinical and pathologic features. Knowledge of its existence and features should prevent any misinterpretation of its true benign biologic behavior, a pitfall which has unfortunately occurred in the past, resulting in poor prognosis and exaggerated modes of therapy.


Cushing's syndrome and functioning adrenal black adenoma. A case of functioning adrenal black adenoma with Cushing's syndrome is briefly presented. This is the fourth reported case of this particular functioning tumor. The other three cases were also associated with Cushing's syndrome. The angiographic feature of adrenal venography in our case is identical to ordinary adrenal neoplasm and is the first documented roentgenologic study.


Unusual cause of jugular foramen syndrome. The jugular foramen syndrome and its more common variants have been described. Extramedullary plasmacytoma of the head and neck was discussed and its relation to cranial nerve dysfunction was reviewed, with presentation of an unusual case of plasmacytoma resulting in a variant of the jugular foramen syndrome.


Coronary aneurysms after a febrile illness: probable mucocutaneous lymph node syndrome. An autopsy of a probable case of MCLS is described. After 10,000 cases have been recorded in Japan, the disease is being recognized in the United States. There may be an overlap with infantile periarteritis nodosa. Pathologic studies of fatal cases of MCLS diagnosed during life have not been reported in this country. Further studies will be necessary to confirm the high incidence of coronary arteritis and aneurysms in this country.


Lingual thyroid.

Lingual thyroid. After 15 years of being asymptomatic, this patient with documented lingual thyroid developed a lump in the throat, with dysphagia. Routine thyroid function tests were within normal limits, but serum TSH concentration was increased to twice normal. On thyroxine therapy TSH levels returned to normal and the symptoms were relieved. TSH determinations and suppressive thyroid hormone administration play an important role in the management of a patient with lingual thyroid.


Chronic illness in non-institutionalized persons. Part I. Prevalence and epidemiology. A survey was conducted to investigate the prevalence and epidemiology of chronic illness in non-institutionalized persons residing in the Municipality of Cape Town. The Black, Coloured and White communities were independently surveyed and the standardized prevalence proportions of chronic illness were 24,7/1 000, 37,4/1 000 and 11,6/1 000 respectively. The epidemiological parameters investigated included age, sex, marital status, income, education occupation and the associated diseases, and the influence of these factors on the prevalence proportions are considered. Methodological problems of chronic illness surveys are discussed.


The mismanagement of benign breast disease. A report of 3 cases. Three cases are presented of complications after bilateral subcutaneous mastectomy with immediate prosthetic replacement, performed for benign breast disease in women who ranged in age from 24 to 32 years, by surgeons outside the field of plastic surgery. This article is submitted as a plea to curb a rapidly increasing tendency by general surgeons to perform a basically mutilating operation on young women with benign breast disease.


Primary sarcoma of the gallbladder. A case report. Primary sarcoma of the gallbladder was encountered in only 1 patient in a 5-year period during which primary carcinoma of the gallbladder was diagnosed in 1,8% of 954 surgically resected gallbladders and in 0,5% of 2 230 autopsies. The autopsy findings of the patient are described.


Changes in food expenditures, 1969--73: findings from the retirement history study. From 1969 to 1973, average expenditures for food at home reported by Retirement History Study respondents increased by almost the same proportion--30 percent--as did the food component of the consumer price index. Changes in these expenditures were not very responsive to changes in income, but income had greater power in explaining total food expenditures. The analysis was based largely on a regression technique that identifies the factors most important in explaining the variation in food expenditures. Size of household was the most important predictor of both the total level of household food expenditures and the per person level. Residence (urban, rural nonfarm, and farm), a proxy variable for home-produced food, was also generally significant. With size of household and income taken into account, a number of socioeconomic variables--including race, sex, age, morale, health, education, and homeownership--were found not significant.


Selection and preliminary characterization of cycloleucine-resistant CHO cells affected in methionine metabolism. Cycloleucine is in vivo a potent inhibitor of S-adenosylmethionine (SAM) biosynthesis and subsequent methylation reactions in somatic mammalian cells. Cycloleucine-resistant (CLr) clones were isolated from CHO cells by single-step selection. Their phenotype was stable when they were grown in the absence of drug. These clones appeared randomly in cultures at the frequency of 5 x 10(-6)/cell/generation, as determined by a fluctuation test. EMS mutagenesis did not significantly increase this frequency. The cycloleucine-resistant phenotype was codominant in intraspecific hybrids. Cycloleucine-resistant clones showed increased SAM pools; on the contrary, methionine pools were not significantly affected in these clones when compared to the wild-type cells. This increased SAM production was correlated with an increase of methionine adenosyltransferase (MAT) SPECIFIC ACTIVITY IN RESISTANT CLONES UNDER VARIOUS GROWm. The mechanism of posttranscriptional control of MAT biosynthesis was not affected in the cycloleucine-resistant clones nor were the kinetic properties of the enzyme modified. The genetic or epigenetic origin of this resistance mechanism is discussed.


Evidence for structural gene alterations affecting aminoacyl-tRNA synthetases in CHO cell mutants and revertants. Aminoacyl-tRNA synthetase (aaRS) activities in extracts of mutant strains of the Chinese hamster ovary line (CHO) were examined for alterations in thermal stability. Mutants having low activity for MetRS, AsnRS, or GlnRS contained aaRSs that were inactivated much more rapidly upon heating than those from wild-type cells. Revertant lines, isolated from cultures of these mutants (Asn-5, Met-2, and Gln-2) after treatment with nitrosoguanidine or ethyl methanesulfonate, had thermolabilities intermediate between mutant and wild-type, and consistently had higher activities than the mutants. With a modified in vivo aminoacylation procedure, two previously exceptional mutants. Arg-1 and His-1, showed pronounced reductions in the amount of arginyl-tRNA or histidyl-tRNA, respectively, under restrictive conditions, compared to wild type. Revertants of Arg-1 (like the mutant itself) had no measurable ArgRS in vitro activity (less than 0.4% of wild type) although in vivo aminoacylation in the one revertant tested was partially restored. These data provide evidence that the forward mutations have occurred in the structural genes of the aaRSs and that most of the reversions are probably the result of second-site point mutations in the aaRS genes.


Induced segregation of human syntenic genes by 5-bromodeozyuridine + near-visible light. Chromosome-breaking agents have been used in two different procedures for promoting segregation of syntenic genes on human chromosome 12. In method A, a human-Chinese hamster cell hybrid containing the single human chromosome 12 was treated either with 5-bromodeoxyuridine BrdU + near-visible light or with X-rays. In method B, normal human fibroblasts were treated with BrdU + near-visible light followed by their fusion with a Chinese hamster glycine-requiring cell mutant CHO-K1/gly-A. Since the human complementing gene for serine hydroxymethyltransferase, an enzyme deficient in gly-A, lies on human chromosome 12, only those hybrids retaining that chromosome can survive the glycine-free medium. Clones isolated from both procedures were analyzed for the loss or retention of four other syntenic genes on chromosome 12, TPI, GAPD, LDH B, and PepB. The results demonstrate that method B is much more effective in generating clones with extensive marker losses. In addition, the segregation pattern and frequency obtained in this study provided information on the linear order of TPI and GAPD on chromosome 12.


Hypophysectomy for stage IV breast cancer. Transnasal, transsphenoidal microsurgical hypophysectomy is a useful therapeutic procedure for patients with Stage IV breast cancer which can be peformed in selected patients with minimal morbidity and mortality. Functionally complete hypophysectomy can be accomplished with regularity, and anything less than this is considered to be a technical failure despite the fact that remissions may occur after incomplete hypophysectomy. In view of the recent outstanding results with antiestrogen therapy in patients with breast cancer, we recommend this as the initial treatment in those patients who are good candidates for endocrine therapy. Hypophysectomy has been shown to induce improvement after antiestrogen treatment, particularly in those patients who have had an initial response to antiestrogens as well as in a few patients who failed to benefit. Estrogen receptor measurements in the tumor tissue have been shown to be useful in selecting patients for hypophysectomy as well as for antiestrogen therapy. Prolactin receptors have been found in about 50 per cent of human breast cancers, and their potential usefulness in selecting patients for hypophysectomy is being explored. Hypophysectomy is a definitive therapeutic procedure that should not be used as a last resort in the terminally ill patient.


The rhomboid flap and partial mastectomy. The use of a rhomboid flap in segmented breast resection is described. This reconstructive technique allows large areas of the breast to be resected with minimal deformity and nipple-areola displacement.


Radionuclide scans in staging of carcinoma of the lung. Radionuclide scans are relatively accurate, non-invasive, diagnostic tools when used in patients with carcinoma of the lung with clinically suspected metastases. Their role as a screening or staging procedure in patients without signs or symptoms of metastases is less clear. Brain scans in asymptomatic patients have a low yield. Liver scans done in the absence of hepatomegaly or elevated liver function tests show a high per cent of false-negative and negative results. Bone scans appear to be of considerable value in patients with or without clinical evidence of metastases, in spite of limitations imposed by frequent false-positive results.


Mesenteric cysts in infancy and childhood. Of 11 infants and children with mesenteric cysts, seven patients were boys and four, girls. Clinical findings included abdominal distention, pain and vomiting in seven patients, while a movable abdominal mass was noted in four. Two patients presented with peritonitis and one patient, in a state of shock. All patients underwent laparotomy-seven as an emergency procedure. Volvulus with perforation and infarction was noted in the two patients uith peritonitis. Excision of the cyst required resection of the small intestine and end-to-end anastomosis in seven patients, while simple enucleation was possible in four. All 11 patients survived, and there have been neither subsequent complications nor recurrences. Early recognition and appropriate resection of these benign, but occasionally life-threatening, malformations is associated with an excellent long term prognosis.


The problem of adherence in dressed wounds. Adherence of the wound dressing is an avoidable problem. Use of the three layered dressing, proper construction of the dressing, knowledgeable and judicious selection of dressing components and reasonably frequent changing of dressings will prevent adherence from developing.


Effect of diminished distal blood flow on the morphologic changes in autogenous vein grafts. Histologic changes in canine autogenous femoral veins were studied after interposition into the femoral artery. After a 50 per cent reduction of distal blood flow, marked fibrosis of the intima, causing narrowing of the intima and focal destruction of the internal elastic membrane and media, were found in the vein graft and the adjacent arterial segment. These changes are probably due to abnormal intraluminal pressure of femoral artery and interposed vein graft following constriction.


The use of serial carcinoembryonic antigen determinations to predict recurrence of carcinoma of the colon and the time for a second-look operation. Our patients have demonstrated that serial carcinoembryonic antigen determinations contributed to the detection of recurrent tumor and that shortening the delay between carcinoembryonic antigen elevation  and reoperation has resulted in an increase from 27 to 78 per cent in instances of resectable recurrent tumor encountered. If these results continue to be substantiated, the carcinoembryonic antigen assay has made a significant contribution in the control of this disease. Serial carcinoembryonic antigen assays should be performed every two months. All benign inflammatory conditions that cause carcinoembryonic antigen elevations must be searched for, and ruled out, before reoperation is decided upon. The physician must be cognizant not only of the significance of the assay but also of the limitations, and he must rely heavily on his clinical judgment.


The effect of age on the distensibility of the abdominal aorta of man. The variation with age in distensibility and the dimensions of the abdominal aorta at the bifurcation have been measured in 43 fresh human cadavers. The age range was from birth to 69 years, both sexes being represented. Patients with vascular disease were excluded. Barium sulfate infused into the aorta through an iliac artery enabled the change in diameter to be measured from a roentgenogram with change in pressure. Incremental strain value could thus be calculated. Strain value increased from 0.02 at birth to a maximum at the end of the first decade of life and then decreased to less than 0.01 by the age of 70 years. Aortas in the age group of four to 11 years showed less stiffness with increasing pressure than at other ages. Variations of strain with age correlate with alterations in the ratio of aortic wall collagen to elastin in the young. An increase in the thickness of the wall and an atheroma, in response to prolonged hemodynamic stress, account for increased stiffness in the older age groups. Other age and disease factors may play a part, but further work is required in man to examine the role of relative wall thickness, elastic modulus and alteration in wall structure in determining the variation of aortic distensibility with age reported herein.


Reassessment of the surgical scrub.

Reassessment of the surgical scrub. This study was designed to reassess the efficacy and necessity of the preoperative ten minute, two brush scrub method currently required for all personnel at this hospital. Three scrub methods-the tem minute, two brush technique with an iodophor, Betadine surgical scrub; a five minute, no brush iodophor scrub with a new iodophor iodine scrub, and a three minute, no brush scrub with plain soap and Septisol Foam-were compared. Fingertip culture results obtained prescrub, immediately postscrub and one hour after wearing gloves revealed no significant differences in the three methods. The findings suggest that, one hour after scrubbing, a shorter, no brush scrub procedure with any of the antiseptics used in this study is as effective in reducing bacterial growth of the hands as the standard longer two brush method. By deletion of the use of scrub brushes and the improved efficiency from the reduced scrub time alone with the additional less likelihood of skin trauma and dermatitis, substantial financial savings may be realized.


Urolithiasis in patients with a jejunoileal bypass. Five hundred and seventeen patients who had a jejunoileal bypass performed at the University of Minnesota Hospitals were studied with regard to the formation of urinary calculi postoperatively. A 9 per cent incidence of stones was found in the 365 patients for whom complete data were available. Men were affected more commonly than women. Of particular note was the correlation between long term oral supplementation of calcium postoperatively and a delay in the onset of symptomatic urolithiasis. A group of 91 recent patients who have been maintained on orally administered calcium are stone-free as long as 12 months after operation, again suggesting that supplementation of calcium may help prevent urolithiasis in patients who have had a bypass procedure.


Generalized infective peritonitis.

Generalized infective peritonitis. A mortality of almost 50 per cent from generalized infective peritonitis was obtained. Diagnosis was made chiefly on clinical grounds. Delay was common. Investigations were primarily useful in determining the degree of metabolic derangement. A worsened prognosis could be predicted by several factors assessed preoperatively. The usual cause of death was continuing intraperitoneal sepsis. This was manifest as multisystem failure in an intensive care environment. Abdominal signs of this infection were infrequent.


Gray scale ultrasonography and rose bengal scintigraphy in the evaluation of the patient with jaundice. In our experience, the ultrasonic examination should be the procedure of choice in the initial investigation of the patient with jaundice. It is independent from liver function and a noninvasive test which can be performed rapidly; in addition, the cause of extrahepatic obstruction can often be determined preoperatively. In our study, in many patients, the rose bengal scintigram has been indeterminate and has not been helpful in predicting whether obstructive or nonobstructive jaundice exists. Rose bengal scintigraphy appears to be of most help only in those patients in whom an adequate sonographic examination cannot be performed. Newer imaging agents currently being developed may prove to be more satisfactory in the future.


Endoscopic retrograde cholangiopancreatography in the diagnosis and management of nonalcoholic pancreatitis. Twenty-eight consecutive patients with idiopathic pancreatitis were studied. Endoscopic retrograde cholangiopancreatography was diagnostic in 21 of 28, while an operation was diagnostic in four of the remaining seven patients. Fifteen of 25 patients had operable disease of the gallbladder, common bile duct, ampulla of Vater or pancreatic duct. Of ten patients who had an operation on the pancreas or biliary tract, or both, for painful attacks of pancreatitis, none had a recurrence in a seven month to three year follow-up study. Two patients had reconstruction of the pancreatic duct for chronic painless steatorrhea, one of whom had marked clinical improvement. Ten of 25 patients had normal biliary tracts with normal or minimally abnormal pancreatic ducts and were treated medically. Visualization of biliary and pancreatic ducts should be attempted by endoscopic retrograde cholangiopancreatography in patients with pancreatitis of unknown cause. Operable lesions were found in 15 of 25 patients, and the postoperative results were excellent.


An experimental study of end-to-side microvascular anastomosis. Forty-nine end-to-side arterial anastomoses were carried out in dogs. The saphenous artery was anastomosed to the femoral artery. Variations in technique were made regarding the shape of the aperture in the large artery and in the incident angle of the small artery. Blood flow was measured in the immediate postoperative period with electromagnetic flowmeters on the saphenous and femoral arteries. There was no significant difference in flow between each of the four types of anastomoses studied. In each of the flow was slightly, but not significantly, higher than the preoperative level.


Effect of biliary diversion on exocrine pancreas. An experimental study was conducted on the effect of bile diversion on exocrine pancreatic function. Twelve dogs were divided into three groups, one group consisting of a choledochojejunostomy; one, a choledochoduodenostomy, and one, a choledochocholedochostomy. In each group, exocrine pancreatic function was observed before and two months after the operation. With combined secretin and pancreozymin infusion, a significant decrease in the rate of flow, bicarbonate concentration and amylase output was seen only after choledochojejunostomy. The function of the exocrine pancreas was markedly decreased late in the period of stimulation. Contrariwise, no pancreatic dysfunction was noted after choledochoduodenostomy or choledochocholedochostomy. The high incidence of peptic ulcer formation after choledochojejunostomy might be closely connected with the postoperative impairment of exocrine pancreatic function.


Conversion of jejunoileal bypass to gastric bypass to maintain weight loss. We have performed jejunoileal bypass procedures in 114 patients during the last nine years. Seven of these patients have had complications develop that required restoration of normal gastrointestinal continuity. In the last four patients in our series, we have performed a gastric exclusion operation at the same time that normal anatomy of the small intestine was restored. These operations lasted only three and one-half hours and were performed without difficulty and without postoperative coomplication. The metabolic derangements have been corrected and weight loss has been maintained. We believe that the gastric bypass provides the surgeon with an effective additional option in managing patients with serious complications of their jejunoileal bypass that necessitates restoration of intestinal continuity.


Optimal hematocrit value in critically ill postoperative patients. Failling hematocrit values are traditionally used to observe the course of active bleeding, since hematocrit values usually reflect acute blood losses. However, evidence from the literature suggests that, after volume replacement, some degree of normovolemic hemodilution may be desirable and that return to normal hematocrit values is not necessarily the appropriate goal of transfusion therapy. The optimal hematocrit value was defined empirically by three methods in a series of 94 critically ill postoperative patients. First, the mortality rates of postoperative patients were lowest with hematocrit values between 27 and 33 per cent. Second, mortality rates were examined when both hematocrit values and the important cardiorespiratory variables were reduced; significantly increased mortalties occurred when hematocrit values were less than an average of 32 per cent. Finally, oxygen availability and oxygen consumption increased significantly after whole blood and packed red cell transfusions were given when hematocrit values were less than 32 per cent but not above 33 per cent. When accurate blood volume measurements are not available, hematocrit values of 32 per cent are optimal; when volume therapy is indicated, blood may be given with hematocrit values less than 32 per cent, crystalloids or colloids are preferred with hematocrit values greater than 32 per cent.


Blood volume and hemodynamic changes in relation to extensive vascular operations. In 37 patients without cardiopulmonary insufficiency, postoperative changes in blood volume have been correlated to changes in the systemic and the central circulation. Postoperatively, the blood volume had decreased an average of 8 per cent, and diastolic blood pressure, 7 per cent, while cardiac index had increased 14 per cent and heart rate, 16 per cent. No significant changes could be demonstrated in pulmonary artery pressures, central venous pressure or invascular resistance. A highly significant correlation between the blood volume and pulmonary artery pressures and a significant correlation between the blood volume and central venous pressure were noted. Hematocrit was negatively correlated to vascular resistance. It is concluded that an unchanged blood volume during the first postoperative hours results in increased pulmonary artery pressures and central venous pressure. Therefore, in patients suspected of having increased pulmonary artery pressures, complete restoration of blood volume should take place over some hours postoperatively. An increase in hematocrit over normal values should be avoided.


To improve the yield of biopsy of the lymph nodes. The diagnostic yield of 290 biopsies of thee lymph nodes performed between 1970 and 1974 was reviewed. A specific diagnosis was made in 63 per cent. In 10 per cent, the working diagnosis preoperatively was changed because of the biopsy. There was no significant variance in the postive yield obtained at the various biopsy sites. The surprisingly high yield from biopsy of inguinal lymph nodes was ascribed to a greater hesitancy on the part of th surgeon to do a biopsy of the nodes in the groin, unless they were strongly suggestive of disease. The highest yield rates were obtained when Boeck's sarcoidosis was suspected. Excellent yield rates were also obtained when the preoperative diagnosis was lymphoma or metastatic carcinoma. A protocol for handling the specimen was devised to maximize the potential yield of biopsy of the lymph nodes.


Preserved saphenous vein allografts for vascular access. Preserved venous allografts were used as an alternate access procedure in 70 patients receiving dialysis during a three year period. The clinical experience with allograft fistulas revealed an extremely high initial patency rate; absence of infection postoperatively and during three years of dialysis; suitability for dialysis a week after implantation, thus greatly obviating the need for Silastic shunts; a low long term thrombosis rate and the weakly antigenic allograft veins produced no accelerated rejection of subsequently transplanted kidneys. Surviving patients average 172 dialysis treatments per allograft. Allograft fistulas constituted 45 per cent of the last 100 vascular procedures, an indication of the extent of usage. Microscopic examination of grafts retrieved from patients who died during the late follow-up period demonstrated that structural components of the wall of the vein were still identifiable. Allograft venous fistulas offer dependable, safe vascular access, especially in the infection prone patient with diabetes who is receiving dialysis treatment. The clinical results of allograft fistulas suggests a major role for this technique in vascular access operations.


Simultaneous treatment of portal hypertension and hepatic cirrhosis by splenohepatoplasty. A study was done on the action of splenohepatoplasty upon intrahepatic and prehepatic portal hypertension. Portal hypertension was induced Wistar rats following the establishment of cirrhotic conditions. Hepatic cirrhosis was obtained in these rats by an oral, daily dose of tioacetamide during a four and five month period. Prehepatic hypertension was produced in dogs by the installation of a rubber cylinder, completely covered by cellophane paper, around the trunk of the vena porta. This procedure brought about a progressive compression of the vena porta. The application of splenoheptoplasty is a highly valuable treatment for portal hypertension as a derivative system and for intrahepatic portal hypertension as a derivative regenerative system.


Surgical leukemia.

Surgical leukemia. The experience of the University of Colorado Medical Center affiliated hospitals with leukemic reticuloendotheliosis, hairy cell leukemia, during the past two years has been reviewed. Eight instances were found. The majority of patients in this study presented with fatigue, pancytopenia and splenomegaly. Diagnosis was based upon finding characteristic hairy cells in the blood, bone marrow or spleen. Treatment, unlike other hematopoietic malignant conditions, was primarily surgical, with splenectomy being the treatment of choice, which may lead to prolonged remission in the majority of instances.


Choledochal cyst.

Choledochal cyst. From the review of the literature it would seem that excision as the most appropriate method of treatment is generally preferred to the internal drainage procedures. Despite the strong arguments in favor of primary excision, approximately two-thirds of patients undergoing Rouxen-Y choledochocystojejunostomy experience excellent results in both the short and long term follow-up periods. There is much to be said for recommending the Roux-en-Y choledochocystojejunostomy as the primary method of treatment of choledochal cysts, especially when the procedure is undertaken by inexperienced surgeons, and to reserve excision for those patients who have complications.


Oligodendrogliomas in children.

Oligodendrogliomas in children. Oligodendrogliomas are quite uncommon in children. In a 41-year period (1935 to 1975) in Connecticut, 12 histologically verified cases of oligodendrogliomas were noted in persons less than 20 years of age, constituting between 1% and 2% of all primary intracranial neoplasms in Connecticut children. Eleven of the neoplasms occurred in the cerebral hemispheres; these cases of cerebral oligodendrogliomas were reviewed and analyzed.


Arachnoid cysts of the middle cranial fossa: surgical considerations. Three cases of arachnoid cysts of the middle cranial fossa are presented. CT imaging before and after peritoneal shunting of these cysts demonstrates the therapeutic value of this cerebrospinal fluid diversionary procedure. Many important facets of this disease such as cyst genesis, histology, natural history and other forms of therapy as reported by various authors in the recent literature are discussed.


Experimentally induced cerebral aneurysms in rats. Saccular cerebral aneurysms were successfully induced in rats treated with beta-aminopropionitrile, deoxycorticosterone and salt hypertension and ligation of unilateral common carotid artery. This experiment was performed on the hypothesis that if hemodynamic stresses were increased on the fragile, cerebral arterial wall of beta-aminopropionitrile-fed animals, cerebral aneurysms might be produced. Although the incidence of cerebral aneurysms was low and the contributory mechanisms of these procedures must be more clearly elucidated, the present results show that saccular cerebral aneurysms are really inducible in experimental animals.


Effect of duration of acute spinal cord compression in a new acute cord injury model in the rat. The effect of duration of acute compression of the spinal cord was assessed in a new model in the rat. The spinal cord was acutely compressed for varying times by a modified aneurysm clip which produced a compression force of 180 grams. The effect of duration of compression was measured by the inclined plane method of assessing the animals' clinical performance. The results showed a linear relationship between log compression time and clinical performance. Thus, the clinical effect of acute compression of the spinal cord injury is inversely related to duration of compression time and the relationship has been precisely quantified. These results suggest that persisting compression should be relieved as soon as possible in order to improve recovery.


Movement of cerebrospinal fluid within the craniospinal space when sitting up and lying down. Postural changes in the lumbar cerebrospinal fluid pressure were recorded in patients with and without a cervical obstruction of the subarachnoid space. In patients with a free communication there was a rapid caudad movement of CSF on sitting up and a craniad movement on lying down. The relation of these changes to cerebral blood volume and to symptoms are discussed.


Pathological studies of spinal nerve ganglia in relation to intractable intercostal pain. Pathological examination, by light and electron microscopy, of spinal nerve ganglia surgically removed in treatment of intractable intercostal pain, has shown changes in sensory cells, whether the etiology of the pain has been trauma related to intercostal nerve, or infection by herpes zoster virus. The possible role of the sensory cell changes in accounting for causalgic type pain is discussed.


Experimental spinal cord trauma, I: Correlation of blood flow, tissue oxygen and neurologic status in the dog. Spinal cord blood flow and tissue oxygen were measured concurrently in a series of paraplegic dogs subjected to experimental spinal cord trauma. Injury to the spinal cord sufficient to cause clinical paraplegia is associated with a significant (P less than 0.01) decrease in blood flow in the central spinal cord from 15.2 to 6.1 ml/min/100gms at two to three hours following injury. Also, at two and three hours post-injury, paraplegic dogs demonstrate a significant (P less than 0.01) decrease in tissue oxygen levels from 35-39 mm Hg to 17-24 mm Hg. No significant changes occurred in systemic blood pressure or carotid blood flow. A delay often precedes the significant onset of blood flow and tissue oxygen alterations, which suggests that therapeutic efforts could be directed during this critical interval.


Cimetidine and gastric blood flow.

Cimetidine and gastric blood flow. The influence of cimetidine on blood flow to the gastric corpus and antrum of the dog was studied using the double isotope microsphere distribution technique. This H2 receptor antagonist caused no changes in blood flow to any portion of the stomach nor did it alter systemic circulatory parameters. The therapeutic effects of cimetidine in diffuse gastric mucosal bleeding depend on some factor other than microcirculatory changes.


Whole blood vs. packed red cells for resuscitation of hemorrhagic shock: an examination of host defense parameters in dogs. Whole blood vs. packed red cells for resuscitation of acute blood loss in dogs was compared with respect to a number of variables of host defense. Dogs subjected to a controlled blood loss equal to 8% of their body weight exhibited significant depressions in serum protein, C3, IgG, and total opsonic activity when resuscitated with packed red cells in saline. No such depression in serum components or activity was observed in identically bled dogs resuscitated with whole blood. There were no differences in the rate of clearance of intravenously injected bacteria indicating an intact reticuloendothelial system (RES) function in both groups. These experiments suggest that whole blood may be preferable to packed cells for resuscitation of acute hemorrhagic shock when the effect on resistance of infection is considered.


The prevention of peptic ulceration by highly selective vagotomy in a new peptic ulcer experimental model: the bile duct-ligated pig. Bile duct ligation produced gross peptic ulceration of the pars esophagea of the stomach, with a 70% mortality rate from hemorrhage or perforation. The situation and histological appearance of the ulcers was identical to the peptic ulcers that occur spontaneously in pigs. Previous work has shown that these ulcers are associated with gastric hypersecretion. The technique of highly selective vagotomy was established in the pig and was shown to have no short-term adverse effects. In a group of 10 pigs, highly selective vagotomy virtually eliminated pars esophageal peptic ulceration and significantly prolonged survival after bile duct ligation. The bile duct-ligated pig experimental peptic ulcer model should be of value in studying peptic ulceration and methods of treatment. Further investigation is required to determine the cause of death in those animals in which peptic ulceration is prevented by treatment, such as highly selective vagotomy.


Hormones and the pathophysiology of fibrocystic mastopathy: elevated luteinizing hormone levels. Serum levels of luteinizing hormone (LH), follicle-stimulating hormone (FSH), prolactin, testosterone, estrone, and estradiol were measured weekly for 1 month in 12 menstruating women with fibrocystic mastopathy. LH levels were abnormally elevated. The remainder of hormone levels were essentially normal. Elevated serum LH may be secondary to hypothalamic-pituitary, ovulatory, or corpus luteum dysfunction. The roles of hormonal abnormalities in the pathogenesis of fibroycstic mastopathy are not known.


Arginine: an essential amino acid for injured rats. The influence of arginine supplements on growth and healing of skin incisional wounds was studied in rats fed either a chemically defined diet lacking arginine or a laboratory chow containing 1.8% arginine. Rats fed the arginine-free diet grew more poorly than did arginine-supplemented rats (1.8 vs. 7.0 gm/day) in the preoperative period. After operation arginine-deficient animals grew very poorly (1 gm/day), while arginine-supplemented rats gained 4.3 gm/day. Arginine-deficient animals showed impaired wound healing, as judged by the breaking strengths of their incisions 10 days after wounding (228 vs. 293 gm for the arginine-supplemented rats). Arginine-deficient rats also showed decreased collagen deposition in a specific wound site, as indicated by the decreased content in hydroxyproline in sponge granulomas (2.5 vs. 4.2 mg/100 mg. of sponge for the arginine-supplemented rats). In rats fed commercial chow, 1% arginine decreased the postoperative weight loss associated with injury (0.7 vs. 5.2 gm) in one experiment and improved wound strength in two experiments (312 vs. 188 gm in one experiment and 309 vs. 246 gm in another). Arginine also increased hydroxyproline deposition in a specific wound area (5.5 vs. 4.1 mg in one experiment and 3.1 vs. 1.9 mg. in another). It is concluded that arginine has two roles in wounded animals. It is essential for the synthesis of the increased amounts of reparative collagen required for wound healing, and it decreases some of the negative aspects of the metabolic responses to injury. These are thought to be associated with an arginine-induced growth hormone release.


Reanastomosis after jejunoileal bypass.

Reanastomosis after jejunoileal bypass. One hundred and one patients underwent jejunoileal bypass after careful preoperative evaluation. These patients were re-evaluated after operation on a frequent basis, and 23% have required restoration of intestinal continuity (reanastomosis) by a mean postoperative time of 44 months. The most frequent reasons for reanastomosis were liver dysfunction (5% of the entire series), severe malnutrition or weakness (5%), and late electrolyte imbalance (4%). Two patients did not survive reanastomosis, both having liver failure. Of the patients who did survive, weight gain (approaching prebypass weight) and improvement in liver function tests, electrolyte balance, serum vitamin levels, and diarrhea have been the rule. Of the entire series of 101 patients who underwent bypass, 58% either had life-threatening complications, had to be reanastomosed, or died. These morbidity and mortality rates raise the important question of whether jejunoileal bypass is an appropriate procedure for the treatment of morbid obesity.


Aortocaval fistula associated with aneurysm of the abdominal aorta: current management using autotransfusion techniques. Two patients with aortocaval fistula associated with abdominal aortic aneurysm were managed successfully using a patient care plan which includes proper monitoring of the hemodynamic state, careful dissection of the aneurysm, and return of blood loss by autotransfusion while the patient is fully anticoagulated with heparin. This unusual and serious problem in vascular surgery can be managed in an orderly and controlled fashion using these techniques.


The noninvasive assessment of aortoiliac disease: a comparison of dynamic isotope angiology with thigh brachial pressure index. In 41 patients with severe claudication, the time taken for an intravenously injected isotope bolus of TC99m pertechnetate to pass from the aortic bifurcation to the common femoral arteries was measured using a gamma camera and computer. This isotope transit time (ITT) then was correlated with the severity of aortoiliac disease determined arteriographically. Highly significant differences in ITT were found between normal vessels and those with minor stenosis of less than 50%, major stenosis of 50% or more, or complete occlusion. With major disease there was a longer ITT than with minor disease (P less than 0.01). ITT gave a greater degree of differentiation between disease groups than did thigh/brachial pressure index, as measured by Doppler ultrasound in the same patients, and was not influenced by superficial femoral artery occlusion.


Acute supravalvular stenosis following replacement of the aortic valve and ascending aorta in a patient with Marfan's syndrome: report of a case. A case report of a patient with Marfan's syndrome who developed acute supravalvular aortic stenosis following aortic valve replacement and reconstruction of the ascending aorta is presented. Early recognition of this complication permitted reoperation and successful repair. One similar case has been reported previously.


Endoscopic retrograde cholangiopancreatography (ERCP) in the diagnosis of chronic pancreatitis. In a personal series of 188 patients with pancreatic disease referred for endoscopic retrograde cholangiography (ERCP), one or more ducts were cannulated in 168 patients; of the 168 patients; of the 168 patients, 19 had carcinoma and 149 had chronic pancreatitis. Abnormalities were found in 71 of the 149 patients with pancreatitis, either in the pancreatic duct, the bile duct, or both ducts. The demonstration of these abnormalities was of critical importance in planning the management of these patients. Ducts were normal in 78 patients. No benefit could be expected from operating upon these patients. It is concluded that approximately one half of the patients with chronic pancreatitis will have demonstrable lesions amenable to operation, and one half will not. ERCP is essential in the investigation and management of patients suspected of having chronic pancreatitis.


Experimental pancreatitis: Effect of plasma and dextran on pancreatic blood flow. In spite of extensive investigations, many aspects of the hemodynamic changes occurring in acute pancreatitis are understood poorly. A dog model was established in which continuous measurements of pancreatic arterial blood flow, cardiac output, and mean arterial blood pressure were made using electromagnetic flow probes and a pressure transducer, respectively. Pancreatitis was induced and the animals were monitored for 3 hours. In addition, control animals (group I) without pancreatitis also were done. All animals 50 ml of saline in the first hours. Three methods of therapy then were instituted in the dogs with pancreatitis and their effects were recorded. group I 6 dogs control animals no pancreatitis saline 50 ml/hr group II 10 dogs saline 50 ml/hr group III 6 dogs plasma 15 ml/kg over 45 min then saline 50 ml/hr group IV 10 dogs saline 50 ml and 1.5 ml/kg of dextran 40/hr These results confirm the observations made previously using a transillumination technique--that the pancreatic circulation rapidly reduces in acute pancreatitis. Administration of plasma produced a significant (P less than 0.05) but transient increase in the cardiac output and pancreatic blood flow; however, the blood pressure remained low. Dextran 40 minimally increased cardiac output, but it significantly improved the blood pressure and maintained the pancreatic blood flow. Low-dose, low-molecular weight dextran 40 appears to help to maintain pancreatic blood flow in acute pancreatitis. The possible mechanisms concerning the made of action of dextran 40 will be discussed.


Surgical management of tracheosophageal fistula complicating caustic ingestion. This report outlines principles of management for extensive corrosive esophageal burns in children complicated by formation of a tracheoesophageal fistula (TEF). Direct operative attack on the fistula usually is unsuccessful, since the tracheal tissues are so damaged that they will not hold sutures. On the basis of experiences with six children, we suggest the following plan of management: (1) early investigation of suspected TEF with thin barium or Dionosil; (2) early tracheostomy using a short, plastic tube; (3) end cervical esophagostomy with closure of the distal stump of the cervical esophagus; (4) gastrotomy; (5) complete disconnection of the intra-abdominal esophagus from the stomach. This can be completed in a single operation and leaves the thoracic esophagus containing the fistula completely isolated so that the trachea is protected from contamination by saliva and gastric juice. The esophageal mucosa in all cases has been destroyed so extensively by the corrosive material that the esophagus heals as a band of muscle and scar. If protected from continuous contamination by saliva, the trachea heals itself with little long-term defect. The esophagus is replaced with colon or a gastric tube 6 to 12 months later when the child is in good health. All four children treated by this regimen have survived and are able to eat normally.


Aortoiliac reconstruction in patients with combined iliac and superficial femoral arterial occlusion. Despite revascularization of the common femoral--profunda femoris system, many patients fail to obtain satisfactory relief from claudication or rest pain. Clinical observations were compared with objective physiological data in 54 technically successful aortoiliofemoral reconstructions for multilevel disease. Nine of 28 operations (32%) for claudication and five of 26 operations (19%) for ischemia at rest had poor results. While the average ankle pressure index (API = ankle blood pressure/arm blood pressure) rose from 0.52 +/- 0.03 (SEM) to 0.81 +/- 0.03 in limbs treated successfully for claudication, it changed insignificantly in those with an unsuccessful result (0.58 +/- 0.04 to 0.61 +/- 0.04). When ischemic symptoms were relieved, API rose from 0.23 +/- 0.04 to 0.55 +/- 0.03 but increased only from 0.22 +/- 0.09 to 0.40 +/- 0.02 in limbs with insufficient improvement. Preoperative thigh pressure index (TPI) in claudicating limbs with poor results (0.96 +/- 0.05) differed little from that in limbs with good results (0.92 +/- 0.05); nor was the TPI of ischemic limbs with poor results (0.83 +/- 0.13) significantly greater than that in limbs with good results (0.60 +/- 0.05). Neither the TPI nor the thigh to ankle pressure gradient was of value in predicting which extremities would respond poorly to aortoiliofemoral reconstruction.


The mortality associated with pelvic fractures. The mortality among 604 patients with pelvic fractures was 12%. Pedestrian accidents were the etiologic agent in 27% of the patients, but accounted for 49% of the deaths and for 73% of the deaths primarily due to pelvic fractures. Although 71 of the 72 patients who died sustained concomitant major injuries (mean, 3.1), 60% of the deaths (43 patients) were attributed entirely or in part to pelvic fractures. Of particular interest were the 26 patients in whom the pelvic fracture was the primary cause of death. Ninety-three percent were in shock or had clinical evidence of hypovolemia at the time of admission. Eighteen patients (69%) exsanguinated from their pelvic fractures shortly after hospital admission (mean, 9 hours). They were more elderly than the eight patients who survived their initial resuscitation, but subsequently died of sepsis or of renal failure (mean, 62 vs. 38 years). Sepsis arising in the pelvic hematoma and acute renal failure induced by pelvic hemorrhage and/or pelvic sepsis each accounted for 15% of the deaths. Ninety-one percent of the patients who died primarily of their pelvic fracture had a single or double break in the pelvic ring. Thirty-one precent had open pelvic fractures, and injury associated with a 50% mortality. Twenty-three percent had pelvic fracture related iliac or femoral vessel disruptions, an injury associated with a 75% mortality. Mortality in these patients clearly resulted from ineffective control of pelvic hemorrhage and from the inability to prevent sepsis in the pelvic hematoma.


Accuracy of techniques to detect intraperitoneal abscess. Three new diagnostic techniques, gray-scale ultrasonography, gallium-67 scanning (67Ga), and computed tomography (CT) were used in combination to detect intraperitoneal abscess in 30 patients. All 30 had sonography, 24 were scanned for 67Ga, and 15 underwent CT. Nine had three tests and 21 had two. Accuracy of results was evaluated by subsequent laparotomy in 16 and by clinical impression in the remainder. Ultrasound was accurate (true positive and true negative) in 12 of 16 (75%) operated patients, with 12% false-positive and 12% false-negative results. Gallium correctly diagnosed nine of 14 (64%) operated patients having 22% false-positive and 14% false-negative diagnoses. CT was accurate in five of seven (71%) patients evaluated by operation, with 14% false positives and 14% false negatives. Overall accuracies for both operated and clinical groups was ultrasound 57%, gallium 54%, and CT 67%, not significantly different results. Three tests agreed in only two of nine patients (22%), with no single test more accurate than another. Two tests agreed in 57%, with no test superior to another. It is concluded that ultrasonography, 67Ga scanning, and CT each have significant limits in diagnosing intra-abdominal pus. No single test is better than another. Disagreement among test results in the same patient obviates use of more than one technique in most instances.


Esophageal atresia and tracheoesophageal fistula: Effect of delayed thoracotomy on survival. Eighty-four infants with esophageal atresia and/or tracheosophageal (TE) fistula were treated from 1972 to 1977. Twenty-eight percent were premature and 24% weighed less than 2.0 kg. Major symptoms included excess salivation (56 patients), respiratory distress (28 patients), cyanosis (26 patients), and choking (nine patients). Pneumonia and or atelectasis occurred in 58% and associated anomalies in 68%. Seventy-three of 84 patients (87%) had proximal esophageal atresia and distal TE fistula (type C defect). Operation was carried out in 79 patients. Gastrostomy was performed in 75 patients, often under local anesthesia with subsequent delayed extrapleural thoractomy (mean, 3.9 days), when the infant's pulmonary condition was improved. Primary anastomosis was performed in 55 patients, division TE fistula and esophagostomy in ten, staged anastomosis in seven, cervical esophagostomy alone in three, division H fistual in two, ligation TE fistula alone in one, and gastrostomy alone in one. Complications were frequent, including need for ventilator support in 28 patients, atelectasis in 28, pneumonia in 18, jaundice in 13, heart failure in 11, anastomotic leak in 10, and stricture in four. Operative mortality was 5% (four of 79). Two deaths followed immediate thoracotomy and two were premature with anomalies. There were eight late deaths 4 to 39 months after operation. Seven had multiple anomalies. The overall mortality was 15%. Management of high-risk cases by preliminary gastrostomy and delayed extrapleural thoracotomy is associated with improved survival (67 to 79) (85%). Neonatal intensive care, detection of associated anomalies, and long-term follow-up are essential factors in reducing mortality.


Induced thrombosis of inoperable abdominal aortic aneurysm. On occasions it may be vital to produce controlled thrombosis of an abdominal aortic aneurysm when resection is not possible. A successful technique was evolved to achieve this in a 57-year-old man with malignant lymphoma. The tumor was found to infiltrate massively the retroperitoneum and the wall of a large abdominal aortic aneurysm. The large aneurysm was deemed to be technically unresectable at operation. An approach was devised to thrombose the aneurysm and to proceed safely with chemotherapy of the malignant lymphoma. An axillobifemoral bypass was made with the limbs anastomosed end to end to the common femoral arteries. The external iliac vessels were exteriorized through the abdominal wall. The aneurysmal sac outflow was occluded by balloon catheters introduced through the exteriorized iliac vessels. A right transaxillary catheter was inserted and placed at the level of the renal arteries to induce and to control the progress of thrombus formation in such a way as to ensure patency of the renal vessels. Thrombin was delivered into the sac via this transaxillary catheter. A high urinary output was maintained. Serial angiograms of the clotting process were obtained. Once the sac was thrombosed, the balloon catheters were removed and a final angiogram was obtained which demonstrated the obliteration of the aneurysmal sac and the patency of the renal vessels. The patient has been fully employed for 20 months.


Bleeding vascular malformations of the intestine. Thirty-nine patients with bleeding vascular malformations were evaluated. The age range was from 3 to 78 years, with a bimodal age distribution. The younger patients had no associated diseases, while those in the older category invariably had an associated cardiac lesion (aortic stenosis in 12 patients and severe atherosclerotic disease in 11 patients). With experience, colonoscopy has become a valuable adjunct to arteriography with the lesion visualized in 12 patients. Arteriography is the most useful study being diagnostic in 35 of 38 cases. Exploration alone was diagnostic in only one of 39 patients. The most common site of bleeding was the cecum (21 patients) followed by the proximal small intestine (eight patients), terminal ileum (seven patients), and ascending colon (five patients). The lesions in the proximal small bowel were much more common in the younger patients and were believed to be congenital. Resection controlled the bleeding in the majority of patients, although four recurrences have been noted. All have been documented angiographically to have been from a new lesion and two were controlled with reoperation. The key elements to control of these patient's bleeding include: (1) systematic work-up with a team approach emphasizing careful visceral angiography, and (2) the avoidance of a premature laparotomy prior to complete evaluation.


Central venous pressure or pulmonary capillary wedge pressure as the determinant of fluid replacement in aortic surgery. Both central venous pressure (CVP) and pulmonary capillary wedge pressure (PCWP) have been used as guides to fluid replacement in patients undergoing abdominal aortic surgery. To test the hypothesis that changes in PCWP (deltaPCWP) may be reliably estimated from changes in CVP (deltaCVP), 55 patients had simultaneous measurements (302 paired observations) of CVP and PCWP, as well as of cardiac output, before and during operation. The correlation between deltaCVP and deltaPCWP was high (r = 0.716, P less than 0.001). The estimated slope for the linear regression was 0.88. The standard error of the estimate was +/- 3.75 torr, making the prediction of deltaPCWP from deltaCVP accurate only to within 7.5 torr. There were five patients who each had a low and failing CVP accompanied by a stable cardiac output and a rising PCWP; for them, a decision to administer fluid based on the CVP might have resulted in pulmonary edema. Although deltaCVP accurately predicted direction and magnitude of deltaPCWP in the majority of patients (90%), there was a small group in whom there was no substitute for direct measurement of PCWP.


Total anomalous pulmonary venous connection (surgical technique, early and late results). Between March 1970 and October 1977, 36 patients underwent correction of total anomalous pulmonary venous connection. The ages ranged from 5 days to 16 years; 27 (75%) were under 1 year and 19 were under 3 months of age at the time of surgery. The overall mortality was 33%. Supracardiac connection was the commonest type and was associated with the lowest hospital mortality (30%). The highest mortality occurred in the mixed and infracardiac types and was related in part to the presence of associated intracardiac anomalies. The use of hypothermia and circulatory arrest in infancy has resulted in a considerably lower hospital mortality compared with cases operated on under conventional cardiopulmonary bypass. The mortality in 23 infants (under 1 year of age) was 26% using circulatory arrest and was lowest when correction was performed within the first three months of life (18%). All four infants operated on with standard cardiopulmonary bypass died, whereas this technique was found to be safe in older children. The surgical technique using a left anterolateral thoractomy with a trans-sternal extension is described. This technique gives an excellent exposure for fashioning a long anastomosis and has been associated with a low incidence of postoperative pulmonary complications. There have been no late deaths and all survivors, who are in excellent condition up to seven years after correction, have a normal exercise tolerance.


Double outlet right ventricle: clinical and anatomical spectrum. Thirty-two patients with double outlet right ventricle (DORV) were studied between 1960 and 1976. Associated congenital defects frequently compounded the difficulty of clinical diagnosis. Cardiac catheterisation was performed in 27 patients, and the ventriculograms were studied with particular regard to the relative positions of the great vessels to each other and to the ventricular septal defect. These relationships determine which corrective operation is possible. Correction has been performed in 12 patients with a perioperative mortality of 25%. Although mitral-aortic discontinuity was demonstrated in all cases, consideration of the anatomical spectrum included in the term DORV suggests that discontinuity is not an essential feature. In common with other clinical data and in contrast with necropsy studies, none of our patients was found to show the normal relationship of the great vessels to each other, in which the aorta lies posterior and to the right of the pulmonary artery. The reason for this difference between the clinical and necropsy findings is not apparent. A similar disparity was shown with regard to pulmonary stenosis, which was demonstrated at catheterisation in 68% of the 27 patients (mean gradient 68 +/- 3 mmHg), in contrast with incidences of 18% and 25% in recent necropsy series. Patients in the necropsy studies were frequently neonates or infants, in whom death may have been the result of intractable cardiac failure secondary to excessive pulmonary blood flow. In older patients without pulmonary stenosis and with pulmonary hypertension, frequent observation is imperative so that surgical treatment can be instituted before the development of irreversible pulmonary vascular disease.


Protrusion of the lung apex through Sibson's fascia in infancy. Apical 'herniation' of the lung is an unusual protrusion of the lung and its pleural coverings through the superior aperture of the thorax. It is supposedly caused by weakness of Sibson's fascia. The phenomenon is an anatomical variation and not a disease entity; however, it must be recognised in order to avoid inappropriate surgery. The condition apparently disappears spontaneously with growth.


Aetiology of unresolved pneumonia.

Aetiology of unresolved pneumonia. Preoperative histological or cytological confirmation of a diagnosis of bronchogenic carcinoma is not always possible, so occasionally non-neoplastic lesions are resected. Of these lesions a significant number are described by pathologists as 'unresolved pneumonia'. We studied the case notes and histopathology of 30 patients from whom lung had been resected and which had been classified as pneumonia. Other non-neoplastic lesions, such as pulmonary infarction, bronchiectasis, and tuberculosis, were excluded. All had a preoperative diagnosis of probable bronchial carcinoma. On review very few appeared to be the consequence of an infective, pneumonic episode. In 11, foreign material was identified, including one typical example of a paraffinoma. Aspiration of foreign material may lead to a localised lesion which simulates carcinoma of the bronchus both clinically and radiographically.


Mechanical properties of the lung in extrinsic allergic alveolitis. The lung function of 14 patients with extrinsic allergic alveolitis caused by exposure to mouldy hay (farmer's lung) or to birds (bird fancier's lung) was studied one week and four to six weeks after the last exposure to antigen. These data, together with lung mechanics measured four weeks after antigen exposure, were compared with measurements in 34 healthy non-smoking control subjects. Shortly after exposure to antigen there were reduction in lung volumes, increased elastic recoil (reduced compliance), and varied effects on expiratory flow and reduced gas transfer. With time, lung volumes and gas transfer improved, but expiratory flow often remained decreased. The data on lung mechanics showed that reduced compliance was often found, but this increased recoil did not always produce high airflow indicating increased upstream airways resistance. Patients with a longer duration of the illness tended to have increased compliance (reduced recoil) and low airflow. These results show that the described pathological changes of airway involvement, fibrosis, and emphysema in allergic alveolitis are manifest in the lung function of patients with the disease.


Spirometry in healthy men: a correlation with smoking and with mild symptoms. Symptoms, smoking history, and variates taken from the forced expiratory manoeuvre were studied in a group of 271 healthy men attending a mass radiography unit. It was found that correlation of the forced expiratory ratio (FEV1/FVC) with the presence of mild or moderate respiratory symptoms was at least as satisfactory as that of technically more complicated measurements such as MEF50 and MEF75. In asymptomatic individuals those differences associated with smoking were the same for FEV1/FVC as for MEF75. Asymptomatic abnormalities of lung function were not observed. Simple measurements such as FEV1/FVC can therefore provide as much information from a forced expiratory manoeuvre to screen for early airways obstruction as MEF50 and MEF75.