Ivermectin for the treatment of periodic malayan filariasis: a study of efficacy and side effects following a single oral dose and retreatment at six months. Ivermectin, a new antifilarial drug and currently the drug of choice for the treatment of onchocerciasis, has been shown to be effective in bancroftian filariasis. We report here, for the first time, the efficacy and safety of the drug in the treatment of filariasis caused by periodic Brugia malayi. Sixty male, asymptomatic microfilaraemics of Alleppey district, Kerala, South India, received single oral doses of ivermectin in a double blind study. Four dosages were used: 20, 50, 100 and 200 micrograms kg-1 body weight. Clearance of microfilariae, which was not complete, began as early as 12 hours post-treatment and was maximal at the end of one month. Microfilaria levels began to rise thereafter and reached 20-50% of pretreatment levels at six months. The two higher doses (100 and 200 micrograms kg-1) were more effective in suppressing microfilaraemia at six months (P < 0.05). After six months, 32 patients were retreated using the same dose of ivermectin that they had received initially. The pattern of clearance was essentially similar to that seen during the first treatment phase and microfilaria levels were 10-35% of pretreatment levels at the end of the next six months. Twenty-eight individuals who were not retreated at six months continued to have increasing levels of microfilariae, reaching 60% of pretreatment levels at the end of the next six months. Side effects (such as fever, headache, myalgia), which were mild to moderate, were seen in most patients and were unrelated to the dose (P > 0.05) or pretreatment levels of microfilariae.(ABSTRACT TRUNCATED AT 250 WORDS)


The prevalence and intensity of soil-transmitted helminthiases in rural communities in southern Nigeria. An investigation of the prevalence and intensity of soil-transmitted helminthiases was undertaken in four villages in Oyo state, Nigeria. Diagnosis was based on examination of stool samples for the presence of helminth ova in all age classes. The prevalence of Ascaris lumbriocoides ranged from 61.5-72.2%, of Trichuris trichiura from 65-74%, and of hookworm from 52.4-63% depending on the village concerned. Intensity, assessed indirectly as the mean eggs per gram of faeces (epg), varied with regard to the four villages. The mean egg count of A. lumbricoides varied from 6815-10,823 per gram, of T. trichiura from 127-246, and of hookworm from 122-267. Host age, sex and household size were found to be significant factors influencing faecal egg output, and indirect measure of the intensity of the helminth infections.


Human Oesophagostomum infection in northern Togo and Ghana: epidemiological aspects. Recently, it has been established that human infection with Oesophagostomum bifurcum is common in northern Togo and northeastern Ghana. Two surveys were conducted in this area. In a regional survey, O. bifurcum infection appeared to occur in 38 of 43 villages. The highest prevalences (up to 59%) occurred mostly in small isolated villages and were usually associated with high hookworm infection rates. The infection was relatively rare in children under five years of age (7% infected). In older individuals, females showed higher prevalences than males (30% vs. 24%). In a second survey, the entire population of two high-prevalence villages was examined. Infection rates were low in children under three years of age, but rose quickly thereafter, suggesting intense transmission. A stable level of infection was reached by 10 years of age. Oesophagostomum larvae were found more frequently in hookworm-positive than in hookworm-negative coprocultures, and possible explanations for the association between infection with Oesophagostomum and hookworm are discussed.


Coagulation abnormalities and ivermectin. Prothrombin ratios were measured 13-16 days after treatment in 148 subjects from Sierra Leone taking part in a double-blind placebo-controlled trial of ivermectin. Prolonged prothrombin ratios were observed more frequently in the ivermectin group, although this difference was not significant and no patients suffered bleeding complications. Further investigation of these patients failed to reveal any abnormality of liver function, although factor VII and II levels were reduced in most affected individuals, suggesting interference with vitamin K metabolism. Ivermectin has a minimal effect on coagulation and concern about mass treatment for this reason appears to be unjustified.


Mediastinitis in heart transplantation.

Mediastinitis in heart transplantation. Between March 1985 and December 1991, mediastinitis developed in 12 of 420 cardiac transplantation patients (2.8%). The mortality rate in this group of patients was 8.3% (1/12). Actuarial survival (1 year, 75%; and 5 years, 65%) was not significantly different from that of the group without mediastinitis (1 year, 88%; and 5 years, 75%). A higher percentage of the patients in the group with mediastinitis were listed as UNOS status 1 (50% versus 35%) and had a history of previous sternotomies (58% versus 44%). The presentation of mediastinitis was typical. Computed tomographic scanning with or without aspiration was a valuable adjunct in the diagnosis of mediastinitis. Induction immunotherapy with minimal steroids in the perioperative period was used in all patients. This may contribute to the patients' ability to mount an appropriate and effective response to infection, permitting earlier diagnosis. The debridement irrigation technique used in 8 of 12 patients had a low success rate of 33%, whereas the debridement muscle flap technique used in 4 of 12 was 100% successful in eliminating infection.


Long-term effect of total fundoplication on the myotomized esophagus. From 1978 to 1983, 17 patients had an esophagocardiomyotomy with an added short total fundoplication as an antireflux procedure. Thirteen had achalasia and 4, diffuse esophageal spasm. All patients initially had the usual symptoms of these motor disorders. Early after the operation all became asymptomatic, but over the years of follow-up, symptoms reappeared in 14 of 17 patients, and 5 required reoperation. The distal esophageal transverse diameter showed progressive dilatation from 3.9 cm preoperatively to more than 6 cm after 10 years of evolution. Over the same period, deterioration in the esophageal emptying capacity caused esophageal stasis to increase from 32% to 75%. Manometric changes were significant after the operation: resting pressures in the esophageal body decreased from 10.5 to 4.4 mm Hg (p < 0.001) proximally and from 12.2 to 4.6 mm Hg distally (p < 0.001). Peak contraction pressures became significantly weaker: 38 to 30 mm Hg in the proximal esophagus (p < 0.001) and from 49.2 to 28.1 in the distal esophagus (p < 0.001). Tertiary contractions were unchanged distally, but peristalsis reappeared in more than 30% of all swallows in the proximal half of the esophageal body. The resting pressure gradient in the lower esophageal sphincter area was reduced from 25.5 to 7.4 mm Hg by the operation. This gradient remained stable over 10 years of follow-up. No significant acid exposure was documented in 8 patients undergoing 24-hour pH recordings after their operation. Endoscopy revealed dilatation and retention without evidence of reflux esophagitis damage. Total fundoplication when associated with esophageal myotomy results in improved symptoms in the early postoperative phase.(ABSTRACT TRUNCATED AT 250 WORDS)


Clinical manifestation of mediastinal fibrosis and histoplasmosis. We treated 20 patients thought to have mediastinal fibrosis secondary to Histoplasma capsulatum. All but 1 were symptomatic. The most common symptoms were dyspnea (8), hemoptysis (6), postobstructive pneumonia (5), and superior vena caval obstruction (2). Nine patients had severe stenosis of the trachea, carina, or main bronchus. Special stains identified Histoplasma capsulatum in surgical specimens in 9 patients. Surgical procedures were done for 18 of 20 patients (resection of subcarinal mass, 6; right middle and lower lobectomy, 5; carinal pneumonectomy, 4; esophagoplasty, 4; sleeve resection, 3 (with right main bronchus in 1, right lower and middle lobectomy in 1, and carina in 1); right upper lobectomy, 1; middle lobectomy, 1; and bronchoplasty of left main bronchus, 1. There were 4 deaths, 3 after complications of carinal pneumonectomy and 1 in a patient with tracheobronchial obstruction that could not be dilated. Two patients were treated with amphotericin and 4 with ketoconazole. Sclerosing mediastinitis secondary to histoplasmosis presents tremendous surgical challenges because of the intense fibrosis encountered. Bronchoplastic procedures are possible in spite of the intense fibrosis. High mortality rates after carinal resection may be encountered. The exact role of antifungal therapy is as yet undefined.


Postcardiotomy centrifugal mechanical ventricular support. From August 1979 through August 1991, 91 patients were supported with centrifugal mechanical ventricular assist. Major indications for its use were postcardiotomy ventricular failure (79) or as a bridge to cardiac transplantation (12). In postcardiotomy use (0.2% of all cardiac procedures), there were 54 male (68.4%) and 25 female patients (31.6%) with a mean age of 54.8 years and a mean duration of use of 3.56 days (range, 1 hour to 19 days). Forty-nine patients (62%) were successfully weaned, and 20 (25.3%) were hospital survivors. In 57 patients the device was inserted to wean from cardiopulmonary bypass, whereas in 22 it was employed later in the postoperative period because of low cardiac output or sudden arrest. Thirty-four (59.6%) of the 57 patients in the former group were weaned, and 15 (26.3%) were discharged, results similar to those in the latter group with 15 (68.2%) weaned and 5 (22.7%) discharged. Morbidity associated with use of centrifugal blood pumps included bleeding (87.3%; mean transfusion requirement, 53.2 units), renal failure (46.8%), cerebrovascular accident (12.7%), thromboembolism (12.7%), and hepatic insufficiency (12.7%). After a mean follow-up of 45.4 months (range, 2 to 142 months), 7 patients had died (35% late mortality), 1 patient is in functional class IV, and all others are in functional class I or II. Lower survival was associated with biventricular failure and renal failure but not with age or sex of the patient.


Device-supported myocardial revascularization: safe help for sick hearts. Although advances in both the technology of artificial oxygenation and our understanding of myocardial preservation have made aortocoronary bypass operations safer, clinical settings remain where even these improvements have limited efficacy. We have recently treated 43 severely ill patients with aortocoronary bypass, using a ventricular assist device for intraoperative hemodynamic support and ventricular decompression. For 34 of the patients, preoperative ejection fractions (multigated acquisition) ranged from 0.12 to 0.28 (average, 0.22); 6 patients manifested cardiogenic shock preoperatively, and emergency operations precluded multigated acquisition studies. Twenty-nine patients had preoperative evidence of congestive heart failure, 10 had a prior bypass operation, 9 had major chronic obstructive pulmonary disease, and 2 were Jehovah's Witnesses. The operative technique involved minimal doses of heparin (1 to 1.5 mg/kg), no cardioplegia, and no cardiopulmonary bypass. Revascularization was accomplished on beating, nonworking hearts, with right (40 of 43) and left (43 of 43) ventricles supported by Nimbus Hemopumps (4 of 43) or Bio-Medicus centrifugal ventricular assist devices for an average of 112 minutes. In each case, the patient's lungs were used as the oxygenator. An average of 3.7 bypass grafts per patient were constructed. The left internal mammary artery was used in 41 patients, whereas at least one coronary endarterectomy was required in 20. Six patients had concomitant placement of an automatic implantable cardioverter defibrillator. Two patients (4.6%) died: 1 (with preoperative cardiogenic shock) of low cardiac output on postoperative day 1, and 1 of a severe neurologic deficit on day 8. Follow-up ranged from 2 to 18 months (average, 8.9 months), with all survivors demonstrating improvement in cardiac function in both the early and late postoperative periods.(ABSTRACT TRUNCATED AT 250 WORDS)


Early cellular events in the lung allograft. We hypothesized that ischemic insult to the lung allograft may render it more susceptible to rejection. Left canine single-lung allografts were subjected to usual periods of cold and warm ischemia (4 hours and 1 hour, respectively). Bronchoalveolar lavage and open lung biopsies were performed at 0, 1, 4, and 24 hours and 1 week after transplantation. Bronchoalveolar lavage fluid was examined for cellular phenotypes, lymphocyte lectin-mediated cytotoxicity, and natural killer cell cytotoxicity. Open lung biopsy specimens were examined for severity of injury/rejection and MHC class II expression. Within 1 to 4 hours of reimplantation, we observed marked influx of polymorphonuclear leukocytes and lymphocytes and an increase in lectin-mediated cytotoxicity (25.6% +/- 14.8% and 50.6% +/- 20.1% versus 5.4% +/- 7.5% preoperatively; p < 0.05). In addition, natural killer cell cytotoxicity increased from 10.2% +/- 13.5% before transplantation to 20.5% +/- 8.6% 4 hours after transplantation (p < 0.03). By 24 hours MHC class II expression became evident and continued to increase while subtle histologic evidence of rejection appeared by 1 week. We conclude that ischemia-reperfusion injury can alter the local bronchopulmonary milieu, thus rendering it more susceptible to the development of rejection.


Bioassay of EDRF from internal mammary arteries: implications for early and late bypass graft patency. To study the basal, luminal release of endothelium-derived relaxing factor, 35-mm segments of canine internal mammary artery (IMA) were cannulated and perfused at 5 mL/min in vitro with physiological salt solution. Vasoactive properties of the effluent were bioassayed on coronary artery smooth muscle. Effluent from IMAs produced significant vasodilation of the bioassay ring compared with effluent from a prosthetic conduit (n = 24; p < 0.05). The vasodilation by the effluent could be eliminated by mechanically removing the intima of the IMA, or by treating the IMA segments with NG-monomethyl-L-arginine or NG-nitro-L-arginine, two competitive inhibitors of nitric oxide synthesis from L-arginine; vasodilation was not influenced by treatment with indomethacin. In 83% of the superfusion experiments, effluent from the left IMA induced greater relaxation of the bioassay ring than did effluent from the right IMA. In addition, the average vasodilation induced by left IMA effluent was 28% +/- 2.3% versus 17.4% +/- 3.1% for the right (n = 24; p < 0.05). However, in organ chamber experiments, right and left IMAs exhibited comparable endothelium-dependent vasodilation to acetylcholine (n = 6). Because endothelium-derived relaxing factor induces vasodilation and also inhibits platelet adhesion, platelet aggregation, and atherogenesis, luminal release of endothelium-derived relaxing factor by the IMA could contribute to superior results when the artery is used in bypass grafting.


Coronary artery bypass without cardiopulmonary bypass. The purpose of this article is twofold: to describe our technique for performing coronary artery bypass grafting without cardiopulmonary bypass (off pump) and to demonstrate that this operation is safe, in terms of mortality and certain indices of morbidity. Very little has been published in regard to off-bypass operations. From 1985 through 1990, 220 patients underwent operation off bypass; 220 on-pump controls were retrospectively matched for number of grafts, left ventricular function, and date of operation. Groups were compared in terms of mortality and ten indicators of morbidity. The same analysis was performed for ten subgroups. We found no statistically significant difference between groups in mortality (off pump, 1.4% [3/220]; on pump, 2.4% [5/220]), which held across all subgroups. Patients undergoing operation off pump required blood far less often (not transfused: off pump, 72.7% [160/220]; on pump, 54.6% [116/220]; p = 0.005 by Fisher's exact test), and the low output state occurred statistically less frequently off pump (off pump, 5.5% [12/220]; on-pump, 12.7% [28/220]; p = 0.01 by Fisher's exact test). Further research should be directed to which subgroups can be operated on to advantage off pump and which, if any, groups of patients should be confined to on-bypass operations.


Left atrial isolation associated with mitral valve operations. Surgical isolation of the left atrium was performed for the treatment of chronic atrial fibrillation secondary to valvular disease in 100 patients who underwent mitral valve operations. From May 1989 to September 1991, 62 patients underwent mitral valve operations (group I); 19, mitral valve operations and DeVega tricuspid annuloplasty (group II); 15, mitral and aortic operations (group III); and 4, mitral and aortic operations and DeVega tricuspid annuloplasty (group IV). Left atrial isolation was performed, prolonging the usual left paraseptal atriotomy toward the left fibrous trigone anteriorly and the posteromedial commissure posteriorly. The incision was conducted a few millimeters apart from the mitral valve annulus, and cryolesions were placed at the edges to ensure complete electrophysiological isolation of the left atrium. Operative mortality accounted for 3 patients (3%). In 79 patients (81.4%) sinus rhythm recovered and persisted until discharge from the hospital. No differences were found between the groups (group I, 80.7%; group II, 68.5%; group III, 86.7%; group IV, 75%; p = not significant). Three late deaths (3.1%) were registered. Long-term results show persistence of sinus rhythm in 71% of group I, 61.2% of group II, 85.8% of group III, and 100% of group IV. The unique risk factor for late recurrence of atrial fibrillation was found to be preoperative atrial fibrillation longer than 6 months. Due to the satisfactory success rate in recovering sinus rhythm, we suggest performing left atrial isolation in patients with chronic atrial fibrillation undergoing valvular operations.


Combined carotid and coronary revascularization: the preferred approach to the severe vasculopath. The timing of carotid endarterectomy (CEA) and coronary revascularization (CABG) for concomitant disease is controversial. Results of combined CEA/CABG in 127 patients (age range, 46 to 82 years; mean age, 65 years; 61% male) from 1978 to 1991 were reviewed. Ninety-five patients (75%) were in New York Heart Association functional class III or IV, 48 (38%) had left main coronary artery disease, and 32 (28%) had depressed ejection fraction ( < 0.50). Forty (32%) had asymptomatic bruits, 61 (48%) transient ischemic attacks, and 26 (20%) prior strokes. Seventy-five (59%) had bilateral carotid stenosis, including 20 (16%) with contralateral occlusions. Perioperative mortality was 7 of 127 (5.5%), and all deaths were cardiac related. Myocardial infarctions occurred in 6 of 127 patients (4.7%) and were nonfatal in 3 (2.3%). Permanent strokes occurred in 7 of 127 (5.5%) and were ipsilateral in 5 (3.9%). Perioperative stroke did not occur in the asymptomatic group, but the risk was higher in those with prior stroke (19%) or with contralateral carotid occlusion (15%). The stroke risk for our patients with carotid disease having CABG without CEA is not known, but the literature reports rates as high as 14%. For our patients without known concomitant disease, the risk of permanent stroke was 1.0% (31/3012) for isolated CABG and 1.5% (7/482) for isolated CEA. The late results after CEA/CABG revealed a 5-year survival of 70% +/- 5%, which correlated with ejection fraction ( > or = 0.50, 81% +/- 5%; < 0.50, 45% +/- 11%; p < 0.003). Freedom from late permanent ipsilateral stroke was 97% +/- 2% at 8 years. Freedom from stroke at 5 years was lower among patients with a previous stroke (71% +/- 10%) compared with transiently symptomatic (90% +/- 4%) and asymptomatic (96% +/- 4%) patients (p < 0.03). Combined CEA/CABG is a useful option in this high-risk group of patients with extensive atherosclerosis; avoids a subsequent hospitalization, anesthetic, and delay period; and provides long-term protection from ipsilateral stroke.


Vascular anatomy of the gastric tube used for esophageal reconstruction. This study investigates the actual, as contrasted with the presumed, blood supply of the greater curvature gastric tube commonly used to reconstruct the gullet after esophagogastrectomy. Arterial and venous corrosion casts of this tube were created in 30 cadavers and demonstrated the following: (1) The right gastroepiploic artery is the exclusive conduit of blood in the pedicle. (2) The contribution of the right gastric artery is negligible. (3) Although tributaries of the left gastroepiploic artery are distributed over the central portion of the tube, the connection between the right and left gastroepiploic vessels is minute. (4) The blood supply of the cranial 20% of the greater curvature tube is through a microscopic network of capillaries and arterioles. These findings constitute an anatomical argument for extremely gentle handling of the stomach throughout its mobilization, during construction and positioning of the tube, and during the anastomosis.


Absent pulmonary valve syndrome: operation in infants with airway obstruction. From 1979 through 1991, 19 infants with absent pulmonary valve syndrome and airway obstruction were seen for surgical treatment. All patients underwent extensive pulmonary artery aneurysmorrhaphy using cardiopulmonary bypass. Fourteen patients had simultaneous transatrial ventricular septal defect (VSD) closure, infundibular resection, and placement of a short transannular patch; 2 had transventricular VSD closure and infundibular resection without a transannular patch; 1 underwent transventricular VSD closure and transannular patching; and 2 underwent pulmonary artery aneurysmorrhaphy alone with the VSD left open. All 19 infants had good hemodynamics when taken from the operating theater, but 3 died postoperatively of severe airway obstruction, despite further tracheobronchopexy procedures in 2 (hospital mortality rate, 16%; confidence limits, 7% to 29%). Among the 16 patients discharged from the hospital, there was one late death. Five other patients have required reoperation for branch pulmonary artery stenosis (n = 2), residual airway obstruction resulting from persistent pulmonary artery dilatation (n = 1), closure of VSD (n = 1), and homograft valve insertion for pulmonary incompetence and right ventricular dysfunction (n = 1). There are 15 long-term survivors. Eight of them have episodic bronchospasm of mild to moderate severity, and all are responsive to sympathomimetic bronchodilator aerosols. The remaining 7 are asymptomatic.


Effect of delay in retroperfusion therapy on infarct size reduction. Retroperfusion of arterial blood through the coronary sinus reduces infarct size if therapy starts immediately after coronary artery occlusion. To determine if a new system of non-electrocardiogram-synchronized retroperfusion is able to reduce infarct size after delays consistent with clinical use, anesthetized pigs were subjected to 4 hours of left anterior descending coronary artery occlusion followed by 1 hour of reperfusion. Retroperfusion of arterial blood commenced immediately after occlusion of the left anterior descending coronary artery in the no-delay group (n = 10) and after a 1-hour (n = 10) and a 2-hour (n = 8) delay in two other groups. In the control group (n = 10), no therapy was used. In all groups, retroperfusion of arterial blood was terminated after 4 hours of occlusion of the left anterior descending coronary artery. Infarct size, expressed as a percentage of the in vivo area at risk (+/- the standard deviation), was smaller in the no-delay group (44.1 +/- 12.9) and marginally smaller in the 1-hour delay group (71.0 +/- 9.8) compared with controls (86.3 +/- 7.5) (p < 0.05). Infarct size in the 2-hour delay group (75.0 +/- 10.7) was not significantly different from controls. Mean coronary sinus pressure (+/- the standard deviation) was 56 +/- 25 mm Hg, 39 +/- 9 mm Hg, and 47 +/- 9 mm Hg in the no-delay, 1-hour delay and 2-hour delay groups, respectively. Thus, this new retroperfusion system limits infarct size by 50% if it is started immediately after coronary occlusion.(ABSTRACT TRUNCATED AT 250 WORDS)


Hyperglycemia increases cerebral intracellular acidosis during circulatory arrest. Phosphorus 31 nuclear magnetic resonance spectroscopy was used to assess cerebral high-energy phosphate metabolism and intracellular pH in normoglycemic and hyperglycemic sheep during hypothermic circulatory arrest. Two groups of sheep (n = 8 per group) were placed in a 4.7-T magnet and cooled to 15 degrees C using cardiopulmonary bypass. Spectra were acquired before and during circulatory arrest and during reperfusion and rewarming. Intracellular pH and adenosine triphosphate levels decreased during circulatory arrest. Compared with the normoglycemic animals, the hyperglycemic group was significantly more acidotic with the greatest difference observed during the first 20 minutes of reperfusion (6.40 +/- 0.08 versus 6.08 +/- 0.06; p < 0.001). Intracellular pH returned to baseline after 30 minutes of reperfusion in the normoglycemic group but did not reach baseline until 1 hour of reperfusion in the hyperglycemic animals. Adenosine triphosphate levels were significantly higher in the hyperglycemic group during circulatory arrest. Repletion of adenosine triphosphate during reperfusion was similar for both groups. These results support the hypothesis that hyperglycemia during cerebral ischemia drives anaerobic glycolysis and thus leads to increased lactate production and an increase [corrected] in the intracellular acidosis normally associated with ischemia.


Barbiturates impair cerebral metabolism during hypothermic circulatory arrest. Barbiturates have been used as a method of cerebral protection in patients undergoing open heart operations. Phosphorus 31 nuclear magnetic resonance spectroscopy was used to assess barbiturate-induced alterations in the cerebral tissue energy state during cardiopulmonary bypass, hypothermic circulatory arrest, and subsequent reperfusion. Sheep were positioned in a 4.7-T magnet with a radiofrequency coil over the skull. Nuclear magnetic resonance spectra were obtained at 37 degrees C, during cardiopulmonary bypass before and after drug administration at 37 degrees C and 15 degrees C, throughout a 1-hour period of hypothermic circulatory arrest, and during a 2-hour reperfusion period. A group of animals (n = 8) was administered a bolus of sodium thiopental (40 mg/kg) during bypass at 37 degrees C followed by an infusion of 3.3 mg.kg-1 x min-1 until hypothermic arrest. A control group of animals (n = 8) received no barbiturate. The phosphocreatine/adenosine triphosphate ratio, reflecting tissue energy state, was lower during cardiopulmonary bypass at 15 degrees C in the treated animals compared with controls (1.06 +/- 0.08 versus 1.36 +/- 0.17; p < 0.001). Lower phosphocreatine/adenosine triphosphate ratios were observed throughout all periods of arrest and reperfusion in the barbiturate-treated animals compared with controls (p < or = 0.01). Thiopental prevented the increase in cerebral energy state normally observed with hypothermia and resulted in a decrease in the energy state of the brain during hypothermic circulatory arrest and subsequent reperfusion. These results suggest that thiopental administration before a period of hypothermic circulatory arrest may prove detrimental to the preservation of the energy state of the brain.


Coronary sinus injuries during retrograde continuous normothermic blood cardioplegia. Injuries to the coronary sinus during cardioplegic arrest are rare but potentially lethal. We herein present case reports of injuries to the coronary sinus occurring during retrograde continuous normothermic blood cardioplegia, and emphasize preventive measures and treatment.


Clinical cardiomyoplasty: preoperative factors associated with outcome. Dynamic cardiomyoplasty has been used clinically to augment the ventricular function of a failing heart. Fifteen clinical dynamic cardiomyoplasties have been performed at Allegheny General Hospital since 1985. Left ventricular ejection fraction improved in long-term survivors from a preoperative value of 0.23 +/- 0.02 to 0.32 +/- 0.05 with postoperative cardiomyostimulation (p < 0.05). There was an average reduction of 2 +/- 0.3 New York Heart Association classes (3.6 +/- 0.2 before operation versus 1.6 +/- 0.4 after operation; p < 0.001). Postoperative mortality was 27% (4/15), and early mortality (within 6 months after operation) was 20% (3/15). Significant preoperative differences between survivors and nonsurvivors were found in right ventricular ejection fraction (0.53 +/- 0.03 versus 0.30 +/- 0.07; p < 0.05), pulmonary artery mean pressure (19 +/- 2 versus 34 +/- 6 mm Hg; p < 0.05), pulmonary artery diastolic pressure (12 +/- 1 versus 25 +/- 5 mm Hg; p < 0.05), and pulmonary vascular resistance (1.4 +/- 2 versus 2.5 +/- 0.7 Wood units; p < 0.05). Dynamic cardiomyoplasty can be done with low operative mortality in patients with isolated left ventricular failure, but mortality is high in those with biventricular failure or pulmonary hypertension. Improvement in functional class and ventricular function can be expected in long-term survivors. Application of these findings to patient selection will improve the risk/benefit ratio for dynamic cardiomyoplasty.


Fluosol cardioplegia results in complete functional recovery: a comparison with blood cardioplegia. Blood cardioplegia is considered by many to be the preferred solution for myocardial protection. Proposed benefits include the ability to deliver oxygen and the ability to maintain metabolic substrate stores. However, the decreased capacity of blood to release oxygen at hypothermic conditions as well as the presence of deleterious leukocytes, platelets, and complement may limit complete functional recovery. Fluosol is an asanguineous solution with the ability to bind and release oxygen linearly at low temperatures. Neonatal piglet hearts (24 to 48 hours old) were excised and supported on an isolated, blood-perfused working heart model. After baseline stroke-work index was determined, hearts were arrested with either normocalcemic blood cardioplegia (group 1, n = 8) or normocalcemic Fluosol cardioplegia (group 2, n = 8). Cold cardioplegia was administered at 45 mm Hg every 20 minutes for 2 hours. Hearts were then reperfused with whole blood. Functional recovery, expressed as percent of control stroke-work index, was determined 60 minutes after reperfusion at left atrial pressures of 3, 6, 9, and 12 mm Hg. Functional recovery at 60 minutes was similar between group 1 (95%, 93%, 93%, 88%) and group 2 (100%, 94%, 94%, 95%) at left atrial pressures of 3, 6, 9, and 12 mm Hg, respectively. Mean lactate consumption 5 minutes after reperfusion was significantly greater (p = 0.0001) in group 1 (31.8 +/- 6.3 micrograms.min-1 x g-1) than in group 2 (-0.59 +/- 0.1 microgram.min-1 x g-1), indicating superior metabolic recovery in the blood cardioplegia hearts. Edema formation, as determined both by water content (group 1, 81.10%; group 2, 81.63%) and by electron microscopy, was not significantly different between groups.(ABSTRACT TRUNCATED AT 250 WORDS)


Influence of beta 1-blockade on myocardial substrates early after a coronary operation. A high adrenergic strain during reperfusion after ischemia impedes functional recovery. Conversely, adrenergic blockade may be beneficial during reperfusion. This study was undertaken to find out if early postoperative high-dose infusion of the selective beta 1-blocking agent metoprolol tartrate has additional effects on metabolic variables related to myocardial energy supply/demand balance compared with those obtained with a late preoperative oral dose. The study included 21 male patients undergoing coronary bypass grafting. All patients received an oral dose of metoprolol before the operation. After the operation, patients were randomized to a control group or a group receiving intravenous infusion of metoprolol. Myocardial uptake of oxygen and substrates was determined before and during atrial pacing. Metoprolol reduced arterial concentrations of free fatty acids, reduced myocardial uptake of free fatty acids, and enhanced myocardial uptake of lactate. During paced tachycardia, the metoprolol concentration correlated negatively with myocardial uptake of free fatty acids (r = -0.80; p < 0.001) and positively with myocardial uptake of lactate (r = 0.53; p < 0.05). It is concluded that postoperative infusion of metoprolol induces myocardial metabolic changes compatible with an improved energy supply/demand balance.


Pleuropulmonary aspergilloma: clinical spectrum and results of surgical treatment. From 1974 to 1991, 77 patients were admitted for pulmonary (55), pleural (16), or bronchial (6) aspergilloma. About 50% were asymptomatic. Sixty-three underwent operation. Pulmonary aspergillomas were operated on for therapeutic need in 26 and on principle in 18; the procedures were 28 lobar or segmental resections, 10 thoracoplasties, and 5 pleuropneumonectomies (1 patient had exploration only). Pleural aspergillosis was treated by operation on principle in 5 and for therapeutic need in 8 patients; 10 thoracoplasties, 1 attempt at pleuropneumonectomy, and 2 decortications were performed. All six bronchial lesions were operated on as a rule. Overall postoperative mortality was 9.5%. Major complications were bleeding (n = 37), pleural space problems (n = 24), respiratory failure (n = 6), and postpneumonectomy empyema (n = 4). All patients with pleural disease experienced complications. The outcome was better after lobar or segmental resection than after thoracoplasty (mortality, 6% versus 15%). Asymptomatic and nonsequellary pulmonary or bronchial aspergilloma also had an improved outcome. We conclude that operation is at low risk in pulmonary or bronchial locations in asymptomatic patients and in the absence of sequellae; the risk is high in symptomatic patients for whom operation is the only definite treatment. Pleuropneumonectomy should be avoided. Only symptomatic pleural aspergilloma should be operated on.


Temporary double exclusion of the perforated esophagus using absorbable staples. A new method for double exclusion of the esophagus is presented. Temporary closure of the cervical and intraabdominal esophagus using absorbable staples allows effective healing of esophageal perforations. The procedure should be routinely combined with drainage of the periesophageal abscess. Complete recanalization of the esophagus occurs 1 to 2 weeks after operation.


Vascular and interstitial effect of University of Wisconsin solution on canine lung. Belzer's University of Wisconsin cold storage solution (UWCSS) has proved useful in extending the shelf life of organs in extrathoracic transplantation and more recently has also been shown to be useful in heart transplantation. I investigated the effect of 4 degrees C UWCSS on the vascular and interstitial properties of the lung to see whether it affected the pulmonary microcirculation or caused pulmonary edema. Infusion of UWCSS was associated with a slight decrease in oxygen tension, but the final oxygen tension was no different from that previously demonstrated with Euro-Collins solution. Vascular conductance was not affected by UWCSS, but average vascular closure increased slightly, indicating that increased vascular tone occurs. This effect is similar to but less than that previously observed with Euro-Collins solution. Based on comparisons of wet to dry weight ratios, estimates of interstitial compliance, transvascular fluid flux, and microvascular filtration coefficient, it does not appear that UWCSS causes pulmonary edema. Further investigation into the usefulness of UWCSS in lung transplantation is therefore warranted.


Safety and efficacy of autologous blood donation before elective aortic valve operation. Although the use of preoperative autologous blood donations for patients undergoing elective cardiac operations has increased dramatically in recent years, patients awaiting elective aortic valve replacement have traditionally been denied access to preoperative autologous blood collection programs. We report our experience with 79 patients, each of whom donated 1 to 3 units of autologous blood before an aortic valve operation. All patients had serious aortic valve disease as evidenced by symptoms and preoperative catheterization data. The patients collectively made 129 blood donations. One patient had a syncopal episode within 2 hours of donation and recovered without difficulty. Of the patients who gave autologous blood preoperatively, 68% avoided any homologous blood donor exposure during their subsequent hospitalization for aortic valve replacement. In contrast, in a group of 298 patients who did not give autologous blood preoperatively, only 31% avoided homologous blood exposure during aortic valve replacement (p < 0.0001). Our experience suggests that preoperative autologous blood donation by patients awaiting elective aortic valve replacement is both safe and effective. Patients with aortic valve disease should not be routinely excluded from preoperative blood services.


Clinical and hemodynamic evaluation of the 19-mm Carpentier-Edwards supraannular aortic valve. The clinical and hemodynamic performance of the 19-mm Carpentier-Edwards supraannular aortic valve is largely unknown compared with that of the larger valves. Over 4 years we implanted the 19-mm Carpentier-Edwards supraannular aortic valve into 21 patients (20 female) with a mean age of 75 +/- 1.2 years (range, 59 to 86 years) and a mean body surface area of 1.6 +/- 0.03 m2 (range, 1.3 to 1.7 m2). There were four deaths, one operative and three late noncardiac deaths. Follow-up of the 17 survivors for a mean of 20 +/- 3.1 months (range, 2 to 42 months) demonstrated symptomatic improvement in all 17 (all are now in New York Heart Association functional class I or II). There were no valve-related complications and no patient required long-term anticoagulation. Doppler echocardiographic studies were used to assess the in vivo hemodynamic profile of the valve. Mean postoperative aortic valve gradient was 34.1 +/- 2.7 mm Hg (range, 19 to 52 mm Hg). Functional valve orifice area was 1.1 +/- 0.09 cm2 (range, 0.6 to 1.8 cm2). Mean cardiac output was 3.92 +/- 0.17 L/min (range, 3.2 to 5.1 L/min) with a mean cardiac index of 2.5 +/- 0.11 L.min-1 x m-2 (range, 2.1 to 3.2 L.min-1 x m-2). In conclusion, we have demonstrated that aortic valve replacement with the 19-mm Carpentier-Edwards supraannular aortic valve has a low operative mortality and offers major clinical benefits despite moderate transprosthetic gradients. This approach provides an alternative management strategy in elderly patients who would otherwise require low-profile mechanical valves or aortic root enlargement.


Optimal approach to the mitral valve: dissection of the interatrial groove. Surgical exposure of the mitral valve has challenged surgeons for more than 30 years. Many ingenious, but often complex approaches have been devised during this time. Using the dissection of the interatrial groove to bring the left atrial incision more anterior and medial, we have achieved excellent exposure in more than 300 mitral valve procedures. This simple technique does not lengthen the procedure and is not associated with an increased risk of either early or late morbidity.


Pulmonary "twinning" procedure: use of lungs from one donor for single-lung transplantation in two recipients. Since the introduction of lung transplantation as an option for patients with end-stage respiratory disease in the early 1980s, there have been substantial advances made in the technical aspects of transplantation as well as the early clinical results. With an ever-increasing number of patients being designated suitable candidates for transplantation, the volume of transplants in the foreseeable future will be limited more on the basis of donor lung supply than any other single factor. Pulmonary "twinning" provides an important step in ensuring that all suitable and available donor lungs are utilized whenever feasible. This report reviews the results of 20 single-lung transplantations carried out in five separate transplantation centers using organs retrieved from ten donors. The overall mortality rate in this group of patients was 5%, which compares very favorably with historical controls. No serious problem was noted with respect to increased perioperative morbidity or increased ischemic times in this group of patients. We suggest that this process should be considered and, wherever possible, adopted by all major lung transplant centers.


Quantitation of particulate microemboli during cardiopulmonary bypass: experimental and clinical studies. An electronic particle-size analyzer (Coulter Counter ZM) was used to quantitate particulate microemboli 15 to 80 microns in size during cardiopulmonary bypass. Through both laboratory studies and clinical research, we confirmed three main causes of microemboli: (1) infusion of banked blood stored for more than 3 days; (2) use of cardiotomy reservoirs; and (3) use of bubble oxygenators. The regression equation between number of particles and blood storage time was Y = 3.7262X + 10.244 (r = 0.886; p < 0.01). The number of microemboli from cardiotomy reservoirs was 2.8 to 5.1 times that from other sources (p < 0.01). The number of solid particles from bubble oxygenators was 1.8 to 3.2 times that from membrane oxygenators (p < 0.01). Electron microscopy showed that a large number of solid particles more than 20 microns in size were formed during heart-lung bypass. They obstructed the microcirculation and damaged pulmonary capillary endothelial and alveolar epithelial cells. The degree of histological damage was related to the number and size of microemboli and the duration of pulmonary microcirculatory obstruction.


Complete cure after a seemingly unsuccessful operation for Wolff-Parkinson-White syndrome. A 48-year-old man with Wolff-Parkinson-White syndrome and poorly tolerated atrial fibrillation underwent surgical dissection of an accessory pathway. After operation electrocardiogram revealed a very unfavorable outcome: sinus rhythm with persistence of delta waves alternated with sequences of complete atrioventricular block. Therefore, an early reoperation was planned. Fortunately, in the next days conduction through the accessory pathway and signs of atrioventricular block disappeared. Complete cure was observed during long-term follow-up.


Pneumatocele complicating hyperimmunoglobulin E syndrome (Job's Syndrome). The case of a boy with hyperimmunoglobulin E syndrome or Job's syndrome is presented to demonstrate the occurrence of pneumatoceles in this syndrome as well as their unusual natural history and failure to spontaneously resolve. Surgical resection was required for two complications in this patient, persistent bronchopleural fistula and a pulmonary abscess that destroyed one lung and required pneumonectomy. Pathologic examination of the specimens demonstrated the wall of the cysts consisted of granulation tissue with chronic active inflammation surrounded by infarcted pulmonary parenchyma with coagulative necrosis. The mechanism responsible for increased immunoglobulin E production in this syndrome is unknown, as is the manner in which elevated immunoglobulin E levels impair normal immune function.


Surgical treatment of postinfarction ventricular septal defect with aortic stenosis. A 69-year-old man with an acute postinfarction ventricular septal defect was also found to have aortic stenosis. Successful management required closure of the postinfarction ventricular septal defect and replacement of the stenotic aortic valve. The contribution of aortic stenosis to the cause of the infarction and the postinfarction ventricular septal defect, as well as the implications for surgical management, are discussed.


Pleural liposarcoma presenting with respiratory distress and suspected diaphragmatic hernia. A young woman with a history of diaphragmatic hernia presented to the hospital in respiratory distress and in premature labor. Her admission chest roentgenogram showed opacification of the left hemithorax, and her arterial blood gas analysis revealed hypoxemia. Emergency cesarean section and exploratory left thoracotomy were carried out; a large tumor occupied the left side of the chest, and pneumonectomy was performed. No diaphragmatic hernia was present. A pathologic diagnosis of primary liposarcoma was made.


Retrograde coronary sinus cardioplegia in the presence of persistent left superior vena cava. Administration of retrograde cardioplegia is hampered by the presence of a persistent left superior vena cava, which results in excessive runoff of solution into the persistent left superior vena cava and the right atrium. Technical modifications are described that permitted aortic valve replacement to be performed in a patient with persistent left superior vena cava using only retrograde cardioplegia.


Post-atherectomy coronary artery aneurysm. A 52-year-old man underwent an uneventful directional atherectomy of the left anterior descending coronary artery. Four months after the procedure unstable angina developed and on angiogram an aneurysm of the left anterior descending coronary artery was noted. The patient underwent bypass of the left anterior descending coronary artery. An attempt to exclude the aneurysm resulted in hemodynamic compromise and was discontinued. Follow-up angiogram 2 months after operation showed the aneurysm to be smaller. The patient is doing well 6 months after operation.


Giant intrapericardial solitary fibrous tumor. A 60-year-old man with a large pericardial effusion was found to have a giant intrapericardial solitary fibrous mesothelioma firmly attached to the ascending aorta and pulmonary trunk. Nine months after excision of the mass the patient is free from symptoms and signs of tumor recurrence. Solitary fibrous mesothelioma is a rare benign tumor and its excision is curative; however, because of the lack of information on its long-term behavior, close noninvasive follow-up of this patient is necessary.


Management of severe bronchial ischemia after bilateral sequential lung transplantation. A case of severe diffuse bronchial ischemia after bilateral sequential lung transplantation is presented. A combination of initial conservative treatment with silicone stenting and late bilateral retransplantation under stable conditions resulted in good clinical outcome. Factors in decision making and technical aspects of the stenting procedure are discussed.


Permanent pacemaker implantation in premature infants less than 2,000 grams of body weight. Pacemaker implantation in premature infants presents technical problems because of the relatively larger size of the pulse generator compared with their bodies. A new technique with which successful generator implantation was performed in 2 premature infants less than 2,000 g of body weight is described. The generator is wrapped in a Gore-Tex surgical membrane. A piece of membrane overlying the electrical contact surface of the generator is removed, and the generator is fixed to the abdominal wall in the peritoneal cavity. The technique is simple to perform and would give relative ease in generator exchange.


Replacement of paracorporeal ventricular assist devices. In this communication we describe a technique to change paracorporeal ventricular assist devices after the development of mechanical complications. This procedure is technically simple and in our experience does not require a sternotomy or cardiopulmonary bypass. Paracorporeal ventricular assist devices can be safely changed allowing continued support and survival.


Inverted Y incision for accurate tailoring of patches and vessels. When anastomosing vessels or using a patch to close a defect, it is often difficult to trim the vessel end or patch to size once the anastomosis is underway. We describe an inverted Y technique that is easy, is completely reproducible, and provides for an even, accurate fit. A continuous suture is run from the heel along either side to the widest part of the anastomosis. A straight incision is made from the tip of the patch or toe of the vessel to a point corresponding to the apex of the defect to be filled; from this point, approximately curved cuts are made to the edges of the patch or vessel just beyond the last sutures. The patch is now accurately shaped and the suture lines are completed.


Repairing the degenerative anterior mitral leaflet. This is a consecutive, nonselected series of 18 patients with degenerative mitral regurgitation requiring a reparative operation on the anterior mitral leaflet. A new technique of double-breasting the two leaflets when flail septal segments are encountered is introduced.


The Nissen fundoplication.

The Nissen fundoplication. The most commonly employed antireflux operation is the Nissen fundoplication. However, its origin and subsequent modifications are rarely defined. These aspects of the operation are reviewed in this article as are the results currently obtainable with the modern version of the operative procedure.


[Value of an algorithm of automatic adaptation of the atrio-ventricular delay to the instantaneous atrial rate in cardiac stimulation]. It has been suggested that an algorithm of automatic adaptation of the AV delay to the instantaneous atrial rate be introduced into the program of DDD pacemakers to reproduce the physiological adaptation of the PR interval to effort, characterised by progressive shortening inversely linearly related to the heart rate. In order to evaluate the potential benefits in conditions of "standard" programming (basal AV delay the same for all patients: maximal frequency of 1/1 AV synchronisation uniformly limited to 120 bpm), a haemodynamic study was undertaken in 10 patients who had permanent DDD pacemakers implanted for advanced AV block. Measurements were taken during two standardized exercise stress tests (20 W/2 mn steps from an initial load of 20 W) performed in a random order, one with a fixed AV delay of 156 ms and the other with an "automatic AV delay" allowing linear reduction from a maximum value of 156 ms at rest to a minimum value of 84 ms at the maximum heart rate of 120 bpm. At the peak of exercise the "automatic AV delay" significantly affected 4 parameters: the paced ventricular rate (p = 0.008) and rate-pressure product (p = 0.005) which increased, pulmonary capillary pressure (p = 0.03) and cycle-to-cycle variability of systolic and diastolic blood pressures (p = 0.02 < p < 0.0001) which decreased. There was a tendency (NS) to slowing of the spontaneous atrial rate and to increase in cardiac output. This increase was significant in some patients and seemed to be due to a good relationship between the individual optimal value of the value basal AV delay measured by Doppler echocardiography and the value programmed in this study (156 ms).(ABSTRACT TRUNCATED AT 250 WORDS)


[Use of sternal zipper in open heart surgery]. A sternal zipper was used in 50 patients with an unstable haemodynamic condition after open heart surgery. The patients were 19 women and 31 men (average age 51.6 years, range 7 to 67 years). The indications for surgery were aortocoronary bypass in 25 cases, replacement of the ascending aorta in 7 cases, valve replacement in 16 cases and correction of congenital heart disease in 2 cases. Twenty eight patients required circulatory assistance. The sternal zipper was used for 4 to 72 hours (average 29.5 hours) and mediastinal toilet was performed at least every 24 hours. At each opening of the zipper, 3 bacteriological swabs were taken from 3 different sites in the mediastinum and sent for culture. Global mortality was 36% (N = 18). The cause of death was a low output syndrome in 12 cases, hepatic and renal failure in 2 cases, resistant arrhythmia in 1 case, neurological complication in 1 case and septicaemia in 2 cases. There was one late death 3 months after hospital discharge which was attributed to a cardiac arrhythmia. The sternal zipper would seem to be a valuable option when the operative conditions are difficult, allowing the chest to remain open, so preventing cardiac compression during a critical period.


[Ventricular repolarization].

[Ventricular repolarization]. Ventricular repolarisation is the period that depolarised cells require to become polarised, that is to say excitable. In general cardiological practice, the duration of repolarisation is assessed by measuring the QT interval on the surface electrocardiogram. This measurement may be difficult because of the lack of precision in defining the end of the T wave. Automatic systems are becoming available and should circumvent these difficulties of manual measurements. Interpretation of a change in the QT interval during drug administration or related to cardiac pathology should take the many sources of physiological variation of ventricular repolarisation into account. One of the main causes of this variation is the heart rate which influences the duration of repolarisation in a complex manner. Analysis of the duration of repolarisation has many implications in pathology and pharmacology. Prolongation of the QT interval and its failure to adapt to the heart rate are trigger factors for torsades de pointe. Many drugs prolonging the duration of repolarisation and of the ventricular refractory period are being developed. Their effects are partially dependent on the heart rate. Finally, prolongation of the QT interval is associated with a poor prognosis after myocardial infarction.


[Double-blind clinical and echocardiographic study of oral enoximone versus placebo in severe cardiac insufficiency]. The effect of enoximone was assessed by a randomised double blind trial versus placebo. The clinical status of the patients was evaluated by the NYHA classification and quality of life score. Inotropic state was estimated from the maximum acceleration of aortic and pulmonary blood flow recorded by Doppler echocardiography. Thirty patients with severe cardiac failure, aged 66.4 +/- 14 years, symptomatic despite maximal therapy associating diuretics, digitalis, nitrate derivatives and angiotensin converting enzyme inhibitors, were included. Fifteen patients were given enoximone 100 mg three times a day orally (Group E) and the other 15 were given a placebo (Group P). The NYHA class and quality of life scores were assessed at D0, D4 and D31. Doppler echocardiography and Holter recordings were performed on D0 and D31. The two groups were comparable at D0. Ten patients abandoned the trial, 3 from Group E (including 1 death) and 7 from Group P (including 3 deaths). At D4, 13 patients from Group E and 8 from Group P were clinically improved (p < 0.05). At D31, the clinical state was stable or improved in 10 of the 12 patients in Group E and 6 of the 8 patients in Group P (NS). No secondary effects were severe enough to warrant the withdrawal of treatment: the frequency of ventricular extrasystoles was comparable in the two groups at D0 and D31. At D31 the maximal aortic acceleration had increased by 20% compared with D0 (p < 0.05) and the maximal pulmonary acceleration by 31% (p < 0.05) in Group E. The same parameters showed no significant change in Group P (-6% and +5% respectively).(ABSTRACT TRUNCATED AT 250 WORDS)


[An unusual cause of sudden death: spontaneous dissection of coronary arteries. Apropos of 2 cases]. The authors report two new cases of spontaneous dissection of the coronary arteries in women under 50 years of age without any predisposing factors and responsible for sudden death. One patient had dissection of the left anterior descending artery and the other had dissection of the left anterior descending and right coronary arteries. Special histological stains allow demonstration of abnormalities of the elastic tissue of the media in both cases. In the first case, a plaque of atheroma was present opposite the site of dissection but did not seem to be causal. In the second case, severe periadventitial cellular, infiltration of unknown origin was observed. This pathology of the young woman, often occurring in the postpartum period, is as rare as it is unpredictable.


[Early postoperative thrombolysis of Saint-Jude aortic valve prosthesis]. The authors report a case of thrombolytic therapy with streptokinase in the early postoperative period after aortic valve replacement with a Saint Jude medical prosthesis. After good initial progress, the patient had to be reoperated on the 12th postoperative day for sternal disunion. Reoperation was followed rapidly by progressive thrombosis of the aortic prosthesis demonstrated by repeated Doppler echocardiographic examination. The impossibility of eliminating mediastinitis led to medical thrombolysis. The outcome was favourable after a regressive cerebral embolic event. This case illustrates the value of Doppler echocardiographic examination in the postoperative period. Thrombolysis may constitute an alternative to reoperation when the operative risk is high. The risk of thrombolysis may not be as great as some believe.


[Recurrent syncope during deglutition. An uncommon form of sinusal dysfunction]. The authors report the case of a 69 year old man with a 16 year history of syncope occurring only while swallowing liquids. Two episodes were observed during a hospital admission to the intensive care unit for unstable angina and allowed documentation of prolonged sinus arrest (7 sec) causing syncope. In the light of this case and a review of the literature, the physiopathological role of deglutition in the genesis of cardiac conduction defects and arrhythmias is discussed and the new classification of sinus node dysfunction proposed by Bashour in 1985 is recalled.


[Chronic dissecting aortic aneurysm and Turner's syndrome. Apropos of a case]. Turner's syndrome is a genetic abnormality which is associated with cardiovascular anomaly in 20% of cases. Coarctation of the aorta and bicuspid aortic valve are the commonest malformations. Aortic dissection is the most serious complication affecting these patients. The authors report the case of chronic aortic dissection of the ascending and transverse aorta in a 27 year old patient with Turner's syndrome. The dissection was diagnosed on angiography. Transthoracic echocardiography showed aneurysmal dilatation of the aortic root. Surgical treatment consisted in replacement of ascending and transverse aorta with a Dacron tube. The anatomopathological analysis showed cystic medianecrosis of the aortic wall. The immediate postoperative evolution was satisfactory. The long-term outcome with a 4 year follow-up was excellent from the clinical and echocardiographic point of view. Turner's syndrome is probably associated with a congenital abnormality of the connective tissue especially of the elastic fibres of the aortic wall, explaining the development, though rare, of aneurysmal dilatation of the ascending and transverse aorta and dissection. These patients should be followed up regularly clinically and by transthoracic echocardiography. Other investigations such as transoesophageal echocardiography, magnetic resonance imaging and angiography are indicated when aortic dilatation, aortic regurgitation or chest pain suggesting aortic dissection are observed.


[Spontaneous angina caused by spasm of the left coronary artery]. A 42 year old woman presented with a one year history of retrosternal chest pain and back pain on effort and at rest sometimes accompanied by minor syncopal attacks. Transient atrioventricular block was documented during one such episode associated with hypotension. Coronary angiography showed spontaneous spasm of the left main coronary artery with clinical symptoms but no electrocardiographic changes. The spasm was relieved by injection of SIN-1. The similarity between the previous clinical symptoms and those observed at coronary angiography was in favour of the diagnosis of spasm of the left main coronary artery without atherosclerotic coronary disease. Treatment with calcium atherosclerotic coronary disease. Treatment with calcium blockers and platelet antiaggregants led to total regression of her symptoms with a follow-up of 5 months.


[Outcome of prognostic factors of infectious endocarditis over a 16 year period. Apropos of 471 cases]. Four hundred and seventy one cases of infective endocarditis (IE) were reviewed: 338 native valve IE and 133 prosthetic valve IE (42 early and 91 late IE). Two periods were compared: 1973-1980 (250 cases) and 1981-1988 (221 cases). There was a decrease in native valve IE (78% to 64%) and an increase in late prosthetic valve IE (13% to 27%), little change with respect to age, causal cardiac disease, delay in diagnosis (except in native valve IE, 39 to 29 days), or frequency of complications, especially cardiac (50% and 51%). However, global mortality decreased from 41% to 27% (p < 0.001). The evolution of the frequency of cardiac complications, cardiac surgery and mortality for the two periods was: for native valve IE respectively 53% to 42%, 41% to 37%, 37% to 20% (p < 0.005); for early prosthetic valve IE respectively, 45% to 55%, 41% to 55%, and 82% to 50% (p < 0.05); for late prosthetic IE, respectively 34% to 69%, 34% to 69% and 37% to 36%. The frequency of surgery had therefore little influence on prognosis except in early prosthetic valve IE. The percentage of infections which could not be controlled medically decreased from 17% to 11%. The mortality of unoperated patients decreased from 46% to 28% (p < 0.01), suggesting more effective antibiotherapy, and the mortality of operated patients fell from 34% to 26%. Global surgical mortality was 35% in the acute phase (positive valve culture), 14% after sterilisation (p < 0.001) and the corresponding frequencies of paravalvular leaks was 17% and 4% (p < 0.01).(ABSTRACT TRUNCATED AT 250 WORDS)


[Immediate and long-term results of coronary surgery under age 40]. The results of coronary artery surgery in young adults have not been extensively studied. We analysed the results of 221 patients under 40 years of age operated between 1979 and 1989 at the Pitié-Salpêtrière Hospital. The patients were 200 men and 21 women with an average age of 36.2 years. The most common cardiovascular risk factors were smoking (69.6%) and hyperlipidaemia (52%). One hundred and eighteen patients (53.4%) had previous myocardial infarction (MI). Triple vessel disease was present in 129 cases, double vessel disease in 59 cases and single vessel disease in 33 cases. Twenty three patients had significant left main coronary disease. The number of bypass grafts per patient averaged 2.3. The operative mortality was 2.07% (6 cases), death being due to myocardial infarction in 4 cases. Perioperative myocardial infarction was diagnosed in 12 cases (5.05%). One hundred and ninety nine patients were followed up for an average of 7.4 years. Seven of the 17 late fatalities were of cardiac origin. The actuarial 9 year survival rate was 84%. Five patients were reoperated after an average of 6.4 years. Eighty five per cent of patients were asymptomatic at the last follow-up examination. In conclusion, the symptoms of coronary artery disease in young adults can be effectively treated with a low operative risk by myocardial revascularisation surgery. Long-term follow-up remains essential to define the outcome in these patients. Systematic use of internal mammary artery bypass grafting should improve these results in the future.


[Heart valve surgery and associated diseases in aged subjects]. The object of this study was to assess the additional risk related to associated pathology in patients aged 70 or over undergoing valvular heart surgery. Two hundred and thirty nine patients aged 70 to 87 years (average 74.6 +/- 3.2) underwent this form of surgery between October 1979 and June 1989. Sixty seven had coronary artery disease, 26 had atherosclerotic occlusive peripheral arterial disease, and 149 had one or more extracardiovascular pathology. Two hundred and thirteen patients underwent monovalvular and 26 bivalvular replacement. Coronary bypass was associated in 25 cases. Eighteen patients (7.5%) died in the 30 days following surgery. The perioperative mortality was not significantly greater in patients with extra-cardiac pathology (9.4% vs 4.4%; NS), in patients with coronary artery disease (11.9% vs 5.8%; NS), in patients with respiratory failure and FEV1 < 1 litre (1 death out of 20 cases) or in patients with renal failure and serum creatinine levels > or = 175 mumol/l (20% vs 6.3%, NS). Respiratory failure was the only extra-cardiac variable identified with increased perioperative morbidity. The perioperative mortality of elderly patients with valvular heart disease is greater than that of patients under 70 years of age (6.4% vs 2.1%) in our experience of the last 6 years p < 0.01). Associated arterial and extra-cardiac pathology does not significantly increase the mortality and strict selection of elderly inoperable patients together with improved surgical techniques and postoperative care has considerably reduced perioperative morbidity and mortality in this group of patients.


[Patency of the artery responsible for myocardial infarction: role on ventricular function and long-term outcome]. Out of 3,171 consecutive patients referred for coronary angiography, 240 were selected on the following criteria: recent primary myocardial infarction, single vessel coronary disease, no angioplasty or coronary surgery after the angiography which was performed 20 to 90 days after the onset of myocardial infarction. The patients were divided into 2 groups according to whether the artery responsible for infarction was patent (Group I: 115 patients) or not (Group II: 125 patients). The left ventricular ejection fraction was significantly higher in Group I (58 +/- 10.8%) than in Group II (53.7 +/- 11.3%) and end systolic and end diastolic left ventricular volumes were greater in Group II (51.8 +/- 22 ml/m2 and 88 +/- 22 ml/m2 respectively). Long-term follow-up (56 +/- 25 months in Group I and 61 +/- 26 months in Group II) was possible in 112 patients in Group I and 123 patients in Group II. Of the 7 patients who died in group II, 4 deaths were of cardiac origin; in addition, 2 cases of sustained ventricular tachycardia were observed in this group. None of the 6 deaths observed in Group I was of cardiac origin and there were no cases of ventricular tachycardia (p = 0.05). The functional status was identical in the two groups at the end of the study. These results suggest that the patency of the coronary artery responsible for myocardial infarction at a distance from the acute event is associated with better left ventricular function and a better long term prognosis.


[Return to work of professional drivers after cardiac rehabilitation]. This study analysed the possibilities of returning to work of professional drivers after a cardiac event and rehabilitation. The population comprised 94 consecutive patients, all men, average age 48.8 years (range 30 to 63 years) referred after coronary bypass surgery (N = 39), myocardial infarction (N = 38), angina (N = 4) or valve replacement surgery (N = 13). Advice on professional reinsertion was given after the rehabilitation program, authorization to drive being given in the absence of cardiac symptoms, residual myocardial ischaemia, severe left ventricular dysfunction and serious ventricular arrhythmias. After 35 months, 4 patients were lost to follow-up; of the 90 remaining patients, the frequency of return to work (maximal at the 9th month) was 65.6% with 84.7% obtaining a renewal of their driving licence. In this series, 81% of patients were asymptomatic, 2 died, 16.7% had further cardiovascular complications. The morbidity and mortality were significantly greater in the group who had to stop driving (N = 40) (32.5% vs 8%, p < 0.001). Non complications occurred during work in those who resumed driving. This study confirms the safety of allowing low risk professional drivers, identified during cardiac rehabilitation by simple, reliable clinical and paraclinical criteria, to return to work.


[Abnormal origin of the left circumflex coronary artery: clinical, angiographic and prognostic aspects. Apropos of 30 cases]. The object of this study of 30 patients with an anomalous origin of the left circumflex coronary artery was to define the clinical and angiographic features of this condition and to assess its influence on morbidity and survival. The 30 patients were 24 men and 6 women with ages ranging from 29 to 76 years. An anomalous origin of the left circumflex coronary artery should be suspected when two angiographic signs are present: firstly, the visualisation of a spur of opacification in the 30 degrees LAO view of left ventriculography, present in 93% or our patients; secondly, during selective left coronary angiography in the transverse view, an ascular zone is observed where the normal left circumflex artery should be. Confirmation of the diagnosis depends on opacification of the left circumflex arising from the right anterior sinus of Valsalva with a separate (37%) or common (23%) orifice with the right coronary artery or arising from a proximal segment of the right coronary artery/(40%). Five patients (17%) had a significant stenosis of the anomalous left circumflex coronary artery but this was always associated with lesions of the other coronary narrowing was observed. Of these patients, one had electrocardiographic signs of myocardial ischaemia and no other cause apart from the anomalous origin of the left circumflex to explain this ischaemia. The 30 patients were followed up for an average of 6.1 +/- 3.9 years. During this period, 1 cardiac death, 1 infarction, 5 cases of angina, 4 coronary bypass procedures, and 6 coronary angioplasties were observed. Nine patients (30%) had no cardiac event during follow-up.(ABSTRACT TRUNCATED AT 250 WORDS)


[New data on the genesis of sleep-wakefulness rhythm in children aged 4-15 months]. The present study deals with the ontogeny of the sleep-wakefulness rhythm in 12 children from the 4th to the 15 month of age. The main findings were as follows: 1. The circadian rhythm of wakefulness and sleep is clearly sep up as of 4 months of age and is characterized by 3 main parameters: a long uninterrupted night sleep period which includes the time interval from midnight to 4 a.m. The duration of this period of time is always equal to or higher than 400 min. The periodicity of the last falling asleep before midnight and the periodicity of the first awakening after midnight are equal or very close to 24 hours. Both seem to be mutually adjusted or connected to each other. 2. Some ages are characterized by significant changes in the daily distribution of the number and duration of sleep spans. 3. These changes suggest the existence of several ultradian rhythmicities which prevail successively throughout the development period under study. 4. There are many important differences between girls and boys.


[Congenital deglutition disorder revealing cerebral stem disorders. 12 cases with neurophysiological study]. Respiratory problems in neonates and infants may be the result of a variety of neuromuscular dysfunctions. Neurologic evaluation of functions, such as sucking and swallowing, may be difficult in these very young infants and can be helped by neurophysiological studies. 12 infants admitted because of repeated episodes of respiratory obstruction due to difficulties of sucking and/or swallowing took part in the study. The neurophysiological studies included electromyography of the facial, lingual and pharyngeal muscles, brain stem auditory evoked potentials and measurement of the blink reflexes. The results were correlated with events during the perinatal period and those that occurred during the follow-up. Dysphagia was evident from the neonatal period; it was complicated by nasal reflux and aspiration bronchopneumopathy. Facial diplegia was observed in 8 patients. 9 patients failed to thrive. The electromyographic patterns showed partial denervation of the facial, lingual and pharyngeal muscles in all cases; the blink reflex was altered in 11 cases, and the brain stem evoked potentials were abnormal in 3 of the 8 cases tested. 7 of the infants had histories of pregnancy and obstetrical abnormalities, and/or fetal distress. The swallowing function partially improved within several months. Neurophysiological studies indicate neurofunctional alterations in the VII, IX, X and XII cranial nerve nuclei, V and VII pathways and the auditory tract. These lesions and the time course of improvement suggest that they are due to pre- or perinatal anoxo-ischemic brain stem injury.


[Treatment of insulin-dependent diabetes mellitus by insulin pump in children under 7 years of age]. Conventional insulin therapy for diabetes mellitus is sometimes inadequate for controlling metabolic disturbances in young children; the risk of hypoglycemia is particularly high at this age. Ten newly-diagnosed insulin-dependent diabetic children aged 1 to 7 years were treated by continuous subcutaneous insulin infusion using a portable pump. The mean duration of treatment was 17 months (4 to 42 months). The mean individual capillary blood glucose calculated over periods of 6 months ranged from 84 +/- 23 to 206 +/- 97 mg/dl. The glycosylated hemoglobin values were 6.5 to 8.9% during the same period. There was no hypoglycemic coma; 7 children experienced a total of 16 episodes of ketonuria. The average daily dose of insulin used by these 10 patients was 0.72 +/- 0.24 units/kg. Continuous subcutaneous insulin infusion is a feasible therapy and it was well tolerated even in the youngest children. External insulin infusion devices appear to be an alternative to conventional insulin therapy and a way of overcoming the therapeutic difficulties encountered with these young patients.


[Dysregulation of plasma 1,25(OH)2D in calcium restriction in hypercalciuric children]. The effect of calcium restriction on the plasma concentration of 1,25(OH)2D in normo- and hypercalciuric children remains unknown. We studied phosphate and calcium metabolism of 8 normocalciuric and 8 hypercalciuric children aged 4 to 16 years, under 3 conditions: on a normal dietary calcium intake after a 5-day calcium-restricted diet, and after oral calcium loading. The healthy, normocalciuric children had histories that included no renal failure of abnormalities of phosphate and calcium metabolism. Four of the 8 hypercalciuric children had urolithiasis, 1 had hematuria and the 3 others had idiopathic hypercalciuria. Blood samples were analyzed for calcium, creatinine, immunoreactive parathyroid hormone, cAMP, 25(OH)D and 1,25(OH)2D concentrations. Urine samples were analyzed for calcium, phosphorus, creatinine and cAMP. On the normal dietary calcium intake, the hypercalciuric children had higher urinary calcium excretion and plasma 1,25(OH)2D levels and lower TmP that did the controls. The 1,25(OH)2D levels of the normocalciuric children were significantly increased after 5 days of dietary calcium deprivation, but those of the hypercalciuric children were not. The other parameters (essentially PTH, cAMP and TmP) varied similarly in the two groups. The results suggest that: a) calcium restriction influences 1,25(OH)2D levels in normocalciuric subjects via a PTH- and phosphor-independent mechanism; b) dietary control of renal vitamin D metabolism is impaired in hypercalciuric patients.


[Cerebral lesions observed in a twin after the in utero death of the other twin. Fetal anoxia-ischemia can be the possible mechanism (3 cases)]. The death of one twin in utero may result in visceral lesions, of possible vascular origin, in the surviving twin when the pregnancy is monochorionic and diamniotic. Case n. 1: The death of one twin and enlargement of the ventricular system in the other were seen by ultrasonography at 24 weeks of pregnancy, 8 weeks after the mother had a fall on the stairs. The heterogeneous imaging in the inferior part of placenta suggested a clot in this area. The pregnancy was terminated at 28 weeks because the ventricular dilatation continued to increase. The newborn died a few minutes later and examination of the placenta showed that the pregnancy was monochorionic and monoamniotic. Case n. 2: The death of one twin with macerating features was seen by ultrasonography at 31 weeks. The other twin was born at 32 weeks of a dichorionic, diamniotic pregnancy. Injection of milk into the placental vasculature failed to visualize any vascular anastomoses between the two placentas, but ultrasonography showed bilateral cystic lesions in the frontal lobes of the brain. Case n. 3: Acute polyhydramnios developed at 21 weeks of pregnancy; it was treated by 3 amniocenteses, while ultrasonography of the twins was normal. A fetal transfusion syndrome was observed at birth, the pregnancy being monochorionic and diamniotic. Cranial ultrasound on day 6 was normal in the recipient twin, but showed numerous cerebral cavities in the donor, which was confirmed at autopsy after that this twin suddenly died at 2 months of age. Brain lesions of vascular origin, can be observed in any type of twin pregnancies. They may be the result of transfusion of clot or thromboplastin-rich blood from the donor fetus through vascular anastomoses in a monochorionic placenta. They also may be due to anoxo-ischemic lesions in the absence of such anastomoses, or, in the fetal transfusion syndrome, to circulatory difficulties in one of the twins, as observed in premature singletons. In the cas of anoxo-ischemic lesions, anticipating the birth of the surviving twin is not justified.


[Familial infantile cortical hyperostosis (Caffey's disease) with osteolytic lesions of the skull]. The parietal and frontal bones are rarely affected in infantile cortical hyperostosis. Case n. 1: A 14-day-old boy developed a swelling of the left eyelid that extended to the face in a few days. It was tender and associated with fever. Laboratory findings were increased (RBC sedimentation rate and other signs of inflammation). CT scan of the sinuses, soft tissues and bones was normal, but at the age of 23 days minimal patches of rarefaction were seen on X-rays of the frontal bones. These lacunar areas gradually extended, with the inflammation persisted. A new CT scan at 6 months of age confirmed the existence of lacunar areas in the skull, but failed to find any lesions of the mandibles or nasal bones. At that time, scintigraphy showed inflammatory lesions of the skull and ribs. All clinical, laboratory and radiological findings spontaneously disappeared within 3 years. Case n. 2: Similar swellings of the face developed at the age of 15 days in the brother of case n. 1. The laboratory findings were identical to those for his brother, and there were minimal lytic areas of the vault of skull without any other lesions. At 3 months of age, X-rays confirmed the existence of skull lesions and showed cortical hyperostosis of the left humerus. Similar cortical hyperostosis of nasal bones appeared at the age of 8 months, while the inflammatory syndrome persisted. All findings gradually and spontaneously disappeared within 18 months. Cortical hyperostosis are usually most prominent in the lower extremities in cases of familial infantile cortical hyperostosis. The lesions were largely confined to the skull in our cases, with no lesions of the mandible. The disease was only identified in the first case after a protracted course with unpredictable remissions and relapses and the discovery of the cortical hyperostosis in his brother.


[A cause of neonatal respiratory distress: cerebral tissue heterotopia in the cavum]. Brain heterotopia can be reflected in disturbances of the oropharynx during the neonatal period, such as acute upper airway obstruction. The main differential diagnosis is encephalocele, which must be recognized before undertaking any surgical procedure. A boy, aged 5 days, with a cleft palate and bifid uvula, was admitted for respiratory distress. The distress initially occurred during bottle-feeding, but later became permanent. A solid mass, seemingly implanted in the superior wall of the pharynx, was successfully removed by forceps. A later CT scan showed the absence of any defect in the cribriform plate, thus excluding diagnosis of encephalocele. Histological, examination of the mass showed glial tissue without neurons. The presence of a pharyngeal mass in a newborn signals three possibilities: teratoma, heterotopic brain tissue or encephalocele. Encephalocele must by ruled out by a preoperative CT scan with a water soluble contrast agent in order to avoid CSF leakage and meningitis. Respiratory distress should be treated by oral endotracheal intubation to allow time for CT scan investigation.


Brain morphology and schizophrenia. A magnetic resonance imaging study of limbic, prefrontal cortex, and caudate structures. We used magnetic resonance imaging to examine the morphologic characteristics of the amygdala/hippocampus, prefrontal cortex, and caudate nucleus in 29 healthy volunteers matched for age, gender, and head of household socioeconomic status and 44 patients with chronic schizophrenia. Total volumes of these structures were determined from 3-mm contiguous coronal sections. Schizophrenic patients, compared with healthy controls, had significantly smaller right and left amygdala/hippocampal complex volumes, smaller right and left prefrontal volumes, and larger left caudate volumes. A secondary analysis revealed reductions in the right and left amygdala and the left hippocampus. In addition, prefrontal white matter, but not gray matter, was reduced in the schizophrenic patients. Moreover, the right white matter volume in schizophrenic patients was significantly related to right amygdala/hippocampal volume (r = .39), data that provide preliminary support for a hypothesis of abnormal limbic-cortical connection in schizophrenia. We studied the implications of these data for the pathophysiology of schizophrenia.


Striatal metabolic rate and clinical response to neuroleptics in schizophrenia. A low metabolic rate in the caudate nucleus and putamen in schizophrenic patients while they were not receiving medication was found to predict a favorable clinical response to haloperidol. Twenty-five patients (21 men and four women) entered a double-blind crossover trial of haloperidol and placebo; to our knowledge, this is the first such trial with positron emission tomography to be reported. Patients received either placebo or medication for the first 5 weeks, and they received the other treatment for the second 5 weeks. Positron emission tomographic scans were obtained at weeks 5 and 10. Patients with low relative metabolic rates in the caudate nucleus and putamen while they were receiving placebo were more likely to show decreases in their Brief Psychiatric Rating Scale scores with haloperidol treatment than individuals with normal or high metabolic rates. Among responders, haloperidol treatment had a "normalizing" effect on metabolic activity in the striatum, with the metabolic rate while they were receiving haloperidol being higher than that while they were receiving placebo. Nonresponders were more likely to show a worsening of hypofrontality while they were receiving medication and an absence of change in the striatum.


Schizophrenics show spatial working memory deficits. The present study demonstrates that schizophrenics are impaired on spatial delayed-response tasks, analogous to those that have been used to assess the working memory function of the dorsolateral prefrontal cortex in rhesus monkeys. Schizophrenic patients and two control groups, normal subjects and bipolar psychiatric patients, were tested on the oculomotor version of the memory task, a haptic version of the same task, and two control tasks: a sensory task that did not require working memory and a digit span test. The schizophrenic patients showed marked deficits relative to the two control groups in both the oculomotor and haptic delayed-response tasks. They were not, however, impaired on the digit span test, which taps verbal working memory as well as voluntary attention, and on the sensory control task, in which their responses were guided by external cues rather than by spatial working memory. These findings provide direct evidence that schizophrenics suffer a loss in representational processing and that this deficit is modality independent. These data on spatial working memory add to the growing evidence for involvement of the dorsolateral prefrontal cortex in schizophrenic disease.


Schizophrenia after prenatal exposure to the Dutch Hunger Winter of 1944-1945. We tested the hypothesis that first-trimester exposure to acute food deprivation is a risk factor for schizophrenia. A sharp and time-limited decline in the food intake of the Dutch population following a Nazi blockade in 1944 to 1945 created a unique if tragic natural experiment to test this hypothesis in three regions of Holland (west, north, and south). In the west, or famine region, birth cohorts exposed to severe food deprivation (an average daily ration under 4200 kJ) during the first trimester showed a substantial increase in hospitalized schizophrenia for women but not for men. Relative risks for women were 2.17 for "broad" and 2.56 for "restricted" schizophrenia. Moderate food deprivation during the first trimester (average daily ration under 6300 kJ) was not associated with increased risk of schizophrenia in the famine region. In the north and south regions, numbers were smaller and there was no exposure to severe famine. Birth cohorts exposed to moderate food deprivation during the first trimester showed a trend toward increased risk of schizophrenia for women. These findings give plausibility to the proposition that early prenatal nutrition can have a gender-specific effect on the risk of schizophrenia.


[Mucous membrane of the gastric antrum in late periods after selective proximal vagotomy with surgical drainage of the stomach and duodenum]. A clinicomorphological analysis was performed of the gastric antrum mucous membrane of 60 patients after selective proximal vagotomy because of stenosing duodenal ulcer. The patients were subdivided into two randomized groups depending on the type of the draining operation. The first group had a gastroduodenoanastomosis for the gastric drainage and the second group underwent duodenum plasty (drainage of the duodenum). Discontinuation of the pylorus function in the gastric drainage operation resulted in higher incidence and intensity of duodenum-gastric reflux and made more severe antrum gastritis; reflux-gastritis developed frequently. Morphological signs of reflux-gastritis in 95% of cases coincided with the results of the radionuclide method. Duodeno-gastric reflux decreased as a rule Helicobacter pylori (HP) contamination of the mucous membrane but did not eliminate it completely in all cases. The combination of these two factors resulted in more severe gastritis than that provoked by each of them separately. The etiology of gastritis and its intensity may be determined only by morphological examination of gastric mucous membrane. The results of endoscopic and histologic methods coincided in 70% of cases. Duodenal-gastric reflux, HP and high acid production play a certain role in ulcer recurrence.


[Gastric ulcers in liver cirrhosis and their exposure to low-intensity infrared laser radiation]. By means of light, scanning electron microscopy and planimetry, the pathomorphology of gastric ulcers (GU) was investigated in patients who had died from liver cirrhosis (LC) and in rats with experimental portal hypertension (PH). It was noticed that GU are frequent (13.3%) in patients with LC. Experimental GU induced in rats with PH persist longer and their areas are larger than in ulcers without cirrhosis. The treatment of ulcers through abdominal wall with low-intensive infrared laser irradiation (LILR) causes significant acceleration of their epithelialization in the rat without cirrhosis. Ulcers in the animals with cirrhosis do not repair under LILR influence, but their area significantly decreases after forming collateral shunting. The congestion in the portal system is the main pathogenetic element in gastroesophageal ulcerogenesis. The laser therapy without decreasing portal hypertension is not efficient.


[Interaction of indigenous parietal microorganisms with cells of the digestive tract mucosa]. By means of light, electron microscopy and stereomorphometry the interaction of microorganisms (MO) and cells of the mouth, stomach and gut mucous membrane was studied in different pathologic conditions on clinic and experimental material. No penetration was noted of MO into cells of the keratinized squamous epithelium, they were present in intercellular spaces. In the stomach, MO as a rule interact with mucocytes altering their surface. Spirillum-like MO sometimes penetrate into the parietal cells. In the small bowel MO may penetrate the cells causing lysis of apical membranes and photocytosis changing the microvilli structure. MO may enter the goblet cells during the secretion. They may settle in the cell cytoplasm without causing its alteration. In crypts, near Paneth cells, MO were subjected to lysis. The peculiarities of MO interaction with cells depend on their structural-functional status.


[Zinc content of pancreatic islets in diabetes]. Content and distribution of zinc was studied in the pancreatic islets in human and rabbit diabetes. The diabetes development is followed by a decrease of zinc content in the insulin-producing cells in parallel with the severity of diabetes. The damage to the islet B-cells is the cause of zinc metabolism disturbance in the endocrine pancreas. Influence of high glucose concentration in the blood may be another factor.


[Immunohistochemical detection of insulin and insulin-like growth factors using antibodies to various parts of the insulin receptor molecule]. The indirect peroxidase-labeled antibody method was used to localize insulin receptors (IR) in the liver and brain of rats under various physiological conditions. Light- and electron-microscopically, specific immunohistochemical reaction was revealed in hepatocytes and endothelial cells of brain vessels with antisera against alpha- and beta-subunits of IR. Immunohistochemical reaction in the hypothalamic median eminence was observed only with antiserum to peptides with amino acid sequence corresponding to sequence 48-77 of human placenta IR. Electron-microscopically, immunohistochemical reaction was revealed on the cytoplasmic membranes and granular endoplasmic reticulum of the fibroblasts in the pericapillary space. The receptors observed correspond to receptors to insulin-like growth factor-1.


[A case of Holt-Oram syndrome].

[A case of Holt-Oram syndrome]. Description of a rare hereditary heart disease in a newborn (heart-hand symptom complex: changes of the shape and structure of a forearm with the absence of thumb and finger V plus atrial septal defect) is presented. The combined effect of genetic and environmental influences is regarded as a cause of the syndrome.


[Recombination transformations as one of the mechanisms of qualitative changes in living systems]. New quality in the nature, according to the author, may appear not only in the process of quantitative changes, but by means of various recombinations (regrouping) of elements composing the system without changing their number. The variants of such regrouping are discussed. Recombinant (conformative) changes which are widely spread in the nature, play an important role in the host adaptive reactions.


Open controlled therapeutic trial of intravenous immune globulin in relapsing-remitting multiple sclerosis. Ten patients with relapsing-remitting multiple sclerosis were treated with intravenous immune globulin, 0.4 g/kg per day for 5 consecutive days, and then with additional booster doses of immune globulin of 0.4 g/kg, once every 2 months, for the next 12 months. Ten untreated patients with relapsing-remitting multiple sclerosis who were matched with the study patients for age, disease duration, and number of attacks per year served as controls. Immune globulin treatment was well tolerated, with no side effects. The exacerbation rate decreased from 3.7 +/- 1.2 exacerbations per year before treatment to 1.0 +/- 0.7 exacerbations per year during the treatment in the immune globulin-treated patients, while it remained unaltered in the controls. The posttreatment Kurtzke Expanded Disability Status Scale score decreased from a mean of 4.45 to 4.15, whereas in controls it increased from 3.55 to 3.75. The results suggest that immune globulin suppresses the ongoing pathologic process in multiple sclerosis and may be a promising treatment to prevent disease exacerbations.


Quality of life in multiple sclerosis. Comparison with inflammatory bowel disease and rheumatoid arthritis. Multiple sclerosis (MS) and other chronic illnesses can drastically decrease quality of life (QOL), but there has been little systematic study of QOL in patients with chronic medical diseases. We analyzed QOL in 68 patients with MS, 164 patients with inflammatory bowel disease, and 75 patients with rheumatoid arthritis. The previously validated test instrument was a standardized interview consisting of 41 questions clustered in four subscales: functional and economic scale, social and recreational scale, affect and life in general scale, and medical problems scale. Patients were included in the study if they had a definite medical diagnosis and disease duration of 10 years or longer. In the patients with MS, Kurtzke's Expanded Disability Status Scale correlated strongly only with the medical problems score. Of Kurtzke's Functional System Scales, only the visual Functional System Scores was correlated with total QOL and subscale scores, suggesting that vision is strongly related to QOL. Duration of MS was unrelated to QOL scores. There were significant differences between patients with MS, inflammatory bowel disease, and rheumatoid arthritis on the subscale and total QOL scores. Results suggested that QOL was best in the inflammatory bowel disease group and worst in the MS group. Numerous statistically significant differences on individual questions were evident, suggesting that unique clinical profiles differentially characterize these diseases. Assessments of QOL are a meaningful addition to impairment scales, such as Kurtzke's Expanded Disability Status Scale. Furthermore, QOL scores may meaningfully measure the impact of a chronic medical disease, such as MS, compare the impacts of different diseases, and assess the effects of therapeutic intervention.


Effects of cigarette smoking on motor functions in patients with multiple sclerosis. The acute effects of cigarette smoking on motor functions were examined in 21 patients with multiple sclerosis and 11 healthy control subjects. The motor function in the upper extremities was assessed by a simple test battery. Sixteen of 21 patients had a transient deterioration of their motor function immediately after smoking, lasting for 10 minutes. The mean decrease in motor performance score for all 21 patients was 14%. With the same tests performed without smoking only three of 14 patients had a deterioration and the group had a mean 8% improvement. The control group showed a steady improvement over time, both in smoking and in simulation experiments. We conclude that nicotine causes a transient worsening of motor functions in patients with multiple sclerosis, which can be due to its effects on the central nervous system or vegetative-vascular functions.


Neuropsychological importance of subcortical white matter hyperintensity. Subcortical hyperintensity on magnetic resonance imaging is a common incidental finding in healthy elderly subjects. The relationship of such changes to cognitive functioning remains unclear, however, because only a small number of studies have examined this issue with conflicting results. We therefore assessed 66 healthy adult volunteers (mean [+/- SD] age, 61.8 +/- 15.8 years) with magnetic resonance imaging scans rated for subcortical hyperintensity, and with two neuropsychological instruments selected a priori on the basis of previous reports in the literature. Findings were highly significant for both the Benton Facial Recognition Test and the Wechsler Adult Intelligence Scale-Revised Digit Symbol. However, in both cases, the majority of variance was accounted for by age and educational level. Effects of subcortical hyperintensity were not significant. We conclude that subcortical hyperintensity in healthy adults does not relate to cognitive functioning, at least with these two instruments.


Comparisons of verbal fluency tasks in the detection of dementia of the Alzheimer type. The performances of 89 patients with dementia of the Alzheimer type (DAT) and 53 demographically matched elderly normal control subjects were compared on four verbal fluency measures (category, letter, first names, and supermarket fluency). Receiver operating characteristic curves were plotted to determine each fluency tasks' sensitivity (ie, true-positive rate) and specificity (ie, true-negative rate). Category fluency demonstrated the greatest degree of discrimination between patients with DAT and normal control subjects (sensitivity, 100%; specificity, 92.5%); letter fluency was the least accurate (sensitivity, 89%; specificity, 85%). Separation of patients with DAT by gender revealed similar findings. In further analyses with a subgroup of 21 mildly impaired patients with DAT, category fluency lost none of its discriminative capabilities, whereas all other fluency measures showed marked reductions in discriminability. We conclude that this superiority of category fluency is due to its dependence on the structure of semantic knowledge, which deteriorates in the early stages of DAT.