Comparative study of the aerobic, heterotrophic bacterial flora of Chesapeake Bay and Tokyo Bay.

A comparative study of the bacterial flora of the water of Chesapeake Bay and Tokyo Bay was undertaken to assess similarities and differences between the autochthonous flora of the two geographical sites and to test the hypothesis that, given similarities in environmental parameters, similar bacterial populations will be found, despite extreme geographic distance between locations. A total of 195 aerobic, heterotrophic bacterial strains isolated from Chesapeake Bay and Tokyo Bay water were examined for 115 biochemical, cultural, morphological, nutritional, and physiological characters. The data were analyzed by the methods of numerical taxonomy. From sorted similarity matrices, 77% of the isolates could be grouped into 30 phena and presumptively identified as Acinetobacter-Moraxella, Caulobacter, coryneforms, Pseudomonas, and Vibrio spp. Vibrio and Acinetobacter species were found to be common in the estuarine waters of Chesapeake Bay, whereas Acinetobacter-Moraxella and Caulobacter predominated in Tokyo Bay waters, at the sites sampled in the study.


Secondary selective enrichment of salmonellae from naturally contaminated specimens by using a selective motility system.

A selective motility medium was used as a secondary selective enrichment medium to examine specimens naturally contaminated with salmonellae. The medium, incubated at 37 degrees C, was inoculated from either selenite brilliant green sulfa enrichment broth or Müller-Kauffman tetrathionate broth, both of which had been incubated at 42 degrees C. The use of the selective motility medium resulted in an increase in the number of positive specimens from 65 and 74% to 80 and 82%, when inoculated at 24 and 48 h, respectively, from tetrathionate broth. Tetrathionate broth, when used singly, was significantly better than selenite brilliant green sulfa broth, which detected 55% of positive specimens at both 24 and 48 h. The use of the selective motility medium of Harper and Shortridge (J. Hyg. 67: 181--186, 1969) for the further examination of specimens culturally negative on primary selective enrichment is advocated.


Lesions of swine lymph nodes as a diagnostic test to determine mycobacterial infection.

Decisions as to the disposition of swine carcasses with lesions attributable to a mycobacterial infection are based upon a lesion criterion which is used as a diagnostic test by federal meat inspectors. Using this criterion, a federal meat inspector classified 58 of 100 pigs as "passed for cooking" and the other 42 pigs passed. Of the 58 pigs passed for cooking and the 42 pigs passed, mycobacterial isolations were made from the lymph nodes of 33 and 15 of the animals, respectively. The lesion criterion as a diagnostic test has the following attributes: 70% sensitive; 53% specific; 23% index of performance; 57% positive accuracy; and 67% negative accuracy.


Evidence by electron micrographs for a high incidence of bacteriophage particles in the waters of Yaquina Bay, oregon: ecological and taxonomical implications.

A variety of viral particles, the majority of them clearly identifiable as bacteriophages, were found in the seawater of Yaquina Bay, Oregon. These phages were obtained as free particles from the seawater without employing specific hosts for enrichments or further purification in the laboratory. A variety of electron micrographs showing different morphologies of phages as well as phage-bacterium interactions found in the seawater are presented. In the area where the bay received organic enrichment from seafood processing plants, a minimum of 10(4) phage particles per ml was estimated. Since the technique used was designed to concentrate particles 0.2 micrometer in diameter or larger it is assumed that the actual number of phage particles is higher than 10(4) particles per ml. The implications of the presence of such phage concentrations in bays and estuaries with a certain level of eutrophication are of obvious importance in considering the microbial ecology of these environments.


Extraction of glucose isomerase from Streptomyces flavogriseus.

Cationic detergent (cetyltrimethylammonium bromide or cetylpyridinium chloride) treatment extracted almost the same amount of glucose isomerase from cells of Streptomyces flavogriseus as mechanical disruption (sonic oscillation or abrasive grinding). The specific activity of the enzyme extracted with cationic detergents was approximately 20% higher than that liberated by mechanical disruption.


The actinic cheilitis of hereditary polymorphic light eruption.

Sixty-four North American Indians with hereditary polymorphic light eruption (HPLE), or a family history of HPLE, had chronic, recurrent, exudative, and exfoliative cheilitis. Fifty-two had the cheilitis by the age of 10 years. Microscopically, the epithelium was either thickened, or thinned and covered by a thick crust. The dermis had a dense infiltration of inflammatory cells, mostly lymphocytes and plasma cells. The condition was not premalignant. The HPLE has to be differentiated from the chronic actinic cheilitis caused by long exposure to sunlight with out any element of hypersensitivity. The latter is potentially premalignant. Chronic recurrent actinic cheilitis associated with hereditary polymorphic light eruption appears to be a specific characteristic of photosensitivity occurring in American Indians. Plasma cell infiltration is not specific for either type of cheilitis.


Metastases in dermatological patients with squamous cell carcinoma.

Two hundred eleven patients in whom squamous cell carcinoma (SCC) of the skin had been diagnosed between 1950 and 1959 were followed up from Jan 1, 1976, to establish the incidence of metastases. A systemic study was carried out through follow-up examinations and tracing through population registers. We found 3.3% metastases in 153 patients with skin SCC and 11% metastases in 55 patients with labial SCC. Three patients with genital SCC were free of metastases. These results and the available literature on patients with SCC of osteomyelitic foci and scars from burns or x-ray treatment indicate that sharp distinctions must be made among three groups of SCC; mucocutaneous, primary cutaneous, and cutaneous SCC secondary to inflammatory and degenerative processes. The incidence of metastases in the three groups is approximately 11%, 3%, and 10% to 30%, respectively. Percentages found are important to dermatology clinics because skin SCC should be considered a malignant tumor with a higher incidence of metastases than previously assumed.


Antibodies eluted from lymphoid cell membrane. Occurrence in certain varieties of scleroderma.

By means of acid elution two antibodies could be removed successfully from the circulating lymphocytes of 11 patients with certain varieties of scleroderma. One was specifically directed against nuclear antigen(s) of endothelial cells (NEC) of the dermal blood vessels, and another against nuclear antigen(s) of epidermal basal cells (NBC) of the involved and uninvolved skin of the patients. In two cases of acroscleroderma, the eluates failed to react with either endothelial or basal cells of involved or uninvolved skin. In none of 20 healthy controls involved in this study could an antibody be eluted from the circulating lymphocytes. The aforementioned antibodies do not bind complement in vitro and do occur in the serum of four patients. Circulating antinuclear antibody (speckled type) was detectable in two cases of scleroderma.


Allergic hypersensitivity to neomycin. Relationship between patch test reactions and 'use' tests.

The prevalence of neomycin patch test sensitivity in the general population is approximately 1%. We describe the relationship between positive neomycin patch tests and clinical "use tests" with two antibiotic combinations (Neosporin G cream and Neosporin ointment). The neomycin use test was positive in seven of eight subjects with a strongly positive patch test, and in two of four subjects with a weakly positive patch test. A positive use test usually occurred earlier and was always more intense with the cream base. The use test reactions were usually mild even with continued application of the antigen. Use tests with commercial products may be helpful in evaluating the clinical relevance of positive patch tests.


Topical tretinoin therapy and oral lichen planus.

The treatment of severe forms of oral lichen planus is still relatively unsatisfactory. In this controlled study, 0.1% tretinoin in an adhesive base was used in 23 patients. Fifteen other control patients were similarly treated with the vehicle alone. In the tretinoin-treated group, 71% of the atrophic-erosive lesions improved while 29% improved from the vehicle (P less than .05). Reticular-plaque lesions improved in 74% from tretinoin and in 15% from the vehicle (P less than .001). Irritation from tretinoin occurs and thorough usage information is mandatory.


Primary cutaneous plasmacytoma. Report of a case and review of the literature.

Clinical, laboratory, and pathologic findings from a case of malignant extramedullary plasmacytoma of the skin are presented. To our knowledge, this is the 11th reported case of extramedullary plasmacytoma of the skin and the second reported case with a complete follow-up and postmortem examination. In these two cases, surgical excision of the tumor mass, radiation therapy, and chemotherapy were ineffective. At necropsy, visceral metastases were found, but there was no bone marrow involvement.


Vasculitis associated with intestinal bypass surgery.

We report two cases in which necrotizing vasculitis with tenosynovitis arthralgia/arthritis syndrome developed after intestinal bypass surgery. Each of these patients had jejunoileostomies, and the excluded segment was placed in an ileal-colonic anastomosis. We speculate that since the attachment of the excluded segment to the large intestine predisposes it to increased bowel overgrowth of bacteria, these bacteria or their debris may have served as antigens for circulating immune complexes, which were detected in both patients by one or more techniques. Patients who have had an end-to-side anastomosis may be less predisposed to the more severe vasculitis syndrome because there is less likelihood of bacterial overgrowth in the bypassed intestinal segment.


Plasmapheresis and immunosuppressive therapy. Effect on levels of intercellular antibodies in pemphigus vulgaris.

A patient with pemphigus vulgaris and serious side effects of steroid therapy was treated by exchange plasmapheresis. Eight plasmaphereses were performed over six weeks. Each procedure reduced the serum level of intercellular antibodies by 50% to 87%. A rebound in levels of intercellular antibodies usually followed their depletion but could be minimized or completely suppressed by administration of cyclophosphamide. After six weeks of therapy, clinical symptoms had greatly improved and intercellular antibody levels had decreased from a titer of 5,120 to 160. It is not possible to ascribe these improvements specifically to plasmapheresis since the patient was concurrently receiving low doses of prednisone and intermittent treatment with cyclophosphamide.


Yellow nail syndrome. Possible association with malignancy.

A dramatic resolution of yellow nail deformity occurred in a 66-year-old man shortly after the removal of a carcinoma of the larynx. Seventeen months later, a productive cough developed and radiologic evidence of bronchiectasis was found. There was no evidence of lymphedema, pleural effusion, sinusitis, or immunologic abnormalities. At least three other patients with a variant of yellow nail syndrome have died of malignancy. Therefore, the resolution of the nail deformity following laryngectomy may not be fortuitous.


Toxoplasmosis appearing to be dermatomyositis.

A case of toxoplasmosis occurred simultaneously with dermatomyositis in a 12-year-old boy. The patient was treated with sulfadiazine and pyrimethamine; within two weeks after initiating therapy, dramatic clinical improvement was noted. Several previous cases of toxoplasmosis occurring in association with polymyositis have been described in the literature. A serologic investigation for Toxoplasma infection might prove to be of value in establishing the cause of dermatomyositis and polymyositis. Moreover, in selected cases of dermatomyositis or polymyositis, treatment with sulfadiazine, pyrimethamine, and folinic acid may be a valuable alternative to the use of steroids and immunosuppressive agents.


Sporotrichoid cutaneous infection due to Mycobacterium chelonei.

Extensive cutaneous lesions that simulated sporotrichosis developed in a patient. Mycobacterium chelonei, a facultative pathogen that exists as a saprophyte in the environment and rarely produces clinical disease in humans, grew from culture of biopsy material. There was no evidence of visceral involvement, and the lesions healed spontaneously within six months.


Eruptive vellus hair cyst. Clinical and histologic findings.

This is, to our knowledge, the second report of eruptive vellus hair cysts. The lesions, which occurred in an 18-year-old woman, consisted of 35 to 40 brownish-black, 1- to 4-mm papules on the anterior aspect of the chest. Histologically, the lesions consisted of small cysts in the middle dermis that contained laminated and amorphous keratinous material and vellus hairs. The cyst wall consisted of several layers of squamous epithelium with a rudimentary follicle attached to its outer aspect. The lesions regressed spontaneously after ten months. The pathogenesis is obscure but the condition appears to be a new distinctive entity.


Radionuclide scanning in pseudo-Kaposi's sarcoma.

Sodium pertechnetate Tc 99m radionuclide scanning is considered to be a sensitive indicator in detecting lesions of Kaposi's sarcoma, including occult infiltrations. This report describes a "false-positive" scan in a patient with acroanglodermatitis (pseudo-Kaposi's sarcoma); therefore, this technique may not be useful in the differential diagnosis of these two clinically and histologically similar diseases. We suggest, instead that the technetium scan may be helpful in deciding on the course of therapy in acroangiodermatitis by demonstrating the nature of the underlying vascular anomalies.


Infantile acropustulosis.

Infantile acropustulosis is a syndrome that is characterized by recurrent crops of 1- to 2-mm, intensely pruritic vesicopustules on the distal extremities. The eruption is unresponsive to topical steroids, and pruritus is relieved only by soporific doses of antihistamines.


Bowel bypass syndrome.

We report two cases of a syndrome related to the bowel bypass surgical procedure. This syndrome consists of a flu-like illness, with temperatures from 38.3 to 39.4 degrees C (101 to 103 degrees F), chills, malaise, and inflammatory papules and pustules, 2 to 4 mm in diameter, on the extremities and upper part of the trunk. The illness lasts two to six days, and then recurs in one to six weeks. During some episodes, myalgia and polyarthralgia occur; between episodes, joints are normal. In both patients, extensive evaluations had been made to determine the cause of the persistent illness before this distinctive syndrome, related to the bowel bypass surgical procedure, was recognized. These two cases are also illustrative of the two therapeutic approaches that may be of value: administration of antibiotics, esecially metronidazole, or reconstitution of the normal bowel anatomy. The relationship of this syndrome to the arthritis associated with bowel bypass and to bypass enteropathy is discussed.


Tar gel-phototherapy for psoriasis. Combined therapy with suberythemogenic doses of fluorescent sunlamp ultraviolet radiation.

To determine the efficacy of suberythemogenic ultraviolet phototherapy in conjunction with administration of a tar gel (SEUV TG), patients with widespread psoriasis were treated by application of a tar gel preparation followed after 12 hours by suberythemogenic doses of fluorescent sunlamp irradiation. In paired comparison studies, therapeutic effects of the following treatments were evaluated: SEUV-TG, a more conventional erythemogenic tar gel phototherapy regimen (modified Goeckerman), the tar gel alone, and SEUV irradiation following application of gel vehicle. Response to therapy was monitored with a severity score system. In patients with psoriasis responsive to phototherapy, smaller quantities of UV energy administered in combination with a tar gel were at least as effective as larger erythemogenic doses. Production of erythema with fluorescent sunlamp radiation does not appear to be necessary to improve psoriasis. Both UV radiation and tar gel have beneficial effects on psoriasis, but the combination is superior.


Sheep erythrocyte rosette formation and phytohemagglutinin-stimulated cells. Two cases of mycosis fungoides with skin tumors and lymph nodes.

Infiltrating cells were harvested by mechanical means from skin tumors and lymph nodes of myocis fungoides. Sheep erythrocyte rosette formation was observed on more than 90% of small lymphocyte-like cells with irregular nuclei but seemed to be hardly detectable on larger cells. The small and large cells that formed erythrocyte rosettes showed similar basic ultrastructures, which suggested that these two types of cells are of the same origin. When cultured with phytohemagglutinin (PHA), 90% of the small cells underwent transformation, and they were found to be lymphoblast-like cells with irregular nuclei by electron microscopy. Only 40% of the large cells were transformed with PHA.


Clofazimine in the treatment of pyoderma gangrenosum.

Ten patients with pyoderma gangrenosum, seven female and three male, 25 to 94 years old, mainly with multiple lesions, have been treated with clofazimine, 100 mg three times daily. Associated disease was registered in three patients: diabetes mellitus, a previous adenocarcinoma of the colon treated by hemicolectomy, and pustulosis palmoplantaris. In a further patient, M-component was found in the serum. In seven cases the lesions were completely healed by two to five months of therapy, and in three cases the ulcers healed partially. Side effects were redness of the skin in seven cases and dryness of the skin in two patients. No hematological side effects occurred. The working mechanism is still obscure.


Cutaneous lupus erythematosus associated with melanoma and BCG vaccine therapy.

Abnormalities in host immunologic defenses may be associated with melanoma and lupus erythematosus, In two patients, cutaneous lupus erythematosus developed in the course of melanoma. Immunoglobulin deposits and complement were seen on direct immunofluorescence of exposed uninvolved skin. One patient was undergoing immunotherapy with BCG vaccine when the eruption occurred.


Nail plate-nail bed separation. An unusual side effect of systemic fluorouracil administration.

A 62-year-old woman with metastatic gastric carcinoma was treated with fluorouracil for her malignant neoplasm. Nail plate-nail bed separation was noted in the fingers and toes after two months of weekly chemotherapy and appeared to be caused by the fluorouracil.


Sebaceous carcinoma of the skin with visceral metastases.

Sebaceous carcinoma is an uncommon cutaneous malignant neoplasm that rarely metastasizes. We report a case in which a moderately well-differentiated sebaceous carcinoma arising on the anterior aspect of the chest produced widespread visceral metastases. This unexpected clinical behavior underscores the fact that sebaceous carcinoma of the skin can sometimes be very biologically aggressive.


Facial granuloma annulare.

Of six cases of granuloma annulare of the face, three cases were not associated with lesions on the extremities or trunk. Histologic examination exhibited typical features of granuloma annulare. One patient's lesion was a recurrent solitary subcutaneous nodule.


Chronic papular dermatitis of the scrotum due to Schistosoma mansoni.

A 17-year-old boy with chronic papules of the scrotum showed no improvement after topical therapy. A skin biopsy specimen showed Schistosoma mansoni eggs. No evidence of bladder or bowel involvement was found. No treatment is necessary for schistosomal infections without severe symptoms or excessive egg production.


Localized scleroderma with cutaneous calcinosis. A distinctive variant.

Two patients had a distinctive variant of localized scleroderma. Both have a history of sclerodermatous changes of the skin over the face developing relatively late in life and accompanied by hair loss, cutaneous calcification, and prominent beaking of the nose. A striking lack of systemic involvement also was noted.


Erythema chronicum migrans with purpura and polymorphonuclear infiltrates.

Erythema chronicum migrans with an intensely purpuric border developed in a 70-year-old woman. A biopsy specimen, in addition to showing the usual perivascular mononuclear infiltrate, demonstrated numerous polymorphonuclear leukocytes associated with leukocytoclasis. Immunofluorescence study showed vascular deposition of IgM and C3.


Unilateral, linear, zosteriform epidermal nevus with acantholytic dyskeratosis.

An infant has a nevus unius lateris with the histopathologic condition of acantholytic dyskeratosis. Similar cases have, in the past, been classified as unilateral Darier's disease. Since it is now recognized that the pathologic changes of acantholytic dyskeratosis are not specific for a given disease entity, we believe the concept of unilateral keratosis follicularis deserves reevaluation.


Zebra-like hyperpigmentation in an infant with multiple congenital defects.

An unusual pattern of zebra-like hyperpigmentation was observed in a black male infant with congenital defects that included an atrial septal defect, dextrocardia, auricular atresia, deafness, and growth retardation. The hyperpigmentation was strikingly linear and symmetrical and followed a dermatomal distribution, with involvement of the trunk and extremities. Results of histological, histochemical, and electron microscopic studies were normal except for an increase in the number of melanocytes in the bands of hyperpigmentation. This pigmentary anomaly appears to be transient and has faded to 50% of its original intensity. A review of the literature has not disclosed any similar cases.


Hypervitaminosis A in a patient with alopecia receiving renal dialysis.

A patient with gradually increasing hair loss was undergoing long-term renal dialysis. Questioning revealed that her supplemental vitamin program had contained vitamin A only to that extent it was included in a portion of multivitamins taken in conventional amounts for approximately three years. Her serum vitamin A level was 140 micrograms/dL (a normal level is 20 to 80 micrograms/dL). Reports have indicated that chronic renal disease results in a state of relative hypervitaminosis A. This is compounded in renal dialysis by failure to remove vitamin A. The administration of low-dose supplemental vitamin A preparations in this select population is discussed with respect to current concepts of vitamin A metabolism in renal disease.


Palmar-plantar lichen sclerosus et atrophicus.

A 57-year-old woman has had lichen sclerosus et atrophicus confined to the palms and soles for the past six years. Diagnosis was confirmed by histologic study. Our patient's disease has been resistant to therapy.


Diagnosis and management of folate deficiency in low birthweight infants.

Significant folate deficiency in 14 out of 37 preterm infants of birthweights 2.0 kg or less was found to be reliably and most conveniently diagnosed by abnormal morphological changes in peripheral blood and confirmed by the response to folic acid. Deficiency appeared to be more common in light-for-dates infants including the smaller of twins. Neither the clinical status nor the levels of haemoglobin or erythrocyte folate was a reliable guide to the presence of megaloblastic erythropoiesis in the very young preterm infant. 100-200 microgram folic acid a day, orally or IM, may be required to ensure an optimal haematological response, and this would be appropriate for therapeutic trial if the diagnosis is in doubt. This amount would also replenish tissue folate stores; larger doses are likely to exceed the requirements of small infants.


New technique for servo-control of arterial oxygen tension in preterm infants.

Equipment has been developed for the servo-control of arterial oxygen tension in sick, newborn babies. Using an indwelling umbilical arterial oxygen electrode as sensor, the equipment successfully regulated the administration of oxygen to 12 newborn babies with respiratory distress syndrome, significantly improving the stability of arterial oxygen tension and lessening the duration of episodes of hypoxia and hyperoxia.


Structural heart disease in the newborn. Changing profile: comparison of 1975 with 1965.

The earlier detection and investigation of babies with congenital structural heart disease has resulted in earlier treatment and better management of these patients. In 1965, at the Hospital for Sick Children, Toronto, 121 cases were assessed and treated; by 1975 this figure had risen to 226 cases. Few changes were noted in the incidence of the 10 most common malformations, except for the obvious increase in the incidence of patient ductus arteriosus due to survival of increasingly premature infants. The sick cardiac neonate was referred earlier in 1975, studied with newer non-invasive investigations, and, according to the severity of symptoms and signs, was sent sooner to cardiac catheterisation. 80% of babies presenting with cyanosis survived the first month and 60% of babies with congestive heart failure survived. With better surgery and perioperative care, the survival rate in the first month after surgery rose from 37% in 1965 to 70% in 1975.


Glycosylated haemoglobin levels in children with diabetes mellitus.

Total glycosylated haemoglobin (HbA1) levels were measured in 94 diabetic children aged between 3 and 19 years. The results were compared with traditional methods of assessing blood glucose control. HbA1 levels correlated with home urine glucose testing (P less than 0.05), with 24-hour urine glucose excretion (P less than 0.01), and with height velocity (P less than 0.001). Within the first two of these parameters there was a wide scatter of results, suggesting the inaccuracy of these methods for assessing control. The association of raised HbA1 levels with height velocities less than 10th centile shows the effect of poor control on growth. HbA1 may prove to be an objective method for assessing long-term blood glucose levels in diabetes, and thus it may be possible to determine the effect of good control in the prevention of the various diabetic complications.


Improved accuracy of continuous measurement of arterial oxygen tension in sick newborn infants. Criteria for reading and recalibrating the electrode.

Improved accuracy of continuous arterial oxygen tension (PaO2) measurement is obtained if allowance is made for the response time of the electrode. Recalibration is necessary only when PaO2 measured in a blood sample differs from the electrode value by more than +/- 11.5 mmHg (1.5 kPa).


Haemorrhage responsive to vitamin K in a 6-week-old infant.

A 6-week-old breast-fed infant presented with vomiting, jaundice, and irritability. Haemorrhage occurred after lumbar puncture, and a coagulation abnormality which responded to vitamin K was found. It would seem prudent to estimate the prothrombin time before invasive procedures in breast-fed infants of this age, or to give vitamin K to such infants when doubt exists about previous vitamin K administration.


Cervical lymphadenitis in childhood due to mycobacteria of the Fortuitum group.

Two children with cervical lymphadenitis due to Mycobacterium fortuitum infection are described; both presented with erythema nodosum.


Progressive hypogammaglobulinaemia in a child born to a mother with Hodgkin's disease.

A young woman developed Hodgkin's disease (nodular sclerosis) in pregnancy and gave birth to a boy who developed common variable immunodeficiency. Initially there was normal IgG with low IgA and IgM, and antibody deficiency. IgG levels fell progressively over 4 years. Cellular immunity was normal. We suggest that this is a further family with immune deficiency presenting with common variable immunodeficiency and lymphoid malignancy.


The respiratory disease questionnaire: use of a self-administered version.

A re-designed and simplified respiratory disease questionnaire was self-completed by 245 coke oven workers who previously were interviewed using the Standardized Medical Research Council/National Heart and Lung Institute form. The self-completion survey yielded significantly greater numbers of positive responses to various questions; nearly twice as many men were classified as having chronic bronchitis based on responses to the self-administered questionnaire. The severity of symptoms correlated with various factors such as the worker's smoking history; family history of lung disease, and job history. We suggest that, when compared with an interview using the British Medical Research Council/National Heart and Lung Institute respiratory disease questionnaire, a simplified, self-completion form may serve as a less expensive, more sensitive, and equally uniform and selective epidemiological tool. Self-completion forms deserve the attention and study previously afforded the interview process.


Effects of asbestos and beryllium on release of alveolar macrophage enzymes.

Rabbit alveolar macrophages were exposed in culture medium to asbestos, beryllium sulfate, and beryllium oxide. The specific activities of the lysosomal hydrolases, acid phosphatase beta-N-acetylglucosaminidase and beta-glucuronidase plus the glycolytic enzyme, phosphohexose isomerase were determined in the medium, whole-cell homogenates, mitochondrial fractions, and supernatant. These hydrolases increased significantly in the medium but not in the mitochondrial fraction of cells exposed to dusts. Asbestos and beryllium sulfate were highly cytotoxic for alveolar macrophages in vitro and the data suggested that these agents were not associated with an increase in enzyme synthesis but rather a direct cytotoxic effect at the macrophage membrane level. For induction of enzyme release in vitro, a higher concentration of beryllium oxide was needed when compared with asbestos and beryllium sulfate. The cytotoxicity and enzyme release induced by these agents may represent an important nonspecific mechanism by which they induce inflammation and perhaps local proliferation of fibroblasts.


Introduction of iron transport by a potent inducer of aryl hydrocarbon hydroxylase, 2, 3, 7, 8--tetrachlorodibenzo-p-dioxin.

A potent enzymatic inducer, 2, 3, 7, 8-tetrachlorodibenzo-p-dioxin, stimulates iron transport in the intestine of the rat. The stimulatory site in the intestine is more available to the inducer given orally than parenterally. Effects on intestinal absorptive mechanisms may be additional public health hazards of enzyme inducers such as 2, 3, 7, 8-tetrachlorodibenzo-p-dioxin.


The effect of carbon monoxide upon erythrocyte delta-aminolevulinicacid dehydratase activity.

The activity of the delta-aminolevulinicacid dehydratase enzyme in the second reaction of the heme biosynthetic pathway has been determined in human blood in the presence of varying concentrations of carboxyhemoglobin. In vivo and in vitro carbon monoxide exposure causes a consistent, but small, significant diminution of activity. At concentrations of carboxyhemoglobin likely to be found in vivo it is unlikely to significantly influence the use of this enzyme as a measure either of lead exposure or of ethanol consumption.


Lack of ozone effects on oxygen hemoglobin affinity.

Ozone exposure has been shown to cause erythrocyte damage and thus may be affecting oxygen delivery by the red cell. Oxyhemoglobin affinity, heme-oxygen binding site interaction (Hill coefficient), and red cell 2,3-diphosphoglycerate concentrations were measured in a total of twenty-two New Zealand white rabbits exposed to ozone. Ozone exposures of 1 and 3 ppm for 4 hr in rabbits had no significant (P greater than .05) effect, immediate or delayed, on the parameters measured.


Carbon monoxide and ventricular fibrillation threshold in normal dogs.

In a blind, randomized study, the effect of breathing 100 ppm of carbon monoxide versus compressed, purified air for 2 hr on ventricular fibrillation threshold was investigated in twenty anesthetized normal open-chested dogs. The mean arterial carboxyhemoglobin level was 1.12% in the air control period, 0.99% after air, 1.10% in the carbon monoxide control period, and 6.48% after carbon monoxide. Carbon monoxide increased the mean arterial carboxyhemoglobin (P less than .001). Mean ventricular fibrillation thresholds were 19.9 +/- 6.5 mA in the carbon monoxide control period, 15.7 +/- 5.6 mA after carbon monoxide 20.8 +/- 6.3 mA in the air control period, and 24.5 +/- 9.5 mA after air. Carbon monoxide decreased the ventricular fibrillation threshold (P less than .005). These data show that breathing 100 ppm of carbon monoxide for 2 hr reduces the ventricular fibrillation threshold in anesthetized normal open-chested dogs.


Pulmonary retention of neutron-activated coal dust.

Coal dust aerosols with cesium-134 and scandium-46 labels were studied in dogs and rats following brief inhalation exposures by external measurement of gamma photons in the 0.6 to 0.8 and 0.9 to 1.1 MeV regions, respectively. Ancillary in vitro studies of the leaching characteristics of the two radionuclides from coal were made and control studies utilizing the "free" radionuclides were undertaken for each of the investigations with radioactive coal dust. The biological data strongly infer that coal dust retention in canine lungs is extremely protracted with a biological half-life no shorter than approximately 4.3 yr and probably much longer. The biological model which was formulated and analyzed to obtain this finding is discussed along with its limitations.


Intake of magnesium and toxicity of lead: an experimental model.

Groups of ten male Wistar rats were fed 100 mg lead/kg body wt . day, or 100 mg lead plus 250 mg Mg . kg body wt . day mixed in the powdered diet as chlorides. Blood and urine were monitored for lead-related enzymes and lead concentrations. Compared to the lead-treated, blood lead and urinary aminolevulinic acid were much lower and blood aminolevulinic acid dehydratase and urinary lead were higher at 30, 45, and 62 days in the lead-magnesium-treated animals. At 45 and 62 days, blood lead was higher in the lead-magnesium group even though the urinary excretion of lead was significantly higher (P less than .01). At 62 days, the lead feeding was discontinued to both groups, but magnesium administration was continued. Both groups of rats were then monitored for urinary excretion of lead and this was significantly higher (P less than .01) in the rats fed magnesium suggesting that magnesium intake helped mobilize lead from bone, thus increasing the blood lead level and subsequent urine excretion. Enzyme levels approached normal values at 106 days only in the lead-magnesium group, thereby indicating low levels of lead toxicity. Lead levels of bones in rats of the lead-magnesium group, when sacrificed at 106 days, were significantly lower (P less than .01) than among those given lead alone, another indication that magnesium helped mobilize lead from bone. The results, therefore, clearly show that feeding magnesium leads to lower retention and increased excretion of lead under the experimental conditions outlined.


Technique for isoperistaltic gastric tube for esophageal bypass.

There has not been described a uniformly successful method for palliation of inoperable carcinoma of the esophagus, especially malignant tracheoesophageal fistula. A gastric tube formed from the greater curvature of the stomach is being evaluated for these patients. The blood supply is based on the right gastroepiploic vessels. Using a stapler, one can form a gastric tube sufficiently long to reach the hypopharynx. Placed substernally, anastomosis to the cervical esophagus is performed. In 30 patients postoperative mortality has been 13%. No tube necrosis has occurred, but anastomotic leakage has been a problem. In those patients who had esophageal bypass for palliation and were discharged from the hospital, swallowing function has been satisfactory and the average survival has been 5.2 months.


The surgical treatment of arterial injuries in the civilian population.

During an 8-year period, 191 consecutive patients were treated for arterial injuries. Blunt trauma occurred in 46 patients (24%), low velocity gunshot wounds in 82 patients (43%), shotgun wounds in 22 patients (12%), stab wounds in 20 patients (10%), iatrogenic injury in nine patients (5%), high velocity gunshot wounds in two patients (1%) and other penetrating wounds in ten patients (5%). Preoperative arteriography was performed in 48 patients (25%) who were hemodynamically stable with injuries to major vessels in the thorax, base of neck or extremities and in whom the exact location or extent of injury was unknown. Surgical repair was performed in 184 of 191 patients (96%); seven patients expired intraoperatively before reconstruction could take place. Repair was accomplished in the 184 patients by end-to-end primary anastomosis in 80 patients (44%), lateral sutures in 21 patients (11%), SVG in 71 patients (85%) and Dacron prosthesis in 13 patients (15%). One hundred seventy patients survived (89%) and 21 patients died (11%), seven of the 21 deaths were intraoperative and ten others were due to the effects of trauma to the aorta or its branches.


Definitive control of bleeding from severe pelvic fractures.

Forty patients with severe pelvic fracture and extraperitoneal hemorrhage were reviewed. Eighteen patients seen prior to 1975 (group I) were clinically similar to 22 patients seen subsequently (group II). Major pelvic fracture hemorrhage was defined as bleeding in excess of 2,000 ml over and above initial resuscitation volumes. Ten of 22 group II patients met the criteria for continued extraperitioneal bleeding and were immobilized in an inflatable G-suit after surgically remediable lesions had been excluded. Ventilator support and hemodynamic monitoring were instituted and clinical response recorded. Prompt cessation of bleeding was observed in nine of ten patients. One patient required selective catheterization of a bleeding artery with subsequent embolic occlusion. Significant reductions in overall mortality and the frequency of shock related death were observed in group II patients. Sepsis was the leading cause of late death in survivors. Immobilization of pelvic fracture patients in the G-suit is recommended as a means of controlling continuing retroperitoneal hemorrhage when surgically correctable bleeding points have been dealt with. Failure of patients to respond promptly to the G-suit strongly suggests arterial bleeding amenable to selective catheterization and embolic occlusion.


Management of genitourinary injuries in patients with pelvic fractures.

Associated injuries frequently occur in patients who sustain fractures of the pelvis. Hemorrhage from intrapelvic vessels, rupture of the urinary bladder and avulsion of the membranous urethra in males are among the integral risks in this trauma. Non-operative methods of managing hemorrhage have gained favor in recent experience. The case records of 282 male patients with pelvic fractures were reviewed to evaluate experience with lower genitourinary injuries. Early recognition is important in bladder injuries, and surgical repair is advised, except in selected patients who may be managed by catheter drainage alone. Delayed complications of bladder injury are rare. Membranous urethral injuries entail a high risk of chronic stricture disease and sexual impotence. The rationale of early repair versus delayed repair of these injuries is discussed. The results in this series show advantage for delayed repair.


Cecal volvulus: analysis of 50 patients with long-term follow-up.

Fifty patients operated upon for cecal volvulus were analyzed. The ages ranged from 14 to 88 years and averaged 53 years. Eighteen were males and 32 were females. The presentation was acute, requiring urgent surgery in 41 patients; nine patients presented with chronic symptoms and were operated upon electively. In 14 patients (28%) the cecal volvulus was temporally related to another acute medical problem. The diagnosis was made radiographically in 22 patients (44%) and at operation in 28 patients (56%). Cecal volvulus was correctly diagnosed by barium enema in 20 of the 29 patients (69%) undergoing the study. Eighteen of the patients were treated by cecopexy, 14 by resection, 12 by detorsion alone, and six by tube cecostomy. Mortality was 12% (6/50) and was associated with gangrenous cecum (33%, 3/9), other systemic diseases (24%, 5/21), age over 50 years (19%, 6/31), and acute presentation (15%, 6/41). In the absence of gangrenous cecum, enterotomy was associated with subsequent wound infection in 23% (7/30), as compared to none (0/11) when enterotomy was not performed. There were no recurrences of cecal volvulus in the entire series during follow-up which extended to 17 years, averaged 5.7 years, and was complete in 96% (42/44) of survivors. When gangrenous cecum is present, resection is the treatment of choice. In the absence of gangrenous bowel, cecopexy is recommended because of a low mortality (0/18), low morbidity (3/18), low recurrence rate (0/18) and absence of need to open the unprepped bowel.


The small bowel tumor problem: an assessment based on a 20 year experience with 116 cases.

Documented rarity, diagnostic difficulty and poor results stimulated this study of 79 malignant and 37 benign small bowel tumors in order to emphasize these lesions, determine their symptomatology and improve diagnosis and results, particularly in the malignant group. Chief symptoms were recurrent abdominal pain and tenderness, signs of obstruction and gastrointestinal bleeding. Fourteen cases were asymptomatic. The mean symptom-diagnosis interval was 6.6 months. Roentgenographic contrast studies were helpful in diagnosing 33 of 43 patients, with false negatives in 10. Laboratory studies were usually not helpful. Metastases were present at the time of surgery in approximately 58%. In the malignant group curative procedures were performed in 36 and palliative in 43, with an operative mortality of 10%. Five and 10 year survival rates were respectively 21/51 (41.2%) and 8/38 (21.2%) for malignancies. Individual 5 and 10 year survival rates were respectively as follows: carcinoid 11/15, 4/8; undifferentiated carcinoma 3/5, 1/3; lymphoma 3/11, 1/9; leiomyosarcoma 2/7, 1/6 and adenocarcinoma 2/13, 1/12. In the benign group results were excellent, except for one death from pulmonary embolism. The study suggests that if results with malignant small bowel tumors are to be improved, prompt diagnostic study and early consideration of laparotomy in patients with suggestive symptoms is mandatory.


Carotid endarterectomy: review of 276 cases in a community hospital.

Two hundred seventy-six carotid endarterectomies performed on 232 patients in a community hospital were reviewed. All the surgery was performed in a routine manner utilizing systemic heparinization and an indwelling shunt. There were three deaths in this series, giving a mortality of 1.08%. A transient neurological deficit occurred in seven patients. All of these cleared within a 7-day period; this represents 2.5%. Only one patient had a permanent deficit. Long-term followup from 6 months to 9 years showed that the majority of deaths occurred from myocardial disease and malignancies. Only eight patients later died from stroke.


What role should the intra-aortic balloon have in cardiac surgery.

Intra-aortic balloon pumping (IABP) to assist the failing circulation has become widely applied and accepted since its introduction in 1968. The elective, preoperative use of IABP for patients undergoing cardiac surgery has now become the controversy. The purposes of this report are to examine our experience with IABP and to determine its appropriate role in high-risk patients. IABP was utilized in 75 of 2333 (3.2%) adult cardiac surgical patients at Emory University Hospital from January 1976 through June 1978. IABP was required for refractory shock following cardiopulmonary bypass (CB) in 53 patients, for preoperative cardiogenic shock after acute myocardial infarction (CSMI) in nine and was electively placed prior to CB in 13. Sixty-two patients (81%) were able to separate from CB with IABP and pharmacologic support and were assisted 24-432 hours (median 64 hours). Fifty-five (73%) were weaned from IABP. Fifty (67%) are hospital survivors; late deaths have occurred in six patients (8%). Hemodynamic effect of IABP was demonstrated by comparison of pumping 1:1 to 1:8 mode in five balloon-dependent patients after CB. IABP was found to decrease systolic blood pressure, left ventricular filling pressure and peripheral resistance (p < .05). It increased diastolic and mean blood pressure, cardiac index and the endocardial viability ratio (p < .05). The post-CB use of IABP resulted in highest salvage when utilized to support failing hearts that required surgery despite recent preoperative infarction or when intraoperative ischemic injury had occurred. Poorest results were in patients with extensive chronic myocardial damage. Except in the case of preoperative cardiogenic shock, it was impossible to establish statistically reliable criteria for patients in whom elective preoperative insertion was found to be necessary. Careful surgical and anesthesia management with good monitoring can be used instead of preoperative IABP in the majority of (if not all) hemodynamically stable patients regardless of risk classification.


Principles for the management of penetrating cardiac wounds.

An experience with penetrating cardiac injuries between 1974 and 1977 has permitted designation of particular findings as indications for emergent operations and appropriate therapeutic approaches. Of the 46 patients with cardiac trauma, 28 suffered gunshot wounds. Seventeen patients died, and 14 of the deaths occurred as a result of asystole, ventricular fibrillation or exsanguination during operation. Two patients died of neurologic sequelae following successful cardiac repair, and one died secondary to injury not disclosed by physical examination or roentgenogram. The surviving 29 patients had five major complications. Sepsis, organ system failure and cardiac defects rarely occurred despite rapidly performed thoracotomy and severe shock. Since delayed operation has been uniformly associated with adverse outcome and because postoperative complications of emergent pericardial exploration are mild, the following conclusions have been reached: 1) Mediastinal entrance wounds, severe hypotension and signs of cardiac tamponade are demonstrative of cardiac trauma. Therefore, virtually any combination of these physical signs mandates pericardial exploration. 2) Subxiphoid or transdiaphragmatic exploration (during laparotomy) of the pericardium has been valuable in diagnosis of suspected heart wounds. 3) Emergent cardiorrhaphy is the treatment of choice. Pericardiocentesis is at best only temporarily effective. Thoracotomies performed in the emergency room were uniformly unsuccessful. If possible, cardiorrhaphy should be done in the operating room. 4) Median sternotomy is the approach of choice. 5) The basic principles of management of cardiac injury are rapid diagnosis, relief of tamponade, control of hemorrhage, repair of cardiac defects and restoration of blood volume.


Skeletal abnormalities after jejunoileal bypass.

Jejunoileal bypass surgery is fraught with many longterm complications, among which is hypovitaminosis D. The relationship, if any, of hypovitaminosis D to the skeletal disease which may occur following this operation is, however, unknown. Consequently, we studied eight patients with low circulating levels of 25-hydroxyvitamin D who had undergone jejunoileal bypass at least two and one-half years previously. Despite the absence of skeletal symptoms, the bone biopsies of six of these patients were abnormal. The volume of trabecular bone was diminished in the group as a whole, and half the patients had an excess of unmineralized skeletal matrix. However, no noninvasive diagnostic technique identified those patients with skeletal disease. We therefore conclude that recognition of those jejunoileal bypass patients potentially at risk to develop clinically significant bone disease requires biopsy of the skeleton.


A stapling instrument for end-to-end inverting anastomoses in the gastrointestinal tract.

A stapling instrument is described for end-to-end inverting anastomoses applicable principally to low rectal anastomosis or esophagogastric or esophagojejunal anastomosis. The instrument creates an inverting anastomosis held by a double staggered row of stainless steel wire staples creating an anastomosis 21.2 mm internal diameter with no significant inverted flange. The early experience is encouraging.


Therapeutic and economic impact of a modern amputation program.

The experience with 142 below-knee amputations for vascular occlusive disease and/or diabetes mellitus in 133 patients has been reviewed. The program utilized Xenon(133) skin bloodflow measurement for the selection of amputation level, emphasized the use of the long posterior skin flap as an important part of surgical technique, and employed immediate postoperative prosthesis with accelerated rehabilitation for postoperative management. The results of this program yielded a 0% postoperative mortality, 89% amputation healing, and 100% prosthesis rehabilitation of all unilateral below-knee amputees, and 93% rehabilitation of all bilateral below-knee amputees. The average time interval between amputation and fitting of a permanent prosthesis was 32 days. The use of Xenon(133) clearance as a measurement of capillary skin bloodflow for purposes of amputation level selection continues to be valid. All amputations with flows in excess of 2.6 ml/100 g tissue/min healed primarily, including the last 58 consecutive amputations. The total amputation of the 172 hospital V.A. system was surveyed and a cost analysis, based upon duration of postamputation hospitalization, comparing immediate postoperative prosthesis with conventional techniques, was performed. The savings to the system, taking into account start-up and maintenance costs for a program which employs immediate postoperative prosthesis, was projected to be $80,000,000 over five years. We conclude that a modern amputation program employing Xenon(133) clearance for amputation level selection and immediate postoperative prosthesis with accelerated rehabilitation is well justified based upon reduced morbidity, negligable mortality, and optimum patient prosthetic rehabilitation at a marked reduction in overall cost.


II. Interference with local myocardial cooling by heat gain during aortic cross-clamping.

We have used a physical model of the thermal conditions of open-heart surgery to study sources of heat input to the heart during local cardiac cooling. Pulmonary and systemic venous return entering the cardiac chambers were the most important sources of heat to the hypothermic heart. In 5 excised hearts, venous return of 100 ml per minute or more entering the left atrium and left ventricle increased mean septal temperature significantly from 8 +/- 1 degrees C to 16 +/- 1 degree C (p less than 0.01). When venous return passed through the right side of the heart and then the left side, it increased mean septal temperature significantly from 7 +/- 0.5 degrees C to 23 +/- 1 degree C (p less than 0.001). Conduction of heat through the pericardium, heat radiation from standard operating room lights, and heat uptake from room air had relatively minor effect and produced no significant increase in myocardial temperature provided all surfaces of the ventricles were irrigated with cold saline. The hypothermic heart can be isolated from heat input by individual caval cannulation, low bypass perfusion rate, systemic cooling to 30 degrees C, and irrigating all surfaces of the ventricles with cold saline.


III. Local cardiac hypothermia: experimental comparison of Shumway's technique and perfusion cooling.

A model of the thermal conditions of the heart during ischemic arrest was used to study the efficiency of Shumway's technique of topical hypothermia. Cooling was improved by increasing the flow of cold saline to 350 ml per minute, reducing the saline temperature, lifting the posterior left ventricular wall away from the pericardium, and irrigating the left ventricular cavity. Perfusing the coronary circulation with cold fluid cooled the heart eight times faster than did surface irrigations by Shumway's technique.


Second primary bronchogenic carcinoma: life-table analysis of surgical treatment.

Twelve patients had curative resection of primary bronchogenic carcinoma. Eleven to 84 months later, a second primary bronchogenic carcinoma was discovered and was operated on. Six patients underwent wedge resection, while the others had a lobectomy or pneumonectomy. There was no operative mortality. Two patients survived longer than 5 years. In addition to these patients, 26 patients who also had successive surgical resections for primary lung cancers were collected from the literature. Two operative deaths were related to respiratory insufficiency. Life-table analysis of this accumulated series of 38 patients revealed the survival rate 1 year after the resection of a second tumor to be 70%, and 2 and 3 years later, 55% and 27%, respectively. Thus, in patients in whom a second primary carcinoma of the lung develops, successive resections tailored to preserve respiratory reserve are compatible with low operative mortality and, in some instances, long-term survival.


Low-energy direct defibrillation of the human heart.

A direct cardiac defibrillation study in 30 patients who underwent heart operations with cardiopulmonary bypass and moderate systemic hypothermia is presented. No patient required more than 10 watt-seconds of energy for defibrillation, and, in 21 of them, 5 watt-seconds or less were sufficient.


Pericardial fluid gas analysis in hemorrhagic pericardial tamponade.

Nine patients with hemorrhagic pericardial tamponade were studied to determine the localizing value of gas analysis of pericardial fluid in therapeutic pericardiocentesis. The aspirate and the central venous blood was analyzed simultaneously for partial pressure of oxygen (PO2), partial pressure of carbon dioxide (PCO2), and hematocrit at the time of pericardiocentesis. In all 9 patients the difference in hematocrit between the pericardial fluid and the central venous blood was not significant. The PCO2 of pericardial fluid was significantly higher than that of central venous blood (p less than 0.025). The PO2 of pericardial fluid was consistently and significantly lower than that of central venous blood (p less than 0.005). We conclude that in patients with hemorrhagic pericardial tamponade, the simultaneous measurement of PO2 and PCO2 of central venous blood and pericardial fluid is a useful rapid bedside method to confirm the site of aspiration during pericardiocentesis. The PO2 determination is statistically the best discriminator between the two fluids in this setting.


Myocardial stimulation impedance: the effects of electrode, physiological, and stimulus variables.

With exposed metal at the electrode tissue interface (8 mm2, 28 mm2, 57 mm2), myocardial threshold stimulation impedance increased as pulse duration was lengthened, with left ventricular intramyocardial stimulation, and with the smaller surface area electrode. An 0.5 mm2 differential-current-density electrode, which eliminated direct metal-to-tissue contact at the electrode-myocardial interface, was associated with notably higher impedances than each of the three metal tip electrodes and did not show increasing impedance levels with changes in pulse duration, confirming the minimization of polarization energy losses with this device. The majority of electrode, electrode tissue interface, and myocardial variables that are characterized by high threshold stimulation impedance are associated with low threshold energy requirements for pacing and reduced pacemaker power source drain. No accurate information about sensing impedances can be derived from current knowledge of pacing impedance.


I. Development of an in vitro model of myocardial cooling: a study of the effect of cardiac size on cooling rate.

A physical model for the study of local cardiac hypothermia was developed using excised animal hearts. The validity of the model was established by showing close similarity between cooling curves of dog hearts in vivo and in the model. The model was then used to compare the cooling rates of three groups of excised hearts using cold saline irrigation. Groups 1, 2, and 3 had mean left ventricular weights of 166, 379, and 1,429 gm, respectively, and mean left ventricular wall thicknesses of 1.5, 2.0, and 3.1 cm, respectively. For the same 10 degrees C temperature fall, Group 1 took 25 +/- 2.8 minutes, Group 2 took 54 +/- 9.2 minutes, and Group 3 took 117 +/- 21 minutes. To avoid slow cooling and consequent ischemic damage in the hypertrophic ventricle, it may be desirable to initiate cooling using coronary perfusion with cold blood or cold cardioplegic solutions.


Pulmonary lymphangiomyomatosis.

Pulmonary lymphangiomyomatosis is a rare but distinct clinical and pathological entity. It is characterized by hamartomatous proliferation of smooth muscle around the lymphatic vessels of the lung, mediastinum, and retroperitoneum. It occurs only in menstruating women and girls and is manifested by spontaneous pneumothorax and chylous pleural or abdominal effusion. As it progresses, the lungs become increasingly involved with subsequent pulmonary insufficiency and recurrent infection. Eventually death results. This entity has not been reported previously in the surgical literature even though the thoracic surgeon is called on to both establish the diagnosis and aid in palliation. The hypothesis that the disease is estrogen dependent is reviewed and the desirability of estrogen ablation in patients with positive estrogen receptors is suggested.


Total lung ectoplasia with systemic arterial supply.

A 6-month-old girl was not to have fever and stridor. Investigations revealed an abnormal lung that communicated with the esophagus and had a systemic arterial supply from the abdominal aorta. Resection of the abnormal lung was performed successfully. We have termed this disorder total lung ectoplasia. Ten patients from the literature were reviewed.


Axillofemoral bypass: intrapleural method.

A new procedure for intrapleural axillary-bilateral femoral bypass is described. This method is proposed as an alternative procedure for bypassing aortoiliac occlusive disease in the high-risk patient.


Drug delivery.

The calculations necessary to allow infusion of a known drug dosage at micrograms per kilogram of body weight per minute are time-consuming and error prone. A simpler method entails multiplication of the patient's weight in kilograms by the factor 15. The resultant figure represents the number of milligrams of drug to be placed in 250 ml of infusate vehicle. The solution, which is delivered through a microdrip chamber (60 gtt per milliliter), will contain 1 microgram per kilogram in each drop. One is thus permitted to define dosage by setting up the solution to have 1 gtt = 1 microgram/kg.


Anomalous origin of the right coronary artery from the pulmonary artery.

Three patients with anomalous origin of the right coronary artery from the pulmonary artery are presented together with a review of the 14 patients with this anomaly previously reported. One of the current patients is the youngest to be diagnosed before operation and the youngest to undergo corrective operation. Although the lesion is usually asymptomatic, it may contribute to sudden death. The only suggestive physical finding is a continuous murmur with diastolic accentuation, which is present only in some patients. There are no diagnostic electrocardiographic or chest roentgenographic changes. Diagnosis is made best by selective left coronary arteriography showing retrograde filling of the right coronary artery from collateral vessels. Operative repair should consist either of direct reimplantation of the proximal right coronary artery into the aortic root or of saphenous vein bypass graft to the coronary artery with ligation of its origin. Operation is recommended when the lesion is recognized.


Survival and probability of cure without and with operation in complete atrioventricular canal.

Actuarial analysis based on postmortem examination of patients who had been treated nonsurgically for complete atrioventricular (A-V) canal defect shows that only 54% survive to 6 months of age, 35% to 12 months, 15% to 24 months, and 4% to 5 years of age. Our surgical experience since 1975 in 39 patients confirms the idea that primary repair is feasible in small infants. The highest risk of hospital death is when the operation is done in the early months of life; it falls to 17% by age 12 months. Between 1967 and October, 1976, the five-year survival rate among patients leaving the hospital alive after repair was 91%. The age-specific probability of "surgical cure" of patients operated upon for complete A-V canal (alive five years later with mean pulmonary artery pressure less than 25 mm Hg) is maximal at 73% when the operation is done at about 14 months of age. Urgent earlier repair is frequently necessitated by the life history of the disease.


Interrupted aortic arch operation in the first week of life: hemodynamic and angiographic evaluation one year later.

Operation for interrupted aortic arch (IAA) was successful in 2 infants during the first week of life. Both had postoperative hemodynamic and angiographic evaluation at one year of age. The first infant had a type A IAA, and prostaglandins were infused to prevent ductal closure prior to the insertion of a graft between the two ends of the interrupted aorta. The second infant had a palliative operation for type B IAA (pulmonary artery banding and graft from main pulmonary artery to descending aorta). These patients represent the ninth and tenth successful operations for IAA in this age group and are reported with long-term reevaluation.


Surgical treatment of double-outlet left ventricle in 2 patients with D-position and L-position of the aorta.

Two cases of double-outlet left ventricle (DOLV) are described, 1 with D-position and 1 with L-position of the aorta. Both patients had situs solitus, atrioventricular concordance with D-relationship of the two ventricles, a ventricular septal defect, and subpulmonary stenosis. The patient with D-position of the aorta was operated on using a technique similar to that for repair of Fallot's tetralogy but including emergency implantation of a bioprosthesis into the pulmonary artery position on the eighth postoperative day. Surgical correction in the patient with L-position of the aorta required the implantation of a composite valved conduit between the right ventricle and the pulmonary artery. The various surgical techniques for correction of DOLV are described, and the literature is reviewed. Postoperative right heart failure in both patients is explained by the impaired function of the right ventricle being exposed to gross pulmonary incompetence or by the persistence of elevated right ventricular pressure.


Posterior midventricular rupture after mitral valve replacement.

Posterior midventricular rupture occurred in 3 patients after insertion of a mitral prosthesis. Iatrogenic surgical trauma was not implicated. There were five clinical factors common to each case: a woman with mitral stenosis; a left ventricle of relatively normal size; the use of intermitent cold cardioplegia; the insertion of a porcine heterograft valve; and transient postoperative hypertension. Rupture in such cases may be caused by hyperdynamic left ventricular contraction against the strut of the prosthesis. Causes of ventricular perforation are discussed.


Cardia lymph in electrical ventricular fibrillation: an experimental study.

The flow velocity of cardiac lymph during electrical ventricular fibrillation under normothermic cardiopulmonary bypass was studied experimentally in dogs. The time needed for the cardiac lymph node to become stained after injection of dye into the apex myocardium of the left ventricle was measured as an indicator in determining flow velocity of cardiac lymph. The flow velocity was markedly decelerated immediately after the commencement of electrical ventricular fibrillation. It was accelerated, however, after 2 hours of continuous electrical ventricular fibrillation. The difference between the two values was significant (p less than 0.01). Absent contractility of the heart influenced the deceleration of flow velocity of cardiac lymph immediately after the commencement of electrical ventricular fibrillation. Acceleration after 2 hours involved stasis of cardiac lymph as a result of absent contractility and increment of lymph production due to the nonphysiological condition of the myocardium.


Unilateral pulmonary emphysema created by ligation of the left pulmonary artery in newborn puppies.

The left pulmonary artery was ligated in 7 puppies 12 to 24 hours after birth. All were followed by periodic chest roentgenograms. At 6 months of age, ventilatory spaces, split-lung function, and static compliances were determined. Bronchograms and arteriograms were obtained, and histopathology was studied. All animals demonstrated a decrease in left lung size with gross and microscopic changes typical of chronic emphysema. There was impressive bronchial artery hypertrophy. Oxygen consumption and static compliances in the left lungs were depressed. These marked alterations in maturation, as well as the degenerative changes, are believed to be related to an impairment in the nutritive circulation of the lung.


Systemic air embolization from penetrating lung injury.

This study evaluates the role of increased intratracheal pressure in developing systemic air embolization. Twenty healthy mongrel dogs were monitored for air embolization, both by means of an extracorporeal arteriovenous shunt constructed from transparent plastic tubing for visualization of air emboli and by means of a Doppler flow probe implanted at the root of the aorta. Systemic arterial, left atrial, intratracheal, and intrapleural pressures were recorded. In 10 of the dogs, a penetrating wound of the lung 1 cm wide by 4 cm deep was produced; in 5 the chest was left open and in 5 the chest was closed. The remaining 10 dogs served as controls (with no wound of the lung); in 5 the chest was left open and in the other 5 the chest was closed. No air embolization occurred in any animals at intratracheal pressures less than 65 mm Hg. However, systemic air embolization occurred in every dog in all groups upon hyperinflation of the lung above 65 mm Hg. The control groups differed from the groups with penetrating wound only in the quantity of embolized air. This study suggests that hyperinflation of the lung to an intratracheal pressure above 65 mm Hg results in systemic air embolization and that the presence of a penetrating wound of the lung at such intratracheal pressure predisposes to a greater quantity of air embolization.


Segmental resection for bronchogenic carcinoma: a surgical alternative for the compromised patient.

Over a twenty-year period, 44 patients with peripheral bronchogenic carcinoma who were unable to tolerate major pulmonary resection underwent segmentectomy as an alternative to nonoperative management. There were 2 immediate postoperative deaths. Of 31 patients eligible, 36% survived five years, and the mean survival time approached four years. Excluding those patients with undifferentiated small cell carcinoma, segmental resection in this compromised group offered a good chance for cure while providing reasonable palliation, and this procedure should be considered as a surgical option to other modalities of treatment commonly offered to these individuals.


Changes in the manufacture of expanded microporous polytetrafluoroethylene: effects on patency and histological behavior when used to replace the superior vena cava.

Polytetrafluoroethylene (PTFE) has been used clinically and experimentally as a vein substitute. Since its introduction, changes have been made in the manufacture of the material. This study was designed to evaluate the effects of pore size (fibril length), PTFE cover, and spiral tube support on long-term patency and histological behavior when this material is used as a replacement for the precava in the dog. A graft of 30-mu pore size has adequate fibroblastic ingrowth, a neointima of 200 mu or less, and the best long-term patency. The PTFE cover results in less fibroblastic involvement of the prosthetic graft and prevents late occlusion caused by transmural fibrosis in the 90-mu graft. The spiral support does not affect patency and may be indicated when external pressure on the tube must be avoided.


Structure-related thrombosis involving a porcine xenograft valve.

A patient developed acute congestive heart failure following chordal rupture and underwent mitral valve replacement with a porcine xenograft. He recovered adequate hemodynamic function but died one month later with widespread bronchopneumonia. Postmortem examination revealed a prominent muscular shelf in the right coronary leaflet of the xenograft, and focal thrombosis involving the adjacent sewing ring and left atrial wall. The location of the thrombus suggests that it formed as a result of local stasis behind the large muscular shelf. Limiting the size of this muscular shelf by valve selection and construction may reduce the thrombogenicity of this prosthesis.


Prospective randomized evaluation of intrathoracic intercostal nerve block with bupivacaine on postoperative ventilatory function.

This prospective and randomized study demonstrates the beneficial effect of intrathoracic intercostal block with bupivacaine on the recovery of pulmonary function after thoracotomy. A significantly (p less than 0.05) better forced expiratory volume was seen in the treated group in the early post-operative period. Similar findings were observed in forced vital capacity. Also, the requirements for analgesics were decreased in the treated group. We believe that intrathoracic intercostal block with bupivacaine when properly utilized can be a good adjuvant in the improvement of pulmonary function after thoracotomy.


Pulmonary reperfusion syndrome.

"Reperfusion syndrome" of the lung may play a role in the pulmonary edema and hemorrhage that occur following pulmonary embolectomy, cardiopulmonary bypass, and shock. Bioenergetic, metabolic, and ultrastructural studies of canine lungs indicate that ventilated lung tissue could tolerate 5 hours of pulmonary arterial occlusion with minimal damage. However, a 24-hour interruption of pulmonary arterial blood flow produced a significant decrease in the ratio of adenosine triphosphate to adenosine disphosphate, and glycogen, and an increase in tissue lactate. Reperfusion of these lungs resulted in even more pronounced biochemical and ultrastructural deterioration, as well as gross pulmonary edema and hemorrhage. The lesion appears to be similar to the reperfusion damage that occurs in other organs, such as the kidney, and the skeletal and cardiac muscles.


Pulmonary artery banding: long-term results in 63 patients.

Sixty-three patients who underwent banding of the pulmonary artery between 1968 and 1975 were studied. Mortality among patients who underwent the banding procedure was 22%, and among those with ventricular septal defect it was 7%. Thirty-eight of the 49 survivors of the banding procedure were investigated for abnormalities of the pulmonary outflow tract caused by the band. Seventy-one percent of these 38 patients had an identifiable abnormality of the pulmonary valve or artery. These complications occurred more frequently in patients banded at a very young age (less than 2 months old) and in patients in whom the band was in place more than two years. Corrective operations have been performed in 24 of the 49 patients who survived banding. Seventy-six percent of the patients with ventricular septal defect survived corrective operation, while only 29% of the patients with more complex lesions survived.


Ventricular fibrillation during cardiopulmonary bypass: long-term effects on myocardial morphology and function.

Mongrel dogs were subjected to hypothermic (28 degrees to 30 degrees C) cardiopulmonary bypass with hemodilution by 50%. In two groups of 8 dogs each, ventricular fibrillation was induced for 60 and 90 minutes, respectively, while the dogs were on bypass. A group of 6 dogs with the heart beating but nonworking served as control. Seven weeks after operation, hemodynamic measurements were made in the survivors (6 in each group) and the heart was fixed by perfusion with glutaraldehyde. Multiple transmural samples were taken from both ventricles. Light microscopy revealed solitary left ventricular scars (0.5 to 3 mm wide) in 2 hearts each from Groups 2 and 3. None of the hearts exhibited diffuse subendocardial fibrosis indicative of healed ischemic injury. All animals were hemodynamically normal. We conclude that in the nonhypertrophied heart, ventricular fibrillation up to 90 minutes with continuous bypass-sustained coronary perfusion (perfusion pressure at or above 70 mm Hg) offers protection from permanent myocardial injury.


Bronchogenic carcinoma with a brain metastasis: a continuing challenge.

Twenty-three patients with carcinoma of the lung and a brain metastasis had both the primary and secondary tumors surgically removed (combined operation). Results revealed that 52% of the patients were unimproved and died during the first 6 months. Operation improved short-term survival in 26%. Five patients (22%) lived longer than 2 years, and 3 of them (13%) are alive and well 10 or more years following operation.


Pulmonary metastatic chondrosarcoma with intracardiac extension.

An unusual case of pulmonary metastatic chondrosarcoma with intracardiac extension is presented. Echocardiography and right heart catheterization with pulmonary angiography demonstrated that resection using cardiopulmonary bypass was possible in a situation initially considered to be inoperable.


Operative correction of total left anomalous pulmonary venous return.

The evaluation, surgical repair, and follow-up are described in an asymptomatic 27-year-old man with unilateral total anomalous pulmonary venous return from the left lung through an innominate vein and a patent foramen ovale. The anomalous vein was divided and anastomosed directly to the left atrium using a vascular technique that produced an orifice larger than the vein diameter. Radionuclide scanning accurately identified the anomaly before operation and allows periodic noninvasive reevaluation after operation. Correction is recommended in all patients with unilateral anomalous pulmonary venous return because disease in the one normal lung could be fatal.


Repair of divided anomalous anterior descending coronary artery in tetralogy of Fallot.

Coronary artery anomalies in tetralogy of Fallot have often compromised surgical repair and imposed an increased mortality rate. Thus accidental division of the anterior descending coronary artery crossing the right outflow tract has previously usually resulted in death. The case is presented of a 13-year-old boy with tetralogy of Fallot in whom the anomalous left anterior descending coronary artery was divided. The blood supply to the left anterior descending artery was successfully restored using a reversed saphenous vein graft.


Cardiac pacing.

The basic electrophysiology of temporary and permanent cardiac pacing is reviewed, as are the indications, the types of pacing systems, and the methods of implantation. Recent developments in power sources and leads are described. The mercury-zinc battery is now obsolete and is being replaced by lithium, rechargeable, and isotopic power systems. While ventricular pacing continues to be the standard, a brief review of atrial programmed systems is given, including atrial pacing and atrioventricular synchronized and atrioventricular sequential pacing. Conventional pacing is aimed at the control of symptomatic bradycardia. Brief reference is made to experimental pacing systems designed to control ventricular or supraventricular tachyarrhythmias.


The role of thoracotomy in the management of pulmonary metastases from malignant melanoma.

Thirty-three patients over a 21-year period underwent thoracotomy for resection of suspected pulmonary metastases from malignant melanoma. Eleven patients were found to have nonmalignant disease (Group 1); 10 were found to have unresectable disease (Group 2); and 12 were rendered disease-free (Group 3). Of the patients found to have melanoma, 20 of 22 received post-operative chemotherapy. The median survival of the patients in Group 2 was 10.5 months (3 to 20 months); in Group 3 it was 12 months (3 to 35 months). There were no 5-year survivors. No factors distinguished the three groups preoperatively. Surgical resection still offers the greatest chance for long-term survival, based on reports of patients in the literature who have survived longer than 5 years following resection of pulmonary metastases from melanoma. Thoracotomy is especially useful for staging purposes in those patients found to have no metastatic disease.


Bone scanning in the evaluation of patients with lung cancer.

Sixty patients suspected of having lung cancer were evaluated for bone metastasis by means of technetium 99m stannous-polyphosphate bone scanning and correlative radiographic bone survey. Diagnosis of lung cancer was histologically proved in all patients. Scans demonstrated evidence of bone metastasis in 20 patients (33.4%) and radiographs, in 10 patients (16.6%). Twenty-four patients had repeat skeletal evaluation at one to eleven months after the first study. Of these patients, 7 initially demonstrating both negative scans and radiographs showed abnormal scans within five months. Bone scans correlated with radiographs in 53.3% and with accompanying bone pain in 33.3% of patients. False negative and false equivocal results were noted in 4 patients. This study suggests that bone scanning with 99mTc stannous-polyphosphate detected early bone metastasis in patients with lung cancer before these lesions became evident clinically or radiographically. Bone scanning is of value during the initial evaluation to determine operability in patients with lung cancer.


The use of computed tomography to evaluate suspected mediastinal tumors.

Thirty patients with suspected mediastinal tumors were evaluated by computed tomography (CT) at UCLA Medical Center. Twenty patients with myasthenia gravis were examined for possible thymomas, benign and malignant; and 10 patients were studied for other mediastinal masses (including teratoma, seminoma, mediastinal lipomatosis, carcinoma, lymphoma, and paravertebral abscess). The CT scan was found useful in several respects: (1) yielding information not available by conventional radiographic techniques; (2) defining the anatomical location and extent of mediastinal tumors; (3) detecting pulmonary metastasis and involvement of mediastinal nodes in cases of malignancy; and (4) establishing the diagnosis of benign mediastinal fatty masses. On the basis of our early experience, we believe CT is a valuable adjunct in the preoperative assessment of patients with suspected mediastinal tumors.


Mitral valve replacement: a nine-year follow-up of risks and survivals.

Experience with mitral valve replacement over a nine-year period is reviewed. Hospital mortality was 8.9%, with an additional late mortality of 18.5% during a mean follow-up period of 4.34 years. Study of the factors influencing the results of valve replacement revealed a direct correlation between long-term survival and New York Heart Association (NYHA) Functional Class, as judged preoperatively, as well as left ventricular end-diastolic pressure, cardiac index, type of valve lesion, and presence of associated coronary artery disease. Hospital mortality was 32% (p less than 0.01) for those patients in NYHA Functional Class IV before operation, compared with 3% for Class III patients. Untreated concomitant coronary artery disease was associated with a significantly higher perioperative mortality of 28% (p = 0.002) compared with an 8% mortality in patients with coronary artery disease treated by vein bypass at the time of mitral valve replacement. Patients with normal coronary arteries documented angiographically before operation had a 1% hospital mortality. Seventy-two percent of all patients are still alive at a maximum follow-up of nine years. Eighty-three percent of those survivors who were in Functional Class III or IV before operation are now considered to be in Class I or II. We conclude that patients should undergo mitral valve replacement before the development of the advanced functional stage of valve disease. In addition, coronary arteriograms should be performed on all patients who are more than 40 years old at the time of cardiac catheterization, and revascularization considered at the time of mitral valve replacement for those patients with significant coronary disease.


Combined multiple-valve procedures: a five-year experience with 125 patients.

One hundred twenty-five patients underwent 128 operations for combined multiple-valve procedures, with an overall early mortality of 16%. Highest mortality was associated with mitral and tricuspid valve disease (28.5%), followed by triple-valve disease (18.2%) and aortic and mitral valve disease (14%). Left ventricular end-diastolic pressure, cardiac index, mean pulmonary artery pressure, pulmonary artery wedge pressure, and arteriovenous oxygen difference were all significantly different in patients with regard to early mortality. Late follow-up of 94% has been achieved in 105 early survivors, with a late mortality rate of 11.2%. Analysis of late functional results reveal that 85% of survivors improved at least one Functional Class. Actuarial 5-year survival of 75% was achieved for early survivors of operation.


Reoperation for coronary graft failure: clinical and angiographic results in 43 patients.

Reoperation because of early or late coronary graft failure was performed in 43 patients who were part of a group of 1,985 patients operated on for coronary artery disease and followed for up to 7 years. Considerable variation in the results was noted depending on whether the patients were symptomatic or not before reoperation. Of the symptomatic patients, 85% were asymptomatic late (30 months) after reoperation whereas of those patients reoperated on despite the apparent lack of symptoms, 71.5% remained free from angina later on. Moreover, patency rate was high (94.4% or 17/18 grafts) in the first group and much lower (38.4% or 5/13 grafts) in those reoperated on solely on the basis of an early angiogram showing malfunctioning grafts. Patency rate was higher when the graft was totally replaced (92.3% or 12/13 restudied) rather than repaired simply through interposition of a segment of vein (37.5% or 3/8). It is apparent that results of reoperation in symptomatic patients are identical to those of an initial revascularization. On the other hand, patients who are asymptomatic despite early evidence of malfunctioning grafts should be reoperated on only when optimal angiographic conditions are present, that is, a coronary artery that is a good size, severely narrowed, and supplying a large myocardial area.


Acquired supravalvular aortic stenosis.

Severe supravalvular aortic stenosis was discovered at reoperation in 3 children with recurrent stenosis of the left ventricular outflow tract. The lesion consisted of gross thickening of the sinus ridge, most marked at the site of the previous aortotomy. The thickening had shortened the free edge of one or more leaflets and had distorted adjacent commissures. Preoperative angiography had indicated valve stenosis, but little commissural fusion was found at operation and the outflow tract obstruction was relieved by inserting a prosthetic patch in the ascending aorta. Recognition of this iatrogenic pathology is important to avoid supravalvular stenosis after aortic valvotomy and unnecessary valve replacement in children requiring reoperation for recurrent left ventricular outflow tract obstruction.


Giant left atrial V-waves in post-myocardial infarction ventricular septal defect.

A 54-year-old man developed a post-myocardial infarction ventricular septal defect with a 4:1 shunt. The first cardiac catheterization showed left atrial V-waves of 70 mm Hg. Assessment of the presence or absence of mitral regurgitation was not possible because of ventricular irritability and rapid runoff from left ventricle to right ventricle. At the second catheterization two months later, the left atrial V-waves had fallen to 34 mm Hg. The absence of mitral regurgitation was shown by observing the time difference in appearance of indocyanine green in the right ventricle and the left atrium after left ventricular injection. The defect was repaired by right ventriculotomy with subsequent normalization of left atrial V-waves. This case shows that very large left atrial V-waves may occur in postinfarction ventricular septal defects without mitral regurgitation and that these V-waves may decrease with time, probably reflecting increased left atrial compliance.


Annular subvalvular idiopathic left ventricular aneurysms in the black African.

The case of a Black African patient with an annular subvalvular left ventricular aneurysm of unknown origin is described, and the pathological findings in this condition together with a review of the literature is presented. We have operated on 12 patients with this condition between 1958 and 1978. Ventricular aneurysm in the Black African is extremely rare; aneurysms resulting from ischemic heart disease have not been encountered in this racial group, and contrary to earlier reports in the literature, syphilis is not the most common cause of left ventricular aneurysms in this group. The aneurysms arise in the fibrous rings below either the aortic or the mitral valve, extend around the valves in this situation, and may occur either singly or in both positions in the same heart. After various etiological factors are excluded, it is probable that in this group of patients the aneurysms develop initially as pulsion diverticula through a congenital weakness in the ventricular wall in the region of the atrioventricular groove.


Massive hyperplastic thymus in a 22-month-old infant.

Huge mediastinal masses in infants are often difficult to diagnose, and thymic enlargement must be considered in each instance, especially when the mass is located anteriorly. In the patient reported on here, the mass occupied approximately 60% of the chest cavity, and surgical intervention was required to establish the precise histological diagnosis. This proved to be massive hyperplastic thymus.


Digital injury using the sternum perforating awl.

Closure of the median sternotomy incision using stainless steel wires passed through the tip of a sternum-perforating awl is a common procedure. Digital injury can result should the awl shaft suddenly snap during sternal penetration. Sheathing the shaft with a plastic guard will prevent injury when this occurs.


Pull-through esophagectomy without thoracotomy for esophageal carcinoma.

Seventeen consecutive patients underwent pull-through esophagectomy using blunt dissection from laparotomy and cervical incisions for carcinoma of the esophagus. Fifteen patients had a middle-third lesion while 2 patients had a distal-third lesion. The gastrointestinal tract was reconstructed using primary gastroesophagostomy in 15 patients and colon interposition in 2. Both the colon and stomach were placed through the posterior mediastinum. The surgical technique and results are described in detail. There were two major complications. One patient died of massive gastric hemorrhage on the eighth postoperative day in spite of emergency operation. Another patient sustained a tear of the membranous trachea at the time of blunt dissection. This was repaired through a right thoracotomy without difficulty. Esophagectomy using blunt dissection offered excellent palliation and resulted in little morbidity in our series. The shortened operating time, minimal blood loss, total lack of postoperative chest pain, minimal pulmonary complications, and the benefit of a cervical anastomosis are several advantages compared with the present surgical approaches.


Aorta-pulmonary artery shunts with expanded polytetrafluoroethylene (PTFE) tube.

Ten patients underwent an aortapulmonary artery shunt with a polytetrafluoroethylene (PTFE) tube between December, 1976, and October, 1977. Five of them were less than 1 month old. The diameter of the PTFE tube was 5 mm in 9 patients and 4 mm in 1 patient. Seven patients survived the operation. One of them had a clotted shunt, which was reoperated on successfully. Three patients died in the postoperative period, and all had a patent shunt. Overall patency was 90% (9/10). Congestive heart failure refractory to medical treatment developed in 1 patient with a patent Blalock-Taussig and PTFE shunt. In our institution, the Blalock-Taussig shunt is the procedure of choice. The PTFE shunt is used when the anatomy of a patient is unsuitable for a Blalock-Taussig shunt. A tube diameter of 5 mm is optimal for infants when further growth is considered, even if digitalization is necessary to control congestive heart failure.


Surgical experience with unroofed coronary sinus.

Between January, 1967, and October, 1977, we performed intracardiac repair in 24 patients with unroofed coronary sinus. Eight patients had the so-called pure form of the syndrome, with the concomitant findings of total absence of the partition between the coronary sinus and left atrium, connection of the left superior vena cava (LSVC) to the upper left corner of the left atrium, and a coronary sinus type of atrial septal defect. In 2 additional patients this combination was repaired, along with repair of the common atrium in 1 and tetralogy of Fallot in the other. In 4 patients with either a partial or complete atrioventricular canal defect, only the distal or downstream portion of the sinus was unroofed so that the coronary sinus ostium was considerably to the left of its usual location. In 6 patients, 5 of whom had situs ambiguous, the unroofed coronary sinus was associated with complex congenital heart disease, and in 5 there was a L(contralateral) SVC. Three of these 6 patients died. The basic repair consists of roofing the coronary sinus from within the left atrium, so that the LSVC drains through the newly created coronary sinus and its ostium into the right atrium. In the absence of a LSVC, the basic repair is simply closure of the coronary sinus atrial septal defect. This leaves the coronary veins draining into the left atrium.


Repair of chest wall defects with prosthetic material.

This report summarizes our experience during a four-year period with the repair of 8 thoracic cage and 3 diaphragmatic defects requiring reinforcement with prosthetic material. Defects as large as the entire left hemidiaphragm or the right anterior chest wall including ribs two through six from the midsternum to the midaxillary line were adequately repaired. The technical approach utilized to obtain a secure, nonmobile thoracic cage involved the placement of sutures through drill holes or around ribs, rather than through the periosteum or pericostal soft tissues. Successful diaphragmatic repair was dependent on proper anchoring of the medial border of the prosthesis, placing sutures in the pericardium as necessary. Skin coverage for thoracic cage defects was achieved with widely undermined and advanced local tissue or previously delayed pedicle flaps. All patients had good evidence of chest wall stabilization after operation, and all were removed from mechanical ventilation within three days. One patient died of myocardial infarction twenty days after operation, and a second patient died later of metastatic disease. On the basis of our experience, we conclude that the range of chest wall lesions that can be surgically corrected or palliated is increased by the use of prosthetics implanted with techniques described here.


Factors influencing better results in operation for postinfarction ventricular aneurysms.

A series of 66 consecutive patients operated on for postinfarction ventricular aneurysm is reviewed with regard to the factors influencing the progressive decline of mortality (3.2% in the last 31 patients seen). The method of myocardial protection has a significant influence on mortality, which was 45% in patients operated on with aortic cross-clamping under conventional hypothermia and 5% in patients operated on under profound local hypothermia. Associated revascularization with vein bypass graft was performed in 28 patients, without mortality. The technique of aneurysmectomy adapted to the extension and location of the fibrotic scar is described, with exclusion of the septal portion of the aneurysm in 85% of the patients. In 36 patients who had postoperative cardiac catheterization, this technique produced normal ejection fraction and near normal left ventricular volumes


Surgical correction of pulmonary atresia with multiple large systemic-pulmonary collaterals.

A young patient in whom the pulmonary blood flow was supplied completely by five systemic-pulmonary collaterals underwent reconstruction of the pulmonary outflow tract by a new technique. This consisted of the insertion of a valve-bearing conduit between the right ventricle and an isolated segment of the descending aorta, which gave rise to three of the collaterals. Although the patient had a hypoplastic pulmonary artery confluence, other factors mitigated against its use as the sole conduit for right ventricular output.


Delayed rupture of the left ventricle after mitral valve replacement with bioprosthesis.

Rupture of the posterior ventricular wall after mitral valve replacement is a complication rarely reported in the literature. Perforation of the left ventricle after mitral valve replacement with a bioprosthesis has been described in only 3 patients. We have had 2 patients with this complication out of 322 patients who had mitral valve replacement with bioprosthesis. These perforations were caused by impingement of the posterior strut of the bioprosthesis on the posterior left ventricular wall, with intramyocardial hematoma and delayed rupture of the left ventricle.


Vascular evaluation for balloon pumping.

The effectiveness of intraaortic balloon counterpulsation is reduced frequently by arterial insufficiency following balloon insertion and occasionally by inability to pass the balloon centrally from a peripheral site. From a series of patients undergoing cardiac catheterization, a subgroup with increased likelihood of needing balloon counterpulsation can be selected. Patients so chosen have received one aortoiliac injection of contrast material at the time of cardiac catheterization. Impressive degrees of vessel irregularity and stenosis on an atherosclerotic basis and of tortuosity of normal lumen size have been noted. Such information, gathered at little additional risk or irradiation, is considered to be important in the subsequent choice of sides for transfemoral insertion and may rule out attempted passage of the balloon by this route, directing the surgeon to a deliberate, prompt, transabdominal or thoracic aortic insertion if necessary.


Abdominal aortic aneurysms: diagnostic review and new technique.

A new technique of computed tomography (CT) applied to the diagnosis of abdominal aortic aneurysms is described, and the experience in 58 patients is reviewed. In all instances the abdominal aorta was clearly demonstrated, even when wall calcification was absent. A series of 37 patients with abdominal aortic aneurysm underwent evaluation by physical examination, abdominal roentgenograms, and ultrasonic and CT scanning. Measurements of the transverse diameter at the point of maximal dilatation were compared with the measurements made at operation. CT not only confirmed the diagnosis in all patients but the measurements obtained by this technique were the most accurate, correlating extremely well with the true dimensions of the aneurysm. The addition of contrast enhancement to CT scanning allowed clear delineation of the aortic lumen and intraaneurysmal thrombus, not possible with any other method, including ultrasonography. The technique appears useful as a screening procedure and in the differential diagnosis of a tortuous abdominal aorta. Patients with a small aortic dilatation can be followed accurately by scanning.


Autotransfusion following cardiac operations: a randomized, prospective study.

To evaluate the safety and effectiveness of the collection and retransfusion of postoperatively shed mediastinal blood as part of a multifaceted approach to blood conservation following cardiac operation, 113 patients were randomized into either an autotransfusion group (54 patients) or a control group (59 patients). Intraoperative and postoperative hemodilution was practiced in all patients. The clinical safety of this technique was confirmed by the lack of septic, hematological, pulmonary, renal, or hepatic complications. However, in this setting where blood conservation is already aggressively practiced, the ability of the technique to further reduce the use of banked blood following cardiac surgical procedures was not demonstrated.