Histopathology of tubotympanum of children with otitis media treated with ventilation tubes.

We studied histopathologically the middle ear (ME) and eustachian tube (ET) in 12 temporal bones from eight children who had had otitis media with effusion that had been treated with ventilation tubes (VTs) for 3 weeks to 11 months. In the ME, 1) only a minimal amount of effusion was seen in most of the ears treated for 3 months or longer, 2) the severity of submucosal inflammation almost paralleled the amount of effusion, 3) the amount of granulation tissue on the tympanic membrane at the site of VT insertion also seemed to parallel the degree of ME inflammation, and 4) epidermal ingrowth was seen in both of the two ears treated with VTs for 10 and 11 months. Pathologic findings in the ET were generally more severe than those in the ME, but tended to decrease with longer VT therapy. In two ears with VTs obstructed by inflammatory granulomatous tissue, the entire ME cavity was filled with effusion, and dense effusion plugged the bony portion of the ET. The results of this study indicate that 3 to 11 months of treatment with a VT is effective for reversing the ME effusion and for reducing inflammation in the ME. Some inflammation may be left in the ET, however, even with 11 months of VT therapy, and epithelial ingrowth should be watched for when VT therapy lasts 10 months or longer. Despite the fact that most of our temporal bones were from infants and children who had a variety of systemic diseases or disorders and in whom their terminal event might have contributed to our findings, we consider these temporal bones to be informative.


Immunologic response of adenoidal lymphocytes to respiratory syncytial virus.

Adenoidal lymphocytes obtained from 43 subjects with serum antibodies to respiratory syncytial virus (RSV) were established in culture in vitro and analyzed for immunoglobulin (Ig) and RSV-specific antibody synthesis. Spontaneous synthesis of Ig was consistently observed in culture supernatants. The ratios of IgA to IgG and IgM to IgG in adenoidal lymphocyte culture supernatant were higher than in serum. In cell cultures stimulated with RSV or pokeweed mitogen, RSV antibody activity was detected in 25 of 43 (58.1%) for IgG, 5 of 43 (11.6%) for IgA, and 4 of 43 (9.3%) for IgM. Also, RSV-specific IgG was detected in some supernatants from unstimulated cultures. In seven cases the cultures of autologous tonsillar lymphocytes were also investigated. Autologous organs exhibited similar polyclonal Ig production and RSV-specific antibody synthesis. These observations demonstrate that both adenoids and palatine tonsils are continuously engaged in synthesis of local antibodies to viral pathogens available to the nasopharynx and respiratory mucosa.


Radiographic analysis of deep cervical abscesses.

Correlation of the radiographic examination and the clinical evaluation of deep cervical abscesses contributes to the surgical program for exposure and drainage. The deep cervical spaces are analyzed with reference to local anatomy, sources of infection, potential for lateral and vertical extension, and identification of regional expansion by standard and computed tomography. Guidelines and recommendations are proposed for clinical application and supported by illustrative cases.


Junctional epidermolysis bullosa of the larynx. Report of a case and literature review.

Epidermolysis bullosa (EB) is a group of rare inherited disorders in which minor trauma causes blister formation in the skin and mucosa, including the esophagus. Morbidity varies with the type of disease and ranges from occasional trivial skin blisters to death in infancy. Laryngeal involvement presenting as hoarseness and respiratory distress has been reported in nine patients, five of whom had junctional EB. We present the sixth case of junctional EB with laryngeal involvement, and offer guidelines for otolaryngologists and anesthesiologists caring for these fragile patients.


Aerobic bacteriology of chronic suppurative otitis media without cholesteatoma in children.

Medical management of chronic suppurative otitis media without cholesteatoma in children was shown recently to be efficacious. We undertook a prospective study in order to determine 1) the organisms associated with the disease and their sensitivity to various antibiotics and 2) their association with clinical variables. Pseudomonas was isolated from 84% of the patients, enteric gram-negative bacilli from 32%, Staphylococcus aureus from 20%, streptococci from 14%, and Hemophilus influenzae from 15%. Pseudomonas aeruginosa was the sole isolate in 48 of the 128 patients (38%). The sensitivity of P aeruginosa (78 isolates) was 100% (of isolates) to mezlocillin and ciprofloxacin, 99% to tobramycin and ceftazidime, 97% to piperacillin, 94% to gentamicin, and 78% to ceftriaxone. The isolated organisms and their sensitivity to antibiotics were not associated with age, sex, duration of otorrhea, or the presence of granulation tissue or polyps. We believe that our data may contribute to the appropriate choice of antibiotics when nonsurgical management of chronic suppurative otitis media without cholesteatoma is considered.


Double aortic arch.

In conclusion, the diagnosis of DAA should be suspected in an infant with either biphasic stridor or feeding-related respiratory distress. Radiographic studies combined with appropriate thorough endoscopic evaluation should confirm clinical suspicion. Thoracotomy with surgical division of the DAA has given excellent long-term results.


Rhinoscleroma and rhinosporidiosis.

For North American otolaryngologists, rhinoscleroma and rhinosporidiosis are moving more into the differential diagnosis of chronic inflammatory diseases of the upper airway, particularly the nasal cavity. This change is occasioned by the influx of immigrants from parts of the world to which the diseases are endemic. Diagnosis is established by identification of the causal organisms, the readily seen Rhinosporidium seeberi for rhinosporidiosis and the more elusive Klebsiella rhinoscleromatis for rhinoscleroma.


Inhibition of nasopharyngeal colonization of Hemophilus influenzae by oral immunization.

Nontypeable Hemophilus influenzae organisms were inoculated into the nasopharynx of BALB/c mice immunized by oral administration of formalin-killed bacteria. Salivary antibodies and the colonization of H influenzae in the nasopharynx were investigated in order to clarify the effect of oral immunization. Salivary immunoglobulin A antibody titers against H influenzae were significantly increased by oral immunization, but salivary immunoglobulin G antibody titers were not. The bacteria inoculated into the nasopharynx were more rapidly eliminated in immunized mice than in control mice. The results suggest that oral immunization might be useful in preventing otitis media with effusion by inhibiting the colonization of the nasopharynx by pathogenic bacteria.


Erythromycin inhibition of lipopolysaccharide-stimulated tumor necrosis factor alpha production by human monocytes in vitro.

The mechanism of clinical effectiveness of low-dose and long-term erythromycin (EM) treatment for diffuse panbronchiolitis, sinobronchial syndrome, and associated otitis media with effusion was investigated by studying the effects of EM on tumor necrosis factor alpha (TNF-alpha) production by cultured human monocytes stimulated with lipopolysaccharide. At concentrations of 0.1 microgram/mL or more, EM inhibited TNF-alpha release from human monocytes stimulated by lipopolysaccharide in a dose-dependent manner. Of the other macrolides tested, roxithromycin, an EM derivative, also showed significant inhibition of TNF-alpha production, whereas josamycin failed to inhibit TNF-alpha release from monocytes. Nonmacrolidic drugs such as minocycline hydrochloride, ofloxacin, or penicillin G had no significant effect on TNF-alpha production. These results suggest that the clinical improvement of chronic respiratory diseases by EM may depend on the suppression of production of inflammatory cytokines such as TNF-alpha.


Immunologic characteristics of cytokines in otitis media with effusion.

Levels of cytokines, interleukin (IL)-1 alpha, IL-1 beta, tumor necrosis factor (TNF), and granulocyte-macrophage colony-stimulating factor (GM-CSF) were investigated in samples of the middle ear effusions (MEEs) from 144 ears with otitis media with effusion (OME) by enzyme-linked immunosorbent assay, followed by cytologic analysis. Middle ear effusions of the acute purulent type contained a significantly higher concentration of cytokines compared with normal control sera (p < .001). Cytokines were observed at lower levels in MEE in adults than in children. Tests of children at the chronic stage of MEE showed higher levels of TNF than IL-1 and GM-CSF. Meanwhile, IL-1 beta showed significantly higher concentrations in acute purulent types than in serous and mucoid types (p < .01). In cytologic analysis, the mean level of IL-1 beta was significantly higher in the neutrophil-rich group than in other groups (p < .05). Cytokines possess several biologic properties, some of which are associated not only with acute otitis media but also with chronic otitis media. This study showed that cytokines, especially IL-1 beta, contribute to infiltration into the middle ear by inflammatory cells. This implies that the persistent presence of cytokines in MEE could be a factor in prolonged OME.


Neutrophil elastase and its complex with alpha 1-antitrypsin in the pathogenesis of chronic suppurative otitis media.

Neutrophil elastase (NE) and its complex with alpha 1-antitrypsin were quantified in ear discharges from 15 patients with chronic suppurative otitis media (CSOM), and their levels were compared to those in middle ear effusions from 10 pediatric patients with chronic otitis media with effusion (OME). The localization of immunoreactive NE was also examined by immunocytologic study. The mean value of total NE was 161.8 +/- 29.5 micrograms/mL in CSOM, which was significantly higher than that in OME (16.5 +/- 6.7 micrograms/mL). The mean value of NE-alpha 1-antitrypsin complex was 13.7 +/- 8.8 micrograms/mL in CSOM and 7.8 +/- 4.0 micrograms/mL in OME. There was no significant difference between culture-positive and culture-negative samples in CSOM. Immunoreactive NE could be observed in the neutrophils of ear discharges, and extracellular release of NE was also observed. Ear discharges in CSOM contain a considerable amount of uncomplexed NE, of which the level does not depend on active bacterial infections. Uncomplexed NE seems to play a role in the chronicity of CSOM.


Interleukin-1 of cholesteatomatous keratinocytes.

Interleukin-1 (IL-1) has been thought to be one of the essential cytokines mainly produced by macrophages. It has recently been reported that epidermal keratinocytes produce IL-1, and attention is being paid to local immune reactions mediated with this cytokine. Interleukin-1 not only activates lymphocytes, but also acts as an osteoclast-activating factor. In this study, we used immunohistochemistry and immunoblotting on cholesteatomatous epithelium with anti-IL-1 alpha antibody and anti-IL-1 beta antibody. Next, the relationship of cholesteatomatous debris to the production of IL-1 by keratinocytes was evaluated. Highly concentrated IL-1 alpha was found in the cholesteatomatous epithelium, especially in the basal cell layer. The intensity of IL-1 beta staining was weaker than that of IL-1 alpha staining. In the immunoblotting study, the 31 kd band, an intracellular immature precursor molecule, was identified. The production of IL-1 alpha from keratinocytes was augmented to a greater degree by cholesteatomatous debris than by lipopolysaccharide or keratin. The keratinocytes did not produce IL-1 beta. These findings suggest that IL-1 alpha is derived from cholesteatomatous keratinocytes. Interleukin-1, mainly IL-1 alpha, from the stimulated cholesteatomatous keratinocytes may be an important factor in the markedly increased bone resorption observed in cholesteatoma.


Distribution of immunocompetent cells in the endolymphatic sac.

To better understand the role of immunocompetent cells in the defense mechanism of the inner ear, the distribution patterns of those cells were investigated in the endolymphatic sac (ES) of mice maintained in three different conditions: germ-free (GF), specific pathogen-free (SPF), and conventional (CV). In another experiment, the recruitment of lymphocyte subsets was examined in the ES of SPF rats undergoing a perilymphatic antigen challenge after systemic presensitization. In the ES of GF mice, no immunocompetent cells were found. In the ES of SPF and CV mice, cells positive for IgG, IgA, IgM, and Lyt-1 were present in much smaller numbers than in the nasal mucosa. Cells positive for Lyt-2 were not seen in the ES of any mice. In the ES of rats that underwent a perilymphatic antigenic stimulation after a systemic presensitization, B lymphocyte subsets (positive for IgG, IgA, IgM) were mobilized in increased numbers, and T cell subsets (helper/inducer and suppressor) were also found 1 week after perilymphatic antigen challenge. These results taken together suggest that the ES is not originally equipped to possess immunocompetent cells and mount an immune response, but that once it has been activated with the inner ear antigenic stimuli, the ES can be the active site of a local immune response of the inner ear.


Pathogenesis of experimental otitis media with effusion caused by a combination of eustachian tube dysfunction and immunosuppression.

Inflammatory factors appear to play an important role in the development of otitis media with effusion (OME). However, otitis media experimentally induced by endotoxin injection or secondary immunoresponse was not persistent. In order to produce refractory OME, two pathologic conditions were necessarily combined: tubal ventilatory dysfunction and suppression of the immunologic defense mechanism by immunosuppressive drugs. In the presence of these two pathologic conditions, all cases that evidenced negative middle ear pressure due to tubal dysfunction developed OME. In the control group with either tubal dysfunction or immunosuppression alone, only 1 of 20 ears developed OME. Transtubal infection due to negative middle ear pressure caused by tubal ventilatory dysfunction may be one of the most important etiologic factors in OME.


Endolymphatic hydrops induced by immune response of the endolymphatic sac: relation to perilymph antibody levels.

This study investigated the effect of a secondary immune response in the endolymphatic sac on the development of endolymphatic hydrops in guinea pigs. Following secondary keyhole limpet hemocyanin (KLH) challenge directly to the sac in systemically presensitized animals, hydrops rapidly developed within 1 week, then gradually reduced by 4 weeks. After 5 weeks, hydrops gradually recurred and developed again. Mean perilymph anti-KLH antibody levels rose from day 1 to 4 weeks and then decreased. The elevation of perilymph anti-KLH antibody levels on day 2 was due to an increased vascular permeability and there was a local regeneration by the challenge of the sac after day 7. The development of hydrops correlated well with mean perilymph anti-KLH antibody levels in the period from day 1 to day 7. After 2 weeks, there was no correlation between them. These results suggest that an immune response of the sac may induce an excess secretion of endolymph in the initial stage and may further lead to irreversible dysfunction of the sac at a later stage.


Vestibular disorders following immune response of the endolymphatic sac in the guinea pig.

The effect of a direct antigen challenge to the endolymphatic sac on vestibular function was investigated in guinea pigs. Following keyhole limpet hemocyanin (KLH) challenge to the sac in systemically presensitized guinea pigs, caloric responses were examined in 18 animals on days 1, 7, 14, 21, and 28. Caloric responses were significantly suppressed in 13 animals by day 7; of these, 5 animals had recovered by day 14 and 8 animals had not yet recovered by day 28. The behavior of spontaneous nystagmus was examined every hour in 10 animals at intervals of 3 to 56 hours after sac challenge. Irritative spontaneous nystagmus preceding paralytic nystagmus appeared in 5 animals, for which the mean onset was 14.6 +/- 3.1 hours and the mean duration was 4.4 +/- 6.5 hours. Paralytic spontaneous nystagmus appeared in all animals, for which the mean onset time was 23.3 +/- 12.3 hours. Neither direct KLH primary challenge of the sac nor phosphate-buffered saline injection to the sac caused significant changes in the vestibular function. These results suggest that an immune response of the sac induces a vestibular disorder and may produce an attack of vertigo similar to that of Meniere's disease.


Localization of type IV collagen and laminin in the guinea pig inner ear.

The distribution of type IV collagen (C-IV) and laminin, which are important components of the basement membrane (BM), was studied immunohistochemically in the inner ear of healthy Hartley guinea pigs. Antibodies against C-IV and laminin were used in this study. The distribution of C-IV in the inner ear was almost the same as that of laminin, but the extent of staining for laminin was less than that for C-IV in some sites. The sites of the inner ear in which these components were most densely localized were the areas surrounding the spiral ganglion cells and nerve fibers, the capillary vessels in the stria vascularis and the spiral prominence, and an area directly beneath the epithelium of the endolymphatic sac. Type IV collagen and laminin were also localized around the other vascular BM and the epithelial BM in the inner ear, but the tectorial membrane, the cupula of the crista ampulla, and the sensory epithelium did not take up stain. These results suggest that the vascular BM of the stria vascularis and spiral prominence, as well as the epithelial BM of the endolymphatic sac, may play an important role in fluid transport, and that the perineural BM of the inner ear might play an important role in the functional maintenance of the optimal environment of the inner ear nervous system.


Alterations of charge barrier in the inner ear following immune reactions.

We investigated electron microscopically the changes of anionic sites of a charge barrier in the capillary basement membrane of the stria vascularis and endolymphatic sac following inner ear immune reactions. Hartley guinea pigs were immunized with bovine type II collagen, keyhole limpet hemocyanin, or horseradish peroxidase, with boosted and challenged antigens through the stylomastoid foramen. Animals were killed painlessly from several days up to 56 days after the antigen challenge. Polyethylenimine was used as a cationic tracer in order to observe the localization of anionic sites of the charge. In the animals immunized with bovine type II collagen or horseradish peroxidase, a significant decrease of anionic charge in the stria and the sac was found in the early stage of immunization. However, the keyhold limpet hemocyanin immunization group did not show any remarkable changes in the charge because of its lesser transfer into the inner ear due to of its high molecular weight and negative surface charge. A decrease of the charge under immunologic conditions may induce a hyperpermeability of vessels and a malabsorption of endolymph, and thus may cause endolymphatic hydrops.


Detection of genomic sequences of respiratory syncytial virus in otitis media with effusion in children.

The reverse transcriptase-polymerase chain reaction and the nested polymerase chain reaction were used for detection of respiratory syncytial virus (RSV) sequences in middle ear effusions collected from children with otitis media. Sequences of RSV were detected in 21 of 34 samples tested. These samples were collected during and/or after natural outbreaks of RSV infection in the community. In those patients from whose nasopharynges RSV was isolated, the viral sequences were highly detectable (75%) in the effusions. These observations suggest RSV as an important factor in the pathogenesis of otitis media with effusion.


Mechanism of immune complex-mediated inner ear diseases.

Tissues of the stria vascularis of normal rabbits were collected as cochlear antigen and injected into the foot pad of guinea pigs. The mechanism of development of endolymphatic hydrops was studied by the tracer method. Damage to the capillary endothelium and an increase in vascular permeability were found in the stria vascularis. Therefore, we studied patients with a raised level of immunoglobulin (Ig) G-class circulating immune complexes (CICs). Hearing loss was found in 3 of 22 patients with significantly elevated IgG CIC levels (13.6%). The relationship between inner ear disease and the presence of CIC was considered to be very significant. The possible mechanism of CIC-mediated inner ear diseases is discussed.


MRL/MP-lpr/lpr mouse as a model of immune-induced sensorineural hearing loss.

Hearing acuity and inner ear disorders of MRL/lpr mice, bred for the study of autoimmune disease, were examined in comparison to those of BALB/c mice. The auditory brain stem response threshold of 20-week-old MRL/lpr mice was significantly higher than that of BALB/c mice of the same age (p < .01). The pathologic changes of 20-week-old MRL/lpr mice were characterized by the degeneration of intermediate cells, widened intercellular spaces, and immunoglobulin G deposition on the basement membrane of strial blood vessels as well as in the basal infolding of strial marginal cells, which were absent in BALB/c mice. That there were no other evident pathologic findings in the cochlea or middle ear suggests that these changes in the stria vascularis seemed to be responsible for the sensorineural hearing loss of this mouse. The MRL/lpr mouse was thought to be a good experimental model to study the spontaneous sensorineural hearing loss caused by an immune reaction.


Cochlear and renal pathology in the autoimmune strain mouse.

This study was designed to investigate the role of immunologic mechanisms in sensorineural hearing disorders and the relationship between inner ear and renal disorders. Autoimmune strain (NZB/kl) mice, in which autoimmune disease can be spontaneously induced, were used in this study. The mice were tested for acoustic brain stem responses, cochlear and renal disorders, and circulating immune complex serology by means of enzyme immunoassay. Pathologic studies consisted of observation of tissue changes following hematoxylin and eosin staining and indirect immunofluorescence staining under light microscopy. Compared to controls, the hearing was impaired in NZB/kl mice. Indirect fluorescence staining showed immunoglobulin G deposits in the stria vascularis. There was a correlation between the degree of hearing impairment and the severity of stria vascularis lesions. The NZB/kl mouse can provide a model for sensorineural hearing disorders secondary to immunologic disorders.


[Pustular dermatoses in the neonatal period].

The diagnosis of pustular dermatosis occurring during the first months of life is usually based on clinical findings. However, some cases may require a few simple investigations including cytological studies, cultures, and skin biopsies. The most common causes of infectious pustular skin lesions include bacterial infections, which may be septicemic (with Listeria as the leading causative agent) or initially localized (staphylococcus); viral infections (varicella, herpes); fungal infections, i.e., candidiasis (congenital or neonatal) or the very recently described form of pustulosis due to Malassezia furfur; or parasitic (scabies). The main benign transient neonatal forms of pustulosis include infantile acropustulosis (for which the relationship with scabies is discussed), toxi-allergic erythema, transient pustular melanosis, and neonatal acne. Lastly, rare causes of neonatal pustulosis are reviewed. The need for investigating every neonate with skin pustules for an infectious disease, especially due to a bacterium, is emphasized.


[Oculocutaneous albinism].

Oculocutaneous albinism (OCA) is an inherited condition characterized by hypopigmentation of the skin, hair, and eyes. Ocular involvement is often severe with photophobia, decreased visual acuity due to foveal hypoplasia, nystagmus, and strabism secondary to defective routing of optic axons in the chiasma. Cutaneous hypopigmentation is responsible for diminished photoprotection that places patients at increased risk for skin cancers. OCA also occurs in a number of life-threatening conditions, including Hermansky-Pudlak syndrome, Chediak-Higashi syndrome, and Griscelli-Prunieras syndrome. Most cases of OCA are inherited on an autosomal recessive basis. Several mutations have recently been identified in type I OCA or "tyrosinase-negative" OCA. Identification of other genetic abnormalities will probably occur in the future and will lead to more accurate classification of OCA syndromes.


[Panniculitis in children].

Panniculitis is an inflammation of subcutaneous fat responsible for fairly uniform clinical features including nodules, plaques or swelling located in the subcutaneous tissue, occasionally progressing to atrophy of subcutaneous fat. Some forms of panniculitis specific of childhood are responsible for readily recognizable clinical patterns. Examples include acute neonatal fat necrosis, sclerema neonatorum, cryopanniculitis, steroid-induced panniculitis, and toxoplasmosis-related multinodular fat necrosis of Royer syndrome. With the exception of erythema nodosum, the cause of panniculitis is identified upon histologic examination of a deep skin biopsy which ensures the differentiation of infectious nodules, vasculitis nodules, and apparently primary forms of nodular panniculitis fitting the description of Weber-Christian syndrome, Rothmann-Makaï syndrome, histiocytic cytophagic panniculitis or lupus panniculitis.


[Allergic vasculitis in children].

Allergic vasculitis is characterized clinically by vascular purpura and histologically by leukocytoclastic angiitis of the small vessels in the middle and superficial dermis. Extra-cutaneous lesions may occur. Among them, the most common are joint manifestations. Renal involvement governs the prognosis. Circulating immune complexes probably contribute to the development of lesions, although this role has not been firmly established. Cellular immunity is probably also involved. A large number of factors may trigger the development of allergic vasculitis. Clinical patterns vary widely across patients. In 50% of patients no cause is identified. In children, Henoch-Schönlein purpura and infections (viral or bacterial) are the most common "causes". The ideal treatment would be elimination of the causative allergen. However this is often impossible to achieve and a variety of symptomatic treatments (rest, dapsone, colchicine, corticosteroids, immunosuppressants...) may be discussed according to the severity of clinical manifestations. Effectiveness of these treatments is variable.


[Kasabach-Merritt syndrome in children].

Kasabach-Merritt syndrome is a combination of thrombocytopenia, intravascular coagulation, and a rapid increase in the size of an angioma. Anemia and disseminated intravascular coagulation may develop. This infrequent syndrome is severe and may be life-threatening. Pathophysiologic mechanisms underlying the condition are incompletely understood and, consequently, many different treatments are used, including systemic corticosteroids, compression, embolization, antifibrinolytic agents, platelet aggregation inhibitors, irradiation, and others. From findings in eight personal cases, the authors review clinical and biological features, pathophysiologic hypotheses and therapeutic strategies.


[Gangrenous ecthyma of the diaper area in infants].

Ecthyma gangrenosum due to Pseudomonas aeruginosa is a skin infection in which necrotic ulcerations surrounded by a red areola develop. The diaper area is the region most often involved in infants. Typically, ecthyma gangrenosum occurs in patients with septicemia and risk factors (chemotherapy, neutropenia). However, transient bacteremia or an infection confined to the skin may be the cause in some patients, with maceration in the diaper area and previous antibiotic therapy as risk factors.


[Cutaneous lesions in the orofaciodigital syndrome].

The term OFD syndrome designates a group of heterogeneous clinical patterns of which seven different types have been described. Type I, or Papillon Léage syndrome, is the most common pattern and the only type in which skin lesions occur. Type I OFD is a sex-linked dominant disorder. Two cases of OFD Type I with cystic lesions of the face are reported herein. The second patient also had polycystic kidneys. This combination has already been reported previously and all children with OFD should be investigated for polycystic kidney disease.


[Menkes syndrome. An unusual pigmentation anomaly in a mother and three sisters].

Menkès syndrome is a sex-linked recessive disease. The authors previously reported a case in a boy whose neurologic condition deteriorated gradually until death occurred at the age of seven and a half months. Diagnosis was confirmed by the finding of very low plasma levels of copper and ceruloplasmin. Evaluation of family members disclosed hypopigmentation of one half of the abdomen in three sisters and in the carrier mother. This hypopigmentation may be ascribed to decreased melanocyte copper-dependant tyrosinase activity. Among cells in the body, this anomaly may be present or absent according to whether or not the abnormal X chromosome is inactivated.


Laparoscopic cholecystectomy: the first 155 patients.

Laparoscopic cholecystectomy has been attempted in 155 patients. Eight patients required conversion to open cholecystectomy (5%): three owing to lack of clear anatomical detail, two procedures were abandoned because of instrument failure, two had a dilated common bile duct on cholangiography, and one owing to a very adherent mucocele of the gallbladder. Cholangiography was performed selectively; successfully completed in 45 (22% of all patients). Common bile duct stones were found in two patients. All patients were drained, with two bile leaks, one requiring a laparotomy. There was one ductal injury. Most patients (85%) were discharged within 48 h. This initial experience suggests laparoscopic cholecystectomy is the procedure of choice for most patients with symptomatic cholelithiasis.


Laparoscopic laser cholecystectomy: results of the technique in 210 patients.

The results of laparoscopic laser cholecystectomy (LLC) in a consecutive series of 210 patients, operated on between May 1990 and August 1991, were assessed to analyse the advantages of the technique and to detail the causes of any technical problems, failures, or complications. The operations were performed by JMcKW and ADNS. A success rate of 98% (206/210) was achieved with a minor complication rate of 13% (26/210) and major complication rate of 3% (7/206), including three patients (3/206; 1.5%) who had a reactionary haemorrhage postoperatively, two requiring laparotomy. The length of hospital stay was 48 h or less in over 80% (148/184) of the patients. The period of absence from work was 2 weeks or less in over 90% (118/130) of the patients. Cholecystectomy can safely be performed laparoscopically and this procedure has significant advantages over open cholecystectomy.


Laparoscopic laser cholecystectomy: our first 200 patients.

A series of 200 consecutive patients were considered for laparoscopic laser cholecystectomy. Laparoscopic laser cholecystectomy was attempted in 195 cases and was performed in 192 cases. Laparoscopy was performed in five patients, but laparoscopic cholecystectomy was not attempted owing to dense adhesions (3), cholangiocarcinoma (1) and an absent gallbladder (1). The indications for operation were symptomatic gallstones which included biliary colic (142), acute cholecystitis (49) and gallstone pancreatitis (9). The median duration of operation was 75 min. Operative cholangiography was attempted in 151 (77%) of cases, and was successful in 85% of attempts. Laparoscopic common bile duct visualisation was performed three times with successful stone extraction twice. The other common bile duct was normal. The median duration of postoperative hospital stay was 2 days, for return to normal activity 6 days, and for return to work 10 days. Mean analgesic and antiemetic requirements were approximately one-third of those for open cholecystectomy. Of the patients, 94% reported good or excellent overall satisfaction and 96% reported excellent cosmetic results. Seven complications occurred (4%). Three patients had immediate conversion to laparotomy owing to haemorrhage (2) and gallbladder rupture (1). Four patients required laparotomy for postoperative complications (common bile duct damage, slipped clips from cystic duct, perforated duodenum and leaking accessory hepatic duct). No complications occurred in the last 140 cases. These data suggest that laparoscopic laser cholecystectomy reduces the discomfort of laparotomy and allows a shorter postoperative recovery. The operation has a learning curve, but will ultimately be applicable to the majority of patients with symptomatic gallstones.


Can cholangiography be safely abandoned in laparoscopic cholecystectomy?

The introduction of laparoscopic cholecystectomy, improvements in ultrasound technology and the success of endoscopic sphincterotomy have raised new questions regarding the role of intraoperative cholangiography. Our aim was to analyse the ability of preoperative clinical and ultrasound assessments to detect common duct stones in 86 patients with symptomatic cholecystolithiasis who then underwent cholangiography after percutaneous cholecystolithotomy. Six patients gave a history suggestive of common duct stones (either jaundice, cholangitis or pancreatitis). Ultrasound showed a dilated common duct in four patients (normal < 6 mm), and one of these had a stone demonstrated in the duct. The latter patient and one other with a dilated common duct had stones on cholangiography (which were extracted at ERCP), no stones were demonstrated in the other two. Ultrasound correctly identified common duct stones in two and excluded common duct stones in four others with a history suggesting the presence of stones. For patients undergoing laparoscopic cholecystectomy we would advocate the use of preoperative ultrasound instead of intraoperative cholangiography, and that endoscopic retrograde cholangiopancreatography is performed in the small number of patients shown to have a dilated duct or common duct stone.


Laparoscopic tube gastrostomy.

A laparoscopic approach to fashioning a permanent mucosal gastrostomy is described for the first time. It has a place in patients in whom endoscopic or radiological placement is impractical.


Use of the hepatic arterial circulation for renal revascularisation.

Renal artery stenosis is increasingly being diagnosed as a cause of hypertension and renal impairment. Surgical intervention can restore function and improve hypertension in selected cases. Over a 42 month period, 12 patients with atherosclerotic renovascular disease underwent surgical revascularisation using the hepatic arterial circulation. All had disease of both renal arteries and 11 had some degree of renal impairment, with five requiring dialysis before operation. There were two deaths within 30 days of operation, eight patients had improved renal function after operation and three of the patients previously on dialysis became dialysis free. The hepatorenal method of renal revascularisation is described and its advantages discussed.


Consequences of immediate failure of percutaneous transluminal angioplasty.

Percutaneous transluminal angioplasty (PTA) is often used for patients who would not previously have been treated, due for example, to their poor general condition or their symptoms being relatively mild. The approximate overall initial success and complication rates are 80% and 10%, respectively. Iliac angioplasties fare rather better than superficial femoral dilatations. There is little information on the outcome of those patients in whom the procedure cannot be completed satisfactorily or who have complications. From 1985 to December 1990, 318 PTAs have been attempted on our unit, the majority within the last 3 years. In 53 (17%) the dilatation was not carried out, due to inability to position the guidewire (31) or balloon (16) satisfactorily, to disease progression (3) or systemic problems (3). None of these patients was made worse and 10 subsequently had a successful angioplasty. Complications occurred in 28 (9%). These included distal embolisation (10), bleeding (9), dissection (1), thrombotic occlusion (4) and vessel rupture (4). Complications were more common after superficial femoral, compared with iliac angioplasty (P < 0.02, chi 2 test). Eight patients with occlusion or embolus were treated with thrombolysis, five successfully. Three of these patients, and seven others, had surgical intervention (three within 6 h of angioplasty). Ten patients were treated conservatively, one died. Of the 28 patients who sustained complications, 27 were improved compared with their status before angioplasty, once their complication had been dealt with. PTA is a generally safe procedure and when complications occur most can be dealt with effectively.


Quality of life of octogenarians after aneurysm surgery.

Abdominal aneurysm repair in octogenarians is controversial. To justify surgery, survival with a reasonable quality of life is required. Between 1980 and 1988, 34 octogenarians underwent aortic aneurysm surgery (14 elective, 20 emergency). Of the 21 survivors, 20 were interviewed to determine their quality of life. At the time of interview the patients had a median survival of 19 months (range 4-67 months). Twenty age/sex matched normal patients, from the same GP population, were interviewed for comparison. A structured questionnaire was used to assess: physical mobility, activities of daily living, sleep and emotional problems. A symptom survey was also performed. The survival trend of elective patients was similar to that of a demographically similar 'normal' population. The survival trend of emergency patients returned to 'normal' after the first postoperative month. Quality of life of the 20 patients was comparable to the lifestyle enjoyed by normal subjects. Of the 20 patients interviewed, 18 had returned home after surgery. Elective and emergency aortic aneurysm surgery can be performed with reasonable survival and a good quality of life, and therefore cannot be denied to octogenarians on the basis of age alone.


Is antibiotic penetration compromised in the ischaemic tissues of patients undergoing amputation?

Antibiotic prophylaxis is indicated for patients undergoing amputation for severe ischaemia or gangrene. However, the adequacy of tissue levels of antibiotics in ischaemic tissue is not known. In this study the serum and tissue antibiotic levels were measured after intravenous administration of metronidazole (15 mg/kg body weight) and cephradine (20 mg/kg body weight). In 11 patients, venous samples were taken at time 0 (induction of anaesthesia) 10, 30 and 60 min. Samples of 2 g each of fat and muscle were collected from the amputation site and three distal sites. Metronidazole and cephradine levels were measured and the degree of limb ischaemia estimated preoperatively by an isotope limb blood flow method. Our results indicate that both metronidazole and cephradine penetrate ischaemic tissues to levels equivalent of a Mean Inhibitory Concentration (MIC) 50 for most organisms encountered in vascular surgery, and that the degree of ischaemia does not alter this.


The diagnosis of soft tissue tumours.

We prospectively analysed methods of diagnosis in 118 patients referred for definitive treatment with documented or presumed soft tissue sarcoma (STS). Of 65 patients with primary STS, 54 were biopsied before referral. Of these, 5 (9%) were biopsied by Tru-cut biopsy, 17 (32%) by incisional biopsy and 32 (59%) by excisional biopsy. The remaining 11 patients with primary STS, referred without biopsy, were all diagnosed by Tru-cut biopsy. An additional eight patients suspected of having STS were referred without biopsy and were found to have malignant tumours other than STS involving soft tissue by Tru-cut biopsy. Nineteen patients were proved to have benign soft tissue tumours; in 13 presumed to have STS, the diagnosis was unknown at referral. In four of these, biopsy was inappropriate. Of nine submitted to Tru-cut biopsy, an unequivocal diagnosis was made in 5 (56%) and incisional biopsy was required in the other four. Therefore, paradoxically, benign soft tissue tumours may be more difficult to diagnose with Tru-cut biopsy than malignant tumours. This study confirms the high degree of accuracy of Tru-cut biopsy in diagnosing malignant soft tissue tumours and highlights the disadvantages of open biopsy techniques.


A simple scoring system to reduce the negative appendicectomy rate.

In a controlled, prospective study the following five criteria were used for the diagnosis and management of acute appendicitis: abdominal pain; vomiting; right lower quadrant tenderness; low grade fever (< or = 38.8 degrees C); and polymorphonuclear leucocytosis (TC > or = 10,000 with polymorphs > or = 75%). The aim of the study was to reduce the negative appendicectomy rate. If four out of five or five out of five criteria were present on admission, appendicectomy was carried out. On the other hand, if three out of five criteria were present on admission, the patient was subjected to active inpatient observation until either the development of the fourth criterion, when appendicectomy was performed, or until the patient recovered and the condition did not progress beyond the third criterion. Generalised peritonitis due to a perforated appendix was excluded from the study. Over a 1-year period, 58 patients (M:F = 45:13) were entered into the study. Appendicectomy was carried out in 46 (80%) of patients; of these, 32 patients (70%) were operated on soon after admission. The remaining 14 (30%) were operated on after a period of inpatient observation decided the development of the fourth criterion. A total of 12 patients (12/58 = 20%) did not undergo operation. The control group consisted of 59 patients upon whom appendicectomy was carried out by another surgical unit over the same 1-year period. The negative appendicectomy rate in the trial group was 6.5% (3/46), whereas in the control group it was 17% (10/59) (P < 0.05). We conclude that the use of a simple scoring system can significantly reduce the negative appendicectomy rate.


Measuring outcome of total knee replacement using quality of life indices.

A series of 26 patients was studied before and after total knee replacement to determine the change in their quality of life, expressed as a gain in Quality Adjusted Life Years (QALYs). Global health status was assessed using the Nottingham Health Profile, disability by the Harris scale, pain by the McGill Pain Questionnaire, and anxiety and depression by the Hospital Anxiety and Depression Scale. Substantial reductions were found in pain, anxiety and depression, and a significant improvement was found in mobility. These data were used to generate a 'QALY' (Quality Adjusted Life Year) comparable to the measure used by Williams (1) in his comparative evaluation of medical and surgical treatments. A gain of only 0.42 QALY was found for knee replacement, which is about one-tenth the figure given by Williams for hip replacement. The difference appears to be attributable not to differences in the success of the operations, but rather to the scope that QALY calculations give for allocating comparable patients to different quality of life states. Tighter criteria are needed if QALYs are to be used to guide resource allocation.


Changing patterns of colorectal cancer in a regional teaching hospital.

A study was performed of all patients who underwent either surgery or endoscopic polypectomy for colorectal cancer in Oxford between 1979 and 1983 to ascertain whether any changes had occurred in presentation, diagnosis, treatment or outcome since a previous study from the same centre undertaken between 1966 and 1971. The average number of patients treated annually had increased from 52.8 to 103.4. The growth of the population of the health district was 6.7%. A similar proportion (25%) continued to present as emergencies. There was an improvement in the proportion of cases presenting with Dukes' A and B lesions (54% vs 41%) (P < 0.001), and a decrease in the number of patients with extranodal disease (from 30.4% to 13.3%) (P < 0.001). Only 13.9% of patients underwent colonoscopy before surgery and 14 patients were treated by endoscopic removal alone. In a health district with a slowly growing population, the number of patients presenting with colorectal cancer had increased dramatically over a decade. Colonoscopy has so far made little impact on making an earlier diagnosis. The increase in colorectal cancer has important implications for resource allocation.


Injuries related to wind speed.

This is a retrospective study of the injuries caused by high wind speeds during the storms of early 1990. Injured patients seen on windy days were compared with those seen on a group of control days. It was found that high wind speeds were associated with an increased risk of injury, especially when wind gusts exceeded 60 knots. This apparent wind speed threshold, above which injury is more likely, corresponds to the curve used by the Meteorological Office to predict wind-related structural damage. It is postulated that this finding may be of use in assisting the Government in formulating its guidelines on when to warn the public that it is unsafe to venture out.


Vascular surgical training in the UK and Ireland.

Fifty-six vascular surgical trainees and 31 recently appointed consultants with an interest in vascular surgery replied to a postal questionnaire about their training. The majority fulfilled the guidelines recommended by the Vascular Advisory Committee of the Vascular Surgical Society of Great Britain and Ireland, which are--a minimum two years of higher surgical training in units with an interest in vascular surgery and a substantial and comprehensive experience of (operative) vascular surgery. However, the operative experience during training was very variable, ranging between 10 and 574 operations reported by new consultants. Minimum standards of operative experience may need to be defined. The survey also identified that training in carotid endarterectomy is sometimes deficient and noted that as much as one-third of operative experience may be gained 'out of hours' on emergency cases. To obtain this experience trainees have to work very long hours, two-thirds of senior registrars have vascular on call rotas of 1:2 or less. Imminent changes in the structure of higher surgical training and the reduction in hours worked by junior doctors may seriously affect vascular surgical training.


Appropriateness of cholecystectomy: the public and private sectors compared.

To investigate the appropriateness of cholecystectomies undertaken in the public and private health sectors. Retrospective case note review using the findings of two consensus panels. 35 consultant surgeons working for North West Thames Regional Health Authority and in the private sector. 269 patients undergoing cholecystectomy during the study period, of whom 17 were excluded because there was insufficient information available. Appropriateness ratings as assessed by two consensus panels, one composed of surgeons and one mixed, containing doctors from different specialties. The mixed panel would have rated 41 per cent of cases appropriate, less than 1 per cent equivocal and 30 per cent inappropriate. The remaining 29 per cent had indications about which the panel did not reach agreement. The surgical panel would have rated 52 per cent appropriate, 3 per cent equivocal and 2 per cent inappropriate. The remaining 44 per cent had indications about which the panel did not reach agreement. Most of the patients who would have been rated inappropriate had vague symptoms only. There were no significant differences between the NHS and private patients as regards their appropriateness. NHS patients were more likely to have more than one ultrasound and to be operated on as an emergency. An appreciable proportion of patients undergo cholecystectomy for indications which were deemed inappropriate by a mixed panel, but not a surgical panel. Variation in clinical judgement is an important factor in the decision to operate--44 per cent of cases had indications, the appropriateness of which the surgical panel were undecided about. There were no significant differences between NHS and private patients as regards the appropriateness of their indications. These findings need to be confirmed by further studies comparing the public and private sectors.


Glove perforation during surgery: what are the risks?

Surgical gloves are important in protecting medical staff from exposure to pathogens during surgery, especially viruses such as hepatitis B and the human immunodeficiency virus. We have studied the incidence and circumstances of surgical glove perforation using a sensitive electronic device. The glove perforation rate during elective general surgery was compared with that seen during an anastomosis workshop, where surgical trainees operated in a laboratory setting. A total of 220 gloves were tested for perforations pre- and postoperatively during general elective surgical procedures. During the surgical training workshop 72 gloves were tested. Fifty-two gloves (24%) were perforated during surgical procedures. Among surgeons, consultants had a significantly lower perforation rate than trainees (26% vs 46%, P < 0.05, chi 2), that for assistants was much lower (9%). The perforation rate for scrub nurses was surprisingly high at 22%. Glove perforation among trainees was significantly lower during workshop procedures than at elective surgery (17% vs 46%, P < 0.05, chi 2), probably because glove perforation occurs commonly at wound closure. Glove perforation remains very common, particularly among surgical trainees. Glove perforation should be reduced by teaching better techniques, especially 'no-touch', particularly for wound closure.


Hazards to surgeons in trauma and elective orthopaedic surgery: use of an electronic device to warn of intraoperative glove perforations.

An electronic device intended to detect glove punctures as they occur peroperatively has been described previously. This study reports the experience of its use in 80 orthopaedic cases. The device detected all punctures, except one, where fluid could have contacted the surgeon's hand (n = 16). Wet gowns and drapes are potential routes for transmission of pathogens, and were responsible for the alarm sounding on 30 occasions. This device can minimise the exposure to potentially hazardous body fluids when glove punctures are not clinically apparent.


Alcohol-related hand injuries: an unnecessary social and economic cost.

Severe hand injuries constitute the largest number of acute referrals to this plastic surgery unit, the admission of these patients often displacing routine admissions due to bed shortages, thus increasing waiting list time. This study showed that a high percentage of these injuries were alcohol-related and were therefore preventable. The economic cost to the unit is discussed.


Non-tumour morbidity and mortality after modified radical mastectomy.

From 1985 to 1987 148 patients underwent mastectomy for breast cancer, of whom 91 underwent modified radical mastectomy. Of these patients (median age 60 years (range 31-86 years)), 89 have been assessed for early (< 30 days) and late (> 30 days) non-tumour morbidity and mortality. A total of 41 patients had nodal metastases. Adjunctive therapy used was tamoxifen in 70 patients and radiotherapy in 20. Overall, 47 patients (53%) developed a total of 75 complications, and there was one 30-day mortality. Of the patients, 26 developed one complication, 14 had two complications and 7 three complications. Early complications were lymphocoele/seroma (n = 22), wound infection (n = 9) and cardiopulmonary problems (five deep vein thrombosis, two pulmonary embolus (1 death), one myocardial infarct). Late complications were lymphoedema (n = 10), pectoralis major wasting (n = 6), frozen shoulder (n = 7), intercostobrachial neuralgia (n = 4), and a small number of self-limiting wound problems (n = 9). There were two late deaths (myocardial infarcts). Early complications were not related to nodal status, and late complications were related to neither nodal status nor radiotherapy. Significant morbidity is attached to radical surgery for breast cancer. Most complications are minor and self-limiting, but there are a small number of late complications which may affect quality of life.


A study of the effect of Picolax on body weight, cardiovascular variables and haemoglobin concentration.

This study compared the effect of Picolax when administered for large bowel preparation in combination with preoperative fasting on body weight, haemoglobin concentration, haematocrit, and cardiovascular variables with matched subjects who were fasted before surgery. Picolax resulted in significantly greater weight loss, increases in haemoglobin concentration combined with cardiovascular changes suggesting hypovolaemia in the Picolax group. Intravenous fluid replacement is recommended in patients receiving Picolax.


Limb exsanguination. I. The arm: effect of angle of elevation and arterial compression.

Limb exsanguination before tourniquet inflation is usually accomplished using mechanical devices although, where their use is contraindicated, exsanguination by elevation alone may be employed. Advice regarding duration of elevation within the literature is a little confusing with recommendations ranging from 20 s to 5 min. Volume changes, during elevation at 45 degrees and 90 degrees, were measured using strain gauge plethysmography in seven male volunteers. In addition, the superimposed effect of brachial arterial compression on elevation at 90 degrees was investigated. To achieve maximal exsanguination it is recommended that the arm should be elevated for 5 min at 90 degrees before tourniquet inflation. Supplementary brachial arterial compression is not recommended as this tends to attenuate changes in volume.


Limb exsanguination. II. The leg: effect of angle of elevation.

Although limb exsanguination prior to tourniquet inflation is usually accomplished using mechanical devices, elevation alone may still be employed under circumstances where mechanical means are contraindicated. The rather confusing advice within the literature as to duration of elevation, stimulated a study in the arm which revealed the optimal duration of elevation to be 5 min, a period somewhat longer than generally advised. Because the pattern of venous drainage within the leg is slightly different to that of the arm, we undertook a similar study to ascertain if our findings for the arm also held true for the leg. Volume changes in the calves of seven male volunteers during elevation at 45 degrees and 90 degrees were assessed using strain gauge plethysmography. To achieve maximal exsanguination it is recommended that the leg should be elevated at an angle of 45 degrees for 5 min. Higher angles of elevation produce slower and less complete exsanguination.


Ionising radiation: are orthopaedic surgeons at risk?

Modern orthopaedic trauma practice involves increased exposure of the surgeon to ionising radiation. However, there have been no studies to investigate whether the doses received are within limits for non-classified workers. In this study, whole body, eye and extremity, namely hand, doses were measured in six orthopaedic surgeons during trauma cases requiring the use of X-rays in theatre. None of the subjects approached the recommended maximum dose levels for either the whole body, eyes or hands. This finding is reassuring. In orthopaedics, the limiting dose is that to the hands. This differs from previously studied groups, such as radiologists and cardiologists, in whom the limiting factor is the dose to the lens of the eye. Although current precautions appear to be adequate, safe practice in the future will depend on continuing vigilance and repetition of studies similar to this one as techniques and workloads change.


Phytobezoar: an uncommon cause of small bowel obstruction.

Phytobezoars are an unusual cause of small bowel obstruction. We report 13 patients presenting with 16 episodes of small bowel obstruction from phytobezoars. Eleven patients had previously undergone surgery for peptic ulceration (eight truncal vagotomy and pyloroplasty). A history of ingestion of persimmon fruit was common and the majority of cases presented in the autumn when this fruit is in season. One phytobezoar causing obstruction at the third part of the duodenum was removed by endoscopic fragmentation, while an episode of jejunal obstruction was precipitated by endoscopic fragmentation of a gastric bezoar. Twelve patients underwent surgery for obstruction on 15 occasions, with milking of the phytobezoar to the caecum performed in ten, enterotomy and removal in four and resection in one patient. Associated gastric phytobezoars were found in two cases and multiple small bowel bezoars in two other cases. These were removed to prevent recurrent obstruction. Phytobezoar should be considered preoperatively as a cause of obstruction in patients with previous ulcer surgery. Wherever possible milking of a phytobezoar to the caecum should be performed. Careful assessment for other phytobezoars should be made. Prevention of phytobezoars is dependent upon dietary counselling of patients by surgeons after gastric resection or vagotomy and drainage for peptic ulcer.


Delayed intracerebral haematomas in moderate to severe head injuries in young adults.

The incidence of delayed intracerebral haematoma formation in moderate to severely head-injured young adults who do not have signs of cerebral contusions on the initial post-trauma head CT scan has been studied. Thirty patients were reviewed and in 6 (20%) a delayed haematoma was diagnosed on a later CT scan, when signs of cerebral contusions were absent initially. Recurrence of intracranial hypertension within 3 to 4 h proved to be a significant indication for the development of these haematomas, despite the initial but inconsistent good response to osmotic diuretics. The average Glasgow outcome score was 3, including two mortalities. Cerebral perfusion pressure directly correlated with the outcome.


A departmental audit of patients with bladder cancer.

In keeping with the recent demands of the Department of Health for medical audit in clinical practice, an audit was undertaken of the management of bladder cancer patients in a large department of urology having three consultants with varied approaches of management. This study revealed interesting controversial areas for further scrutiny. For example, the poor prognosis of grade 3 T1 tumours with and without associated carcinoma-in-situ (CIS) and the speed of progression to invasive disease have indicated that a change to a more aggressive approach to the management of these tumours is necessary. High recurrence rates at the site of the original tumour (60%) and the presence of CIS also indicate the need for expert and thorough initial tumour assessment. The delays in diagnosis and treatment lend further support to the need for a 'haematuria clinic' to minimise such delays, which may influence prognosis. To reduce the occurrence of systematic errors in the recording, follow-up and surveillance of patients with bladder cancer, a protocol is suggested for a structured approach to optimise results, particularly in the poor prognostic categories.


Intestinal ischaemia in the unconscious intensive care unit patient.

This paper highlights the difficulties of diagnosing intestinal ischaemia in unconscious patients on an intensive care unit. We have analysed the clinical details and investigations of eight such patients in whom a preoperative diagnosis of intestinal ischaemia was made on clinical grounds. Intestinal ischaemia was confirmed at laparotomy in only four cases (50%). These patients showed no significant differences in any of the commonly accepted parameters of intestinal ischaemia from the four patients who had a negative laparotomy. In particular, all patients exhibited a metabolic acidosis with fever and a leucocytosis. There was a mean delay of 13.6 h between surgical opinion and laparotomy in the four patients with ischaemia, only one of whom was salvaged. There was no morbidity associated with the laparotomy in this small series. It is suggested that, in the intensive care setting, early laparotomy should be performed immediately the clinical suspicion of intestinal ischaemia arises.


Blood loss and transfusion requirements in total joint arthroplasty.

We report a prospective trial of 100 consecutive patients undergoing primary total hip or knee arthroplasty in order to assess their blood transfusion requirements amid recent fears of the transmission of viruses, particularly hepatitis C, from donor to recipient. Of the patients, 84% were transfused one or more units of blood in the perioperative period and the mean percentage blood loss per replacement represented 30% or less of their estimated circulating blood volume. We suggest that with preoperative blood volume calculations and haemoglobin concentrations, a more cautious approach to blood transfusion should be employed when other blood volume expanders would suffice. We believe, firstly, that where blood losses of 30% or less of the blood volume occur, blood transfusion is not always required in patients with high haemoglobin concentrations and large blood volumes. Secondly, cross-matching should be undertaken according to the individual patient's estimated needs, rather than to a group as a whole.


Acute colonic pseudo-obstruction: a pharmacological approach.

Acute colonic pseudo-obstruction is a functional disorder that closely mimics mechanical large bowel obstruction, and in which inadvertent laparotomy carries a high mortality. Eleven such patients were treated by pharmacological manipulation of the autonomic innervation to the colon with guanethidine and neostigmine. Eight responded to treatment with passage of flatus and/or stool within 10 min with complete resolution of symptoms. In three patients the treatment failed. Postural hypotension occurred in only one patient and no other serious side-effect was apparent. This pharmacological approach to the management of acute colonic pseudo-obstruction is suggested as an alternative to the other treatment options of colonoscopic decompression or surgery, when conservative management has failed.


Emergency treatment of tracheal tear during pharyngolaryngectomy.

Longitudinal tracheal tear (of the trachealis muscle), an unusual but acknowledged complication of pharyngolaryngectomy, was encountered during a total pharyngo-oesophagolaryngectomy with gastric replacement. Due to serious ventilatory difficulties a rapid repair was required to obtain an airtight seal to allow continued mechanical ventilation. A reinforced polytetrafluoroethylene (PTFE) vascular graft was used as an intratracheal stent to seal the air leak. This technique proved effective and the tracheal defect had healed by the time the stent was removed 10 days later.


The Royal London Hospital Helicopter Emergency Medical Service: first phase 1990.

A Helicopter Emergency Medical Service (HEMS) has been introduced to improve trauma care in the Southeast of England. The majority of the workload comes from the area bounded by the M25 ring road. In 1989 a Dauphin 365N helicopter equipped for pre-hospital primary rescue and emergency inter-hospital secondary transfer was certified by the Civil Aviation Authority. The helicopter commenced carrying patients with a paramedic and a doctor on board early in 1990. In September 1990 this service was further improved by the opening of a helipad at the Royal London Hospital and a designated HEMS desk at London Ambulance Service central control. Eighty-four patients were transported in primary rescue missions and 107 as emergency transfers in 1990.


Pulmonary intravascular macrophages: a review of immune properties and functions.

Pulmonary intravascular macrophages (PIMs) are mononuclear cells found apposed to the lung capillary endothelium in a number of mammalian species. Although first described in the 1970s, it was not until the 1980s that they were more completely described. In several species of veterinary interest (bovine, porcine, ovine, and feline), PIMs are very important in blood clearance, which is not the case in mice and rats. Only recently have the immunological activities of PIMs been verified. In this review, we present an overview of PIM research with particular emphasis on the immune functions of this highly reactive macrophage population.


Slow release bolus for small ruminants: in vitro release of tetracycline compared with serum concentrations of the antibiotic in sheep.

Two formulations of slow release boluses for small ruminants containing tetracycline hydrochloride in a compressed form were investigated in vitro and in vivo in adult sheep. An in vitro dissolution test was used for the preliminary selection of the 2 boluses. It was shown that the non-cumulative kinetics of tetracycline release in vitro were predictive of the tetracycline serum levels in sheep treated orally with the 2 boluses. The maximum concentrations revealed by the in vitro and in vivo curves were obtained at almost the same Tmax and, in vivo, the therapeutic serum levels were maintained for about 5 days. It is concluded that an in vitro approach is of value in predicting the kinetic profiles of a long-acting tetracycline bolus in sheep.


Susceptibility of the rabbit to an enteropathogenic strain of Escherichia coli 0103: effect of animals' age.

Experimental infections with an enteropathogenic strain of Escherichia coli 0103 were studied in SPF rabbits of different ages. Whatever the age, the weight gains in all animals were reduced more or less significantly. However, mortality differed considerably according to the age. Four to 5-week-old rabbits were most susceptible to the infection, with 80-100% mortality associated with diarrhoea, generally of the hemorrhagic type. Peak mortality was observed between 5-10 days post-inoculation. In general, 21-day-old rabbits died from the second week post-inoculation onwards. After the 6th week of age, mortality was rare. Study of the microflora showed that the colonization of the gut by E coli 0103 occurred whatever the age as 10(6)-10(9) bacteria per g of feces of the inoculated strain were recovered. The role of specific receptors has been discussed.


Assessment of liver copper status in cattle from plasma copper and plasma copper enzymes.

Copper status determined by liver biopsy was also assessed by 3 plasma parameters: total plasma copper (Cu) as well as ceruloplasmin (Cp) and amine oxidase E.C.1.4.3.6. (AO) activities. While 14 out of the 98 cattle, all kept in field conditions, had liver copper levels of less than 20 mg/kg only 5 of these could be distinguished by low plasma Cu and 3 by low Cp activity. In addition, some animals with apparently adequate liver copper had relatively low plasma Cu values, ca 0.5-0.6 mg/l. None of the cattle had decreased AO activity. When all 3 plasma parameters were combined in the form [AO] divided by ([Cp] x [Cu]), detection of the low liver copper was improved in that 9 out of 14 could be distinguished, whereas animals with more than 20 mg/kg DM liver Cu could not. It is suggested that this relationship, tentatively called an index, would merit examination in other situations, since it might provide a better guide to copper status and indicate whether copper repletion therapy was worthwhile.


In vitro colonization of porcine trachea by Mycoplasma hyopneumoniae.

Porcine tracheae maintained in culture were used in order to study the colonization by Mycoplasma hyopneumoniae. Rings excised from tracheae of newborn piglets were infected with M hyopneumoniae strain BQ 14 and, after different incubation times, were examined by light and electron microscopy. Non-infected tracheal mucosae maintained a normal appearance for several days. Infected tracheal rings showed progressive colonization with concomitant progressive damage to the mucosal surface. Early on during the infection, few mycoplasmas occurred over a ciliated epithelium. As the infection progressed, there was gradual loss of cilia; mycoplasmas tended to form microcolonies and to accumulate over the remaining ciliated cells. Mycoplasmas, first seen at the apex of the cilia, were then seen deeper in the inter-ciliary space; some were even seen in contact with microvilli. In histological investigation, the final stage of the infection was characterized by a marked destruction of the epithelium with exfoliation of the epithelial cells. Infected mucosae showed typical damage caused by M hyopneumoniae, namely reduction of ciliary activity after 5 days, loss of cilia, and sloughing of ciliated cells. Our data indicate that porcine tracheal organ culture can be advantageously used to study colonization by M hyopneumoniae.


[Perioperative transfusion strategy].

Tactics in blood transfusion have evolved considerably during the last ten years. Awareness of infectious risks and economic considerations have lead legislators to draw the guidelines for a safer transfusion. Their aim is to promote a better transfusion in smaller quantities at a lower risk. The goal of perioperative blood replacement is to maintain hemoglobin, blood volume and coagulation factors at an adequate level. This can be carried out by either homologous or autologous transfusion. Fresh frozen plasma transfusion is only required in severe bleeding where coagulation factors are depleted. The plasma substitutes must be used according to their intrinsic properties and their cost. The choice of an autologous technique depends on the type of surgical procedure, the expected blood loss and the economic resources available. Autologous blood transfusion may be optimized by the association of various techniques. This transfusion strategy must be elaborated by all the medical protagonists implicated in transfusion procedures.


[Hepatic resections for metastases].

Between January 1981 and December 1990, 79 liver resections were performed for hepatic metastases in 73 patients. Eight of these patients had a repeat resection (2 patients had their first resection performed before 1981). This figure represented 35% of 228 liver resections performed during this period. Mean age was 56.5 years (23 to 81 years). There were 38 men and 35 women. Fifty-four resections were performed for colorectal metastases and 25 resections for secondaries of other origins. There were 45 major hepatectomies (57%), defined by the resection of at least 3 Couinaud segments, and 34 minor resections (less than three segments). In 12 patients, liver resection was associated with excision of the primary tumor. Complications were observed in 25 patients (32%), pulmonary complications being the most frequent. Five re-explorations were necessary: 3 for postoperative bleeding, one for an abdominal abscess and one for intestinal obstruction. Mean postoperative stay was 18 days. There was no mortality for the first liver resections in 71 patients. One death was encountered among the second resections in 8 patients, with a global mortality of 1.3%. Follow-up was obtained for all patients but one (lost to follow-up at 5 years). Actuarial survival for the 50 patients operated on for colorectal secondaries was 98% at 6 months, 83% at 1 year, 46% at 2 years, 24% at 3 years and 15% at 5 years. In non-colorectal secondaries, the survival depended on the nature of the primary tumor but was very different from one patient to another.(ABSTRACT TRUNCATED AT 250 WORDS)


[Results of portacaval shunt after failure of sclerotherapy in patients with cirrhosis].

Therapy of variceal bleeding is currently based on endoscopic sclerotherapy. However, the treatment of bleeding recurrences after sclerotherapy has not yet been established, but consists of the choice between continuation of sclerotherapy or a surgical procedure. We report herein the results of portocaval shunt performed in 26 cirrhotic patients among the 175 cirrhotic patients (15%) admitted between 1985 and 1990 to our Intensive Care Unit for variceal bleeding. These 26 patients were operated because of failure of sclerotherapy as defined by haemostasis failure (n = 1), the persistence of unchanged oesophageal varices after six sessions of sclerotherapy (n = 1), and the occurrence of at least one severe episode of rebleeding (n = 24). Emergency and elective portocaval shunts were performed in 12 and 14 cases respectively. The time delay between admission and surgical procedure was equal to 21 +/- 8 hours and 12 +/- 4 days in the two groups respectively. The operative mortality (30 days) was equal to 23% and was observed in emergency shunts only. Actuarial survival rates were significantly different between the two groups (p < 0.01). Predictive factors of mortality as assessed by univariate analysis were the emergency nature of the procedure, serum aminotransferases and urea levels at the time of the index bleeding, and the number of bleeding episodes related to portal hypertension before the index bleeding. The prognosis at one year was not influenced by the number of bleeding recurrences between the index bleeding and the bleeding episode justifying the shunt.(ABSTRACT TRUNCATED AT 250 WORDS)


[Endoscopy of the small intestine in 1991: is it the end of the tunnel?].

Small bowel enteroscopy in 1991 is now feasible in two clinical situations: in the case of malabsorption or diffuse intestinal disease, it is easier to visualise the small bowel with the "push enteroscopy methods". The most proximal and distal ends of the small intestine can be viewed through standard instruments or better with videocoloscope beyond the ligament of Treitz. The ileocecal valve can be intubated after total colonoscopy for the evaluation of Crohn's disease, tuberculosis and small bowel lymphoma. In the case of occult gastrointestinal hemorrhage small bowel enteroscopy now permits visualization of large amounts of small intestinal. When the gastrointestinal bleeding is severe, we recommend intraoperative enteroscopy. When the bleeding is not severe and chronic, it is possible to perform a non surgical total small bowel enteroscopy with an enteroscope or videoenteroscopoe. Prototypes are under development. The procedure is safe an can be performed on an outpatient basis. The limitations of the procedure are the impossibility of intervention and inability to inspect the total mucosal surface. It is not a "first line" or "second line" investigation in these situations. It should be considered after previous investigations have been negative. Push enteroscopy should be performed by general endoscopists, non surgical and total enteroscopy should be reserved, for instance for skills and motivated team endoscopists.


[Cholecystectomy by celioscopy. Experience in two Upper Normandy hospital units. Apropos of 178 procedures].

Laparoscopic cholecystectomy (LC) emerges as an effective alternative to classical cholecystectomy, but its safety, benefits and indications still need to be clarified. From September 1989 to March 1991, 178 LC were performed by 8 surgeons in 2 hospitals, on 142 women and 36 men with a mean age of 48.2 years. The gall bladder wall was thin in 160 cases and thick in 18 cases (with 6 cases acute cholecystitis). We observed no deaths, 147 simple procedures with a hospital stay and drug requirement lower than with the usual cholecystectomy via laparotomy. But in 21 cases, the procedure needed a laparotomy, and in 10 cases complications occurred, requiring laparotomy in 6 cases. Our results suggest: a) LC is an improvement in the treatment of uncomplicated gallstones; b) a trained surgeon and extreme caution are required in complicated cholelithiasis; c) classical cholecystectomy is still useful in many circumstances.


[Appendectomies by celioscopy. Results in 78 patients].

The recent development of laparoscopic surgery has included the treatment of acute appendicitis. We report our results after three years' experience of this type of surgery. We have operated on 78 patients (54 men, 44 women) mean age 28.9 years, suspected of varying degrees of acute appendicitis. The operation was completely carried out by laparoscopy on 71 occasions, including treatment of an abscess in 4 cases and peritonitis in 4 cases (3 of which were sub-mesocolic and one was generalised). The laparoscopy was transformed into laparotomy in 7 cases, 4 of which were due to difficulties of appendix dissection. Mortality was zero. Four complications occurred: 2 minute infections of the trocar hole, one more severe parietal infection which was a cause of readmission and antibiotic treatment, one "syndrome of the fifth day". In conclusion, laparoscopic appendicectomy appears to be quite feasible in the majority of cases, particularly when the appendix is ectopic, with marked abdominal thickening and peritoneal reaction. The postoperative course is uneventful. The laparoscopic technique is very comfortable for the patient during the postoperative period. This technique is becoming increasingly feasible with the operator's experience, and this appears to us to constitute good training for any form of laparoscopic surgery.


[Gastric metastases. Apropos of 17 cases].

Seventeen cases of gastric metastases are reported; some of them appeared after a long latency period. Two cancers prevail from an aetiological standpoint: melanoma (7 cases) and breast cancer (4 cases). Endoscopic appearance is often typical in melanoma, but suggests a primary carcinoma or radiation-induced lesions in breast cancer. Surgery is reserved to located lesions, but seems to have no incidence on prognosis. Overall mean survival is 11 months with a range of 3 months to 5 years.


[Leiomyosarcomas of the rectum. Amputation of the rectum or local resection?].

Two cases of high grade leiomyosarcoma of the rectum treated by local excision are reported. The first patient presented a local recurrence associated with liver and pulmonary metastases and eventually died, respectively 11 and 22 months after resection. The second patient's tumor recurred 3 months after excision and was treated with pelvic exenteration and CYVADIC regimen as chemotherapy and died 3 years later from local recurrence. A review of the literature indicates that local surgical excision in comparison to a more radical surgical approach, such as abdominoperineal resection, is as effective in improving survival. Lesions less than 2.5 cm in diameter, confined to the bowel can be treated by local surgical excision. To date no adjuvant therapy is effective in terms of survival or local control.


[Implantable insulin pump: surgical implantation under local anesthesia. (Technical note apropos of 35 cases)].

The authors report 35 cases of implantation of a programmable implantable insulin pump, under local anesthesia. This technique allows creation of an subcutaneous pocket and introduction of an intraperitoneal catheter for insulin delivery. The morbidity is mainly due to the catheter which becomes thrombosed by a fibrotic pannus at its tip. We observed only one case of mechanical dysfunction of the pump. Subcutaneous migration is secondary to reoperation without new fixation. With a mean follow-up of 7 months, 75% of the patients are doing well.


["Cholethorax" revealing injury to the common bile duct after celioscopic cholecystectomy].

The case-report describes the unusual formation of a bilious pleural effusion or "cholethorax" revealing a common bile duct injury secondary to laparoscopic cholecystectomy. Pleural drainage led to a diagnostic ERCP. Subsequently a Roux en Y hepatico-jejunostomy allowed a satisfactory outcome.


[Surgical treatment of toxic megacolon complicating pseudomembranous colitis. Apropos of a case, review of the literature].

Toxic megacolon complicating pseudomembranous colitis has been rarely observed. Only 36 cases have been previously reported. We present herein a new case report in which pseudomembranous colitis was secondary to prophylactic antibiotherapy with pefloxacin for hip prosthesis. Despite specific oral treatment (against Clostridium difficile) by vancomycin, toxic megacolon required urgent subtotal colectomy with ileostomy and sigmoidostomy. Postoperative course was uneventful. Analysis of the reported cases demonstrates the high overall mortality of the series (32%); the procedure of choice seems to be subtotal colectomy, which removes the septic focus, with a 12% operative mortality rate.


[Regulation of arteriolar tonus and EDRF].

The physiological significance of the release of NO by endothelial cells was discussed according to the effects of inhibitors of NO formation and to the observations of Mellander et al. on the reactivity of resistance vessels in cat skeletal muscle. Whole results indicate that NO continually takes patent arteries and decreases systemic resistances. However, NO has minimal effects on the arteriolar side of the vascular tree.


Indication for surgery of asymptomatic carotid lesions.

The incidence of cerebrovascular diseases with transient or persistent neurologic dysfunction has increased significantly. Although patients with symptomatic carotid artery stenosis clearly benefit from operative therapy, the indication to prophylactic surgery of asymptomatic carotid lesions however is still controversial. Based on data from a recently completed prospective randomized study and on analysis of the literature the indication and results of surgical treatment of asymptomatic stenoses of the carotid arteries are discussed. From 1970 to 1990 a total of 744 uni-or bilateral reconstructions of the internal carotid artery were performed in 631 patients. The perioperative morbidity (permanent neurologic deficiency) and mortality was 1.1% (n = 8) resp. 0.8% (n = 6). During the follow up period up to 18 years another 9 patients suffered from stroke (1.2%). The annual stroke incidence amounted to 0.2%. An important prerequisite for surgery is the so called critical internal carotid artery stenosis, implying reduced cerebral vasomotor reactivity or high embolic risk of an ulcerative plaque. Proper selection of patients (exclusion of multiple concomitant diseases) and an experienced team of vascular surgeons with operative morbidity and mortality below 1-2% validates surgical treatment of asymptomatic carotid artery stenoses.


[Measurement of cardiac output by invasive methods: methods and variability].

Invasive techniques for the measurement of cardiac output include the Fick method, the marker dilution method and radiological ventriculography. The principles, methods and accuracy of these techniques are described. The reference method remains that of Fick, despite its being less widely used now because of its complicated nature and its technical limitations (need for strict baseline conditions, precision of sampling). The thermodilution method is often performed. It is easy and provides reliable results, except in conditions of low cardiac output or when there is severe tricuspid insufficiency. Radiological ventriculography is used less for the measurement of cardiac output, since it is heavily dependent upon heart rate and theoretical geometrical models. It remains valuable for the quantification of mitral and aortic regurgitation.


[Evaluation of cardiac output by Doppler echocardiography. Basic principles and practice].

The measurement of cardiac output by the Doppler-echocardiography method is of considerable interest since, in contrast to other available techniques, it offers the possibility of the measurement of output at each valve orifice, thus providing a quantitative approach to valve regurgitation. The 4 basic data items required are: the surface area of the valve orifice, trans-valvular Doppler velocity spectrum, duration of ejection and of filling, and heart rate. A large number of studies have analysed the various investigation techniques and have shown their excellent correlation with reference invasive methods. In the light of experience acquired in our Echocardiography Laboratory, we recommend, in accordance with data from the literature, the exclusive use of pulsed Doppler and measurement of valve orifices by two-dimensional imaging at the point of insertion of the aortic and sigmoid cusps as well as at the mitral ring. A simplified method for the measurement of mitral surface area on the basis of TM records is suggested.


[Evaluation of cardiac output by Doppler echocardiography. Correlation of aortic, pulmonary and mitral ring flow rates. Study of 103 subjects free of valve leak].

Measurement by Doppler-echocardiography of blood flow rates has the advantage over techniques for the measurement of cardiac output of determining the latter for each valve orifice, and of opening up an approach to the quantification of aortic and mitral regurgitation. This prospective study involving 103 subjects free of any valve leak showed the absence of an significant difference between aortic, pulmonary and mitral ring flow rates in a given individual. Correlations between results obtained at the three measurement sites were: r = 0.92 between aorta and pulmonary artery, r = 0.90 between aorta and mitral ring and r = 0.90 between pulmonary artery and mitral ring. These results support the validation of this technique and would justify its use in the evaluation, quantification and monitoring of mitral and aortic valve leaks.


[Measurement of mitral flow at the extremity of the valves. Validation of a simplified method based on 101 cases].

The measurement of cardiac output at the extremity of the mitral cusps, by Doppler-echocardiography, is of fundamental value, in particular for the evaluation of valve regurgitation. However, it comes up against a theoretical difficulty resulting from constant variation in the surface area of this orifice during diastole. After reviewing the main measurement methods available in the literature, a simplified method based upon the diameter of the ring and calculation of a mean diastolic intercusp distance by TM is suggested. Evaluation of this technique in 101 patients free of valve of leak showed its feasibility to be close to 100% and the correlation with aortic (r = 0.90), pulmonary (r = 0.91) and mitral ring (r = 0.88) outputs was entirely satisfactory. Our method would thus seem to be a good compromise between digitalised integration methods for the measurement of mitral surface area--optimal but complex--and the aim of simplification compatible with routine clinical use.


[Measurement of cardiac output by Doppler echocardiography at the 4 cardiac valves].

Many observers remain sceptical with regards to the utilization of Doppler-echocardiographic measurements of intracardiac outputs for the quantification of shunts and regurgitations. In this context, we evaluated the feasibility and validity of measuring output at the level of the four cardiac valves in a population of 35 normal subjects (24 M, 12 F) aged from 23 to 37 years (mean +/- SD = 28 +/- 4). Measurement of stroke volume and output using predetermined criteria was possible in the aortic position in 35 (100%) subjects, in the mitral position in 34 (97%), in the pulmonary position in 20 (57%) and in the tricuspid position in 10 (29%). In 14 subjects (40%), measurement was possible at 2 sites, in 14 (40%) at 3 sites and in 7 (20%) at 4 sites. Inability to measure output was most often due to poor visualization of valvular annulus. There are excellent correlations between aortic stroke volume on the one hand and the mitral (r = 0.97, SEE = 3.41 cc), pulmonary (r = 0.97, SEE = 3.69 cc) and tricuspid (r = 0.96, SEE = 2.77 cc) stroke volumes respectively on the other. These results suggest that reliable measurements of output are feasible in a majority of cases in the aortic and mitral positions but to a much more limited extent in the pulmonary and tricuspid positions; given the small SEE's, they should be useful to quantitate shunts and regurgitations, when feasible.


[Determination of aortic and pulmonary flow by Doppler ultrasonography].

Numerous studies have demonstrated the reliability of ultrasound Doppler in measuring aortic flow. It is generally agreed that aortic surface area and flow rate should be measured at the arch. In contrast, determination of the pulmonary flow by ultrasound Doppler, validated in children and infants, is difficult in adults due to problems encountered in measuring the diameter of the pulmonary arch.


[Quantification by transthoracic Doppler of tricuspid valve insufficiencies].

Various methods are available today for the quantification of regurgitation by transthoracic Doppler. The present review deals with their respective usefulness in tricuspid insufficiency (TI). Despite their contribution in the domain of mitral and aortic insufficiency, precise quantification methods remain of very limited value regarding the tricuspid orifice, and this because of practical difficulties of application. Evaluations of the severity of TI is based, essentially, on a semiquantitative approach. Cartography of the regurgitation stream, by colour Doppler, is the chief method, despite its limitations which are clearly emphasised by the effects of the contrast test. The discovery, by pulsed Doppler, of laminar systolic flow is a sign of capital importance. It is indicative of massive TI and of particular anatomical and hemodynamic conditions, but it is uncommon. Systolic reversal of flow in the inferior vena cava is a good sign of severity but lacks specificity. In contrast, measurement of maximum velocities of TI, while essential for the evaluation of pulmonary pressures, is of no value in terms of the quantification of regurgitation. Transthoracic Doppler data must be taken together with those of transthoracic echocardiography, the esophageal approach offering nothing special, being essentially useful in lesion evaluation. The quantification of TI, by transthoracic Doppler, has derived only very little benefit from the current orientation of Doppler methods.


[Measurement by Doppler echocardiography of the ratio of pulmonary/systemic flow rates in atrial septal defects. Apropos of 15 cases].

Fifteen patients with an ostium secundum type atrial septal defect, aged between 5 and 68 (mean = 31) underwent Doppler-echocardiographic evaluation of the ratio of pulmonary and systemic flow rates. Systemic flow was evaluated at the aortic orifice, as well as at the mitral ring and at the extremities of the mitral cusps, based upon the measurement of valve diameters by 2D or TM echocardiography, pulsed Doppler velocity curve and hear rate. Pulmonary flow was measured by the same technique at the site of insertion of the pulmonary cusps. The values obtained were compared with cardiac catheterisation findings, the reference method being an oxymetric measurement of the shunt ratio. Feasibility of the Doppler investigation was 100 per cent. Correlation between the two techniques was r = 0.85 when the Doppler measurement was at the aorta, r = 0.81 for the mitral ring and r = 0.71 at the extremity of the mitral cusps. Doppler-echocardiography thus appears to be a reliable and reproducible method for the evaluation of left-right shunts, confirming data from the literature.


[Doppler echocardiography and double chamber pacing].

Doppler-echocardiography is playing an increasing role in cardiac pacing: 1) Before implantation, to determine any cardiac disease possibly accompanying the conduction disturbance, and the quality of atrial function in order to identify the appropriate indications for the type of pacing which will restore normal AV synchronism. Alongside morphometric data (size of atria, etc.), this analysis is based above all on the evaluation of LV filling flows and ejection, if necessary during provisional pacing in DRV mode. It is important to be aware of and prevent certain problems: 1st degree AV block with very long PR, high degree interatrial conduction disturbances, etc. 2) To evaluate the possible benefits of pacing in certain new indications, e.g. obstructive hypertrophic cardiomyopathy (measurement of intra-LV gradient in sinus rhythm and with DRV pacing with total ventricular capture). 3) After implantation, to optimise the programming of double-chamber pacemakers and in particular AV intervals (base-line AV interval with paced atrial cycle, AV interval with detected atrial cycle, hysteresis of AV interval corresponding to the difference between the two previous values, slope of automatic variation in AV interval during exercise, etc.). Individual programming of these parameters based upon analysis of transmitral and ejection flow rates, at rest and, if necessary, during exercise, enables the optimisation of cardiac function (which is above all useful in the presence of concomitant organic heart disease) while at the same time improving the electrophysiological behaviour of the pacemaker at high frequencies.


[Transesophageal echocardiography in infectious endocarditis].

During the past 20 years, TTE has acquired a role of choice in the positive diagnosis as well as in the prognostic evaluation of endocarditis. However, it is a non-histobacteriological technique and is also operator-dependent. If often enables the detection of high risk patients: large vegetations, severe valve damage with major leaks, threatened complications: abscess, fistula, sometimes leading to referral of the patient for emergency surgery when required by hemodynamic conditions (often without recourse to catheterisation) or when infection is uncontrolled despite proper medical treatment. Embolism is the chief cause of morbidity and mortality in IE. In this context, the size of vegetations appears to be a risk factor. TEE enables refinement, precision and completion of TTE findings. It should be requested in the following circumstances: 1) strong clinical suspicion of IE but TTE negative, 2) monitoring of severe forms due to virulent organisms, 3) whenever there is suspicion of IE affecting a valve replacement.


An epidemiological survey of respiratory morbidity among granite quarry workers in Singapore: radiological abnormalities.

This report presents baseline findings from the first of a series of epidemiological studies to evaluate inter alia the effects of control measures introduced in 1972-79 to reduce dust exposure in all quarries in Singapore. The prevalence of radiological abnormalities among 219 currently employed quarry workers were estimated according to a number of parameters of dust exposure. Large-sized chest x-ray films were read, independently and in random order, by a panel of three experienced readers, who were "blinded" to the personal particulars and exposure of the subjects, using standard chest x-ray films to record opacities according to the International Standard Classification of Radiographs of Pneumoconioses. Silicosis as defined by radiological small opacities (both rounded and irregular) of profusion 1/1 or greater as read by at least two readers were noted in 11 subjects. The prevalence of silicosis was 12.5% in highly exposed drilling and crushing workers, and 0.8% in maintenance and transportation workers with low level exposure to granite dust. Among those who were first exposed to granite dust after 1979, no cases of silicosis were noted in any quarry worker. It is concluded that reduction in dust exposure since 1979 has so far been successful in producing nil or negligible risks of silicosis among active quarry workers over ten years, but further follow-up studies are needed.


An epidemiological survey of respiratory morbidity among granite quarry workers in Singapore: chronic bronchitis and lung function impairment.

Respiratory symptoms of chronic bronchitis and measurements of lung function were studied in an epidemiological survey of the total population of workers currently employed in granite quarries in Singapore. There were 85 rock drilling and crushing workers with current exposure in high levels of silica dust. Their respiratory parameters were studied with reference to an internal comparison group of 154 quarry maintenance and transport workers with low dust exposure, and an external comparison group of 148 Telecoms postal delivery workers with no granite dust exposure. The highly exposed workers showed greater prevalences of chronic cough and phlegm, a mean reduction of 5% in forced expiratory volume in one second (FEV1) and forced vital capacity (FVC). The increased respiratory morbidity were independent of other factors such as age and smoking. Similar results were also noted after excluding those with silicosis (defined radiologically as profusion greater than 1/1 as read by at least two of three readers). This study strongly indicates a demonstrable risk of "occupational" bronchitis (mucus hypersecretion) and obstructive and restrictive lung function impairment, apart from the "classical" risk of silicosis. Measures taken to protect the health of workers exposed to silica dust should also be based on considerations taken to protect against the risk of these respiratory disorders as well.


Xq28: epidemiology and sex-linkage between red-green colour blindness and G6PD deficiency.

Xq28 is the genetic locus of two closely associated conditions of red-green colour blindness and G6PD deficiency. Epidemiologically, both rank among the more frequent sex-linked clinical problems that affect military servicemen in Singapore. This retrospective study is based on the findings of 35714 subjects screened at the Medical Classification Centre--Central Manpower Base (MCC--CMPB) over an eighteen-month period using pseudoisochromatic and fluorescent techniques as well as anomaloscopic and spectrometric methods. The overall prevalence rates of red-green colour blindness, G6PD deficiency and association were determined to be 4.8%, 2.2% and 0.1% respectively. Malays showed the highest prevalence rates among the major races. Statistically significant difference was found with regards to the prevalence rates of G6PD deficiency and its association with red-green colour blindness. Review of literature yielded comparable results with a few local studies of good sample size done over the past twenty years. Sex-linkage analysis was hindered by the lack of pedigree studies.