American College of Physicians Ethics Manual. Third edition.

Medicine, law, and social values are not static and must be re-examined periodically. This edition of the ACP Ethics Manual covers emerging issues in medical ethics and revisits some old issues. The overview of the evolution of medical ethics, which appeared in previous editions of the Manual, has been eliminated to allow more space for the consideration of today's ethical dilemmas. Other changes include a revised chapter on end-of-life care, discussion of physician-assisted suicide, revised sections on conflicts of interest and on medical risk to the physician and patient, given developments in human immunodeficiency virus (HIV) infection and the acquired immunodeficiency syndrome (AIDS), and discussion of sexual contact between physician and patient. A statement on disclosure of errors and a section on care of the physician's family have also been added. The sections on confidential information told by a patient's family or friend to the physician; on physician-pharmaceutical industry relations; on physicians in training; and on the impaired physician have been expanded. Sections on advertising, peer review, and resource allocation have been revised. The literature of biomedical ethics expands at a rate that does not allow a bibliography to remain current, so an exhaustive list of references or suggested readings is not included in this manual. Instead, only cited references are listed.


Breast cancer screening among women from 65 to 74 years of age in 1987-88 and 1991. NCI Breast Cancer Screening Consortium.

To compare breast cancer screening rates from the 1991 survey with data from 1987-88 for women aged 65 to 74. Surveys of women from five communities. Five control communities of the National Cancer Institute's Breast Cancer Screening Consortium. White, non-Hispanic women, ages 65 to 74; 499 in 1987-88 and 2156 in 1991. Response rates for the first survey wave ranged by area from 65% to 77% and for the second survey wave, from 62% to 85%. Mammogram and clinical breast examination during the past year and performance of monthly breast self examination, with the screening rates in wave 2 directly standardized to the income and education distribution of wave 1 in each area. Mammography use between waves increased significantly (P < 0.05 after adjusting for education, income, and age) in all but one area (from 19% to 33% in wave 1 to 35% to 59% in wave 2). Among women who had a mammogram, the percent who also had a clinical breast examination decreased between waves from 95% to 85% (P = 0.001). Mammography in older women increased dramatically over 3 years, although the use of clinical breast examination may be decreasing.


Emotional support and survival after myocardial infarction. A prospective, population-based study of the elderly.

To compare the survival of elderly patients hospitalized for acute myocardial infarction who have emotional support with that of patients who lack such support, while controlling for severity of disease, comorbidity, and functional status. A prospective, community-based cohort study. Two hospitals in New Haven, Connecticut. Men (n = 100) and women (n = 94) 65 years of age or more hospitalized for acute myocardial infarction between 1982 and 1988. Social support, age, gender, race, education, marital status, living arrangements, presence of depression, smoking history, weight, and physical function were assessed prospectively using questionnaires. The presence of congestive heart failure, pulmonary edema, and cardiogenic shock; the position of infarction; in-hospital complications; and history of myocardial infarction were assessed using medical records. Comorbidity was defined using an index based on the presence of eight conditions. Of 194 patients, 76 (39%) died in the first 6 months after myocardial infarction. In multiple logistic regression analyses, lack of emotional support was significantly associated with 6-month mortality (odds ratio, 2.9; 95% CI, 1.2 to 6.9) after controlling for severity of myocardial infarction, comorbidity, risk factors such as smoking and hypertension, and sociodemographic factors. When emotional support was assessed before myocardial infarction, it was independently related to risk for death in the subsequent 6 months.


Ferrous sulfate reduces thyroxine efficacy in patients with hypothyroidism.

To determine whether simultaneous ingestion of ferrous sulfate and thyroxine reduces the efficacy of thyroid hormone in patients with primary hypothyroidism. Uncontrolled clinical trial. Outpatient research clinic of a tertiary care center. Fourteen patients with established primary hypothyroidism on stable thyroxine replacement. All patients were instructed to ingest simultaneously, a 300-mg ferrous sulfate tablet and their usual thyroxine dose every day for 12 weeks. After 12 weeks of ferrous sulfate ingestion with thyroxine, the mean level of serum thyrotropin (thyroid stimulating hormone, TSH) rose from 1.6 +/- 0.4 to 5.4 +/- 2.8 mU/L (P < 0.01), but the free thyroxine index did not change significantly. Subjective evaluation using a clinical score showed that nine patients had an increase in symptoms and signs of hypothyroidism; the mean score for the 14 patients changed from 0 to 1.3 +/- 0.4 (P = 0.011). When iron and thyroxine were mixed together in vitro, a poorly soluble purple complex appeared that indicated the binding of iron to thyroxine. Simultaneous ingestion of ferrous sulfate and thyroxine causes a variable reduction in thyroxine efficacy that is clinically significant in some patients. The interaction is probably caused by the binding of iron to thyroxine.


Hormone therapy to prevent disease and prolong life in postmenopausal women.

To critically review the risks and benefits of hormone therapy for asymptomatic postmenopausal women who are considering long-term hormone therapy to prevent disease or to prolong life. Review of the English-language literature since 1970 on the effect of estrogen therapy and estrogen plus progestin therapy on endometrial cancer, breast cancer, coronary heart disease, osteoporosis, and stroke. We used standard meta-analytic statistical methods to pool estimates from studies to determine summary relative risks for these diseases in hormone users and modified lifetable methods to estimate changes in lifetime probability and life expectancy due to use of hormone regimens. There is evidence that estrogen therapy decreases risk for coronary heart disease and for hip fracture, but long-term estrogen therapy increases risk for endometrial cancer and may be associated with a small increase in risk for breast cancer. The increase in endometrial cancer risk can probably be avoided by adding a progestin to the estrogen regimen for women who have a uterus, but the effects of combination hormones on risk for other diseases has not been adequately studied. We present estimates for changes in lifetime probabilities of disease and life expectancy due to hormone therapy in women who have had a hysterectomy; with coronary heart disease; and at increased risk for coronary heart disease, hip fracture, and breast cancer. Hormone therapy should probably be recommended for women who have had a hysterectomy and for those with coronary heart disease or at high risk for coronary heart disease. For other women, the best course of action is unclear.


Determinants of gastroesophageal junction incompetence: hiatal hernia, lower esophageal sphincter, or both?

To examine the effects of hiatal hernia and lower esophageal sphincter (LES) pressure on the competence of the gastroesophageal junction under conditions of abrupt increases in intra-abdominal pressure. Acute experiments. University-hospital-based gastroenterology practice. Sixteen asymptomatic volunteers and 34 patients with endoscopic findings suggestive of hiatal hernia. A series of eight provocative maneuvers entailing abrupt changes in intra-abdominal pressure. Five radiographic measurements relevant to the presence and extent of hiatal hernia were made from videotaped barium-swallow examinations. Lower esophageal sphincter pressure was measured immediately before each maneuver. The percentage of maneuvers that resulted in gastroesophageal reflux was calculated as the reflux score. A stepwise regression analysis was then used to model the relation between measured variables of the gastroesophageal junction (manometric and radiographic) with reflux score. Patients with hiatal hernia had substantially higher reflux scores and lower LES pressures than either patients without hernias or volunteers. In diminishing order of significance, the terms in the model of susceptibility to reflux were axial length of hernia measured between swallows; LES pressure; and an interaction term in which a progressive increase occurred in the risk for reflux associated with a hypotensive lower esophageal sphincter as hernia size increased. Gastroesophageal junction competence during abrupt increases in intra-abdominal pressure is compromised by both hiatal hernia and low LES pressure. These factors interact with each other to determine susceptibility to reflux.


Kidney transplantation from living unrelated donors.

To compare patient and graft survival of recipients of kidneys from living, unrelated donors (LUDs); cadaveric donors; and living, related donors (LRDs) matched for zero (mismatched), one, or two (identical) haplotypes. Cohort study. Sixty-three renal transplantation centers affiliated with the Brazilian Transplantation Registry (accounting for more than 95% of the transplantation activity in Brazil). Patients having renal transplantation between January 1987 and March 1991. Of 2892 patients, 165 (6%) received transplants from LUDs; 964 (33%), from cadaveric donors; 183 (6%), from zero haplotype, HLA-matched LRDs; 1259 (44%), from one haplotype-matched LRDs; and 321 (11%), from two haplotype-matched LRDs. Patient and graft survival. Patients were followed for an average of 15.8 months. After adjustment for age, race, diagnosis of primary disease, history of previous transplantation, cyclosporine use, and number of transplants from LUDs per center, patient survival did not differ statistically for recipients of kidneys from LUDs and recipients of cadaveric kidneys (risk ratio [RR], 1.16; 95% Cl, 0.68 to 1.98). Little difference was seen between the adjusted death rate for recipients of zero haplotype-matched LRDs and recipients of cadaveric kidneys (RR, 1.13; Cl, 0.69 to 1.87). Similarly, in a multivariate analysis, recipients of kidneys taken from LUDs and zero haplotype-matched LRDs had a risk for graft failure that did not differ statistically from that of cadaveric kidney recipients (RR, 0.74; Cl, 0.45 to 1.22 and RR, 0.82; Cl, 0.53 to 1.25, respectively). Graft survival for recipients of kidneys from LUDs is similar to that from zero haplotype-matched LRDs and is at least as good as that achieved with cadaveric transplants.


Anticardiolipin antibodies and the risk for ischemic stroke and venous thrombosis.

To determine whether the presence of anticardiolipin antibodies is a risk factor for ischemic stroke and venous thrombosis in healthy adult men. A nested, case-control study in a prospective cohort. A nationwide study of physicians. The study sample was drawn from the Physicians' Health Study, a randomized, double-blind, placebo-controlled trial of aspirin and beta-carotene in 22,071 male physicians. At entry, 68% of the participants submitted plasma samples that were subsequently frozen at -80 degrees C. During 60.2 months of follow-up, follow-up for nonfatal outcomes was 99.7% complete and ascertainment of fatal outcomes was 100% complete. We identified men with documented ischemic stroke, deep venous thrombosis of the leg, or pulmonary embolus and for whom a plasma sample was available. A control was matched by age, smoking history, and length of follow-up to each of the 100 patients with ischemic stroke and the 90 patients with deep venous thrombosis or pulmonary embolus. Plasma samples were assessed for IgG anticardiolipin antibodies by enzyme-linked immunosorbent assay. The mean anticardiolipin antibody titers of the case patients in the two diagnostic groups (ischemic stroke; venous thrombosis or pulmonary embolus) were compared with those of the control groups, and relative risks were calculated for patients in increasing percentile categories of anticardiolipin antibodies by conditional logistic regression. The anticardiolipin antibody titers were higher in case patients with deep venous thrombosis and pulmonary embolus than in their matched controls (P = 0.01). Persons with anticardiolipin antibody titers above the 95th percentile had a relative risk for developing deep venous thrombosis or pulmonary embolus of 5.3 (95% CI, 1.55 to 18.3; P = 0.01). The anticardiolipin antibody titers in case patients with ischemic stroke and controls were not significantly different (P > 0.2), and no clear trend of higher risks among those with elevated levels of anticardiolipin antibodies was observed. An anticardiolipin antibody level above the 95th percentile is an important risk factor for deep venous thrombosis or pulmonary embolus but not for ischemic stroke in healthy adult men.


[Low anterior resection in the curative surgical treatment of rectal cancer].

Abdominoperineal resection for rectal cancer are being performed with decreasing frequency in favour of sphincter-saving resections. It remains to be demonstrated that sphincter preservation has not resulted in compromised local disease control and survival. For this purpose 342 patients with rectal carcinoma have been studied. A curative resection has been carried out in 232. Sphincter-saving procedure was performed whenever possible: the length of margin of resection was at least 2 cm. The operation were: 71 abdominoperineal excisions (AP), 147 anterior resections (AR), 14 transanal excisions. The thirty-days mortality was 7 patients (9.9%) for AP and 5 (3.4%) for AR. Local recurrence was: AP 10 cases (15.6%), AR 16 cases (11.3%); for tumors 4-8 cm from anal verge recurrence was 17.1% for AP, 16.2% for AR. Concerning staging, local recurrence was more common in the Dukes C stage (24.3%) than in the Dukes B (10.2%) or in the Dukes A (3.8%). 5 years survival after AP was 62.2 percent and after AR 67.9 percent. Concluding, in our experience, there was no relationship between local recurrence or survival and type of curative surgery (AP or AR). Local recurrence and survival were only related to tumor stage: lateral tumor extension in these advanced and aggressive lesions appears to be the major determinant of local recurrence. Further investigations are necessary to determine whether the addition of adjuvant radiotherapy or of extended abdomino-iliac lymphadenectomy should be able to improve the results.


[Thyroid carcinoma. Criteria for the selection of surgical treatment].

Surgery is still today the first choice treatment in the thyroid neoplasm. The authors examined 37 patients with thyroid cancer out of 389 thyroidal operation performed in the period 1982-85 at the Institute of Surgical Pathology II and Surgical Clinic of University of Bari. The pro-operation screening was scintigraphy, US study and needle biopsy. In 23 case, with positive cytology examination and/or clinical malignancy the performed operation was total extracapsular thyroidectomy. Other nine patients underwent lobectomy and in 2 cases the operation chosen was sub-total strumectomy completed by thyroidectomy after histologically proved malignancy. The laterocervical lymphadenectomy was done only in the case of nodes involvement. Operative mortality was 0 and post-operative stay was about 6 days. The extracapsular total thyroidectomy is the first choice operation for cancer. Nevertheless recently some Authors proposed less destructive operation in the small differentiated type cancers with good results.


[Neopterin and interleukin 2 soluble receptors as biochemical markers of cellular immune response to surgical trauma].

In 67 patients submitted to surgical procedures serum neopterin (NPT) and Interleukin 2 soluble receptors (IL2R) were evaluated at the end of the operation as well as 24, 48, 72 hours later. Thirty seven of the subjects (Group B) had undergone minor surgery (average time of operation: 40 +/- 10 min.), thirty (Group A) had undergone major surgery (average time: 180 +/- 30 min.). The results showed elevated NPT and IL2R levels in the latter cases and, in particular, 48 and 72 h after surgery. Neopterin levels were positively correlated with IL2R (r = 0.548 p < 0.01). These data suggest an activation of the cellular immune response which parallels the magnitude and length of surgical trauma. Thus NPT and IL2R levels could represent biochemical markers of postoperative disorders of the immune homeostasis.


Antioxidant vitamins and prevention of lung disease.

Although the evidence for oxidative stress for air pollution in the human lung is fragmentary, the hypothesis that oxidative stress is an important, if not the sole, mechanism of toxicity of oxidizing air pollutants and tobacco smoke is compelling and growing. First, biochemical mechanisms have been worked out for oxidation of lung lipids by the gas phase of cigarette smoke, NO2 and O3. The oxidation of lung lipids can be prevented by both vitamins C and E. Vitamin C is more effective in preventing oxidation by NO2, and vitamin E is more effective against O3. Second, multiple species of experimental animals develop lung disease similar to human bronchitis and emphysema from exposure to NO2 and O3, respectively. The development of these diseases occurs over a near lifetime exposure when the levels of NO2 or O3 are at near ambient air pollution values. Third, isolated human cells are protected against oxidative damage from NO2 and O3 by both vitamins C and E. Fourth, the vitamin C level in the lung either declines on exposure to NO2 for short-term exposures or increases on chronic cigarette smoke exposure. The effects of cigarette smoking on serum vitamin C is apparently complex and may be related to the daily intake of vitamin C as well as smoking. Serum vitamin C levels may be poor indicators of lung demands when daily vitamin C intakes are above 100 mg/day. Fifth, vitamin C supplementation protects against the effects of ambient levels of air pollution in adults as measured by histamine challenge. An augmented response to histamine challenge may represent increased lung permeability brought about by air pollution. In experimental animal and human experiments, the amount of vitamin C or E that afforded protection was in excess of the current recommended dietary allowance. Although animal studies do not provide evidence for complete protection against NO2 or O3, they do illustrate that current recommended daily allowances are inadequate for maximum protection against air pollution levels to which over 100 million Americans are exposed. The problem of air pollution and its effects on humans is truly of global concern. Air pollution is not restricted to North America or Japan where it was first recognized, but is a major public health problem in Europe as well. When data are available, air pollution probably will be shown to be a major public health problem in all urban areas of the world.(ABSTRACT TRUNCATED AT 400 WORDS)


The effects of vitamins B12, B6, and folate on blood homocysteine levels.

The interaction between plasma homocysteine levels and vitamins B6, B12, and folate is an exciting field and one that has gathered great momentum over the past few years, with the recognition that homocysteine probably plays an important role in occlusive vascular disease. Our understanding in this field is greatly advanced compared to just a few years ago. There are a number of important issues, however, that will need to be addressed in the future if we are to develop a sufficient knowledge base to effectively minimize the risk of occlusive vascular disease ascribable to hyperhomocysteinemia. These include (1) definitive evidence that homocysteine is the actual agent that mediates accelerated occlusive vascular disease and the mechanism by which this occurs; (2) an understanding of what constitutes a pathologic elevation in homocysteine (is there a threshold concentration in the plasma below which no vascular injury occurs? is the peak concentration achieved the critical determinant of injury, or is the area under the curve, or some other feature, more important?); (3) understanding what synergies might exist by adding B6 or B12 to a regimen of folate supplementation (what doses are most appropriate? will toxologic issues limit the utility of supplementation?); and (4) determining the circumstances where reduction of plasma homocysteine will retard or reverse the process of occlusive vascular disease.


Ischemia: reperfusion injury and restenosis after coronary angioplasty.

Percutaneous transluminal coronary angioplasty (PTCA) is a very effective technology that allows, without surgery, successful mechanical revascularization of acutely or chronically obstructed coronary arteries. The success of PTCA in patients with acute myocardial infarction or unstable angina is questioned by early coronary reocclusion and by so-called reperfusion injury. In a biochemical context, reperfusion injury occurs as a very complex interaction between the different tissues that build heart muscle. Free radicals play a pivotal role and initiate a deleterious cascade of events after reperfusion. Protective mechanisms such as superoxide dismutase, glutathione peroxidase, and catalase are normally present in the cell to prevent damage by free radicals. Endothelial cells have a greater number of specific physiologic and metabolic functions and influence the microcirculatory flow. In the presence of exogenous glucose, coronary endothelial cells show a pronounced lactate production under well-oxygenated conditions. Low energy demand and high glycolytic activity may be the cause of why the coronary endothelium is less severely injured than the cardiomyocytes in the ischemic and anoxic heart. The success of PTCA in patients with chronically obstructed coronary arteries (stable angina) is questioned by vessel occlusion and restenosis. Restenosis is a very complex process involving clinical, morphological, procedural, regional flow-dependent, and biological determinants. Early platelet deposition, formation of mural thrombus, coronary vasospasm, and elastic recoil forces of stretched vessel wall may contribute to early restenosis in the first days after PTCA, but the peak incidence of restenosis occurs between two and three months after PTCA. Intimal hyperplasia or proliferation of smooth muscle cells is believed to be the fundamental process of restenosis. To solve the problem of restenosis, much effort has been expended, which includes several technical and pharmacological approaches. Pharmacological strategies, systemically or locally administered, aim at increased vasomotor tone, platelet function, smooth muscle cell proliferation/migration, and fibrocollagenous healing. Up to now none of the proposed drugs has been able to reduce the restenosis rate. There is experimental evidence for a claim that the antioxidant functions of vitamins (E, C, and beta-carotene) may prevent restenosis post-PTCA. Until recently, in most post-PTCA restenosis trials the angiographic analyses were not performed using computerized measurement methods. In order to assess the efficacy of acute or long-term interventions on the natural course or acute complications of coronary artery disease, quantitative measures have been introduced and validated that make use of digital coronary angiography and computerized image processing techniques.(ABSTRACT TRUNCATED AT 400 WORDS)


Antioxidant functions of vitamins. Vitamins E and C, beta-carotene, and other carotenoids.

Tocopherols and tocotrienols (vitamin E) and ascorbic acid (vitamin C) as well as the carotenoids react with free radicals, notably peroxyl radicals, and with singlet molecular oxygen (1O2), this being the basis of their function as antioxidants. RRR-alpha-tocopherol is the major peroxyl radical scavenger in biological lipid phases such as membranes or low-density lipoproteins (LDL). L-Ascorbate is present in aqueous compartments (e.g. cytosol, plasma, and other body fluids) and can reduce the tocopheroxyl radical; it also has a number of metabolically important cofactor functions in enzyme reactions, notably hydroxylations. Upon oxidation, these micronutrients need to be regenerated in the biological setting, hence the need for further coupling to nonradical reducing systems such as glutathione/glutathione disulfide, dihydrolipoate/lipoate, or NADPH/NADP+ and NADH/NAD+. Carotenoids, notably beta-carotene and lycopene as well as oxycarotenoids (e.g. zeaxanthin and lutein), exert antioxidant functions in lipid phases by free-radical or 1O2 quenching. There are pronounced differences in tissue carotenoid patterns, extending also to the distribution between the all-trans and various cis isomers of the respective carotenoids. Antioxidant functions are associated with lowering DNA damage, malignant transformation, and other parameters of cell damage in vitro as well as epidemiologically with lowered incidence of certain types of cancer and degenerative diseases, such as ischemic heart disease and cataract. They are of importance in the process of aging. Reactive oxygen species occur in tissues and cells and can damage DNA, proteins, carbohydrates, and lipids. These potentially deleterious reactions are controlled in part by antioxidants that eliminate prooxidants and scavenge free radicals. Their ability as antioxidants to quench radicals and 1O2 may explain some anticancer properties of the carotenoids independent of their provitamin A activity, but other functions may play a role as well. Tocopherols are the most abundant and efficient scavengers of peroxyl radicals in biological membranes. The water-soluble antioxidant vitamin C can reduce tocopheroxyl radicals directly or indirectly and thus support the antioxidant activity of vitamin E; such functions can be performed also by other appropriate reducing compounds such as glutathione (GSH) or dihydrolipoate. The biological efficacy of the antioxidants is also determined by their biokinetics.


Localized deficiencies of folic acid in aerodigestive tissues.

The notion that requirements for folic acid may be higher in some tissues than others, resulting in localized deficiencies in spite of blood levels in the normal range was first suggested by the observation of megaloblastic changes in the cervical epithelium that responded to folate supplementation. Theoretically, such deficiencies may arise from elevated folate turnover in response to rapid tissue proliferation or repair; inactivation or alteration of its function by external agents such as tobacco, alcohol, or drugs; or altered metabolism or tissue uptake caused by an inborn error. Marginal dietary intake could aggravate these effects on cells at risk. Evidence for the possible existence of localized folate deficiencies in the aerodigestive tract includes lower circulating folate levels in smokers as compared with nonsmokers; yet lower circulating levels in smokers with bronchial metaplasia; lower folate levels in scrapings of the buccal mucosa of smokers than non-smokers; apparent improvement in bronchial atypical metaplasia in smokers supplemented with folic acid; lower erythrocyte folate levels and higher prevalence of cellular features compatible with folate deficiency in geographic areas and individuals in South Africa at high risk for esophageal cancer; and a trend toward a lower prevalence of colonic dysplasia in ulcerative colitis patients who use folic acid supplements. These observations, as well as animal and in vitro studies, also suggest that folate deficiency may be co-carcinogenic. Further research in this area will be aided by the development of animal models of localized folate deficiency and of methodologies capable of measuring folate levels in minute quantities of tissues and exfoliated cells.


Vitamin E. Neurochemistry and implications for neurodegeneration in Parkinson's disease.

Recently there has been a great deal of interest in the potential therapeutic use of supplemental vitamin E in amelioration of diseases of the nervous system. Even though many studies have provided encouraging results, the mechanism of any beneficial effect remains elusive. Experimental studies suggest that the presence of high levels of vitamin E in tissues prior to injury is essential for biological efficacy because administration of the vitamin after insult is often ineffective. The rationale for this phenomenon is unknown at present. Some of the remaining areas of investigation include the biochemical interaction of vitamin E with other biological antioxidant substances such as vitamin C and sulfhydryl compounds; the relative potencies of different molecular forms of tocopherols, such as trienols and various optical isomers; and the optimal dosage and mode of administration of the most potent tocopherol molecule. Future research on these and other topics will shed more light on the effective use of vitamin E in neurodegeneration.


A study of the performance and comparability of the sampling response to cotton dust of work area and personal sampling techniques.

In order to compare and contrast the sampling response to cotton dust of two forms of dust sampling 85 work areas were identified over a 2-year period for investigation in eight Lancashire spinning mills. Three hundred and five work area dust samples were undertaken and 252 personal dust samples were performed. Operatives who spent a minimum of 80% of their working shift in the area in which work area sampling was also performed were selected for personal sampling. Work area dust exposures have recently shown an upward trend, with highest concentrations occurring in the ring spinning room (median 1.15 mg m-3, range 0.82-2.06). Personal dust samples showed a reduction in dust exposures as cotton processing progressed, from a high in the opening room (median value of 6.24 mg m-3, range 1.0-41.5) to a minimum of 1.02 mg m-3 (range 0.30-0.93) in the winding room. The ratio of measured personal sampling dust exposure to work area sampling exposure was used to compare the relative performance of the two techniques. This ratio was highest in the early processes. There was a 7.8-fold difference in measurement between the two techniques in the opening processes, falling to 4.9 in carding and 4.2 in the other card-room processes. However in ring spinning the ratio was only 1.4, suggesting a degree of comparability in the methods at this stage of processing. The value rose to 2.5 for the last stage (winding). Respiratory disease is known to occur predominantly in the early stages of processing (opening and carding) where high dust concentrations are found using the personal technique. These data support the use of personal sampling for setting exposure limits to cotton dust in preference to the current recommended method using work area sampling techniques, which may significantly underestimate dust exposure in the high risk work areas and is outdated.


Occupational exposure to carbon monoxide and sulphur dioxide during the manufacture of carbon black.

The manufacture of carbon black is known to generate carbon monoxide and sulphur dioxide in the 'production gas' and the pyrolysis products of the 'production gas', respectively. Adverse health effects have been reported as associated with both contaminants (coronary heart disease with carbon monoxide and respiratory morbidity with sulphur dioxide). A major cross-sectional and longitudinal respiratory morbidity study is being conducted to assess the effects of exposure to carbon black on lung function, on chest X-rays and on responses to a questionnaire. The questionnaire includes questions on respiratory and cardiovascular symptoms, so that information regarding confounding exposure is essential. The working population of 18 manufacturing plants in seven European Countries was split into 13 job title numbers (1-13) which were then amalgamated into five job categories (A-E), with an appropriate (statistically) number of samples taken from each plant-job category. In total, 1322 carbon monoxide samples and 1301 sulphur dioxide samples were taken, using actively pumped longterm colorimetric tubes. In the majority of cases, more than half of the samples in each plant-job category were either zero or trace, thereby preventing the accurate estimation of the average exposure. The highest median carbon monoxide concentration was from the amalgamated data from all 18 plants in job number 9 (furnace operators), the highest median sulphur dioxide concentration was only 'trace'. The large number of zero and trace values also precluded the generation of current and retrospective exposure indices.


Assessment of dermal and inhalation exposure to zineb/maneb in the cultivation of flower bulbs.

In bulb farming the use of pesticides for crop protection and bulb disinfection is extensive. To estimate long-term occupational exposure to pesticides, generic levels of exposure specific to the method of working were needed. In order to derive these values, dermal and inhalation exposure to the fungicide mixture zineb/maneb was assessed for different methods of mixing and loading a wettable powder formulation. Further, dermal exposure was also assessed for two methods of disinfection of bulbs. Observed exposure was expressed in terms of method-specific levels of exposure, which makes it possible to compare exposure resulting from different methods of working, with respect to the amount of pesticide handled, or whether ladling the pesticide with a scoop or dipping the bulbs using baskets resulted in high exposure. Moreover, the relative importance of dermal and inhalation exposure routes was estimated. The results show that during mixing and loading with bare hands dermal exposure is by far the greater contributor (greater than 99%) to the total estimated exposure. Comparing these results and also some preliminary results of the dermal protection provided by working gloves, with tentative health-based limit values of exposure, emphasize the need for a programme on appropriate dermal protection.


Solvent exposure and related work practices amongst apprentice spray painters in automotive body repair workshops.

As part of a multidisciplinary study into the health effects of solvents, workplace assessments and airborne solvent vapour monitoring was conducted in 46 spray painting workshops in the Sydney metropolitan area. Breathing-zone samples were taken from 50 apprentices and 14 experienced spray painters. An interview schedule was developed to obtain information about the use of acrylic or two-pack paint systems, the use of engineering controls, the use of personal protective equipment and the availability of material safety data sheets. Contaminants typical of the chemical products used in this industry were encountered (aromatic hydrocarbons, C5-C7 aliphatic hydrocarbons, ketones, esters). The results of airborne solvent monitoring indicate a total solvent exposure in the range 1-99% of a combined Worksafe Australia exposure standard, with a mean of 19%. Solvent exposure was highest when spraying acrylic paint in the open workshop and lowest when spraying two pack paint in a spray booth. Much the same personal protective equipment was available in all workshops, but wide variation in its use was observed. Material safety data sheets were not observed in any of the workshops.


A pilot study to evaluate Japanese standard radiographs of pneumoconioses (1982) according to the ILO 1980 International Classification of Radiographs of Pneumoconioses.

The Japanese Classification of Radiographs of Pneumoconioses (JC) is characterized by its own standard films, including limit films which are defined to represent the upper limit of category 0 or the lower limit of category 1. This pilot study was aimed at evaluating the JC standard radiographs according to the ILO 1980 International Classification of Radiographs of Pneumoconioses (IC) in which some of the JC standards were read according to the IC by two groups of experienced British workers, four non-medically qualified (NM panel) and six medically qualified (MQ panel). The Japanese standard limit films, with rounded opacities of category 0/1 or 1/0, were classified by both groups as having lower categories in the IC than in the JC. With the standard mid-category films showing rounded or irregular opacities, the NM panel tended to produce higher categories than the MQ panel. From reading results by both panels, however, it may be said that the JC mid-category standards agree with the IC in terms of category.


Occupational exposure to carbon black in its manufacture.

Carbon black is manufactured by the vapour phase pyrolysis of heavy aromatic hydrocarbon feedstocks. Its manufacture is worldwide and the majority of its production is for use in the rubber industry especially tyre manufacture. Its carbonaceous nature has led many to investigate the occurrence of exposure-related medical conditions. To quantify any such relationships, it is necessary to assess exposure accurately. As part of such an epidemiological investigation survey involving the measurement both of respirable and of total inhalable carbon black was undertaken in 18 plants in seven European countries between mid-1987 and mid-1989. A total of 1298 respirable samples (SIMPEDS cyclone) and 1317 total inhalable samples (IOM head) were taken and deemed of sufficient quality for inclusion in the study. The distributions of the time-weighted average values were assessed and found to be best described by a log-normal distribution, and so exposure is characterized by geometric means and standard deviations. The data are presented in terms of 13 separate job titles for both dust fractions and shows a wide variation between job titles, with the highest mean exposure experienced by the site cleaners, and 30% of the samples taken from the warehouse packers being in excess of the relevant countries' occupational exposure limits for total inhalable dust. The quality and extent of this data allows both for comparison with exposure standards and for generation of occupational exposure indices, which will be presented in another paper (Gardiner et al., in preparation).


Determination of exposure to cobalt and nickel in the atmosphere in the hard metal industry.

Cobalt and nickel, matrices of hard metal, have been shown to be respiratory sensitizers. Airborne dust at hard metal-grinding worksites in a factor with a work-force of about 180 grinders was analysed for cobalt and nickel. The electron-microscopic X-ray microanalysis of airborne dust particles demonstrated that they had the same metallic components as hard metal products. Andersen sampling revealed that 66% of total dust was respirable (< 7 microns). Consecutive personal sampling for individuals indicated log-normally distributed concentrations of total dust and cobalt. Of the workers surveyed, 12% (16 out of 133) were exposed to cobalt at more than 50 micrograms m-3, while 1.5% (two out of 133) were exposed to nickel concentrations of more than 50 micrograms m-3. A correlation between cobalt exposure concentrations and nickel concentrations for individuals was significant and positive. Further improvement of the working environment is necessary because of the hazard caused by exposure to cobalt and nickel.


Occupational exposure to chromium, copper and arsenic during work with impregnated wood in joinery shops.

CCA-impregnated timber contains copper, chromium and arsenic (CCA), and occupational exposure to wood dust as well as the CCA compounds may occur in work with such timber. Dust from commercially available impregnated wood has been found to contain hexavalent chromium, which is regarded as a carcinogen. Apart from determinations of the total amounts of the CCA compounds, specific determination of hexavalent chromium is therefore essential. Selective methods have been applied for control of the work environment in six joinery shops. The mean exposure to wood dust was found to be below 1 mg m-3. The mean airborne concentration of arsenic around various types of joinery machines was in the range from 0.54 to 3.1 micrograms m-3. No hexavalent chromium was detected in any samples and no increased concentrations of arsenic were found in urine from the workers. The presence of arsenic in the work-room air must be considered for appropriate assessment of the occupational environment in joinery shops.


Pulmonary clearance of fibrous and angular SiC particulates in the sheep model of pneumoconiosis.

Both angular and fibrous SiC (carborundum) particulates can be emitted by SiC production operations. Carborundum pneumoconiosis is now recognized as an occupational lung disease with specific pathological features. These were previously reproduced in the sheep model of pneumoconiosis with fibrous SiC but not with angular SiC. To further document this question, the pulmonary retention in the sheep of the two morphological types was studied. Animals were injected in the tracheal lobe with equal mass (100 mg) of particulates prepared from SiC materials taken in the field. Particles were measured by analytical transmission electron microscopy in samples of bronchoalveolar lavage fluids (BAL) obtained at months 2, 4, 6 and 8 after the injection. They were also measured in samples of lung parenchyma obtained at month 8. Measurements in BAL and in lung samples both indicated a much lower retention for fibrous than for angular SiC. The retention rate in lung parenchyma at month 8 was 30 times lower for fibrous SiC. The half-life of decrease of concentrations was 3.4 times shorter for fibrous SiC. Other data in the literature support the notion that fine fibres are cleared more effectively than coarser angular particles.


Clinical results of glaucoma surgery using the White glaucoma pump shunt.

The findings are reported in 37 patients with refractory glaucoma who were treated with the White glaucoma pump shunt for 6 months to 2 years (average follow-up, 14 months). Thirty-three patients (89%) had an intraocular pressure 22mmHg after six months and beyond, with or without medications. The decrease in intraocular pressure ranged from 24 to 33mmHg. Visual acuity improved in 12 patients, remained the same in 18 patients, and decreased in seven patients (all decreases were caused by progression of unrelated ocular disease).


Biometric aspects of diffractive multifocal intraocular lenses.

A retrospective biometric study was done on 132 patients with diffractive multifocal intraocular lenses. The two principal focal points induced by the intraocular lens were refracted for distance in each patient. The difference in diopters between the refractions was obtained, and the A constant (SRK formula series) and anterior chamber depth (ACD, Binkhorst formula) were calculated. Our results showed the A constant was 116.46. This value was consistent and not affected by the axial length of the eye in the 22mm to 24.5mm range. In patients who had emmetropia with the intraocular lens power implanted alone, the constant was equal to 116.3. The ACD was 3.94mm. This value was lower in shorter eyes and higher than 3.94mm in longer eyes. On the basis of the data obtained, when the SRK-II formula is used, an A constant of 116.4 should be used in preoperative biometric calculations.


Bilateral inferotemporal dialysis in identical twins.

Retinal detachment associated with inferotemporal dialysis comprises approximately 10% of all retinal detachments. We describe the cases of two patients with bilateral inferotemporal dialyses who were identical twins. This finding suggests that genetic factors play a role in some cases of inferotemporal dialysis. One of the twins was asymptomatic, stressing the importance of examining other family members of patients with nontraumatic retinal dialysis. We believe that the cause of inferotemporal dialysis is multifactorial and there is a definite subpopulation in which a genetic predisposition is present.


Idiopathic preretinal macular gliosis: a retrospective study of 200 patients.

The charts of the last 200 patients with idiopathic preretinal macular gliosis (IPRMG) seen in the Retina Service of Montefiore Medical Center, Albert Einstein College of Medicine, were reviewed. We found that IPRMG is a disease of older people, tends to have a nonprogressive course, and rarely causes severe visual loss. In our series, 91.5% of the patients were older than 50 years of age, 80% of eyes lost less than two lines of vision, and only 4% of eyes had a visual acuity 20/200.


Trabeculectomy with 5-fluorouracil subsequent to circular buckling operation and cataract extraction.

Six patients, each with one eye that had previously undergone circular buckling surgery for the repair of retinal detachment before or followed by cataract extraction with or without intraocular lens implantation, underwent trabeculectomy with 5-fluorouracil (5-FU) for intractable glaucoma. Surgery was done through scarred subconjunctival tissues that were excised partially. The total doses of 5-FU ranged from 65 to 100mg (mean +/- standard deviation, 84.2 +/- 13.2mg) Eight to 47 months later, intraocular pressures were 18mmHg in five eyes, two of which were not receiving hypotensive medications. In the sixth eye, the intraocular pressure was 26mmHg with maximum hypotensive treatment. Intraocular pressures in the six eyes were significantly lower postoperatively than preoperatively (P < .05). This preliminary study suggests that filtering surgery with 5-FU may be beneficial after intraocular operations even in eyes where it is done through postoperative scarred subconjunctival tissues.


False-positive magnetic resonance imaging of a metastatic carcinoma simulating a malignant melanoma.

Previous studies have shown the value of magnetic resonance imaging (MRI) in the diagnosis of malignant melanoma of the choroid. We describe the case of a patient with a choroidal mass whose MRI study was characteristic of malignant melanoma. Subsequently the eye was enucleated. However, on histopathologic examination, the mass was a metastatic carcinoma to the choroid. This false-positive study makes us question the value of MRI in the diagnosis of malignant melanoma of the choroid.


Radiotherapy resolves leukemic involvement of the optic nerves.

A 40-year-old woman with acute lymphoblastic leukemia had a visual disturbance OD. The optic disc was slightly swollen in the right fundus, and blast cells in the cerebrospinal fluid were found. Radiotherapy to the brain and orbit resolved these findings. Five months later, visual acuity decreased OS. Radiotherapy also was effective in treating the leukemic involvement of the optic nerve.


Farnsworth-Munsell 100-hue test for patients with diabetes mellitus.

We evaluated 164 eyes of 87 patients with diabetes mellitus compared with 50 eyes from 25 healthy subjects as the control group. We compared 87 patients with diabetes mellitus (164 eyes) in relation to their duration of diabetes, fundus findings, visual acuity, and color vision defects. In all patients, color vision defects were determined using the Farnsworth-Munsell 100-hue test, and the total error score was established on the basis of age norms from subjects without diabetes. No color vision defect was detected in the control group. In the diabetic group, fundus degeneration and color vision defects were observed and correlated with the duration of diabetes. The dominant color defect was of the blue-yellow type.


Typical ocular coloboma affects three generations in one family.

We found bilateral colobomas of the iris, choroid, retina, and optic nerve head in a son, mother, and grandmother in one pedigree. This represents a rare incidence of typical ocular coloboma in three generations.


Sneezing as a cause of acute angle-closure glaucoma.

We report the case of a patient who had an attack of acute angle-closure glaucoma precipitated by sneezing, probably as a result of a sudden increase in venous back pressure. This young woman had a history of allergic sinusitis.


New applications of the neodymium: yttrium aluminum garnet laser in the Q-switched mode: experimental results.

We describe the interaction of the neodymium: yttrium aluminum garnet (Nd:YAG) laser energy with intraocular lenses using the laser in the Q-switched mode. Using this method, it is possible to treat opacities that eventually might occur at the level of the visual axis on the optic faces of polymethylmethacrylate intraocular lenses (IOLs) if safety parameters (perfect focusing, use of additional lenses, and slight and continuous movement of the focal point of the laser) are followed. However, it is not possible to treat the silicone IOLs with the Nd:YAG laser because the threshold values for damage to the IOL are lower than the energy values required for destroying the capsular opacities on the optic axis.


Atropine after trabeculectomy.

Thirty-eight patients requiring trabeculectomy for control of open-angle glaucoma were randomized into two groups. One group received topical atropine immediately after trabeculectomy; the second group began treatment on the first postoperative day. The two groups were compared over the first three postoperative days. The theoretic benefit of atropine instillation immediately after trabeculectomy is discussed. Our results showed no significant difference between the two groups except there was a significantly larger pupil diameter in the treated group on the first postoperative day.


Digital fundus imaging of subretinal neovascularization.

Digital fundus imaging was used for fluorescein angiography in patients with subretinal neovascularization. After laser treatment, digital red-free photographs were obtained and compared against pretreatment angiogram frames to determine the margins of treatment. This technique allowed instant review of images and confirmation of complete laser treatment of the lesions. Of 15 eyes treated and followed for at least one year, there were two eyes with early recurrences (13%). A total of five eyes had recurrences during the follow-up period (33%). Digital imaging is a useful tool for treating subretinal neovascularization.


Endothelin does not affect experimentally induced corneal neovascularization.

Endothelin, a potent vasoconstrictor, was found to be ineffective in the treatment of experimentally induced corneal neovascularization. Endothelin was administered topically, subconjunctivally, and intraluminally in serial concentrations ranging from 0.0005 to 5.0 micrograms/mL in New Zealand white rabbits without effect. Electron microscopy of the neovascular cornea revealed the vessels consisted only of endothelin and pericytes. Hence, the vessels were not responsive to endothelin because they lacked contractile smooth muscle.


[Reduction laryngoplasty by external approach for glottic incompetence. Current role, demonstration of its efficacy by objective analysis of parameters of vocal quality].

Authors talk about the place of surgical treatments with cervicotomy in abducted vocal cord, about the statistics of the department of Phoniatrics of the Hospital Edouard Herriot in Lyon. These techniques have actually a marginal place. But the analysis of a recent case shows us that endoscopic treatment for vocal fold augmentation with biomaterials such as collagen or teflon can fail. So ENT surgeons have to absolutely know the Guerrier's technique to improve the quality of the voice when injectable biomaterials fail. With the description of this case, we will describe the objective analysis methods of the voice parameters that we use in the department.


[Reconstruction of the mandibular arch using free vascularized iliac and scapular grafts. Arguments in favor of using scapular grafts].

In 12 cases of surgically removed mandibular symphysis malignancies, the bone and mouth floor were reconstructed using osteo-musculocutaneous flaps from the iliac crest or free osteo-cutaneous scapular flaps. In our experience, the latter provide the best results. Removed in dorsal decubitus, they allow floor replacement. During the dissection of the tumor site, we also preserve labial and clin structures, which favours a good restoration of phonation and swallowing.


[Long-term esophageal and oropharyngeal pH-metry in ORL manifestations of gastroesophageal reflux in children].

Several studies published over the last few years have pointed out the importance of gastroesophageal reflux (GER) in the pathogenesis of certain cases of chronic or recurrent pharyngo-laryngitis. While the presence of an acid reflux at the level of the pharyngo-larynx has recently been demonstrated in certain cases, the real incidence and pathogenic impact of this reflux is not precisely known. A new technique of continuous 24 hour bi-level monitoring of endoluminal pH in the esophagus and the oro/hypopharynx has made it possible to observe the variations in acid-base balance in contact with the pathological mucosa. 21 patients, 2 months to 7.5 years old, presenting recurrent episodes of pharyngitis or laryngitis, underwent continuous pH monitoring during a 24 hour hospitalization. 6 control subjects, 1 month to 13 years old, presenting no chronic or recurrent ear, head or neck pathology and no sign or symptom of GER were subjected to the same monitoring regimen. A statistically significant difference between the 2 groups is evident for most of the parameters analysed. The most discriminative parameter is the fraction of the total recording time where the pharyngeal readings remain under ph6 (p < 0.0005). These results demonstrate that, in this clinical condition, acid of gastroesophageal origin is in contact with the pharyngeal mucosa. This suggests that the acid has a causal role in the pathological changes observed in the pharyngolaryngeal mucosa.


[Exposure of the facial recess through the ear canal. Value in posterosuperior retraction pockets (initial results)].

19 patients had surgery for progressive [17] and/or symptomatic [2] posterior attic retraction pockets involving the facial recess. Exposition of the suprapyramidal region was obtained after endaural incision by thinning the posterior wall of the ear canal and removing the posterior-superior portion of the tympanic sulcus. This technique is less complicated than intact canal wall tympanoplasty with mastoidectomy. Yet gives similar functional results. After a mean follow-up of 20.3 months, we have observed no residual cholesteatoma and no recurrent retraction pockets. Unlike posterior tympanoplasty, this technique makes it possible to meticulously remove the osteitic bone invariably found in the facial recess when there is infection of the retraction pocket.


[Improvement of clinical results by digitalization of a single channel cochlear implant].

For 1973 we have been among the first to claim the multichannel cochlear implant superiority regarding single channel efficacy. However we actually thing that single channel cochlear implant is indispensable in case of total ossified cochlea, and very useful when efficacy/coast ratio must be considered. In order to narrow the gap between multi and single channel device efficacy, we used the new microprocessors possibilities to digitalize the analogic emietter of the single channel system, which we designed in 1987. Owing to a PC keyboard the new emietter allows the speech therapist to select the frequency band width of the input signal, and to determine the threshold level and the dynamic value as a function of six steps values of the stimulus wave frequency. These improvements supply the patient with a better speech intelligibility excepted for vowels discrimination. Comparison of clinical results obtained through the two analogic and digital systems are reported on 4 post lingually and 4 pre lingually deaf patients.


[Indications and results of cochlear implants in young children].

In order to determine the criteria for patient selection and the preoperative prognostic factors for hearing recovery after cochlear implants in young totally dead children, the results of hearing rehabilitation were studied in 15 children who had undergone cochlear implantation at from 2 to 9 years of age. The choice of implant is determined by the permeability of the cochlear duct. A multi-system should be used, except when the cochlea is totally ossified. The reliability and efficacy of mono and multi system implants make it possible to offer a solution to the urgent therapeutic problems posed by total deafness in the young child.


[Value and control possibilities of the vertebral artery in tumor surgery at the base of the skull].

Following anatomical description of the third segment of the vertebral artery (from C2 to the foramen magnum), the surgical techniques which permit to expose and control this artery at this level are presented. Choice is between the posterior approach in sitting or procubitus position and the lateral approach in supine position. The former is mainly applied on intradural tumors or prolongments and the latter on extradural tumors. These techniques were utilized on more than 60 cases including for the most frequent types meningiomas, neurinomas, paragangliomas and osseous tumors and were associated with a very low morbidity and mortality.


[Local immunologic system of the nose and paranasal sinuses].

The mucus membranes of the nasal chambers may be compared to a local immune system which has been called the NALT. The submucosa contains a lymphoid infiltration of T-helpers, T-suppressors and a set of plasma cells capable of synthetizing four IgG subgroups, IgM, IgA and IgD. The IgA plasma cells are most numerous. There is no local synthesis of IgE. Macrophages and langerhans' giant cells are present. The epithelium is an immunological entity which is composed, in addition to secretory cells, of uliated cells, lymphocytes, and M cells. The epithelium is able to synthesize secretory component and allows the transport of IgA and IgM into the secretions. The NALT has multiple immunological functions: antigenic information, humoral immune response, and expression of local cellular immunity. Modifications in T lymphocyte subpopulations are observed in allergic rhinitis. Secreted interleukins modify the local efflux and affluence of effector cells (mastocytes and eosinophils). Abnormalities of the NALT are characteristic of deficiency in humoral IgA and IgG subgroups. The possible presence of alterations of cellular immunity in chronic rhinosinusitis has been suggested.


Point-touch technique of botulinum toxin injection for the treatment of spasmodic dysphonia.

Intralaryngeal injections of botulinum toxin (Botox), under electromyographic guidance, have emerged as an effective treatment for adductor spasmodic dysphonia. To remain effective, these injections must be repeated every 3 to 9 months as the symptoms recur. One drawback to the current method is the need for electromyographic confirmation of needle placement into the thyroarytenoid muscle. This report describes an anatomic approach to Botox injection that requires only flexible nasopharyngeal endoscopy and careful evaluation of the anatomic landmarks. This technique has been used successfully on 13 patients, and objective pretreatment and posttreatment measures are reported.


Quantitative mapping of the effect of botulinum toxin injections in the thyroarytenoid muscle.

Spasmodic dysphonia has been successfully treated by thyroarytenoid muscle injections of botulinum toxin (Botox) with dosages ranging from 0.625 to 25 U. In some patients, excessive paralysis with resulting breathiness and aspiration have been noted. In order to maximize the efficiency of Botox injections, the histologic effects of various Botox dosages were examined in the dog. Nine canine thyroarytenoid muscles were injected with 0.5 to 12.5 U of Botox. After 24 hours, the recurrent laryngeal nerve to the injected muscle was electrically stimulated in order to deplete the glycogen within the muscle fibers. Frozen sections of this muscle were then stained for glycogen. Those fibers that retained their glycogen were presumed paralyzed by the Botox injection. The extent of paralysis was found to be dose-related from 1.0 to 7.5 U. At 10 U and above the muscle was completely paralyzed. Spread of the toxin to the lateral cricoarytenoid muscle was seen at doses as low as 1.0 U. Clearly, doses less than 10 U appear sufficient for clinical paralysis.


Continuous positive airway pressure as a promoter of laryngospasm during halothane anesthesia.

Twenty mongrel dogs were anesthetized with halothane 2.0%, 1.25%, 0.94%, and 0.63% in oxygen. Thyroarytenoid (TA) and posterior cricoarytenoid (PCA) electromyography (EMG) tracings were recorded with the animal at rest, following mechanical irritation of the glottis, and during 20 mm Hg continuous positive airway pressure (CPAP) following either airway occlusion or hyperventilation. Adductor laryngospasm was defined as continuous tonic TA EMG activity, silent PCA EMG, and vocal cord adduction. Abductor laryngospasm was defined as continuous tonic PCA EMG activity, silent TA EMG, and vocal cord abduction. Combined laryngospasm was defined as continuous tonic PCA and TA EMG activity, with variable vocal cord position. The incidence of adductor laryngospasm following mechanical irritation was 30% to 50%. The combined incidence of laryngospasm during application of CPAP following airway occlusion or hyperventilation was 25% to 50%, and differed from the incidence of irritation-induced adductor laryngospasm by 5% or less at the same anesthetic level. Continuous positive airway pressure appears to be a stimulant of laryngeal muscle spasm comparable to mechanical irritation of the glottis.


Laryngotracheal reconstruction in adults with the sternocleidomastoid myoperiosteal flap.

Subglottic or tracheal reconstruction may be required in cases of subglottic stenosis, invasive thyroid carcinoma, or trauma. The sternocleidomastoid myoperiosteal flap uses clavicular periosteum on a muscle pedicle to provide vascularity. Clavicular periosteum is fibrous and durable and will conform to the shape of the trachea, forming bone to provide stability to the airway. The procedure is relatively simple and involves single-stage reconstruction. Success has been achieved in reconstruction of long-standing subglottic and/or tracheal stenosis and in cases of extreme tracheal defects. On the basis of 8 years' experience with this flap, we present the results from a series of 26 patients who underwent subglottic or tracheal reconstruction with the sternocleidomastoid myoperiosteal flap. Twenty-five of the 26 patients were successfully decannulated. Complications have been expanded to include one case of osteomyelitis of the sternum with mediastinitis, and 1 patient required revision. Subsequently, modifications of technique and patient management have been adopted. The complications compare favorably in frequency and in seriousness with those of other techniques for laryngotracheal reconstruction. We describe additional experience with this procedure and longer follow-up to establish its position as a first-line reconstructive approach for widespread clinical use.


Detection of regulatory factors of lymphokine-activated killer cell activity in head and neck cancer patients treated with interleukin-2 and interferon alpha.

Interleukin-2 (IL-2) and interferon-alpha (INF-alpha) are biologic modifiers that have met with limited clinical success in the treatment of human malignancies. We conducted a phase 2 trial of IL-2-IFN-alpha in patients with advanced or unresectable squamous cell carcinoma of the upper aerodigestive tract. Two patients were analyzed sequentially for serum induction phase-blocking factors of lymphokine-activated killer (LAK) cell activity in their therapy. Serum also modulated LAK activity independent of autologous or allogeneic effector cells. Significantly inhibitory serum samples were stable in multiple freezings and thawings. Heat-treating the inhibitory serum, at 56 degrees C for 30 minutes, only partially removed the serum inhibitory capacity. Sequential analysis of p55 and p75, subunits of IL-2 receptors, showed that absence of effector cell lytic activity was associated with markedly decreased fluorescence of the IL-2Rp75 subunit only. No significant alteration of the IL-2Rp55 subunit occurred with therapy. These studies support the theory that lymphocyte and multiple serum factors, developing during IL-2-IFN-alpha therapy, regulate the induction of in vitro LAK activity. Further understanding of these factors may lead to improvements in biologic modifier therapy.


Bilateral choanal atresia associated with malformation of the anterior skull base: embryogenesis and clinical implications.

A number of craniofacial and systemic malformations have been described in association with choanal atresia. We report a case of bilateral choanal atresia associated with congenital absence of the cribriform plate, crista galli, and perpendicular plate of the ethmoid bone. The anterior skull base defect was detected by using high-resolution computed tomography with three-dimensional reconstructions. The findings support the mesodermal flow theory of choanal atresia, in which there is excess migration of neural crest cells into the developing nasal septum and posterior choanae. This occurs at the expense of cells that would otherwise form the rest of the ethmoid complex. Clinical implications include the need for adequate preoperative imaging of the anterior skull base and consideration of potential intracranial complications during surgical repair.


Laryngeal adenocarcinoma, not otherwise specified, treated with carbon dioxide laser excision and postoperative radiotherapy.

Glandular carcinomas of the larynx are aggressive neoplasms that comprise less than 1% of all laryngeal malignancies. Adenocarcinoma, not otherwise specified, is the most common histologic type. The rarity of these lesions has prohibited clarification of definitive therapy. Traditionally, radical surgery is performed because of the usually high stage at presentation and the relative insensitivity to radiotherapy. A case of glottic T1 adenocarcinoma, not otherwise specified, is reported. The tumor presented clinically as a vocal fold granuloma. The treatment modalities included endoscopic excision with the carbon dioxide laser and postoperative radiotherapy. The patient has been followed up for 39 months without evidence of recurrence or metastases. The current literature is reviewed in regard to treatment of laryngeal glandular carcinomas.


Facial canal dehiscence: histologic study and computer reconstruction.

The incidence, location, shape, and dimensions of dehiscences in the facial canal to the middle ear space were studied in 160 temporal bones obtained from 129 individuals 24 gestational weeks to 109 years of age at death by means of light microscopy and our computer reconstruction and measurement method. Dehiscences were observed in 95 of the 129 individuals (74%) and in 119 of the 160 bones (74%). The incidence was found to be quite high among fetuses and newborns, lowest in individuals in their twenties and then again quite high in the geriatric population (chi 2 test, chi 2 = 5.45 and 4.41, p < .05). The most frequent site of dehiscence was the oval window area, particularly in its posterior half (57% of all ears) on the inferior to inferomedial aspects of the canal; these dehiscences were clearly demonstrated in reconstructed images. The incidence of dehiscence in the area of the cochleariform process was 16%, and all these dehiscences were on the lateral to superolateral aspect of the canal. The second genu area and the mastoid portion were sites of dehiscence in 21% and 18%, respectively, of specimens; more than half of the dehiscences in the second genu area and mastoid portion were on the lateral to anterolateral and posterior aspects of the facial canal, respectively. The shape of the dehiscence tended to be oval in the oval window area, but rather irregular in the other areas. The dehiscences ranged from 0.4 to 2.64 mm in length, from 0.12 to 1.59 mm in width, and from 0.03 to 1.87 mm2 in surface area. The proximity of these dehiscences to the field of otologic surgery is stressed.


Skull base dumbbell tumor: surgical experience with two adolescents.

Pediatric skull base tumors are rare and until recently were considered unresectable. We present two patients with tumors of similar anatomic position with an extracranial component in the infratemporal fossa and parapharyngeal space, an isthmus at the foramen ovale, and a superior component in the middle cranial fossa in the region of the cavernous sinus. A 15-year-old girl experienced contiguous spread of a spindle cell sarcoma; an 18-year-old boy developed a chondrosarcoma. A middle fossa approach provided the advantage of surgical avoidance of structures such as the middle ear and mastoid, facial nerve, and mandible. Postoperative recovery was rapid. Our impression is that preoperative carotid artery occlusion and a middle fossa approach for tumor resection can be performed in a young patient with acceptable morbidity and at least short-term benefit. Surgery can, therefore, provide an additional therapeutic approach to complement irradiation and chemotherapy.


Rat model for a vascularized laryngeal allograft.

A new rat model was developed to reexamine the potential for laryngeal transplantation. The final anatomic derivation evolved from two earlier developmental phases. The first model had only a single arterial anastomosis; the second had an end-to-end arterial anastomosis with an end-to-end arteriovenous shunt. The final product employed an end-to-side arterial shunt and an end-to-side arteriovenous shunt for revascularization. The allografts were sited in tandem with the intact recipient larynges and were not innervated. A total of 16 animals were studied in phase 3; 2 died and the remaining 14 had a 64% arterial patency at intervals of 1 to 14 days. Our purpose is to detail the relevant technical considerations of this new model and compare it with historical controls.


Embryoma (sialoblastoma) of salivary glands.

There are four clinicopathologic categories of the exclusively major salivary gland tumors that present in the perinatal period. The two with the smallest representation among the 20 cases reported to date are those with a hamartomalike appearance and those with benign adult equivalents--the pleomorphic and monomorphic adenomas. Five cases have been undifferentiated or basaloid salivary carcinomas. Embryomas (sialoblastomas) are the most numerous. These tumors manifest a histologic phenotype like that of the epithelial anlage of the salivary glands, albeit in an arrested state of differentiation.


[Primary cutaneous lymphoma, with the exception of mycosis fungoides].

Cutaneous lymphomas other than mycosis fungoides (MF) form a rare and heterogeneous group. Their clinical behavior remains largely unknown. In this study, the clinical, immunohistological characteristics and follow-up data of 27 well-documented cases of primary cutaneous lymphomas other than MF, limited to the skin (stage IE) were reviewed. The tumors were divided into large-cell lymphomas (LCL) (21/27 = 77 p. 100) and small-cell lymphomas (SML) (6/27 = 23 p. 100). A B-cell phenotype was most often expressed by cutaneous lymphomas (23/27 = 85 p. 100). The clinical course of cutaneous lymphoma was closely dependent upon the histological subtype. Fourteen patients with LCL were treated by radiotherapy alone. Nine patients (64 p. 100) relapsed within two years post-treatment. Seven of them relapsed in the skin outside the initial site, suggesting that radiotherapy alone is not an adequate treatment for these patients. The preliminary results concerning 7 other patients with LCL treated with an initial third generation polychemotherapy regimen are presented.


[Atypical cutaneous mycobacterium diseases. Results of a national survey].

We report the results of a retrospective inquiry concerning atypical cutaneous mycobacterioses in France over the last 5 years. Ninety-two cases were observed, contracted from aquariums (50 p. 100), in swimming pools (4.4 p. 100) and as a result of mesotherapy (15.2 p. 100); 66.3 p. 100 of the patients had no other pathology; 17.4 p. 100 were immunodepressed. Bacteriological examination was positive in 44.7 p. 100 of the cases; swabbing, scratching and punturing were better than biopsy to obtain a bacteriological culture. Mycobacteria were identified in 59.8 p. 100 of the cultures. In order of frequency, the pathogens were Mycobacterium marinum (from aquariums), M. chelonae (from iatrogenic lesions) and M. avium-intracellulare (in immunodepression). M. fortuitum, M. ulcerans, M. flavescens, M. haemophilum and M. kansasii were rare. The formation of epithelial giant-cell granulomas was observed in patients without any other pathology. Non-specific infiltration was found in patients with immunodepression and bacteriological examination was often positive in those with non-specific infiltrates. The treatment of atypical cutaneous mycobacterioses is always difficult; third generation tetracyclines and antibacterial combinations are often prescribed, but the results of in vitro tests are not reproducible in vivo. New antibiotics, such as clarithromycin, quinolones, ansamycin and clofazimine, are currently being tested.


[The green and the red in pharmacy].

The green colour is historically used as a symbolic mark for the French Pharmacy. Green and red are important for the labelling of dangerous and toxic drugs respectively. Etymological channels about green and red are studied for many words belonging to the pharmaceutical vocabulary and the authorized dying matters. Discussion is led in the field of the semantic signification in Pharmacy at several times.


[Immunocompetence in the elderly].

Ageing is associated with a progressive decline of the immune systems, characterized by impaired T cells and changes in the antigenic repertory related to both the humoral and cell-mediated immune responses. The major alterations have been demonstrated in the T cells which undergo functional changes, such as a decrease in precursor frequencies of helper and cytotoxic T-cells, and accumulation of T cells which does not respond to activators. In general, T cell-dependent, cell-mediated responses decline with age. The elderly are at great risk for low consumption of proteins and of several micronutrients, such as zinc or vitamins C, E and B6 which play a critical role in the maintenance of normal immune function. As a consequence, the incidence of inflammatory and infectious disease, auto-immune disorders, cutaneous pathological changes, and skin cancers increases. Morbidity and mortality rates due to tetanus, pulmonary infections and influenza remain high in elderly populations. Depressing the rate of immunosenescence and restoring a normal immunocompetence in the elderly may involve improved nutrition through proteins, micronutrients and vitamins, and should deal with the economic and psychosocial problems of the elderly. Vaccinations against tetanus, pneumococcus and influenza proved to be efficacious and well-tolerated. Consequently, they should be applied systematically to non protected elderly individuals.


[Towards a status of pharmacists responsible to humanitarian associations?].

The creation and aims of ANPCM (Association Nationale Pharmaceutique pour la Collecte des Médicaments = National Chemists for Drug Collection) are recalled. In 1988, only a simple letter of the French Ministry of Health gave recommendations concerning left unemployed drugs. A clear codification of the status of the Responsible Chemist of Humanitarian Associations Collecting Drugs should therefore be useful.


[Comparative study of absorbent dressings].

The quality of six absorbent dressings of fluffy padding has been compared. The study show one variability of the quality of products which can influence on scarred up the wounds. The part of hospital pharmacist in the choice of this articles is very important.


[5-Fluoro (3H) pyrimidine-4-ones: synthesis, reactivity and pharmacological properties].

Fourteen fluoro pyrimidine-4-ones, four fluoro bispyrimidine-4-ones and two fluoro pyrimidine-4-ones with fused ring have been prepared. The reactivity of the carbonyl group of two pyrimidine-4-ones phosphorus oxychloride was studied. The 4-chloro pyrimidines reacted with ammonia or morpholine giving 4-substituted pyrimidines. Eight compounds are evaluated for their anti-inflammatory and anti-convulsivant properties: they were found to be weakly active against oedema and three of them protected rats form tonic convulsions.


Facial video image processing: standard facial image capturing, software modification, development of a surgical plan, and comparison of presurgical and postsurgical results.

Video imaging is a maturing technology that will challenge the 35-mm photograph in its usefulness to the plastic surgeon. Computer modification of a patient image communicates to the patient a reconstructive plan. A comparison of the presurgical and postsurgical images keenly sensitizes the surgeon to the results of surgical technique. The equipment required for video imaging also provides a powerful tool for creation of presentation graphic prints (for publication), 35-mm slides, and, with additional software, educational video tapes. I describe here a video method for standard alignment of patients. The preoperative and modified patient image (surgical plan) is compared with the postoperative image to determine the degree of success in achieving the reconstructive goals. Comparison of standardized presurgical and postsurgical images offers the surgeon greater objectivity in his analysis of the surgical technique than is possible by comparison of clinical photographs. The value of video imaging to the reconstructive surgeon magnifies the success (or disappointment) of surgical technique.


Soft-tissue reconstruction of the face: a comparison of dermal-fat grafting and vascularized tissue transfer.

Eight patients treated with dermal-fat grafts and 8 patients treated with vascularized tissue transfer were retrospectively reviewed to determine the efficacy of the two methods in the treatment of the soft-tissue defects in Romberg's disease, clefting syndromes including hemifacial microsomia, and traumatic defects. Follow-up averaged 4 years and ranged from 1 to 9 years for the vascularized transfers and 1.5 to 11 years for the dermal-fat grafts. Both techniques were able to provide enduring augmentation. The vascularized transfers were able to provide a greater amount of augmentation. We conclude that dermal-fat grafting is a satisfactory technique for mild to moderate defects, but that vascularized transfers are required for moderate to severe defects.


Bipedicled fasciocutaneous flaps in the lower extremity.

It is well known that a bipedicled skin flap permits survival of longer flaps due to the secondary recruitment of vascularity. Inclusion of the deep fascia with such a flap, obeying the principles of the single-pedicled fasciocutaneous flap, provides even greater security for the immediate transposition of yet larger or riskier flaps without the need for delay maneuvers. This variation is especially valuable for the management of difficult wounds encountered in the lower extremity when no other local options may be available. Thirteen local bipedicled fasciocutaneous flaps including both vertical and horizontal orientations, without isolation of any discrete fascial perforators, have been successfully used for soft tissue coverage in the distal leg and ankle with only three (23%) minor complications as untoward sequelae. Another major advantage of this bipedicled version of the fasciocutaneous flap was that the inclusion of a distal pedicle simultaneously may be designed to prevent bone or tendon exposure at the donor site that otherwise frequently is a concern with a unipedicled flap.


The chondromucosal sleeve for the secondary correction of the unilateral cleft lip nasal deformity.

We present a new procedure for the secondary correction of the cleft lower lateral cartilage in the unilateral cleft lip nose deformity. A chondromucosal sleeve based entirely on mucosa is combined with an open rhinoplasty to facilitate a medial to lateral rotation of the cleft lower lateral cartilage. In 52 patients, we have found that this technique improved the results of the deformity and is more successful than lateral to medial rotation procedures alone. The chondromucosal sleeve adds to the medial to lateral rotation techniques the ability to obtain a controllable and reproducible result.


Distally based turnover flap and preputium plasty for distal hypospadias repair: a preliminary report.

A surgical procedure for hypospadias correction using a proximally based turnover flap, glanuloplasty, and preputium plasty is described. The flap is vertically disposed and distally based on the external urethral meatus, and the shape is spatulated. It is dissected from proximal to distal, turned over, and sutured to the glans to reconstruct the missing portion of urethra. A glanuloplasty is performed and the preputium is restored by careful reconstruction of its inner and outer surface. The technique is useful in distal penile and glanular hypospadias without chordee or meatal stenosis. Very good functional and aesthetic results, and no complications, were obtained with this technique. Preliminary results and a 3-year follow-up are presented and discussed in this report.


A venous thrombosis technique for experimental thrombolytic therapy.

A technique for the experimental creation of a venous thrombus in the rat is described. This technique involves a circumferential stretching of the intima, which maximizes intraluminal collagen exposure without complete separation of the vessel wall. This thrombotic method was 94.4% effective at complete vessel occlusion after 24 hours in 40 treated veins. This model is of particular interest in the in vivo evaluation of thrombolytic agents in the laboratory setting and as an adjunct to thrombotic complications in microsurgery.


Cutaneous vascular anatomy of the thoracic region of the dorsum and its role in flap design in the rat.

The cutaneous vascular anatomy of the proximal one-half of the dorsum (the thoracic region) and its role in flap design was studied in the rat. The investigation included anatomical dissection, ink injection into the axial artery, and flap harvesting in live animals. Anatomical dissection and india ink injection of the thoracic region revealed that the skin derives its principal blood supply from the lateral thoracic artery. The cutaneous vascular territory of the lateral thoracic artery was defined as follows: the medial border, along the midline of the back from the level of the inferior angle of the scapula to the lower border of the last rib; the lateral border, anterior axillary line corresponding with the length of the medial border; the cephalic border, a line joining the medial and lateral border at the level of the inferior angle of the scapula; and the caudal border, a line corresponding to the lower border of the last rib. Bilateral vascular pedicle island cutaneous flaps were harvested in living rats based on the vascular territory demarcated by India ink injection. All flaps survived; hence, this flap is reliable, with consistent vascularity, and is easy to harvest, and therefore, can be used as a vascular pedicle experimental model to study flap hemodynamics.


Squamous cell carcinoma following breast augmentation.

Controversy over the safety of breast implants has increased significantly over the past several years. Several companies have discontinued their manufacture of silicone implants. Although there have been reports of breast cancer developing in a patient who previously had undergone breast augmentation, a review of the literature has failed to reveal a patient with cancer arising from the breast implant capsule. We present a woman with squamous cell carcinoma apparently arising from an implant capsule 15 years after breast augmentation.


Tissue expansion of sensate skin for pressure sores.

The surgical treatment of pressure sores has improved with the development of many techniques to provide coverage of these defects. Few deliver sensate coverage. This report describes tissue expansion of back skin to provide definitive sensate coverage of a pressure sore, thereby preventing its recurrence. Follow-up of 5.5 years is presented with a review of the literature.


Restoration of the mandible by full-thickness calvarial bone flap.

Two patients with reconstruction of a massive mandibular defect with vascularized full-thickness calvarial bone flaps are reported. In Patient 1, the mandibular body developed osteomyelitis and once was replaced with a metallic prosthesis. The prosthesis later perforated the skin and was removed. Full-thickness calvarial bone flaps were elevated bilaterally to reconstruct the mandibular body. In Patient 2, the mandible was totally destroyed by invasion of squamous cell carcinoma. The lower one-half of the face was resected and replaced with a large island scalp flap with full-thickness calvarial bone.


Misdiagnoses: a timely reminder.

This case report of an occult infection masquerading as palindromic arthritis was misdiagnosed for almost 2 years. The episodic bouts of erysipelas were not obvious, and it was even suggested that the silicone implanted 7 years previously could possibly be inciting an autoimmune disease. Approximately 2 years after the onset of the recurrent episodes of fever, myalgias, and arthralgias, coagulase-negative staphylococci were found residing in the valve stems of bilumen breast implants, which were removed. The symptom complex disappeared and has not recurred.


Benign mesodermal tumors producing nasal deformity.

Tumors of neurogenic (ectodermal) origin are well-described causes of nasal deformity. We present a patient with a benign mesodermal tumor (unclassified spindle cell) producing nasal deformity. A retrospective review of the two senior authors' records provided an additional three patients with nonvascular benign mesodermal nasal masses (fibroma and leiomyoma). Benign mesodermal masses can occur in the midline of the nose and need to be differentiated from dermoids and gliomas. Misdiagnosis is the rule. Excisional biopsy is required for definitive diagnosis. In addition, excisional biopsy is curative and can help to minimize the subsequent nasal deformity if performed early in the disease process. Immunohistochemical and electron microscopy may be required for comprehensive diagnosis and treatment.


Reconstruction of facial contour deformity with the buccal fat pad flap.

The primary goal in unilateral facial reconstruction is to mirror, with three-dimensional or volume symmetry considerations, the contralateral normal structures in form and function. This case study indicates that, along with other proved options, the buccal fat pad can successfully be used to add small to moderate volume in facial reconstructions.


Abdominoplasty following colostomy.

An abdominoplasty was performed on a 57-year-old woman, 5 years after she had undergone a permanent colostomy for ulcerative colitis. The abdominoplasty was performed in an attempt to reduce the increased abdominal girth thought to be responsible for excess leakage of effluent from the colostomy site with changes in posture and increased abdominal pressure. A simple abdominoplasty flap was designed to decrease the excess abdominal tissue without impinging on the colostomy site. The result was dramatic in accomplishing the set-out goals. An added bonus was a reversal of preoperative urinary incontinence. This outcome is thought to be a result of more efficient voiding after abdominal muscle plication and stabilization.


Prediction of nipple viability following reduction mammoplasty using laser Doppler flowmetry.

The assessment of viability of a pedicled nipple-areola complex after reduction mammoplasty frequently may be frustrating due to equivocal clinical signs of adequate blood flow. Although conversion to a composite graft is always a safe option, the aesthetic result may be inferior. An objective monitor might be beneficial to maximize the surgical outcome while minimizing the risk of nipple necrosis. Laser Doppler flowmetry provides a safe, simple, and noninvasive objective monitor that allows continuous intra-operative or postoperative evaluation of nipple perfusion. An evaluation of 31 nipples in 16 patients undergoing breast reduction based solely on the surgeon's judgment would have resulted in 9 false positive or negative results as compared with 3 using the laser Doppler. Four nipples that may otherwise have been converted to free grafts were instead preserved. However, conclusions from this data limit the laser Doppler as a valuable supplement, but not a replacement, for experienced clinical acumen.


The use of bifid nasolabial flaps in the reconstruction of the nose and columella.

The repair of defects involving the tip of the nose and columella still pose a problem in reconstructive surgery. The use of bifid nasolabial flaps versus other reconstructive methods is discussed in this article.


Lower facial recontouring in craniofacial asymmetry.

The secondary correction of facial asymmetry due to early posterior cranial deformation is presented. The combination of mandibular skeletal reduction of the gonial angle and inferior border, masseter muscle thinning, and auricular setback can be an effective camouflage technique when the facial skeleton and occlusion do not require repositioning.


Nasal tampon packing in rhinoplasty: a simple and safe method of hemostasis.

To absorb bleeding and pack the nasal cavities after rhinoplasty, a sterile commercial vaginal tampon was used. It has the following advantages: high absorbency, round configuration, and safety removal cord included to preclude gliding into the nasopharynx.


Vector-running subcuticular sutures in high-tension and high-mobility areas.

Routine cuticular sutures pierce the epidermis, and if left in place long enough, will noticeably scarify, a process called "tracking." Alternatively, the running subcuticular suture has the advantage of minimizing suture tracking, especially following a prolonged usage, because it does not pierce the epidermis along most of its course. A "hybrid" modification of these two sutures, described herein, allows for prolonged tight closure under high tension in high-movement areas, avoidance of tracking, and rapidity of placement. This innovation is called the vector-running subcuticular suture.


[Peroperative cholangiography in cholelithiasis. Results of a multivariate analysis].

This study was done to select patients with a low risk of common bile duct (CBD) stones in whom operative cholangiography could be avoided. Operative cholangiography was performed upon 511 patients. Two different groups of patients were identified: patients with CBD stones visualized by CBD exploration (n = 90) and patients with no CBD stones at the time of operative cholangiography (n = 42). Multivariate analysis (stepwise logistic regression) showed that five variables were correlated with the presence of CBD stones: size of CBD equal to or greater than 12 millimeters, gallstones equal to or less than 10 millimeters, advanced age, chronic or acute cholecystitis and pas history of biliary colic. Using a scoring system, a group of patients with a low risk (less than 2%) of CBD stones could be easily determined. In this group of patients, operative cholangiography may be avoided.


[Hartmann's procedure. A retrospective study of 86 cases].

The purpose of this retrospective study is to define current indications and results of Hartmann's procedure (H). From 1978 to 1989, 86 H were performed, 52 (60%) as emergency surgery. Indications were: colo-rectal cancer (37): 15 complicated and 22 as an elective procedure, diverticular disease acute or complicated (24), ischemic colitis (10), volvulus of the pelvic colon (5), inflammatory bowel disease (4), colonic perforation (3), traumatic hematoma of the sigmoid mesocolon (1). Fourteen patients died after operation (mean age: 79). There was no death after elective H for cancer. Post-operative complications were numerous: pulmonary (25%), abdominal would sepsis or disruption (21%), rectal strump leakage (14%), the later being harmless due to the associated Mickulicz drainage. Seven patients were reoperated on for necrosis of the colonic stoma. Mean initial hospital stay was 31 days. Restoration of the gastrointestinal continuity was done in 27 cases (37% of the surviving patients, 76% of the diverticular diseases). The authors conclude that for complicated diverticular disease H procedure improves survival without preferable continuity. For cancer, H procedure is permanently compromising gastrointestinal in the elderly to hazardous low anastomosis, and to palliative abdomino-perineal resection.


[Supramalleolar derotation osteotomy for torsion of the leg in children and adolescents. Techniques and results: apropos of 22 patients (32 legs)].

We have performed 32 supramalleolar osteotomies described by Mc Nicol to correct excessive internal or external tibial torsion in 22 patients (aged from 4 to 8 years, with different indications, with a follow-up of 16 months to 7 years). The consolidation of the osteotomy was obtained in 6 weeks. Eighteen patients (27 osteotomy) have a good result, 2 results are fair and 2 patients have a poor result. The indications for correction of excessive internal or external tibial torsion are very uncommon, and reserved to cases with functional disorbility of fitting appliances, or unaesthetic or uncomfortable gait.


[Echo-endoscopy of the digestive system].

Endoscopic ultrasonography of the gastrointestinal tract allows a precise ultrasound study of the accessible gastrointestinal walls (oesophagus, stomach, duodenum, rectum) and, through these walls, of the adjacent organs (lymph nodes, posterior mediastinum, pancreas, extrahepatic biliary ducts and perirectal region). This method is better than computerized tomography to evaluate the local and regional extension of oesophageal and cardial carcinomas producing little or no stenosis and of gastric and rectum carcinomas and lymphomas. It is the examination of choice to detect a perianastomotic recurrence of these cancers and to evaluate submucosal tumors of the gastrointestinal tract. This method, with no morbidity, is better than computerized tomography or ultrasonography in the aetiological diagnosis of obstacles in the biliary tract and in the diagnosis and pretherapeutic assessment of pancreatic cancer or endocrine tumors.


[Intraperitoneal resorbable mesh in the prevention of postoperative wound dehiscence. A comparative study].

The purpose of this study was to compare efficiency of polyamide mesh externally applied to the skin and intraperitoneal resorbable mesh of polyglactine 910, for the prevention of wound dehiscence. Two consecutive and homogenous groups of 100 patients, operated by the same surgical team and presenting one or more risk factors of evisceration, were retrospectively compared. Use of intraperitoneal polyglactine mesh, significantly reduced rate of wound dehiscence (4% vs 13%), lowered frequency of reoperation in eviscerated patients (25% vs 61%), but did not improve prognosis of this complication (50% mortality). Potential effect of resorbable mesh on late fascial disruption remains controversial.


[Darier-Ferrand dermatofibroma. An unusual tumor of the soft tissues].

Darier and Ferrand dermatofibroma is a rare skin tumour arising in the dermal connective tissue. It has a slow course over several years and presents very unusual histological features. It is characterised by a marked potential for local recurrence, frequently multiple due to insufficient primary resection. It has a very low metastatic potential. Its diagnosis is difficult but essential in order to perform an appropriate surgical procedure which ensures its excellent prognosis.


[Peristomal pyoderma gangrenosum after colectomy for Crohn disease. Successful medical treatment].

A case of Pyoderma gangrenosum with two different abdominal sites in a female patient suffering from colonic Crohn's disease is presented. Local trauma on the midline scar of an incisional hernia and around the stoma were the possible triggering factors. Despite the major abdominal wall defect and an infected parietal collection, steroid therapy was very effective without the need for surgery.


[Endometriosis and diaphragmatic defect in catamenial pneumothorax].

Two cases of catamenial pneumothorax are reported, a rare condition characterized by its sudden occurrence in a female patient between the ages of 30 and 40 years, always at the onset of the menstrual cycle. Its exact origin is unknown, but the frequent co-existence of endometriosis and a defect in the diaphragm suggests that endometriosis may be important in the etiology both of the pneumothorax and the diaphragmatic lesion. Pelvic endometriosis was present in both our patients, one of whom also had diaphragmatic endometriosis. The treatment of the pneumothorax in both our cases consisted of pleural decortication with excellent results so far.