[Value of multiple cortical perforations for the rehabilitation of massive deep-frozen bone allografts. Experimental study in sheep]. Incorporation of massive cortical bone allografts in human is slow and remains incomplete. Late biopsies of implanted allografts or histological studies of explanted allografts always show the partial substitution of necrotic bone by new bone from the host. The aim of the present study was to evaluate the effect of drilling the massive deep-frozen cortical allografts in order to induce osteogenesis. Thirteen sheep were operated on and a standard segment of the proximal ulna was removed and the gap filled either by an unperforated allograft or by a perforated one. Based on histological and microradiographic examination, a quite complete substitution of the perforated allografts was observed but in this model no statistically significant difference was observed between perforated and unperforated allografts. Further study is needed to assess the effect of the perforations.


[Artificial hearts. The experience of Henri Mondor University Hospital]. Results obtained with 52 patients referred for urgent heart transplantation or when transplantation was impossible because no graft, mechanical assistance or circulatory support were available, are reported. These suggest that the protocol used to select the indications of assistance and transplantation, based on the response to the introduction of enoximone into the medical treatment, allows reconciling the patients' interest-their survival-with the community's interest-i.e. the control of the costs of implemented treatments.


[Mediastinoscopy in the evaluation of the extension of primary bronchial cancer. Techniques, indications and therapeutic deductions]. In order to achieve mediastinal lymph node staging in bronchial cancer, axial mediastinoscopy (combined with left anterior mediastinoscopy for cancers of the left upper lobe) is by far the most efficient and the most reliable technique. Since mediastinoscopy has been part of the investigations that can be made before thoracotomy, the number of exploratory thoracotomies has considerably decreased in all teams, thus reducing intraoperative mortality at the same time. Thoracic CT, which arrived in the diagnostic weaponry against lung cancer a long time after mediastinoscopy, has a major asset in that it allows selecting the patients for whom mediastinoscopy seems to be useful, on the basis of criteria related to the size of mediastinal lymph nodes (10 mm generally being the threshold chosen to perform mediastinoscopy or not). For almost all authors, systematic mediastinoscopy is no longer useful at present. Similarly, positive mediastinoscopic findings must not lead to systematically refuse patients, as the invasion or absence of invasion of a mediastinal lymph node is neither necessary nor sufficient to discuss a surgical indication. While some still automatically refuse all patients with positive mediastinoscopy, most authors still remain very interventionistic for N2 patients selected on the basis of very accurate criteria that are analyzed above, and surgery can then be performed at once or, for some authors, after a "neo-adjunctive" therapy, the long-term efficacy of which has unfortunately not been rigorously demonstrated as yet.


[Shoulder prosthesis].

[Shoulder prosthesis]. In our department, 25 shoulder prostheses were laid in 24 patients. The main indication remains omarthritis with or without necrosis (13). Fifteen Neer's prostheses (13 total, 2 simple humeral ones) were laid. The posterior approach was chosen in 14 cases. Out of the 20 shoulders reviewed, 8 presented with preoperative muscle atrophy, 8 with no postoperative muscle atrophy, including 8 with posterior approaches. In 4 cases of posterior approach, postoperative atrophy of the infraspinatus muscle was noted, but these four patients were all satisfied or very satisfied. The analysis was carried out according to our grading (0 to 20) of Neer's prostheses. The overall results are excellent for simple humeral prostheses on traumatic lesions. In the other cases, the main benefit is obtained for shoulders in a stable state. The improvement remains poor for the mobility and function of the shoulder. The patients are satisfied on a whole, especially with the improvement of pain.


[Peroperative cholangiography during laparoscopic cholecystectomy]. The aim of this study was to assess the ease and the success of a laparoscopic technique of cholangiography. Following an initial period of training to gain expertise in laparoscopic surgery, 70 patients were included in the study. Six of them had a history of suggestive choledocholithiasis. Intraoperative cholangiography was performed using an angled catheter (Judkins) and a specific tubular cannula (Olsen, Storz) designed to guide and maintain the catheter in the cystic duct. Catheterization of the cystic duct and cholangiography were achieved in 61 patients. In 3 cases, stones were found in the common bile duct. The mean duration of the examination was 11 minutes (6.21). Cholecystectomy was performed after cholangiography. No biliary injuries were observed. These results show that intraoperative laparoscopic cholangiography is easy and not time-consuming. It obviates the need for preoperative investigations looking for biliary stones and provides an excellent definition of the biliary anatomy for safety purposes.


[Problems posed by the association of streptococcus D infectious endocarditis and colorectal tumor]. The problems arising from the discovery of a colorectal tumor during an infectious endocarditis caused by Streptococci D have rarely been mentioned in the surgical literature. The frequency of association of an asymptomatic colorectal tumor and of a Streptococcus bovi endocarditis is now undisputed. This notion implies the systematic search for an intestinal lesion (adenoma or carcinoma) in case of endocarditis or septicemia without involvement of the valves, caused by a streptococcus of group D. The authors report about 3 cases of enterococcal (1 case) and S. bovis (2 cases) infectious endocarditis revealing a colic adenocarcinoma (2 cases) and a villous adenoma (1 case), all being perfectly latent. The specific therapeutic problems arising from this association are outlined, including the antibiotic therapy, the role of the anticoagulant treatment and the priority given to valve surgery in case of hemodynamic instability.


[Biliary cysts. Resection of the protruding dome using celioscopy]. After giving the highlights on the few surgical indications of biliary cysts, the authors present a film of the resection of the protruding dome with celioscopy for an 80-mm cyst of the 3rd segment of the liver, in association with cholecystectomy for lithiasis. The simple technique and uncomplicated postoperative period emphasize the merits of this procedure, although this should not lead to inappropriate indications.


["Open palm" technique in Dupuytren's disease. Postoperative complications and results after more than 5 years]. From 1974 to 1988, 868 open palm and/or finger operations were carried out by a surgeon at the SOS Main emergent hand surgery unit in Strasbourg. Out of these, 107 patients making up 140 fingers were seen again after a period of more than 5 years. The essential advantage of the method is the low rate of postoperative complications relative to the other methods involving skin closure. All patients had an ambulatory treatment with regional anesthesia. The palm was opened in 85% of cases, and both the palm and the base of the fingers in 14%. The average healing time was 26 days, with an average sick leave of 28 days. Postoperative pain was noted in 20% of cases, requiring medication in 10% for an average of 3 days. Postoperative bleeding requiring new dressing occurred in one case, after the patient had already been discharged (0.7%), while 3.5% of all patients had anticoagulants. No hematoma and no flap necrosis were noted, and temporary dysesthesia was noted in 4.6% of cases, nerve involvement in 3.1%, and neurovascular dystrophy in 7%, including 4 only with a functional deficit (2.8%). On the other hand, results after 5-6 years are similar to those of selective aponeurectomies published in the literature, with frequent recurrence (40.6%, including 23% severe enough to require second surgery). Extension was noted in 39% of all cases, and the total activity of the disease was present in 55% of all studied hands.(ABSTRACT TRUNCATED AT 250 WORDS)


[Hemorrhagic ulcer of the bulb. Plea for gastric resection]. Bleeding remains on of the most fearsome complications of duodenal ulcer disease. It is, as if H2 Blockers, while never curing the ulcer, were in fact promoting its most severe forms, i.e., posterior huge ulcers, the control of which has to be a gastric resection. On the basis of a short but consecutive serie of 10 patients, the authors plead in favor of the exclusion of the ulcer from the digestive tract, using the wheeling off procedure to close the duodenal stump.


[Pain and its pathways. A study for therapeutic action]. Pain is as old as mankind. It has a threshold beyond which nobody can escape it. Pain is a biological and physiological phenomenon, an integrated part of our body and ego. Will all our efforts eventually make it disappear? Is its disappearance desirable? Pain is one of the major expressions of sensation. It is integrated by the central structures and expressed as a behavior of avoidance or attenuation of the effects produced by the cause of pain. The study of this behavior and of the transmission of the pain message corresponds to the study of how to fight against this message, which means that it should logically lead to the treatment of pain.


[Aneurysms of the abdominal aorta with periaortic fibrosis. A retrospective study of 23 consecutive successful operations]. Aneurysms of the abdominal aorta associated with periaortic fibrosis (AFPA) are a different clinicopathological entity from atheromatous aneurysms and nonspecific inflammatory periaortitis. The physiopathology and diagnostic and therapeutic modalities for these AFPAs are controversial. Over a 12-year period, 23 aneurysms with periaortic fibrosis (4%) confirmed by a histological study were operated at Beaujon hospital. Four patients were operated at the rupture stage, 2 with acute rupture and 2 with contained chronic rupture. Uni- or bilateral ureteral obstruction was noted in 8 patients. The diagnosis was suspected preoperatively in 60% of cases. Surgery confirmed the accuracy of the anatomical information provided preoperatively by the CT examination performed in 9 patients. Debridement and grafting were performed in 22 patients. Three patients with associated ureteral obstruction were treated with ureterolysis during the same operative step at the beginning of our experience. Later on, 3 documented cases of hydronephrosis receded after the isolated debridement and grafting of the aneurysm. Hospital mortality was of 5% in 19 patients operated electively. Two patients died later, after 2 months and after 5 years, and 16 are still alive and without symptoms at present, after and average time lapse of 68 months.(ABSTRACT TRUNCATED AT 250 WORDS)


[Bisection of the liver for transplantation. Simplification of the method]. Blind bipartition of a whole liver to obtain two transplants is problematic, because of frequent vasculo-biliary duplications, especially arterial (mainly on the left) and biliary (mainly on the right) duplications. Arteriography and cholangiography on the back table are necessary to obtain a map of the arterial and biliary distributions without injuring the vessels of the biliary ducts enclosed in the vasculo-biliary sheaths. The surgeon may use three special maneuvers: resection of segment IV when the arterio-biliary duplication involves segment IV; attribution of the common hepatic artery on the side of the arterial duplication (frequent on the left); attribution of a short segment of the common hepatic duct on the side of a biliary duplication (frequent on the right). In an anatomical study of 93 vasculo-biliary casts, the following results were obtained: in 4 cases: bipartition not possible; in 22 cases: "ideal" bipartition (no duplication); in 57 cases: partition right-left livers: in 37 cases 1 maneuver, in 19 cases 2 maneuvers, in 1 case 3 maneuvers; in 10 cases: partition right liver-left lobe: in 2 cases 1 maneuver, in 8 cases 2 maneuvers. We report 8 bipartitions and 16 transplantations (10 children and 6 adults). The duplications we noted do not differ statistically from those reported in our former anatomical study. Survival of the patients (100% in usual cases, 66% in case of extreme emergency or terminal hepatic insufficiency) and survival of the transplants (68,75%) do not differ either from those noted in other transplantation methods. Complications, especially arterial thrombosis, were within the same statistical ranges.(ABSTRACT TRUNCATED AT 250 WORDS)


[Familial form of primary cancer of the parathyroid glands. A disease entity or incidental association?]. Three cases of parathyroid neoplasms in familial hyperparathyroidism are reported. There were not associated with other endocrine glands or parathyroid glands lesions. Parathyroid gland carcinoma was diagnosed in 2 cases. Review of 7 cases of familial parathyroid carcinoma, diagnosed in 5 different families and issued from the literature, indicates that it can be associated to multiple endocrine neoplasia or other parathyroid lesions. The familial parathyroid carcinoma entity needs further studies before to be fully recognised.


[Role of accessory spleen in recurrent chronic hematologic diseases]. Among 533 patients who were splenectomized between 1967 and 1981 for a chronic haemopathy, 8 were reoperated because of the reappearance of an accessory spleen, which was responsible for the relapse of the disease. Five patients were followed for idiopathic thrombopenic purpura (ITP), 2 for hereditary spherocytosis and 1 for a Hodgkin disease (this patient had been operated for an abdominal exploration and splenectomy). In all patients, a hepato-splenic scintigram with Tc 99 m permitted the discovery of the accessory spleens and the exploration was completed by the study of the half lifetime and sequestration of platelets or red blood cells. The disappearance of the haemorrhagic syndrome after removal of the accessory spleen was frank and didn't need any complementary treatment for 3 cases of ITP and 2 cases of spherocytosis and was incomplete and had to be completed by a secondary treatment for 2 cases of ITP and for the Hodgkin disease. The analysis and the interpretation of the results of this study can be helpful to establish the diagnosis and decide the treatment of accessory spleens which are discovered by a relapse of a chronic haemopathy, primarily treated by splenectomy.


[Linitis plastica of the stomach. Factors influencing prognosis]. The authors make a retrospective study of a series of 57 patients aged 63 years in average, followed up from 1979 to 1989 for linitis plastica of the stomach. Surgical exeresis was performed in 49 patients (34 total gastrectomies and 15 partial gastrectomies, including five 2/3 gastrectomies, two 3/4 gastrectomies, four 4/5 gastrectomies and four upper polar esogastrectomies). The overall actuarial survival rate (n = 57) was 62.5% at 1 year, 40% at 2 years and 12.5% at 5 years. The prognosis did not vary with the delay of diagnosis, the invasion of the area of resection, the associated tissue differentiation and the invasion of lymph nodes. It did very according to the height of the tumor: 22% survival at 5 years for tumors under 6 cm, against 0% for tumors exceeding 6 cm (p < 0.001).


[Azygo-portal disconnection for hemorrhagic cirrhosis. Results and value of abdominal and thoracic approach apropos of 20 cases]. The authors report about the results of 20 azygoportal deconnections for the treatment of hemorrhagic cirrhosis caused by the rupture of esophageal or cardiotuberosal varices. All patients had an ethylic cirrhosis of Child-Pugh classes A (1), B (15) or C (4). All had a contraindication to calibrated laterolateral portocaval shunting. Azygoportal deconnection was performed with a thoracic approach in 7 cases, using a Bérard eso-clip in 6 cases and a Prioton button in 1. In 13 cases the approach was abdominal, using EEA circular mechanical clamps. In this cases, trunk vagotomy was performed in 12 cases, in association with pyloroplasty in 10 cases and gastroenteroanastomosis in 2 cases. Splenectomy was performed in 3 patients and the ligation of the splenic artery in a 4th patient. Mortality at 2 months is of 30%, the 6 deaths being caused by hepatic insufficiency in 3 cases, heart and esophageal fistula after an eso-clip was laid in 1 case. The two patients with chronic ascites died of hepatic insufficiency. Mortality at 2 months is of 23% for patients operated in an elective period, and 43% for semiergent operations. Twenty-six percent of the Child B patients and 50% of the Child C patients died. The percentage of residual varices is 57% in the surviving patients. Every second patient had complementary sclerosis. All had had azygoportal deconnection with mechanical clamps. Bleeding recurred in 2 patients (16.6%). Survival is 50% at 1 year and 39% at 3 years.


[Colostomy-induced varices in portal hypertension]. Varices of the colostomy are a rare complication of colostomy performed in patients with portal hypertension. This work is based on 14 cases. The colic stomy is the terminal operation in surgery for cancer in twelve cases, and a bypass stomy in two cases. Portal hypertension is due to cirrhosis in 10 cases and to metastases to the liver in 4 cases. All 14 colostomy varices were expressed by bleeding. In 7 cases, oesophageal varices were detected with fiberendoscopy. Only one of these patients had an upper digestive hemorrhage. Colostomy hemorrhages are the revealing complication and the main sign of the disease. The emergent treatment of bleeding of the colostomy must combine several methods, most often consecutively: local compression, ligation, sclerotherapy. Once bleeding is controlled, the radical treatment must be primarily medical (hygienic and dietary habits, beta-adrenergic blocking agents), but complementary surgery may prove to be necessary, most often to redo the colostomy with additional deconnection. The prognosis mainly depends on the function of the liver, the deterioration of which is accelerated by the successive hemorrhagic accidents. Hepatorenal failure is the main cause of death.


[Evaluation of combined CA-19-9 and CEA assay in monitoring recurrences and metastases of colorectal cancer]. The results of combined CA-19-9 CEA assay were measured in 216 cases of colorectal cancer. In 28 preoperative patients, the positive rate 16.67% in Dukes' A group, 25% in B, 55% in C and 40% in D. It was proved less valuable in early diagnosis. The positive CA-19-9 alone in 66 with relapsed or metastases out of 182 undergoing radical resection was 63.63%, CEA alone 62.12%, and combined assay 86.36%. The false positive rate of CA-19-9 and CEA was 6.03% and combined assay 11.21%. In 27 palliative resections CA-19-9 in 40.74% cases, CEA in 44.44%, and combined assay in 59.2% was positive. In cases of nonresectable tumors, the positive rate was 66.7%, 66.7% and 83.33%, respectively. There was no definite correlation between the value of CA-19-9 and CEA. The data showed significantly higher sensitivity in combined assay than in either CA-19-9 or CEA alone. Combined assay with the sensitivity of 86.36% and the specificity of 88.79%, was more useful in finding of postoperative. recurrences or metastases. We suggest that this method should be used routinely in monitoring postoperative patients with colorectal cancer.


[Interleukin I activity and prostaglandin E2 content in peripheral blood monocytes in patients with colorectal cancer]. Immunoregulatory function of peripheral blood monocytes was studied in 20 patients with colorectal cancer, by assaying interleukin 1 (IL-1) and prostaglandin E2 (PGE2) in the culture supernatant of lipopolysaccharide-stimulated monocytes. The results showed that IL-1 activity of the monocyte culture supernatant was decreased in the preoperative patients, compared with that of controls or postoperative groups; the PGE2 content of the culture supernatant of monocytes from the preoperative cases was increased, compared to normal controls or to the postoperative groups. Again, we found that there was significant negative correlation between IL-1 activity and the PGE2 content, with the activity of IL-1 the lowest and the content of PGE2 the highest in advanced colonic cancer patients.


[The activity of immunologic cells from peripheral blood, splenic venous blood and spleen in patients with advanced gastric cancer. A comparative study]. To elucidate the immunologic function of the spleen in AGC patients, peripheral blood lymphocytes (PBL), splenic venous blood lymphocytes (SVL) and spleen cells (SC) from 40 patients were tested for NK cell activity and T-cell subsets. Significant impairment of NK cell activity, decreased rate of CD+3 and CD+4 cells, declined CD+4/CD+8 ratio, and increased CD+8 cells were noted in SC of AGC patients as compared with PBL of normal subjects. NK cell activity and CD+4 cells of SVL and SC were significantly lower than those of PBL in AGC patients. More significant decline of CD+4/CD+8 cell ratio was found in SVL and SC when compared with PBL in AGC, mainly as a result of the marked decrease of CD+4 cells in SC. In conclusion, AGC tends to weaken the immune status of patients and the immunosuppressive role of the spleen would become more evident with the development of the tumor.


[The expression of MG7 corresponding antigen in gastrointestinal polyps and its relation with cancer]. We studied 112 patients with polyps of the stomach, gallbladder and colorectum by immunohistochemical staining with monoclonal antibody (MG7) against gastric cancer and avidin-biotin complex (ABC) technique. The positive expression of the MG7-corresponding antigen (MG7-Ag) was 100%, 100%, and 60.0% respectively in villous, mixed and tubular polyps. A close correlation was shown between dysplasia of grade II and the positive expression of MG7-Ag (p < 0.05). The positive expression was significantly related to canceration (P < 0.025). No malignancy was found in 45 patients with negative expression. But 12 of 67 patients with positive expression developed cancers in 3 to 38 months. The patients with positive expression of MG7-Ag were high risk group developing cancer.


[The relationship between bile acid and factors relative to gastric cancer]. By high performance liquid chromatography and 3a-hydroxysteroid dehydrogenase determination, we quantitatively analysed the content of 8 combined biliary acid salt and pH of gastric juice from 35 patients with gastric disease and healthy controls. It was found that both the content of various kinds of biliary acid salt and pH value of gastric juice were much higher in patients with gastric cancer, gastric ulcer, and chronic atrophic gastritis than in normal controls, bile acid salt is known to be harmful to gastric mucosa and that the damage becomes more severe with the increase of bile acid salt concentration and prolongation of exposure, therefore our results suggest that the bile acid salt in the gastric juice is one of the carcinogenic factors.


[Treatment of unstable fractures of thoracolumbar spine with neurologic injury using a reduction fixation spinal pedicle screws system]. Twenty-six patients with unstable burst fractures, chance fractures and fractures dislocations of the lower thoracic and lumbar spine were treated with a spinal pedical screw reduction fixation system (RF system). This system is a new device designed by Chinese scientists. In biomechanical testing, it provided three-dimensional reduction forces. The special design of angle pedicle screw provided accurate angle to restore the normal thoracic lumbar lordosis and to maintain it. The three-column spine in a lordotic position maximized the reduction and indirectly achieved a neurologic decompression in the spinal canal. All patients had an anatomical reduction by RF system except one case operated two weeks after injury, the spinal canal area increased over 30% by CT (P < 0.01). Except four cases with Frankle A out of twenty patients with neurologic deficits, all other patients had at least one grade progress. Of them one improved from A to D, ten from C and D to normal. These twenty patients were followed-up over six months. All of them maintained anatomical reduction by RF system. Bone grafting had successful fusion by follow-up X-ray examinations. There were no important complications after surgery. The system is of simple structure facilitation implantation and enable the patients beginning ambulatory movements early, therefore it gives more satisfactory results over conventional Harrington and other segmental spinal instrumentation systems.


[An anatomic study of transpedicular posterior fixation of spine and its clinical application]. Intact anatomic specimens of spinal column from T8-L5 were obtained and the height and width of vertebral pedicles, the distance between the pedicle to the upper and lower borders of the vertebral body, the angle of inclination of the coronal surface of vertebral pedicles, and other parameters were measured. Simulating pedicle screw implant in operation, K-wires were inserted into the pedicles and after taking X-ray films the pedicles were sectioned transversely. A series of morphologic parameters of the pedicles were obtained. The distances between the two K-wires' entry and exit points, and between the two pedicles of the same or the adjacent vertebra were measured. The relationships of the sites of determining the pedicle screw site was evaluated also from roentgenograms. Twenty two patients of thoracolumbar fracture were treated. The vertebral body height, kyphotic deformity and the displacement were corrected obviously. After operation the neural functions from incomplete paraplegia were recovered. Several problems about the pedicle screw implant technique were discussed.


[Adjustable thoracic-lumbar vertebrae fixation and traction brace: development and clinical usage]. We developed an adjustable traction and fixation brace for thoracolumbar vertebrae, which is made from heat-sensitive plastics and consisted of four pieces of oppositely directed bolts serving as the elevation dropping system. The brace has strong anti-bending strength and draught force. With which, every direction of movement of the spinal column can be restrained effectively and the vertical pressure on the diseased vertebrae can be eased. The biomechanical effect of this brace is in accordance with the demand of spinal cord biomechanics. It can be used at 1-2 weeks after injury. It can be used in patients with thoracic-lumbar fracture, tumour and tuberculosis after operation. The efficacy rate of 98% was achieved in 102 patients. 31 patients with injured thoracic-lumbar vertebrae could walk and squat down without any pain and complication, and the deformity was corrected or alleviated.


[Operative treatment for lumbar disc protrusion with fragment of nucleus pulposus in the dural sac]. Four cases of lumbar disc protrusion with fragments of nucleus pulposus in the dural sac are reported, representing 0.3% of 1555 cases surgically treated over the past 35 years. All four cases were severely affected with distinct clinical manifestations of prolapsed disc, acute onset or sudden deterioration, pain, numbness, weakness, partial or complete paraplegia, and disturbances of urination and defecation accompanied by symptoms of severe and extensive spinal stenosis. They were treated with total laminectomy, section of dural sac, separation of adhesion and removal of fragments of nucleus pulposus. The results were excellent in one, Good in two and fair in one patient as revealed by the follow-up study which ranged from 4 months to 6 years. The clinical features, pathology, cause of prolapse, diagnosis, some points for attention concerning its management as well as that of adhesive arachnoiditis are discussed.


[Hepatectomy in patients with advanced hepatocellular carcinoma after hepatic artery chemotherapy/embolization or hepatic artery embolization/ligation]. Eight patients with advanced hepatic cancer underwent hepatectomy after repeated hepatic artery chemotherapy/embolization (HACE) or hepatic artery embolization/ligation (HAEL). Seven of the 8 patients survived for more than one year after operation, the longest being up to 73 months. The results showed that both HACE and HAEL are effective for the treatment of liver cancer, and in some patients they can make large tumors resectable.


[Reoperation of esophageal achalasia].

[Reoperation of esophageal achalasia]. From 1980 to 1989, 18 patients with esophageal achalasia had postoperative restricture. Inadequate myotomy was shown in 7 patients, scar constriction in 5, gastroesophageal reflux in 3, and paraesophageal hiatus hernia in 1. Seventeen patients underwent reoperation including modified myotomy (11), esophagastrotomy (4), operation for esophageal hiatus hernia (1), and cardioplasty combined with fundoplication (1). The causes of restricture, diagnostic methods, operative procedure and methods of precaution are discussed.


[Experiences in diagnosis and treatment of chronic subdural hematoma]. Diagnosis and treatment of 95 patients with chronic subdural hematoma (CSDH) are presented. There were 92 males, 56 patients (59%) over 51 years old and 66 of them with history of head injury. The majority of our patients appeared increased intracranial pressure. Mental confusion and incontinence of urine and stool usually occurred in senile patients. Ultrasonic and electroencephalography examination were helpful in location of the hematoma. Cerebral angiography could make actual diagnosis. CT scan were more useful in diagnoses of CSDH and may discover multiple hematomas. If CSDH image were iso-dense on CT scan cerebral angiography should be performed. In the early years extirpation of CSDH including the capsule was performed. Now an irrigation drainages by cranial bur hole was performed usually. 5 patients had complication. The mechanism and prevention of CSDH are discussed.


[Application of temporary arterial occlusion during intracranial aneurysm surgery]. Temporary arterial occlusion during aneurysm surgery was performed in 52 patients. It account for 37.1% of all aneurysm operated in the same period. After operation 1 patient died (1.9%), 10 (19.2%) remained neurological deficits but 48 (98%) got excellent and good recovery. Selection of patients and supplement therapeutic measures were discussed in the article.


[Diagnosis and treatment of blunt renal injury]. 157 renal injury cases (22.2%) of 708 blunt abdominal injury cases admitted at our hospital from January, 1981 to April, 1991 were evaluated. The results suggested that large dose IVP have certain limitations, while modern ultrasound findings have important practical value. We think that the patients with renal injury more than 3 degree must be operated immediately. Nephrectomy may be considered on injured kidney if the contralateral renal function is normal, in order to avoid late complications. In cases of using inosine, dopamine and large furosemide during operation, the time lag of indicamine presenting in urine is helpful for judging and protecting contralateral renal function.


[Right renal vein graft extension for cadaver kidney transplantation]. Short renal vein can make renal transplantation difficult. We successfully used the vena cava to extend right renal vein in 20 grafts in 590 renal transplantations. Four types of venoplasty were used in this study. The method to obtain adequate length of the right renal vein from the vena cava is simple, physiological, and effective.


[Re-open heart surgery in congenital heart disease. An analysis of 23 cases]. The authors reported 23 cases of re-open heart surgery in 1473 patients with congenital heart disease treated surgically in the last ten years. The incidence was 1.6%. In 13 cases of the 23 re-open heart procedure was performed before closing the chest during the operation because of missed diagnosis in 5, incomplete correction of the anomaly in 5, and injure to important organ in 3. All of the 13 patients were recovered and discharged. Of the 23 cases re-open heart surgery was performed during the early postoperative period in 8 cases, including 4 cases of misdiagnosis, and 4 incomplete correction. 1 patient with VSD had still residual ventricular septal shunt post reintervention and died of circulatory failure. Re-open heart surgery was performed during the late postoperative period in 2 of the 23 cases. There was 1 missed diagnosis, and another incomplete correction. 1 patient died of massive bleeding during the reoperation. The anthers pointed out that accurate diagnosis and error-free operation is of most importance in avoiding re-open heart surgery. Through exploration to the heart after resuscitation during the operation and positive re-opening of the heart when necessary were emphasized. Indication of early and late postoperative re-open heart surgery and methods to prevent its complication were listed.


[Changes of hepatic blood flow and intrahepatic microvascular bed in rats with chronic biliary obstruction]. The effective hepatic blood flow (EHBF) and intrahepatic microvascular bed (IMB) of rats were studied with hydrogen clearance and India ink perfusion 1, 2, 3 weeks after common bile duct ligation (CBDL). The EHBF decreased significantly in all 3 CBDL groups, compared to control (P < 0.0001). There was no significant difference among CBDL groups (P > 0.05). In a given group no significant difference was noted between the blood flow of the left lateral lobe and that of the middle lobe. The IMB was destroyed severely in all CBDL groups. It was concluded that when chronic biliary obstruction developed the EHBF decreased significantly because of shrinkage of IMB resulting from extensive fibrosis of the liver, and necrosis of liver cells.


[Hemodynamics in skin and tissue expansion]. The capillary blood flow (CBF) of the random flaps constructed on expanded and unexpanded skin of dogs was determined by radioactive microsphere technique. The CBF was significantly higher (P < 0.001) in the skin flaps of the expanded group (387 +/- 23 microliters/min/flap) than that of the acute group (127 +/- 16 microliters/min/flap). There were no significant differences in the expanded group, the delayed group (374 +/- 35 microliters/min/flap) and the control group (389 +/- 48 microliters/min/flap). Even at the pedicle site, the CBF of the acute group was already significantly lower than that of other three groups (P < 0.001). The general tendency of gradual CBF reduction from the pedicle to the distal end of all the flaps was observed. The CBF at the point 8cm from the pedicle of the acute group was 12 microliters/min/g, whereas in other three groups, at point 13 cm from the pedicle the CBF was 12 microliters/min/g. The results suggested that during skin expansion the area of skin is enlarged, and its CBF and survival length may be increased. The problem of capsulectomy during flap construction was discussed.


[Clozapine (Leponex) in France].

[Clozapine (Leponex) in France]. Leponex (clozapine) is an atypical neuroleptic indicated in severe schizophrenia, launched in France in December 1991. The safety and efficacy data pertaining to 1,062 patients treated on a compassionate needs basis between May 1989 and December 1991 constitute the first French experience on the drug. The results of an interim analysis pertaining to 602 patients, i.e. available data on 03-15-1992, generally collected on a retrospective basis, by means of a specific questionnaire are reviewed. The population included patients with severe and long-standing schizophrenia i.e. 15.71 +/- 9.3 years, resistant to usual neuroleptic therapy (90.86% of cases), and rarely with a history of intolerance to this class (2.49%). The indication was in the majority of the cases a paranoid schizophrenia (67.2%). The mean maintenance daily dose was 419 mg/d (+/- 152). Overall, with respect to associated drugs, neuroleptics were recorded in 16.4%, another psychotropic drug in 44.7% and symptomatic treatments for extrapyramidal disorders in 21.3% of patients. Of interest is the fact that, for those patients started on Leponex more recently, the drug is more often prescribed on a single basis. Leponex was stopped in 24.3% for the following reasons: adverse events 10.6%, lack of efficacy 6%, non compliance 3.8%, other reasons 3.8%. The adverse event profile is consistent with the literature data, taking into account the fact that certain adverse events were more commonly described: fatigue of lower limbs 11.8%, leucocytosis 19.8% and eosinophilia 4.3%.(ABSTRACT TRUNCATED AT 250 WORDS)


[Indications for Clozapine].

[Indications for Clozapine]. Clozapine does not constitute a first-line treatment due to the occurrence of agranulocytosis. However, the benefit risk/ratio fully justifies its use in two situations: resistance to neuroleptics, intolerance to neuroleptics. There are no internationally recognized objective criteria to define resistance. The ones defined in the well-restricted methodological environment of a clinical trial are generally not applicable to daily practice. In particular, the accepted criteria do not always take into account the personal factors, the social and environmental context and rehabilitation programs. May et al. for example defined in 1988 the degree of response to therapy based on clinical improvement as well as social integration. It is widely recognized that if the severity of residual symptoms (grade 5 response) requires the hospitalization, treatment with clozapine is warranted. For partial responders to classical treatment (grade 4 response) who could benefit from clozapine, the risk ratio of clozapine needs to be further evaluated. The identification of predictive factors of response to therapy would allow a novel approach of this indication. According to certain authors, paranoid type responds best to therapy. However, the evidence collected to date needs to be confirmed. In particular, the effects of clozapine on predominantly negative symptoms require further investigations. In contrast to several european studies, intolerance to neuroleptics is rarely a reason for initiation of clozapine therapy. This would indicate that the appreciation of intolerance to neuroleptics notably varies from one country to the next. Intolerance criteria need to be further specified as well as the benefit risk/ratio.(ABSTRACT TRUNCATED AT 250 WORDS)


[When to continue or stop Clozapine therapy?]. The decision whether or not to stop clozapine therapy in schizophrenic patients depends on a lot of factors involving the benefit/risk ratio. Thus, authors successively analyse various data: the clinical status of the patient is the first one. The evaluation has to take into account short and long-term efficacies; the problem of the minimal duration of clozapine therapy required before concluding to ineffectiveness is still open: from 4 to 12 months; the question of efficacy of the drug according to the type of symptoms is also quite difficult. Efficacy on positive symptoms among schizophrenic patients seems most prominent; negative symptoms also improve but the reasons why are quite difficult to evaluate. It is sometimes difficult to indicate if the improvement in negative symptoms is independent of the improvement in positive symptoms; the patient's request and his feeling (including tolerability) are another decisional factor; because of the lack of dystonia and other extrapyramidal side effects, some patients are more compliant under clozapine therapy; the side effect (hematologic, cardiovascular, hepatic and central nervous systems) lead to discontinuation of clozapine treatment when severe. The most frequent ones are: sedation, EEG alteration, seizures, increase of liver enzymes, hypotension/collapse, hypersalivation, fever (> 38), ECG alteration, tachycardia, gastro-intestinal adverse effects, weight gain, and leucopenia. In the event of a white blood cell count (WBC) below 3,500/mm3, the patient should be evaluated immediately with respect to the WBC and the differential count (DC). Should the results confirm a WBC below 3,500/mm3 and/or reveal an absolute neutrophil granulocyte count of 2,000 to 1,500/mm3, the leucocytes and the granulocytes must be checked at least twice a week.(ABSTRACT TRUNCATED AT 250 WORDS)


[Clozapine: an exclusive treatment?].

[Clozapine: an exclusive treatment?]. Clozapine is an atypical antipsychotic drug which must only be prescribed for the treatment resistant schizophrenic patients. Contra-indications and precautionary measures (F.e no use of a drug that can enhance the potential for a granulocytoxic reaction) have to be well known and respected. There is an increased risk of granulocytopenia, and 1 or 2% of granulocytopenia may induce an agranulocytosis. This risk is compared with what is observed with other psychotropic drugs, phenothiazines particularly. Beyond clozapine adverse effects, three cases of severe cardio-vascular and respiratory dysregulation, one case of sudden death, and one case of induced coma are presented in detail from the literature: possible interactions between clozapine and adjunctive medications are discussed. Appropriate patients should be proposed a treatment by clozapine, in principle without association to any other psychotropic drug and in all the necessary precautions.


Importance of nasal clipping in screening investigations of flow volume curve. Comparative analysis of some basic lung indices obtained from a screening investigation of the flow volume curve by using two techniques, with a nose clip and without a nose clip, was made on a cohort of 86 workers in a factory shop for the production of bearings. We found no statistically significant differences between the indices obtained by the two techniques. Our study showed that the FVC and FEV1 obtained in workers without using nose clips were equal to or better than those obtained using nose clips in 60% of the workers. The reproducibility of the two methods was similar. The analysis of the data has shown that the flow volume curve investigation gives better results when performed without a nose clip, especially in industrial conditions.


Comparative analysis of some methods for standardizing the maximal expiratory flows. Maximal expiratory flows were obtained in 40 patients with chronic non-specific pulmonary diseases displaying mild obstruction of air flows and in 35 clinically healthy subjects with normal ventilatory functions and similar anthropometric characteristics. The flows for the two groups and their standardized values by referring to FVC, TLC, H and H3 were compared. The u-criterion and V% were used as measures for the diagnostic value of the flows and their standardized values. In the patients with mild airflow obstruction the highest u-criterion and the lowest V% were obtained by standardizing the maximal expiratory flows through referring to H3. This is an indication that this method of standardization is to be preferred to other methods in the functional diagnostics of mild obstructive disorders.


Radiologic methods used in the diagnostics of vasculogenic erectile dysfunction. Contemporary methods of assessing erectile dysfunction include instrumental registration of nocturnal penile erections, the penile brachial index, Doppler sonography, use of vasoactive substances and various contrast radiologic methods along with studies of the hormonal profile, the neurologic status, examination of prostate excrements, etc. These methods are still not widely used in Bulgaria although their scope of application is quite well known. We report here our own experience in using the contrast radiologic methods for studying this pathological condition, in particular, the technique of digital subtraction pharmacocavernosography with cavernosometry introduced by us and used for this purpose. In some of the cases we used it in combination with digital subtraction angiography of pelvic arteries. Using these methods we can detect not only morphological but also functional disorders. On the basis of the data obtained we determine the particular therapeutic approach, specify the nature of the disorder and the effect of eventual surgical intervention.


Digital subtraction angiopulmography in children. The digital subtraction angiography has revealed the great potential of the angiographic diagnostics of children lung diseases with its intravenous introduction of contrast material, greatly reduced amount of the contrast agent used and the irradiation dose applied. Angiopulmography is one of the basic methods for proving the presence of malformations, their characteristic and degree of development. We did 29 digital subtraction angiographies in 13 children aged 2 months to 7 years. We found the following malformations: hypoplasia of one of the branches of a. pulmonalis with the other branch aneurysmally dilated, hypoplasia and agenesis of a lobar branch, confirmed also by digital bronchoradiography, lobar emphysema, mediastinal and pulmonary hemangiomatosis. In addition to the advantages given above the digital subtraction angiography reduces the trauma rate due to the possibility of avoiding catheterization by using peripheral venous pathways. It also allows both qualitative and quantitative processing of the image.


Application of recombinant human erythropoietin in patients with polycystic kidney disease and chronic renal failure. Recombinant erythropoietin was used in the treatment of the anemic syndrome in 5 patients (4 women and 1 man), aged 45-63, with confirmed autosomal dominant polycystic kidney disease. All patients were with II stage chronic renal insufficiency. The treatment was conducted with Eprex (Silag, Switzerland) administered subcutaneously in a dose of 50 U/kg of body weight for three months. Once weekly, hemoglobin, hematocrit, erythrocytes, and serum iron were investigated in all patients. Simultaneously, we used recombinant erythropoietin in the same dose and treatment protocol on a control group of 3 women and 2 men with II stage chronic renal insufficiency but without polycystic kidney disease. The control patients were suffering from other diseases leading to uremia. In both groups, the hemoglobin and hematocrit were found to be significantly increased whereas their serum iron tended to decrease which required inclusion of iron containing preparations in the treatment. We found no significant differences both in the dynamics of influencing the disease and in the final results of the treatment with erythropoietin between the patients with polycystic kidney diseases and those without polycystosis and chronic renal insufficiency. No allergic reactions were observed during treatment. Arterial pressure was elevated in all patients. We think that recombinant erythropoietin can be used successfully in the treatment of renal anemia in patients with polycystic kidney disease and chronic renal insufficiency in the predialysis stage.


Motor cortex transcranial magnetic stimulation topography assessed by distribution and size of evoked potentials. 25 volunteers aged 18 to 70 were examined. Bilateral EMG was performed of m. m. biceps brachii et flexores digitorum profundus using surface pick-up electrodes. The evoked potentials were recorded on Nicolet Pathfinder II. Magstim 200 Novametrix was used for stimulation with A and B sides of a coil with mean diameter of 9 cm. The examinees were sitting on chairs, their forearms flexed voluntarily to approximately 90 degrees, resisting a standing pressure of 5 Nm exerted by the torque motor. Three groups were examined. In the first, we recorded the amplitude, the latencies and spreading of potentials in the muscles on the left and right stimulating with the A and B sides and positioning the coil on the vertex (Cz), 2 and 4 cm forwards and backwards. Moving the coil away from Cz brought about reduction of the amplitudes of the evoked potentials or resulted in the disappearance of potentials. This was better seen in backward shift of the coil. The latencies did not change. The responses were bilateral in 10 out of 11 subjects the amplitudes being higher on the side corresponding to the destination of stimulation. In the second group we wanted to see what the effect of the shift of stimulation away from the meddle line would be. C-P1, C-P2, Cz1 and Cz2 are not suitable sites for obtaining potentials. Stimulation at C-F1 and C-F2 yielded potentials which, contrary to the expectation, evoked ipsilateral responses. In the third group stimulation was combined with focal sensor influence. At the beginning it was a focused attention which, however, was difficult to define.(ABSTRACT TRUNCATED AT 250 WORDS)


Effects of phenobarbital, carbamazepine and a combination of both on corazol-induced changes in the bioelectric activity of rat brains. Combined forms of epileptic seizures are known to require combinations of antiepileptic drugs for their management. This study investigated the effects of such a combination consisting of phenobarbital and carbamazepine (mixed in the 1:4 ratio) as well as the effects of each component used separately on the Corazol-induced bioelectrical brain discharges. The effects were studied in a group of rats that received only a single dose of the drugs, as well as in a group that underwent 14-day anticonvulsant treatments. The bioelectric activity of the brain was recorded using an EEG method. In a single dosage, the combination of phenobarbital and carbamazepine was found to be more effective than its components. The decrease of Corazol-induced discharges was more pronounced in a single administration of the combination than when it was applied repeatedly. Development of a cumulative effect was observed in respect to carbamazepine action on the Corazol-induced discharges.


Changes in the plasma levels and basic pharmacokinetic parameters of digoxin used in combination with gentamicin, amiodarone and spironolactone. Digoxin was administered intravenously (0.035 mg/kg b.w.). A prior five-day treatment with gentamicin (100 mg/kg b.w., 10 mg/kg b.w., i.m.), amiodarone (30 mg/kg b.w., s.c.) and spironolactone (10 mg/kg b.w., p.o.) caused elevation of plasma digoxin levels primarily because the alpha half-life was prolonged (t1/2 alpha). In a combined five-day application of digoxin with gentamicin (10 mg/kg b.w., i.m.), and of digoxin with amiodarone, the plasma levels of digoxin rose due to the lengthened beta half-life (t1/2 beta). In administering a combination of digoxin and spironolactone, the plasma digoxin levels dropped, t1/2 alpha decreased and t1/2 beta increased. A 15-day digoxin treatment tested combinations of digoxin, from days eight to 15, with gentamicin (10 mg/kg b.w., i.m.); with amiodarone, or with spironolactone. The digoxin level was elevated with the combinations of digoxin-amiodarone and digoxin-spironolactone: t1/2 alpha was longer in both cases, while t1/2 beta was longer only for the digoxin-amiodarone combination. No changes were found in the creatinine clearance or renal histology of experimental animals after treatment, nor were any deviations found in the values of T3, T4 and TTX.


Changes in the behavioral reactions of experimental animals after repeated treatment and withdrawal of a combination of phenobarbital and carbamazepine. The present study investigates changes in behavioral reactions, muscle tonus and staticokinetic reflexes of white rats after repeated applications and subsequent discontinuation of a phenobarbital-carbamazepine combination. These changes were compared to those induced by the two preparations when given alone. The study found a reduction in the orientation capacity of animals treated with single applications and repeated dosages (continuing up to four days) of the anticonvulsants phenobarbital and carbamazepine. Withdrawal of the pharmaceuticals is followed by significant changes in the motor activity and orientation capacity. This is especially apparent on the third day after the pharmaceutical combination was applied. Changes in the other parameters are insignificant, ambiguous and irregular. The described manifestations resulting from discontinuation of the combination treatment is considered to be a warning about the risk of physical dependence on the drug combination.


PROFORCE--a new, high-biologic-value protein product for athletes. The protein product PROFORCE has been developed from a base of egg, milk and cereal using linear optimization. Its balanced composition has been specially designed to meet the physiological needs of athletes practicing endurance-demanding sports. A medicobiologic evaluation using a routine technique was performed using three concentration levels of protein feeding. This enhanced the range of the investigated parameters. The following results were obtained: Protein Efficiency Ratio (PER) = 2.64 +/- 0.22 (p < 0.001); Net Protein Ratio (NPR) = 3.27 +/- 0.22 (p < 0.001). Comparison with the control group shows that the protein product is of high quality. Albumin, cholesterol, triglycerides and total protein were determined for the three protein-feeding concentrations. The most favorable influence on the protein parameters and cholesterol levels were observed when feeding experimental rats on the nine-percent protein concentration. Amino acid content of the product was compared to a number of proteins of proven high quality. The comparison suggests that the product is suitable for athletes practicing endurance-demanding sports. The conclusion is that PROFORCE has a wide range of applications which would include use by athletes practicing aerobic sports.


Importance of the breathing manoeuvre in detecting mild air flow obstructions in a lung function screening. Maximal expiratory flow-volume curves (MEFVC) were recorded in 610 workers using two different breathing manoeuvres. Inspiration in one was forced and maximal, while in the other, it was slow and maximal. In both manoeuvres, the ventilatory function was defined according to the diagnostic classification proposed by I. Kirin. Two groups of workers with mild obstructive changes were found. In one group, we diagnosed a condition defined as transitional state to obstructive ventilatory disorder (Tr.OVD) using both manoeuvres. In the second group, we detected normal lung functions using one of the breathing manoeuvres while the other manoeuvre disclosed Tr.OVD. In the second group, the relative share of workers scoring below the lower limits on the test of Tiffeneau was significantly lower than in the first group. Instantaneous flows also were significantly lower in the second group. Also, the FEV1, FEV1/FVC and MEF25-75% were significantly higher in the second group. The results showed that obstructions were milder in the second group than in the first. A new approach is suggested to detect obstructions milder than Tr.OVD. This approach would be practical for use in mass epidemiological screening studies because its performance does not require complicated equipment.


Relationships between some oxygen and carbon dioxide indices in patients with chronic lung and cardiovascular diseases. A total of 281 patients were divided into groups according to their clinical diagnosis and were examined using capnography, spirometry and blood-gas analysis. The highest percentage of patients with arterial hypoxemia was found in the group with chronic bronchitis and emphysema. The same group had the highest number of patients with moderate hypoxemia and was the only group containing patients with severe hypoxemia. Alveolar hypoventilation and increased ventilation-perfusion ratio were most pronounced in patients with chronic bronchitis and emphysema. The greatest negative correlation between PaO2 and PaCO2 was found, again, in this group. We also found the greatest direct correlation between the oxygen and carbon dioxide gradients in this group. These results suggest that the relationships between the partial pressures of O2 and CO2 depend on the type of the pulmonary and cardiovascular diseases. The relationships between the partial pressures of O2 and CO2 as well as between their gradients, become stronger with the increase of the ventilation-perfusion ratio. The relationships between the expired alveolar gases are approximately the same as those of these gases in blood.


Studies on the plasma cholesterol and triacylglycerols in chronic methemoglobinemia in rats. Plasma cholesterol and triacylglycerols were measured in rats with modelled chronic two-stage (mild and moderate) intermittent nitrite methemoglobinemia for 15 and 30 days. It was found that at the moment of methemoglobinemic peak (60 +/- 10 min) the experimental animals had mixed (hemtoxic, anemic and hypoxic) hypoxemia. The every day "pulse" decrease of the total oxygen concentration during the 30-day methemoglobinemia was accompanied with a significant rise (p < 0.05) of cholesterol concentrations in the high-density lipoproteins and the total cholesterol, as well as a decrease in the amount of triacylglycerols. These changes are considered to represent the side effects of adaptation for whose elucidation further research is needed.


Effects of the butyric short-chain fatty acid on the bioelectric brain activity of rabbits. The effects of the butyric short-chain fatty acid, an agent with proved comagenic action, on the bioelectric brain activity of rabbits was studied. In all monopolar leads, paroxysms were recorded which manifested themselves 15 to 30 minutes after the infusion of butyrate. The analysis used F2 exogenic prostaglandins and indomethacin, an inhibitor of prostaglandin synthesis. It was found that the system for prostaglandin synthesis plays a role in the effects of butyrate.


The size and development of the ossification centers of the sternum in fetuses of cattle. Fetuses aged from 17 to 42 weeks were investigated. Using X-ray pictures the size of the ossification centers of the sternum were measured. In fetuses at 17 weeks all ossification centers of sternum are present.


Electron microscopic picture of pterygopalatine ganglion in the rat after hypothermia. Ultrastructure of the neurons of the pterygopalatine ganglion in two groups of rats with body temperature reduced to 22 degrees C and 18 degrees C of rectal temperature for periods of 3 hours, was examined. In both experimental groups various degree of cytoplasmic dispersion and widening of endoplasmic reticulum and cisterns of Golgi complex were observed. Nuclear envelope was often folded. In some mitochondria reduction of their crests and density of matrix and swelling were visible. Enlargement of the endoplasmic reticulum in the glial cells were also observed. The degree of ultrastructural changes in the group of animals cooled to the rectal temperature of 18 degrees C were more pronounced than in the group cooled to 22 degrees C.


The long colic nerves in human fetuses. I. Macroscopic studies. The long colic nerves were investigated in 50 fetuses aged 13 to 21 weeks. The long colic nerves arise from the pelvic nerves, pelvic plexuses, hypogastric nerves, and intermesenteric plexus. The nerves may take origin from two or three sources, and in most cases they arise from the pelvic nerves. They ascend along the sigmoid and descending colons reaching the left portion of the transverse colon.


Cytoarchitectonics of the nucleus of the lateral olfactory tract in the rat. The cytoarchitectonics of the nucleus of the lateral olfactory tract (NLOT) was studied on Nissl stained sections in 6 brains of adult Wistar rats by using morphometric methods. The neuronal density of layer III (11,866 +/- 547 mm-3) is on average about three times smaller than that of layer II (30,947 +/- 1110 mm-3). The average cross-section area of neurons in layer III (254.3 +/- 3.8 microns2) is about twice as large as that of neurons in layer II (115.8 +/- 0.8 microns2). The layer II is rather homogenous in contrast to layer III which possesses neurons of various size. Other morphometric parameters of layer II and III are also different.


Developmental anomalies of the cranial vena cava in the sheep and dog. It was found in sheep that the left cranial vena cava formed by two brachiocephalic veins terminated in coronary sinus together with left azygous vein and great as well middle cardiac veins. The right azygous vein escapes into right atrium. In dog two cranial venae cavae were observed. The right vena cava terminated in the right atrium, the left vena cava escapes together with cardiac veins into widened coronary sinus.


The application of the computation pattern for recording of a flexion creases alignment on the human fetus palms. We have investigated palm prints of 100 fetuses and palm prints of 8 human neonates. Flexion creases investigation have shown that creases alignment has a threefold form: independent, joining and crossing. To describe them we have used our own graphical recording of a triangle. This system widens and improves dactyloscopic methods of creases recording; it seems to be simple and versatile therefore it is proposed to implement it as per instruction.


The spinal nucleus of the accessory nerve in human embryos at stage 13. In 8 serially sectioned human embryos the spinal accessory nucleus was traced. It was found that the spinal nucleus of the accessory nerve extends as continuation of the medial part of the nucleus ambiguus in the cervical segments of the spinal cord to the 5th segment. The nucleus forms small group of cells lying dorsolaterally in the ventral horns. Fibers from the nucleus leave the spinal cord close to the sulcus limitans.


Early days in the St. Mary's Medical School Photographic Department: Part 1. This article gives an account of the problems which faced medical photographers in the late 1940s and early 1950s. The lack of suitable equipment particularly in regard to cinematography led to ingenious but laborious techniques. The attitude of teaching staff towards the use of lantern slides was coloured by the cumbersome apparatus of the period.


Non-accidental injury: photography and procedures. Medical photographers have a duty to produce high quality photographs of cases involving non-accidental injuries, which may be used as evidence in a court of law. The accurate recording of these inflicted lesions can have an influential role in any evaluation of child abuse. The abused child differs from the average clinical patient in many ways. This paper examines the photographic requirements together with legal and ethical issues paying particular attention to the photography of patterns of lesions in physical abuse. The recording of signs in emotional and sexual abuse is also discussed.


Medical Television Network--an expanding, interactive teleconference facility. Using proven satellite technology, Medical Television Network has set up a series of permanent UK receive sites for regular, interactive medical teleconferences. The format of the programmes regularly transmitted educates and updates busy doctors in fast-changing fields of medicine, encourages peer-group discussion, and enables the audience to question the expert faculty. This article describes the rationale for this development, the importance of shared 'ownership' with the postgraduate medical centres (PGMCs), the evaluation of audience response, and exciting areas for future growth and development.


Variable angle retinal nerve fibre layer photography: a review. Optic disc and retinal nerve fibre layer (RNFL) photography have been an integral part of the routine screening of glaucoma patients, ocular hypertensives and glaucoma suspects in Perth since 1979. During this period 60 degrees, 40 degrees, 30 degrees and 8 degrees angles of view were examined for potential use in RNFL photography. The degree of dilation and media opacity is highly variable in glaucoma patients because of the age group involved and the miotic therapy. It was found that the 30 degree angle of view gave the most consistent results for routine RNFL photography. Ocular hypertensives tended to be of a lower mean age and 40 degrees wide angle photography was possible but required two different photographic techniques and was not continued. Both 60 degrees and high-magnification RNFL photography are currently used only with selected patients for teaching and demonstration. A modified Hasselblad 120 roll film camera was used for high-resolution RNFL photography. The Hasselblad adaptors, high-resolution results and comparisons with wide-angle RNFL photographs are illustrated in this paper.


Viable myocardium identified by reinjection thallium-201 imaging: comparison with regional wall motion and metabolic activity on FDG-PET. Reinjection thallium-201 scans were performed in 68 patients with coronary artery disease after the routine stress-delayed scans for more accurate identification of new fill-in. Following the stress and 3 hour delayed thallium-201 SPECT scans, 40 MBq (1.1 mCi) was injected at rest, and 10 min later, the reinjection SPECT scan was obtained. To determine whether the reinjection method can aid in identifying ischemic but viable myocardium, the thallium-201 findings were compared with regional wall motion on radionuclide ventriculography in 61 patients and with metabolic activity on positron emission tomography (PET) using F-18 fluorodeoxyglucose (FDG) in 18 patients. The reinjection scan identified new fill-in which had not been shown on the stress-delayed scans in 6 of the 22 patients (27%) or in 29 of the 105 segments (28%). Regional wall motion was preserved more in the segments that exhibited new fill-in after reinjection (wall motion score = 1.64 +/- 1.29) than in those without new fill-in (score = 2.72 +/- 1.04) (p < 0.01). In the comparative study with FDG-PET, persistent FDG uptake was observed in all segments with new fill-in (20/20 segments: 100%); whereas, it was seen in only 7 of the 28 segments (25%) without new fill-in after reinjection (p < 0.05). We concluded that the segments having new fill-in after reinjection may represent ischemic but viable myocardium. Thus, the reinjection thallium-201 scan should be performed to identify ischemic myocardium which occasionally cannot be detected by the routine stress-delayed thallium-201 scans.


[Acute myocardial infarction: comparison of results of Tl-201, Tc-99m pyrophosphate and In-111 antimyosin Fab imagings]. To evaluate the extent and characteristics of infarct areas, we performed indium-111 monoclonal antimyosin Fab (InAM), thallium-201 (TL) and Tc-99m pyrophosphate (PYP) imagings in 17 patients with acute myocardial infarction, and tried to find out the mechanism that causes difference of these imagings. In each study, the extent scores as an index of the infarct area were obtained by single photon emission computed tomography (SPECT), and comparisons were made between the results obtained. The overlap between InAM and TL imagings obtained by SPECT was evaluated. Location, severity, extent and patterns of accumulation were compared between InAM and PYP with both planar image and SPECT. The extent scores of InAM correlated well with those of TL (r = 0.73, p < 0.01). However, the overlap of both methods was recognized in 8 of 17 patients, in whom wall thickness of the infarct area as obtained by echocardiography was well preserved. The left ventricular regional asynergy was mild in 6 of these 8 patients. Coronary angiography showed poor or no collateral circulation in these cases. Although there were generally close correlations of the extent scores between InAM and PYP, discrepancy was noted in 2 cases for location; 2 for severity, 5 for extent, and 3 for patterns of accumulation. These differences may be attributed to the timings of imaging, coronary reperfusion and different mechanisms of accumulation. In conclusion, the extent of acute myocardial infarction obtained by InAM correlates well with those obtained by TL and PYP, with some exceptions.


[Three-dimensional display and its quantification of exercise stress myocardial tomography using thallium-201]. For accurate and stereoscopic delineation of the location and extent of perfusion abnormality by exercise stress myocardial emission tomography using thallium-201, three-dimensional myocardial images (3D image) were reconstructed from ordinary tomograms. We also quantitated perfusion abnormality, with myocardial thickness taken into consideration. We evaluated the usefulness of these 2 methods in patients with coronary artery disease (CAD). Sixty-one patients with 75% or more narrowing of at least one of their major coronary arteries were studied. Myocardial imaging was performed with thallium-201 immediately after exercise stress, and 3 hours thereafter (redistribution) using a rotating gamma camera. We reconstructed 3 routine oblique images and bull's eye maps which included myocardial thallium-201 washout rate maps. In addition to visual interpretation, washout rate abnormality (< 30%) was used as a criterion for exercise-induced myocardial ischemia. For reconstruction of 3D image, we used short-axis images. To identify the cardiac surface, an appropriate count threshold level was determined and image elements exceeding the threshold level were considered the cardiac surface. The heart was observed from 16 points around it and the brightness of the cardiac surface was adjusted in accordance with the distance between the observation point and the cardiac surface. Gradient shading was added and a stereoscopic 3D image was obtained. For the quantitative analysis of the perfusion abnormality, we selected short-axis images. By approximating each short-axis image using 2 circles which contacted the epicardial and endocardial surfaces, we readily calculated the total left ventricular myocardial voxel numbers and the perfusion abnormality voxel numbers. The ratio between these 2 parameters was expressed as % defect. The sensitivity of the 3D image for detecting CAD was 84%, which was similar to that of routine oblique images and the bull's eye method. We also detected the location and extent of perfusion abnormalities and their changes between exercise stress and redistribution in real size and stereoscopically. In patients who had initial myocardial infarction and one-vessel disease but no exercise-induced additional perfusion abnormalities, % defect correlated linearly with the left ventricular ejection fraction (r = -0.85, p < 0.005) and the peak level of the serum cardiac myosin light chain I in the acute phase of myocardial infarction (r = 0.81, p < 0.01). In addition, the relationship between % defect and the number and/or location of coronary artery stenosis in 22 patients with CAD, in whom exercise-induced perfusion defects had completely resolved at redistribution, showed that % defect is a useful indicator for quantitating perfusion abnormalities. In conclusion, the extent of perfusion abnormalities can be expressed in the unit of gram with this method.


[Importance of lipoprotein(a) in patients with ischemic heart disease]. Elevated levels of lipoprotein(a) [Lp(a)] have been associated with an increased risk of ischemic heart disease (IHD), and higher levels of Lp(a) are associated with lesions of significantly greater severity. We have examined Lp(a), total cholesterol (TC) and high density lipoprotein-cholesterol (HDL-C) levels in patients with IHD including those with normal coronary arteries with vasospastic angina. The study population consisted of 206 patients (166 males and 40 females) who underwent diagnostic coronary angiography for known IHD. Twenty-eight patients had effort angina, 36 rest angina, 8 unstable angina and 134 old myocardial infarction. IHD patients were categorized as zero vessel disease (0VD), single vessel disease (SVD) and multi-vessel disease (MVD). To investigate the relationship between atherosclerosis and IHD, these patients were further divided into 3 groups based on angiographic findings. Eighteen patients had entirely normal coronary arteries (normal group), 24 discretely diseased coronary arteries (discrete group) and 80 diffusely diseased coronaries (diffuse group). The results were compared with those obtained from 50 healthy individuals. Lp(a) levels for IHD patients (12.4 mg/dl) were significantly higher than those of controls (7.1 mg/dl, p < 0.05). However, there were no statistical differences between 0VD (13.1 mg/dl) and MVD (12.8 mg/dl). Similarly, no statistical differences of Lp(a) values were found among the normal group (13.3 mg/dl), discrete group (12.0 mg/dl) and diffuse group (12.9 mg/dl). Mean levels of HDL-C in 0VD (51.3 +/- 13.5 mg/dl) were significantly higher than those of SVD (42.9 +/- 11.5 mg/dl, p < 0.05). However, no significant differences were observed between controls (59.5 +/- 15.3 mg/dl) and 0VD (51.3 +/- 13.5 mg/dl).(ABSTRACT TRUNCATED AT 250 WORDS)


Prominent negative T waves with QT prolongation indicate reperfusion injury and myocardial stunning. To observe the clinical course after reperfusion and recovery from myocardial stunning of the left ventricular anterior wall, we prospectively reviewed and analyzed cardiac enzymes, ECG changes, echocardiograms, and cineangiograms in 8 patients with the acute ischemic syndrome who fulfilled the following criteria: 1) no history of previous myocardial infarction, 2) repeated and/or prolonged episodes of chest pain, 3) critical stenosis of the left anterior descending artery with wall motion abnormalities, 4) successful emergency percutaneous transluminal coronary angioplasty, and 5) normal wall motion on repeat cineangiography 4 to 8 weeks later. Creatine kinase (CK) and/or its cardiac isoenzyme (CK-MB) were minimally elevated in all cases. Wall motion was normalized with the reduction of end-systolic volume (end-diastolic volume: from 139 +/- 25 to 140 +/- 37 ml, ns, end-systolic volume: from 68 +/- 16 to 39 +/- 13 ml, p < 0.001, ejection fraction: from 51 +/- 6 to 71 +/- 6%, p < 0.001). Serial echocardiograms showed normalization of wall motion within 4 to 28 days. T wave inversion in the left precordial leads developed 30 min to 5 hours after the cessation of chest pain or successful reperfusion, and prominent negative T waves (1.6 +/- 0.6 mV) with QT prolongation (0.56 +/- 0.08 sec) in V3 or V4 reached their peak values within one to 5 days. ECG abnormalities resolved after 21 to 95 days. These ECG findings may indicate reperfusion injury and the presence of myocardial stunning in the anterior wall of the left ventricle.


[Left ventricular volume decrease during isovolumic relaxation period in gated blood pool scintigraphy: observations in patients with old myocardial infarction]. We studied left ventricular (LV) volume decrease, namely, the downward displacement of the LV volume curve, during the isovolumic relaxation period on the time-activity curves obtained from gated blood pool scintigraphy in patients with old myocardial infarction (OMI). To evaluate the mechanism and clinical significance of this phenomenon, 113 consecutive patients with OMI undergoing gated blood pool scintigraphy, left ventriculography, and Doppler echocardiography were studied. 1. This phenomenon was observed only in patients with anterior OMI (13 of 51 patients: 25%). Presence (Group I) or absence (Group II) of this phenomenon was examined. 2. On left ventriculography, dyskinetic or aneurysmal wall motion was observed in the anterior or apical region more frequently in Group I (11 of 13 patients: 85%) than in Group II (20 of 51 patients: 39%) (p < 0.001). 3. Doppler echocardiography showed that the presence of abnormal LV reversed flow over 20 cm/sec from the apex to the base during the isovolumic relaxation period is more frequent in Group I (7 of 13: 54%) than in Group II (4 of 51: 8%) (p < 0.001). These results suggested that this blood shift in the left ventricle is attributed to asynchronous LV relaxation occurring simultaneously with LV volume decrease on gated blood pool scintigraphy. In conclusion, this phenomenon suggests the presence of asynchronous LV relaxation.


[The relation of physical and mental stress to magnesium deficiency in patients with variant angina]. In this study we assessed the role of psychological factor in the etiology of coronary vasospasm using the Cornell Medical Index (CMI), focusing attention on the relationship between stress and serum magnesium (Mg). The study subjects consisted of 25 patients with variant angina (VA), 32 with old myocardial infarction without vasospasm (OMI), and 34 healthy men (controls). On a neurosis-discriminative diagram of CMI, areas I and II were considered as normal and areas III and IV were considered to be a neurotic disorder. The stress test included exercise and a quiz. Exercise test was performed in 8 patients with VA, 6 with OMI, and 5 controls, and a quiz was given to 4 patients with VA. Plasma catecholamines [noradrenaline (NA), adrenaline (Ad), dopamine], aldosterone, adrenocorticotropic hormone (ACTH) and serum electrolytes (Mg, Ca, Na, K, Cl) were measured before and after exposures to stress. The following results were obtained: 1) Of the patients with VA, 40.0% were categorized as area III or IV, compared to 18.7% of the patients with OMI, and 2.9% of the control subjects. 2) Among patients with VA, 64.0% exhibited anxiety states compatible with a psychological disorder. 3) NA and Ad were increased after exercise stress. 4) Serum Mg and Ca were also increased after exposure to exercise stress in all groups, and the degrees of these changes were correlated to the exercise intensity. The %delta Mg/%delta NA ratio, a parameter of the effect of catecholamine on the serum Mg, was greater in patients with VA than in those with OMI and the controls.(ABSTRACT TRUNCATED AT 250 WORDS)


[Effects of isosorbide dinitrate on coronary and systemic circulation in children: comparison with dipyridamole]. The effects of isosorbide dinitrate (ISDN) on the coronary and systemic circulation were evaluated in comparison with the effects of dipyridamole (DP) in 8 children with histories of Kawasaki disease and angiographically normal coronary arteries. ISDN (100 micrograms/kg) was administered as an intracoronary injection. DP was administered intravenously at the rate of 0.56 mg/kg for 4 min. In the coronary circulation, DP induced a significant reduction of the afterload, resulting in an increase in cardiac output. However, the pulmonary artery pressure, pulmonary capillary wedge pressure and left ventricular end-diastolic pressure, which are related to the preload, were significantly reduced one min after the ISDN injection. The systolic blood pressure was reduced, while the heart rate was increased. The cardiac output, pressure-rate product or systemic vascular resistance showed no significant change. The systolic work index, however, was significantly reduced. In the coronary circulation, DP significantly increased the coronary sinus blood flow due to dilatation of the resistant vessels. However, ISDN significantly dilated the conductant vessels by 4.0 to 12.9% in diameter. There was, however, no change in the coronary blood flow, coronary perfusion pressure nor coronary vascular resistance. The grade of dilatation of the coronary vessels caused by ISDN was lower in children than in adults.


[The effects of intracoronary injection of nitroglycerin on the coronary circulation: evaluation using a Doppler catheter]. To evaluate the effects of intracoronary injection of nitroglycerin (NTG) on the coronary circulation, we measured the flow velocity of the coronary artery using a Doppler catheter. The Doppler catheter was introduced into the region proximal to the left anterior descending artery (LAD) via an 8F guide catheter positioned at the orifice of the left coronary artery. We measured the flow velocity at a point of 3 mm distal to the catheter tip. One mg (2 ml) of NTG was injected via the 8F guide catheter for 10 sec, followed by injection of 3 ml of normal saline. Then the increasing rate of the diastolic coronary flow velocity in the LAD was calculated. Five ml of iopamidol (dye) was also injected for comparison. The subjects consisted of 14 normal persons (G-N), and 12 patients with angina pectoris accompanying critical stenoses of the LAD, who had no ECG changes or no abnormalities by left ventriculography. The subjects with angina pectoris were subclassified as 90% stenoses (G-A: 5 patients), and 99% stenoses (G-B: 7 patients) in the LAD. 1. After intracoronary injection of NTG, the aortic pressure dropped to various degrees in G-N. In 7 of the normal subjects, who had less than a 20% aortic pressure drop, the increased diastolic flow velocity was more rapid than the control diastolic flow velocity 30 sec after the peak velocity.(ABSTRACT TRUNCATED AT 250 WORDS)


[Effects of exercise training on restoration of residual myocardial ischemia after percutaneous transluminal coronary angioplasty]. The effects of exercise training on the restoration of hibernating myocardium after percutaneous transluminal coronary angioplasty (PTCA) were evaluated. Symptom-limited treadmill exercise with thallium-201 myocardial single photon emission CT (SPECT) was performed at one and 13 weeks after PTCA in 15 patients with training and in 15 control patients without training who had no restenosis on repeat angiography. For quantitative analysis, counts for the regions of interest (ROI) were calculated in the hypoperfused area on the polar map. Percent T1 uptake was determined by dividing counts of the hypoperfused area by counts of a normal reference area on the initial image (%IU) and delayed image (%DU). The difference between %DU and %IU, defined as percent redistribution (%RD), was a parameter of residual ischemia in the hypoperfused area. %DU increased significantly in the trained group (65 +/- 11 to 73 +/- 9.3%, p < 0.01) and in the untrained group (66 +/- 14 to 70 +/- 15%, p < 0.05). %RD decreased significantly in the trained group (6.3 +/- 3.2 to 2.8 +/- 2.3%, p < 0.01); whereas, there was no significant change in the untrained group (6.1 +/- 2.8 to 5.2 +/- 3.8%). These findings suggest that, after successful PTCA, exercise training helps alleviate myocardial ischemia, probably by fostering the promoting effects which restore the hibernating myocardium.


[Percutaneous transluminal coronary angioplasty and coronary bypass grafting for refractory angina in chronic dialysis patients]. Between June 1983 and July 1989, 25 consecutive chronic dialysis patients with medically refractory angina pectoris underwent revascularization, either percutaneous transluminal coronary angioplasty (PTCA) or coronary artery bypass grafting (CABG) (21 males and 4 females, mean age of 57 +/- 10 years, and mean duration of dialysis of 3.7 +/- 5.0 years). Patients with single-vessel disease and/or mildly calcified lesions received PTCA (n = 15), while those with multi-vessel disease and/or severely calcified lesions received CABG (n = 10). As controls for PTCA-treated dialysis patients, 208 non-dialysis patients who received initial PTCA in 1988 were used. The mean number of diseased vessels was 2.7 +/- 0.7 for CABG group, and 1.5 +/- 0.8 for PTCA group (p < 0.01). In both groups, 80% of patients were successfully revascularized. In CABG group, however, 7 of 10 patients had major complications including 2 hospital deaths, while no complications occurred in the PTCA group. During the follow-up period after CABG (35 +/- 30 months), recurrent angina developed in one patient, who was successfully treated with PTCA. In the PTCA group, angiographic success was initially obtained in 16 of 21 lesions (76%), which was significantly lower than that in the control group (92%, p < 0.05). Follow-up angiography revealed restenosis in 6 of 16 lesions with successful PTCA (38%), similar to that observed in the control group (32%, p = ns). A second PTCA was successful in 5 of 6 patients with restenosis, however, 4/5 patients developed recurrent angina. Three of 4 patients with a second episode of restenosis underwent a third PTCA, and angina recurred in 2.(ABSTRACT TRUNCATED AT 250 WORDS)


[Silent myocardial ischemia in myocardial infarction patients: its prognostic significance]. To evaluate the prognostic and clinical significance of silent myocardial ischemia (SMI), we examined cardiac events in 160 patients with old myocardial infarction who underwent ambulatory Holter monitoring, treadmill exercise testing and coronary angiography. Using the Cox's proportional hazard regression model and the survival curves with the Kaplan-Meier method, we identified the predictors of cardiac events. The incidence of cardiac events for all the patients during the 44-month follow-up period was 18%. The significant predictors of unfavorable outcomes were severe coronary lesions and SMI. The incidence of SMI was 38%. The cardiac event rate in patients with SMI was higher than in those without SMI (32 vs 9%, p < 0.05). The most frequent cardiac event in patients with SMI was reinfarction, and the significant predictors of cardiac events for these SMI patients were lower ejection fraction and maximum ST depression on Holter monitoring. In conclusion, SMI proved to be a significant predictor of unfavorable outcome in patients with old myocardial infarction. It was, therefore, suggested that revascularization (PTCA/CABG) should be used as early as possible in patients with SMI whether anginal symptoms are present or not.


[Relationship between left ventricular systolic function and the myocardial gray level distribution in patients with idiopathic dilated cardiomyopathy]. Dilated cardiomyopathy (DCM) is characterized by progressive left ventricular (LV) systolic dysfunction of nonspecific etiology. Fifty-nine DCM patients were serially observed by echocardiography for 4.5 +/- 2.6 years, and 7.3 +/- 3.4 times M-mode and two-dimensional echocardiography was performed during the observation period using SSH-11A (Toshiba). To assess LV systolic function, ejection fraction was calculated by Pombo's method. Myocardial gray level distribution shown by echocardiography was calculated to assess the myocardial tissue character. Two-dimensional echocardiographic images were obtained in the parasternal short-axis view, recorded on U-matic videotape, and transferred to an image processing computer system (MIPRON, Kontron). The images were digitized and stored on the computer. The regions of interest (ROI) were placed in the LV septum, posterior papillary muscle, posterior wall, anterior papillary muscle and entire LV wall. The gray level distributions in each ROI and its quantitative parameters (mean, SD, skewness, excess) were calculated. The corrected myocardial gray level of every ROI (CMD) was also calculated and expressed as the ratio to the mean gray level of the LV cavity. Seven patients exhibited significant decreases in ejection fraction (more than 10%) during the observation period (group A); the remainders showed less change (group B).(ABSTRACT TRUNCATED AT 250 WORDS)


Risk factors and the effects of xamoterol in idiopathic dilated cardiomyopathy. A long-term follow-up study was performed for 110 patients with idiopathic dilated cardiomyopathy (DCM) for 34 +/- 12 months (range 3-122 months). Thirteen patients died of heart failure, 15 of sudden death and one of non-cardiac death. The 3- and 5-year survival rates were 78 and 62%, respectively. The important factors in predicting the 3-year survival rate were left ventricular end-diastolic volume index (LVEDVI > or = 150 ml/m2 = 66%, < 150 ml/m2 = 93%, p < 0.01), myocardial cell diameter (> 25 microns = 42%, < or = 25 microns = 87%, p < 0.05) and sustained ventricular tachycardia (VT present = 32%, absent = 85%, p < 0.01). In a prospective study, 26 patients with DCM were given a beta 1-partial agonist, xamoterol (200 mg daily) and were followed for 35 +/- 15 months (6-53 months). The cardiothoracic ratio, left ventricular end-diastolic dimension and exercise heart rate decreased, and the exercise duration, fractional shortening and ejection fraction increased after xamoterol therapy. The 3-year survival rate was 83%. These results suggest that the important factors in predicting the survival rate of DCM patients were LVEDVI, myocardial cell diameter and the occurrence of VT. Adjunctive xamoterol therapy in DCM had a beneficial effect on hemodynamics and symptoms.


Systolic and diastolic left ventricular dysfunction in middle-aged asymptomatic non-insulin-dependent diabetics. Radionuclide ventriculographic studies were performed at rest and during exercise in 15 middle-aged asymptomatic patients with non-insulin-dependent diabetes mellitus (NIDDM) whose mean age was 58.7 +/- 10.5 years (mean +/- SD), and in 10 age- and sex-matched normal control subjects. The patients had neither clinical evidence of cardiovascular diseases nor obvious perfusion defects during maximal exercise testing with thallium-201 myocardial scintigraphy. The average left ventricular ejection fraction (LVEF) at rest was 69.1 +/- 5.3% in the diabetic patients and 65.6 +/- 4.2% in the control subjects, and during exercise, the average LVEFs were 68.3 +/- 6.9% and 72.1 +/- 5.0%, respectively. The changes in LVEF during exercise were -0.7 +/- 7.6% in the diabetic group and +6.5 +/- 2.6% in the control group (p < 0.01). However, the filling fraction during the first third of diastole at rest was significantly less in the diabetic group than in the control group (p < 0.05), the time to peak filling rate (TPF) was longer, and the TPF/R-R, normalized by the R-R interval and expressed as a percentage, was greater in the NIDDM patients than in the control subjects. There was close correlation between the abnormal response of LVEF to exercise and the reduced early diastolic filling in the diabetic patients. We concluded that 1) not only the response of LVEF to exercise but also the early left ventricular diastolic filling at rest are impaired in middle-aged asymptomatic NIDDM patients, and 2) some common factors could cause dysfunction of both the systolic and diastolic left ventricles in NIDDM patients, possibly latent global myocardial ischemia or metabolic myocardial disturbances.


[Response of coronary arteries to intracoronary acetylcholine infusion in patients with familial hypercholesterolemia]. Loss of the vasodilator response to acetylcholine (Ach), an endothelium-dependent vasodilator, has been demonstrated in animal models of atherosclerosis and in atherosclerotic coronary arteries of humans studied in vitro. The response of normal coronary arteries on angiograms to the intracoronary injection of Ach in patients with familial hypercholesterolemia (FH) was studied. Ten patients with FH (mean age, 53.6 +/- 6.5 years) with a mean serum total cholesterol of 334.8 mg/dl and 12 controls (mean age, 55.8 +/- 14.5 years) with a total cholesterol level of 183.6 mg/dl, and with normal coronary arteries on angiograms were studied. Patients with clinical histories suggestive of coronary spastic angina were excluded from this study. A bolus of 20, 50 micrograms Ach and 2 mg isosorbide dinitrate (ISDN) were infused into the left coronary artery in each subject. Changes in coronary diameters were measured after each injection with a videodensitometric analysis system. In the control group, the diameter at the middle segments of the left anterior descending artery (LAD) and at the proximal and middle segments of the left circumflex artery (LCX) increased significantly in response to Ach; whereas, in the FH group the diameter at the proximal segments of the LAD decreased significantly. There were significant differences in the coronary diameter changes in response to 50 micrograms Ach at the proximal and middle segments of the LAD and the LCX between the 2 groups. In contrast, between these 2 groups, there were no significant differences in the vasodilator responses to ISDN, a direct vascular smooth muscle dilator. The vasodilator response of coronary artery to Ach was diminished in patients with FH.


[Echocardiographic assessment for surgical treatment in patients with aortic stenosis]. The diagnostic value of preoperative echocardiography was assessed in 51 patients with aortic stenosis. We measured 1) left ventricular-aortic pressure gradient (LV-Ao PG), 2) aortic valve area (AVA), 3) grade of LV hypertrophy and function, and 4) aortic annulus diameter for determining the availability and size of a prosthesis. The maximal instantaneous PG (max-PG) by continuous-wave (cw) Doppler echocardiography correlated well with the peak-to-peak PG by cardiac catheterization (cath), and their correlation equation was y = 1.49 x -48.3 with a correlation coefficient of 0.90. Excellent correlations were also found between cw-max PG and cath-max PG (r = 0.84), and between cw-mean systolic PG and cath-mean systolic PG (r = 0.80). The AVA of the echocardiogram, which was derived from the stroke volume using Gibson's M-mode echocardiographic formula and the cw-Doppler echocardiographic mean gradient, correlated well with the AVA of the cardiac catheterization using Gorlin's formula (y = 1.33 x -0.61, r = 0.79). Preoperative LV pump function, which was obtained from the M-mode echocardiogram, correlated inversely with end-systolic wall stress, and a depressed LV pump function was observed in patients with inadequate hypertrophy. In such patients, however, depressed function was alleviated after surgical treatment. Thus, we considered that cardiac catheterization for further examination is unnecessary, even in such patients. To determine the available size of the prosthesis, measurement of the inner diameter of the aortic annulus on the long-axis cross-sections was the most useful.(ABSTRACT TRUNCATED AT 250 WORDS)


[Influence of systolic left ventricular blood flow direction on genesis of senile calcification of the aortic valve]. To assess the factors which may initiate and accelerate degenerative senile calcification of the aortic valve, two-dimensional echocardiograms and the clinical characteristics of 259 consecutive cases with senile calcification of the aortic valve were studied. The results were compared with those of similar studies among 186 consecutive cases with the normal aortic valves. An aortic cusp with an area of increased echo greater than 3 mm in width and with decreased pliability was regarded as calcified. Among patients with calcification of one aortic cusp, 114 exhibited calcification of a noncoronary cusp, 17 calcification of the left coronary cusp and 3 calcification of the right coronary cusp (p < 0.001). Among patients with calcification of 2 aortic cusps, 39 had calcification of a noncoronary and left coronary cusps, 3 calcification of the left and right coronary cusps and 16 calcification of the right and noncoronary cusps (p < 0.001). In patients with calcification of their aortic valves, the end-diastolic angle between the interventricular septum and the ascending aorta was 102 +/- 10 degrees; whereas, it was 89 +/- 10 degrees in the control group (p < 0.001). There were no differences in frequency of aortic root calcification, mitral annular calcification, hypertension, ischemic heart disease, hyperlipidemia, hyperuricemia, or hyperglycemia, between patients with and without calcification of their aortic valves. Of the female patients ranging in age from 65 to 74 years, 88% in those with calcification of 3 cusps and 30% in those with calcification of one cusp (p < 0.05) had mitral annular calcification.(ABSTRACT TRUNCATED AT 250 WORDS)


[The pitfalls in the clinical diagnosis of dissecting aortic aneurysm]. It is sometimes very difficult to diagnose dissecting aortic aneurysms (DAA), particularly in its early stage, due to manifold signs and symptoms. The purpose of this study is to clarify the reasons for such erroneous diagnoses. A total of 41 patients with DAA were referred to our hospitals for further examination and/or surgery from April 1986 to August 1989. In 18 of these patients, the diagnostic possibility of an underlying DAA was overlooked by the referring physicians. Among these 18 patients, 2 were mistakenly diagnosed as uncomplicated myocardial infarction (MI), one as pneumonia, 2 as cerebral infarction, 6 as acute abdominal disease, one as cholelithiasis, 5 as thrombosis of the lower extremities, and one as malignant metastasis to the pericardium. The following is the detail: In 2 cases thought to be uncomplicated MI, an expanding dissecting ascending aorta had crushed the lumen of the left coronary artery, causing MI, in turn, wasting clinical treatment and consuming precious time. In one case, enlargement of the descending aorta on the chest radiography was overlooked and the patient's symptoms were mistakenly attributed to pneumonia. In 2 cases in which symptoms of cerebral ischemia were thought to be attributed to cerebral thrombosis, the real cause turned out to be occlusion of the brachiocephalic artery following aortic dissection. Among 6 cases which were initially considered to have only acute abdominal disease, 3 presented with symptoms and signs of ileus, and their exploratory laparotomies yielded no positive findings.(ABSTRACT TRUNCATED AT 250 WORDS)