HIV and AIDS among adolescents in the United States: increasing risk in the 1990s. Acquired immunodeficiency syndrome (AIDS) and human immunodeficiency virus (HIV) are growing problems among U.S. adolescents. By examining recent data on AIDS surveillance and HIV seroprevalence, surveys on teenagers' knowledge, beliefs, and behaviors related to HIV/AIDS, key treatment issues, and barriers to prevention, this manuscript reviews the problem and proposes possible ways of combating it. African American youth have the highest rates of AIDS and white youth the lowest. However, the largest number of AIDS cases overall has been recorded in white males, reflecting relatively high case rates in boys with hemophilia and in young male homosexuals. Predominant HIV risk factors for adolescents are unprotected sex and/or sharing injection drug equipment with an infected partner. Relatively high rates of HIV infection in adolescent females may indicate their greater physiological vulnerability than adult females to sexually transmitted diseases (STDs). Data from HIV seroprevalence studies suggest a substantially increased heterosexual epidemic in the 1990s, especially in large east coast cities and southeastern rural areas where drug use and/or STDs are highly prevalent. More comprehensive prevention and treatment services are needed to prevent ongoing expansion of HIV infection and AIDS in the adolescent age group.


Sexuality and AIDS: attitudes and behaviors of adolescents in east and west Berlin. The study which was conducted in 1990 in Berlin, Germany, compares two samples of 542 adolescents from West Berlin and 340 from East Berlin. The present investigation shows that the general trend toward sexual liberality among adolescents is continuing and that necessary processes of adolescent sexual development appear not to be influenced by the threat of AIDS. Though the level of knowledge about the threat of AIDS is, on the whole, satisfactory, this does not in itself guarantee determined and consistent AIDS-preventive behavior. Fewer than one-third of sexually-active adolescents, and even fewer than one-fourth of those in the most sexually-active group, can be described as consistent users of condoms. The attitudes of adolescents in regard to contraceptive characteristics only partly suggest a preference for condoms. When adolescents are asked directly about condoms, they additionally emphasize their effect of reducing feeling and pleasure. Adolescents with experience of sexual intercourse rate condoms more negatively than do those without such experience. However, AIDS-education efforts can make use of the fact that consistent condom-users expressed clearly more positive attitudes to condoms than did others. Although the comparison between East and West Berlin adolescents yielded differences in certain details, these differences are not of significance to AIDS-education programs which seek to increase AIDS-preventive behavior.


The AIDS awareness and sexual behaviour of young people in the South-west of England. A programme of surveys was undertaken in collaboration with District Health Authorities to assess the AIDS awareness and sexual behaviour of young people, in order to help the development and implementation of HIV/AIDS risk-reduction strategies. Given that the patterns of findings were strongly replicated in the different districts, the data is presented in terms of a combined data set comprising 2955 respondents aged 16-24. The surveys indicate fairly reasonable levels of knowledge about HIV/AIDS but very low personally perceived vulnerability to infection. The sexual culture is one of fairly early ages of first intercourse, moderate levels of partner change and low (one third) levels of condom use. The findings are discussed in terms of their implications for HIV/AIDS risk-reduction strategies.


The social context of adolescent sexuality: safe sex implications. This study was an examination of the sexual worlds of 153 adolescents aged 15 to 18 years through the content analysis of interviews on the topics of love, romance, relationships between the sexes, sexual values and sexual behaviors. The aim was to develop more detailed descriptions of the dimension of adolescent sexuality and relate these dimensions to sexual risk, that is, the tendency to engage in unprotected intercourse, an activity which increases vulnerability to AIDS and other sexually transmitted diseases. To this end, seven themes were isolated from the interview scripts, these being permissiveness, double standards, belief about sexual control (the Id Factor), romance, regrets about permissiveness, sexual aggression, and questioning. Measures of four of these themes were constructed, and sex and sub-group differences explored, as were the relationships between themes and sexual risk. The implications of different "pathways" to sexual risk-taking were discussed.


Self-control and ego identity development as predictors of unprotected sex in late adolescent males. Male college students completed an anonymous self-report questionnaire assessing HIV-related knowledge, attitudes, moral development, personality factors and behaviors. Bivariate analyses were used to identify factors associated with high-risk sexual intercourse. Significant demographic psychosocial and behavioral predictors were entered into a logistic regression analysis to evaluate the independent influence of each predictor on unprotected sexual intercourse. Behavioral factors were the most powerful predictors of unprotected sexual intercourse. Adolescents reporting multiple sex partners, drinking and picking-up sex partners were significantly more likely to engage in sex without condoms. Examining psychosocial factors alone, it was found that adolescents who had low scores for ego-development (goal-directedness) and self-control were significantly more likely to engage in sex without condoms. Identification of two personality constructs as underlying predictors of high-risk behavior, while potentially important for the development of effective HIV prevention programs, needs corroboration to further define the interrelationships between these factors and other psychosocial constructs.


Sex education: more is not enough.

Sex education: more is not enough. Increasing demands for sex education have been associated with a plethora of recommendations, regulations and resources with resulting variability of content, strategy, quality and outcome. While numerous studies confirm that the health behaviour of teenagers is not altered by the teaching of facts alone, other data suggest that appreciation of personal risk and learned assertiveness skills are associated with changes in population behaviours. Peer led teaching is a powerful and probably essential component of school health and sex education. Evaluated interventions with agreed purpose and acceptable methodologies are essential if there is to be any real expectation of health benefit from sex education.


Adolescent coping behavior when confronted with a friend with AIDS. The coping strategies employed by adolescents (n = 871) when presented with a hypothetical situation of a friend with AIDS were examined. Adolescents reported a wide range of imagined responses that were generally adaptive. Girls more than boys and distressed students more than nondistressed students were likely to endorse adaptive coping items. Comparison of the students with a separate sample (n = 472) that responded to a hypothetical situation of a suicidal peer revealed more distress in girls for the AIDS problem and more distress in boys for the suicide problem, contrary to expectations. Adolescents were more distressed and endorsed a wider variety of coping strategies in response to the AIDS scenario than to the suicide problem. Implications for care of adolescents dealing with these significant issues are discussed.


The basics of decision analysis.

The basics of decision analysis. Historically, decision analysis (DA) arose from economics, psychology, and statistics. Medical and dental applications have developed over the past two decades. While decision psychology explores how people make their decisions, the DA process involves construction of a model and development of insights into the strengths and uncertainties about recommendations derived from analysis of model outputs. Uncertainties are represented as probabilities and values are assigned to desirable or adverse outcomes according to preferences expressed by the decision maker. The model unifies probabilities and values by calculation of the expected value for each decision choice. The decision maker can improve his or her insight into uncertainties in the model by conducting sensitivity analyses, and can take action based on this improved insight. The DA process is illustrated using the decision to take or skip influenza vaccination. People's decision making behavior for this problem has also been analyzed using methods from decision psychology. Distinctions between clinical DA and cost-effectiveness analysis are given, as are caveats about especially complicated subtopics in decision analysis for medical problems. In closing, opportunities for further study of decision analysis are presented.


Psychology and decision making: modelling health behavior with multiattribute utility theory. The success of much of dental practice is linked to patient behavior. Understanding the issues that influence patients' decisions when they choose to not follow preventive or therapeutic dental recommendations is instrumental to improving adherence, and ultimately, to improving dental health outcomes. Multiattribute Utility Theory (MAU) provides a methodology for systematically exploring these issues. It is based on a well-established body of knowledge in the psychological literature, and currently represents a state-of-the-art model for predicting behavior and delineating potentially modifiable behavioral determinants. Two examples are presented to illustrate how MAU can be used in clinical settings. In the first example, MAU is used to identify key reasons why nearly 70 percent high-risk patients did not obtain flu shots, a behavioral problem comparable to many confronted in dentistry. MAU correctly predicted the vaccination behavior of 82 percent of patients, and an intervention based on MAU findings nearly doubled vaccination rates. The second example used MAU to identify physician behaviors that influenced patients' satisfaction with an ambulatory care visit. MAU findings from this study identified specific behaviors in a provider's style that if modified may improve patient satisfaction. These MAU applications also emphasize the importance of soliciting the patient's perspective in clinical interactions since some of the most important determinants of patient behavior are not represented in traditional clinical decision models.


Legal considerations in clinical decision making. Decision analysis has wide application across disciplines. The purpose of engaging in formal analysis is to enhance the understanding and description of problems, aiding the decision maker to be more explicit and more comprehensive in the search for a preferred course of action. Legal considerations arise out of clinical decisions. The legal implications are illustrated with actual applicable issues arising out of current dental litigations.


Decision analysis in restorative dentistry. Standardization of clinical decisions in restorative dentistry should be based on the tenets of the Hippocratic Oath. Although there is wide variability in preventive and operative treatment decisions, some of these decisions may lead along parallel courses to similar, clinically ethical outcomes. However, what parameters must be considered in judging the relative magnitude of positive and negative outcomes? This paper proposes several decision-making strategies for selecting optimum treatment plans for preventive and restorative situations. The caries-risk level of patients must first be identified in a systematic way and then it must be coupled with treatment options that are consistent with the potential future caries increment. A decision-tree approach and/or the treatment-index concept can then be applied to specific clinical conditions and preventive-restorative options to derive an "expected value" for each possible outcome.


Clinical decision making for temporomandibular disorders. Temporomandibular Disorders (TMD) encompass a number of clinical problems that involve the masticatory musculature, the temporomandibular joint (TMJ), or both. In any given patient, there exists the possibility of several overlapping TM disorders, an orofacial pain condition mimicking a TMD, or a concomitant TMD and non-TMD disorder. Since differential diagnosis involves the determination of which diseases or disorders a patient is suffering from by systematically contrasting the clinical characteristics, differentiation from among multiple possible conditions complicates the diagnostic process, which often must be approached with a certain degree of uncertainty. In addition, the therapeutic decisions that emanate from the diagnostic process have their own predictive uncertainties. These uncertainties can be ameliorated by coupling available clinical research data with structured clinical problem solving methods during the diagnostic-therapeutic decision making process. It is within this context that this article includes a discussion of the rationale for why the clinician should use decision making methods for TMD, a review of previous attempts at developing decision models for TMD, a discussion of the diagnosis of TMD with particular emphasis on the reliability and validity of their diagnostic criteria, a summary of the efficacy of therapeutic modalities and their application to treatment decisions, a sample decision tree analysis of a TM disorder, and some general recommendations for dental education.


Decision making in radiographic imaging. In 1987, the U.S. Department of Health and Human Services issued guidelines for prescription of dental radiographic examinations, and although these recommendations have been reprinted in several widely circulated publications, it seems that the adoption of these guidelines is far from common, even among U.S. dental schools. The recommended criteria are founded on the existing knowledge of prevalence and progression of the most common dental diseases and on the fact that occult diseases within the jaws are uncommon. There are, however, other factors that may influence the decision on the time and extent of a radiographic examination, which may lead to deviations from the suggested guidelines. These factors include: education, peer influence, patient's preference, legal considerations, the dentist's field of interest or specialty, the training of the staff, and practice routine. The diagnostic interpretation of radiographs is far from a completely objective process, even if it is a question as simple as the presence and/or extent of a carious lesion. Numerous studies have shown a large variation among observers, both with regard to the occurrence and extent of carious lesions, in bite-wing radiographs. Caries diagnosis is only one example of many situations where significant observer variation is found. The more complex the diagnostic task, the more variation can be expected. The effect of observer variation on treatment decisions regarding carious lesions is used as an example of the problems encountered daily in the dental practice.


Decision analysis for periodontal therapy. Current decision-making approaches in clinical medicine and dentistry are based on principles developed when diagnostic and therapeutic options were few. The rapid pace of new technology development and the role of third-party payment systems are increasingly requiring that health-care providers and patients confront very complex decisions. These decisions typically involve significant uncertainty (e.g., How will a specific patient respond to each possible treatment?) and difficult tradeoffs (e.g., How much are patients willing to pay in money, time, and treatment effectiveness to avoid pain and discomfort?). This paper discusses high-quality decision-making. High-quality diagnostic and therapeutic decisions result from a well-developed decision basis that represents the alternatives, information, and preferences pertaining to the decision at hand. An effective decision basis is framed to address patients' and clinicians' key concerns. The resulting recommendation for action is based on an understanding of what factors are most sensitive in determining the best course of action. Moreover, the value of additional information-gathering efforts (e.g., further diagnosis) can be measured before the information is obtained to determine whether it is worth more than it costs. The paper illustrates the need for better decision-making methods with a sample patient case, discusses key decision analysis principles and methods, identifies specific areas where periodontal decision-making can be improved by decision analysis, and presents a periodontal decision analysis case. It then discusses how intelligent decision system technology can make decision analysis widely available in a clinical setting and concludes by exploring how a future dental office might use this technology on a routine basis.


Dental implants and decision making.

Dental implants and decision making. Treatment choice and effectiveness in prosthodontics has largely depended on educated anecdote and asseveration. Still, this approach has to a very large extent enabled dentists to enrich the quality of their patients' lives. However, the trade-off between the need for prosthetic intervention per se and the biologic price inherent in certain therapeutic endeavors has demanded strict concerns regarding clinical decision making and treatment outcomes. The technique of implant prosthodontics is certainly one that has focussed such concerns, particularly since the concept of osseointegration was introduced to North American dentists at the 1982 Toronto Conference. Clinical research and opinion in this area have elicited both clinical euphoria and polarization vis-a-vis newer possibilities for resolving the predicaments of partial or complete edentulism. The past decade has witnessed clinical trials, as well as highly relevant exemplary reports, on the application of the osseointegration technique. It is now necessary to compare the merits of implant prosthodontics to traditional therapies, and to determine those criteria which comprise optimal functional and aesthetic restoration, with minimal risk of morbidity, along with cost concerns. This paper seeks to provide a systematic and rational basis for the identification of such criteria.


The family relations, peer relations, and criminal activities of Caucasian and Hispanic-American gang members. Juvenile gang members present serious problems to society, yet few empirical studies have examined their criminal activity, family relations, and peer relations in comparison with other highly antisocial youths. In a 2 (Gang Membership) x 2 (Ethnicity: Hispanic-American vs. Caucasian) design, 131 incarcerated male juvenile offenders were administered a battery assessing criminal activity, family relations, and peer relations. Results demonstrated (a) higher rates of criminal behavior (i.e., general delinquency, index offenses, school delinquency) among gang members than among offenders who did not belong to gangs, (b) higher rates of general delinquency and home delinquency among Caucasian offenders than among Hispanic-American offenders, and (c) greater aggression and less social maturity in the peer relations of gang members than in the peer relations of offenders who did not belong to gangs. In addition, gang membership mediated sociocultural differences in hard drug use. Findings are integrated with the extant literature.


Aggression in boys with attention deficit-hyperactivity disorder: methylphenidate effects on naturalistically observed aggression, response to provocation, and social information processing. High and low-aggressive boys with attention deficit-hyperactivity disorder (ADHD) were compared and the effects of methylphenidate were examined on measures from three domains of aggression: (1) directly observed verbal and nonverbal aggressive behaviors exhibited in the context of a day treatment program, (2) aggressive responding when provoked during a laboratory task, and (3) social information processing patterns exhibited on tasks designed to tap the putative cognitive components of aggression. The high-aggressive (HA) and low-aggressive (LA) subgroups differed significantly on observational measures of aggression and on the laboratory provocation task, but the HA group showed more deviant cognitions on only one of the numerous measures of social information processing. Regarding medication effects on the direct observation measures, methylphenidate decreased aggression for both subgroups. On the laboratory provocation task, methylphenidate had only minimal effects. Significant drug effects were obtained on only two recall social information processing measures.


Mothers' attributions and expectancies regarding their conduct-disordered children. As an extension of Patterson's family coercion model, we hypothesized that parental attributions about the causes of child misbehavior and parental expectancies concerning the effectiveness of parenting techniques are involved in the establishment and maintenance of coercive exchanges. Mothers of 40 conduct-disordered children and 40 matched control children completed questionnaires measuring their attributions regarding the causes of their children's misbehavior and their expectations concerning the general and personal effectiveness of parenting techniques. Results supported the hypotheses: parents of conduct-disordered children were more likely to regard their children's misbehavior as intentional and to attribute it to stable, global causes beyond the parents' control. They also were less likely to see their own parenting as effective. We speculate that these parents hold cognitive stances of blame and helplessness that contribute to aversive parent behavior as well as to parent withdrawal in the face of escalating child aggressiveness.


Attention deficit disorder and age of onset of problem behaviors. In the course of a prospective longitudinal study, we examined age of onset of behavior problems in a group of boys and girls identified with attention deficit disorder (ADD) at age 11. Onset occurred during the preschool years, by the first year of schooling, or by the end of the second year of school. Onset was strongly related to informant source at age 11, pattern of comorbidity of disorder at age 11, and developmental language, perceptual motor, and IQ measures. Onset by the first year of schooling was particularly related to poor reading skills. By age 15, nearly three-quarters of those with onset of problems before age 6 had one or more DSM-III disorders.


Parenting stress among families of children with attention deficit hyperactivity disorder. Prior research has shown that parenting stress levels can be quite high among families of children with attention deficit hyperactivity disorder (ADHD). This study investigated the degree to which such stress was related not only to the child's ADHD, but also to various other child, parent, and family-environment circumstances. Multimethod assessments were conducted on 104 clinic-referred children with ADHD. Data collected from these subjects were entered into hierarchical multiple-regression analyses, utilizing the Parenting Stress Index as the criterion. The results showed that the child and parent characteristics accounted for a substantial portion of the variance in overall parenting stress. The child's oppositional-defiant behavior and maternal psychopathology were especially potent predictors. The severity of the child's ADHD, the child's health status, and maternal health status also emerged as significant predictors. These findings are discussed in terms of their impact upon the clinical management of children with ADHD.


Negative cognitive errors and positive illusions for negative divorce events: predictors of children's psychological adjustment. This study examined the relations among negative cognitive errors regarding hypothetical negative divorce events, positive illusions about those same events, actual divorce events, and psychological adjustment in 38 8- to 12-year-old children whose parents had divorced within the previous 2 years. Children's scores on a scale of negative cognitive errors (catastrophizing, overgeneralizing, and personalizing) correlated significantly with self-reported symptoms of anxiety and self-esteem, and with maternal reports of behavior problems. Children's scores on a scale measuring positive illusions (high self-regard, illusion of personal control, and optimism for the future) correlated significantly with less self-reported aggression. Both appraisal types accounted for variance in some measures of symptomatology beyond that explained by actual events. There was no significant association between children's negative cognitive errors and positive illusions. The implications of these results for theories of negative cognitive errors and of positive illusions, as well as for future research, are discussed.


The effects of a positive behavioral context on the social impact of aggressive behavior. The hypothesis is experimentally examined that a positive behavioral repertoire can ameliorate the negative social impact of aggressive behavior. Sixty-six fourth- through sixth-grade girls viewed and rated a series of videotaped interactions between two female confederates. The proportion of positive to aggressive behavior viewed by each subject was manipulated across six experimental conditions by varying the number of positive behaviors exhibited by one of the confederates (target) while the number of aggressive behaviors displayed by her remained constant (i.e., 0%, 20%, 43%, 60%, 80%, and 100% positive). Each subject provided sociometric ratings of the target and selected trait descriptors that best described her from a checklist. The results indicated that positive behavior exhibited in high rates (80% or more, compared to aggressive behavior) offset the negative effects of aggression on both sociometric ratings and positive and negative descriptors.


Social stimulation and joint attention in young autistic children. The present study was designed to examine the effects of social stimulation on the joint attention behavior of 20 autistic children under 6 years of age, 20 receptive language-matched Down syndrome children, and 20 receptive language matched-normally-developing infants. Children's social and non-social engagement states were measured during two experimental play sessions and during free play with parent. For all groups, joint attention was increased when adult play behavior closely followed and was contingent on the behavior of the children; however, the autistic children were significantly less responsive to the experimental manipulation than control subjects. In contrast, the autistic children were no less responsive in terms of other forms of social engagement. Results are interpreted as supporting a model of joint attention deficits in autism that involves factors inherent to the disorder in transaction with social context.


Do childhood anxiety measures measure anxiety? The Fear Survey Schedule for Children-Revised (FSSC-R), Revised-Children's Manifest Anxiety Scale (RCMAS), and the Modified State-Trait Anxiety Inventory for Children (STAIC-M) are three widely used self-report measures of childhood anxiety. While previous studies have established the reliability of these measures, their validity in discriminating anxious from non-anxious youngsters remains to be established. The present study examines the discriminant validity of the three measures by comparing clinic referred samples of boys with an anxiety disorder (n = 105) or ADHD (n = 59) with a community sample of never-psychiatrically-ill boys (n = 49). Results indicated that the two patient groups differed significantly from the never-psychiatrically-ill group on the RCMAS and STAIC-M, but the anxious and ADHD groups did not differ from each other. None of the three groups differed on the FSSC-R. The implications of these findings for the assessment of childhood anxiety disorders are discussed.


Contextual factors in vigilance testing of children with ADHD. The effect of contextual factors on continuous performance testing was examined by administering a vigilance task to 51 children with ADHD under conditions of examiner presence and absence at different times (i.e., beginning and middle) of an assessment battery. The results showed that the ability to differentiate target stimuli from distractors (d-prime) was related to examiner presence vs. absence, and that response bias (beta), a measure of the subject's carefulness in responding to stimuli, was associated with the time of task administration. The decline in d-prime under conditions of examiner absence was shown to be related more to level of aggression as opposed to level of inattention. Children with ADHD having relatively high levels of aggression demonstrated a significant decline in d-prime scores under conditions of examiner absence, but those with relatively low levels of aggression did not. The results demonstrated the importance of contextual factors on vigilance task performance and suggested a differential impact of contextual variables on children who are inattentive vs. aggressive.


Six-year stability of parent-reported problem behavior in an epidemiological sample. An epidemiological sample of 936 Dutch children originally aged 4-11 years was assessed at 2-year intervals over a 6-year period. Parents completed the Child Behavior Checklist (CBCL) on all four occasions. Stability coefficients computed for eight CBCL syndromes, Internalizing and Externalizing dimensions, and total problems revealed considerable long-term stability. There was no significant difference in the 6-year stability of internalizing vs. externalizing scores. This finding was at odds with reports of considerably lower stability of internalizing behavior, and was consistent with findings suggesting that the stability of internalizing problems should not be underestimated. The magnitude and specificity of the long-term stability of internalizing and externalizing scores lends support to the validity of these behavioral dimensions as tapped by the CBCL. No significant sex or age differences in the stability of problem behaviors were found.


Gut-derived substances in activation of hepatic macrophages after partial hepatectomy in rats. When liver perfusion with nitro blue tetrazolium and phorbol myristate acetate was performed in rats 24 h after two-thirds liver resection, there were marked deposits of formazan converted from nitro blue tetrazolium in hepatic macrophages throughout the liver, indicating macrophage activity. The extent of the deposits was significantly reduced when perfusion was performed following oral administration of polymyxin B sulfate, a non-absorbable bacteriocidal agent against gram-negative bacilli which can also bind endotoxin lipopolysaccharides. Polymyxin B sulfate administration also attenuated the derangements of SGPT and the histological liver injury provoked by endotoxin administration after partial hepatectomy. These results suggests that gut-derived substances sensitive to polymyxin B sulfate may contribute to activation of hepatic macrophages after partial hepatectomy in rats.


Long-term follow-up of non-A, non-B (type C) post-transfusion hepatitis. One hundred and thirty-five patients who developed non-A, non-B post-transfusion hepatitis mostly after cardiac surgery, were followed for a mean (+/- S.D.) of 90 +/- 41 months (range: 13-180) to evaluate clinical and histological outcome. Thirty-one cases resolved within 12 months, while 104 (77%) progressed to chronicity. Twenty-one of 65 (32%) biopsied patients developed cirrhosis at the end of the follow-up, and one further progressed to hepatocellular carcinoma. One patient had a complete histological remission (1%). The remaining cases had chronic active (37%), chronic persistent (27%) or chronic lobular hepatitis (3%). About half of the cases with cirrhosis developed portal hypertension, and three of these died due to esophageal varices hemorrhage, one due to liver failure, and one due to hepatocellular carcinoma. Out of 26 patients with the initial histologic diagnosis of chronic hepatitis that were rebiopsied during follow-up, 13 (50%) progressed to cirrhosis. These patients were significantly older than patients who did not develop cirrhosis (mean age 57 and 45 years respectively; p < 0.01). During acute hepatitis anti-HCV was positive in all but one of the 114 patients tested. Percentages were similar for patients who recovered (95%) and those who developed chronic hepatitis (100%). However, during follow-up, 71% of the 1st generation and 21% of the 2nd generation ELISA test patients with acute resolved hepatitis became anti-HCV negative, while the same figures in chronic cases were only 8.5% (p < 0.0001) and 1.4% (p = 0.012). This suggests a correlation between anti-HCV antibody activity, hepatitis C virus replication, and the development of chronic liver disease.


Monitoring of serum markers for fibrosis during CCl4-induced liver damage. Effects of anti-fibrotic agents. Liver fibrosis was induced in rats by repeated peritoneal injections of carbon tetrachloride (CCl4) over a period of 2-11 weeks. Serum procollagen III peptide (SPIIINP), prolidase (SP) and alanine aminotransferase (SALT) levels were monitored during the period of induction. The extent of fibrosis was semi-quantitatively estimated after collagen staining, and the anti-fibrotic effects of 16,16-dimethyl prostaglandin E2 (DMPGE2), colchicine, and zinc sulphate were studied. SPIIINP and SP were increased the first 2 weeks after CCl4 administration and peaked at 6 weeks. Alterations in SPIIINP and SP correlated well to the semi-quantitative histological score of liver sections during the first 6 weeks, and SP was positively related to SPIIINP throughout the whole induction period. DMPGE2 decreased SPIIINP, SP and SALT significantly in addition to a markedly decreased formation of liver collagens. Colchicine had a similar but less dramatic effect, whereas zinc sulphate only reduced SPIIINP without influencing liver damage. In conclusion SPIIINP seems to be a valuable indicator of liver fibrogenesis, and SP may play a limited role in indicating accelerated collagen metabolism in the liver. DMPGE2 obviously inhibited the production of collagens induced by CCl4. Colchicine also had an apparent effect on liver fibrosis, whereas zinc sulphate merely seemed to postpone it.


A prospective study of alcoholic liver disease and mortality. We report the 10-year survival of 510 patients with a histological diagnosis of alcoholic liver disease. Eight centres in Scotland and North England contributed to this study. Information was available on 92% of the initial cohort. Age was important, with each decade increasing mortality by 55%. A highly significant interaction between sex and histology was observed with a marked survival benefit for males with non-cirrhotic alcoholic liver disease, while in cirrhotic subjects the pattern was reversed. Patients with decompensated liver disease had a relative increase in mortality in excess of 86% while the increase in mortality for alcoholic hepatitis, 'active' cirrhosis and 'inactive' cirrhosis were 52%, 57% and 91% relative to fatty liver. Alcohol intake at the time of diagnosis did not influence outcome. This study emphasises yet again the increased mortality rate of individuals abusing alcohol compared with the general population.


Value of measurement of mean portal flow velocity by Doppler flowmetry in the diagnosis of portal hypertension. To establish the sensitivity and specificity of the mean portal flow velocity in the diagnosis of portal hypertension, a population of 304 consecutive cirrhotic patients, in whom 246 abdominal Doppler examinations were performed, was prospectively analysed between June 1988 and December 1990. To avoid equipment-related variability only examinations performed using the same equipment were considered. Further inclusion criteria were the absence of portal vein thrombosis or reversed flow in the portal vessels and the absence of spontaneous, ultrasonographically detectable, portosystemic shunts. The parameter evaluated was mean portal flow velocity calculated directly from the Doppler trace by specific, operator-independent, software. 123 patients satisfied the inclusion criteria. As a control group 60 healthy age- and sex-matched subjects were examined. Mean portal flow velocity was significantly lower in cirrhotic patients than healthy subjects (13.0 +/- 3.2 cm/s vs. 19.6 +/- 2.6 cm/s; p < 0.001). There was also a decrease in mean portal flow velocity in cirrhotics in each Child-Pugh category (13.8 +/- 2.8 cm/s in Child-Pugh A class; 12.1 +/- 3.5 cm/s in Child-Pugh B class and 11.0 +/- 2.4 cm/s in Child-Pugh C class) with a statistically significant difference between each Child-Pugh category and healthy subjects (p < 0.001), between Child-Pugh A and B (p < 0.01) and between Child-Pugh A and C (p < 0.005). The sensitivity and specificity of mean portal flow velocity in the detection of portal hypertension was then analyzed with the receiver operating characteristic curve.(ABSTRACT TRUNCATED AT 250 WORDS)


Characteristics of oleate binding to liver plasma membranes and its uptake by isolated hepatocytes. To clarify mechanisms of hepatic free fatty acid uptake, [3H]oleate uptake by isolated rat hepatocytes was studied, using solutions of 150 microM bovine serum albumin at oleate:albumin molar ratios of 0.033-6.7:1. Oleate partitioning between liver plasma membranes and albumin was also studied, and used to ascertain the membrane binding function for oleate. The experimental uptake curve was complex, but could be resolved by computer fitting into a sum of two components, one a saturable and the second a linear function of the unbound oleate concentration. The saturable component comprises > 90% of total oleate uptake when the oleate:albumin molar ratio is < 2.5, but < 50% when this ratio is > 5. Membrane binding also consisted of a sum of a saturable and a linear component. By comparison of the computer-fitted uptake and binding functions, separate rate constants for the transfer into the cell of the saturably and non-saturably bound oleate were estimated to be 0.7 s-1 and 0.05 s-1, respectively. The former is compatible with a specific, protein-mediated process. It is 15-times greater than the corresponding rate constant for transfer of non-saturably bound oleate into the cell, which in turn is similar to reported rates of non-specific 'flip-flop' of fatty acids across lipid bilayers. The observed kinetics are not consistent with models in which uptake occurs principally from the albumin-bound pool of oleate, or solely from the oleate which has partitioned passively into the lipid bilayer of the plasma membrane.


Responsiveness to synthetic parathyroid hormone in the portal vein of portal hypertensive rats. In addition to its hypotensive action, the parathyroid hormone also decreases portal pressure in portal hypertensive rats. The purpose of this study was to characterize the vascular effects of the parathyroid hormone on the portal vein of portal vein-stenosed rats. When intravenously infused at the rate of 1.62 x 10(-11) mol/kg per min, the parathyroid hormone lowered portal pressure (15.1 +/- 0.7 vs. 14.0 +/- 0.8 mmHg) without affecting systemic blood pressure. With the portal vein isolated, the parathyroid hormone shifted the dose-response curves of KCl and acetylcholine to the right. However, the vasodilator effect of the parathyroid hormone was significantly less in portal hypertensive rats (EC50 of KCl increased 129.2% and acetylcholine 199.3%), compared to sham-operated rats (EC50 of KCl increased 158.7% and acetylcholine 270.2%). Similar results were found for the vasodilator action of verapamil (10(-9)-10(-6) M). On the other hand, the vasodilator effect of forskolin was similar for both groups. These results suggest that decreased responsiveness to the parathyroid hormone may be associated with calcium utilization by vascular smooth muscles.


A randomized controlled trial comparing octreotide and vasopressin in the control of acute esophageal variceal bleeding. This randomized controlled trial was conducted to compare the efficacy of intravenous infusion of octreotide (a synthetic long-acting somatostatin analogue) with vasopressin in 48 cirrhotic patients with endoscopically proven bleeding esophageal varices. Twenty-four patients received a continuous infusion of octreotide 25 micrograms/h for 24 h after an initial bolus of 100 micrograms and another 24 patients received a continuous infusion of vasopressin 0.4 U/min for 24 h. Bleeding was initially controlled after 6 h of drug infusion in 88% (21/24) and 54% (13/24) of the patients treated with octreotide and vasopressin respectively (p = 0.03). Complete control of bleeding after 24 h of drug infusion was achieved in 15 (63%) patients receiving octreotide and in 11 (46%) patients receiving vasopressin (p > 0.05). Side effects during drug infusion such as headache, chest pain and abdominal pain were significantly lower in the octreotide group (3/24) than in the vasopressin group (11/24). Serum gastrin and insulin levels fell significantly following octreotide infusion, but plasma glucose levels remained unchanged. Mortality related to bleeding esophageal varices was no different between the two groups. This report showed that octreotide infusion was more effective and had fewer side effects than vasopressin in initial controlling of acute esophageal variceal bleeding until an elective endoscopic sclerotherapy could be performed.


Alpha-tocopherol deficiency fails to aggravate toxic liver injury but liver injury causes alpha-tocopherol retention. The possible aggravation of liver injury by impaired cellular antioxidant function was investigated. A vitamin E-deficient diet (0.5 mg/kg alpha-tocopherol; control 100 mg/kg) significantly reduced rat liver alpha-tocopherol concentrations after 4 weeks (1.8 +/- 1.7 micrograms/g; control 34.4 +/- 2.4 micrograms/g, p < 0.001). The effects of copper loading (Cu, 3 g/kg diet); galactosamine (GalN, 0.85 g/kg i.p.); or carbon tetrachloride (CCl4, 10 mmol/kg i.p.) were examined. Serum aspartate transaminase activity was elevated slightly by vitamin E deficiency but not by hepatic copper accumulation. In vitamin E-replete (E+) and vitamin E-deficient (E-) rats, GalN or CCl4 caused a large and comparable elevation in serum AST and OCT activity. This effect on AST was markedly reduced by copper loading in vitamin E replete (E+) rats, but in E(-) rats copper had significantly less protective effect. Copper also diminished the OCT response to GalN in E+, though not E-, rats. A significant rise in total hepatic alpha-tocopherol content followed administration of GalN or CCl4 in both normocupric and copper-laden E(-) rats. Thus alpha-tocopherol deficiency (a) was not hepatotoxic per se; (b) failed to potentiate the toxicity of copper, GalN or CCL4; but (c) partially abolished the protection by copper against toxin-induced liver injury. Retention of hepatic alpha-tocopherol after liver damage may partly explain low serum vitamin E levels seen in clinical liver disease.


Distal spleno-renal shunt versus endoscopic sclerotherapy in the prevention of variceal rebleeding. A meta-analysis of 4 randomized clinical trials. Meta-analysis was used to evaluate 4 clinical trials comparing distal spleno-renal shunt (DSRS) with endoscopic sclerotherapy (EVS) in the prevention of variceal rebleeding: the interval between bleeding and therapy ranges from < 14 days to > 100 days. A questionnaire was sent to each author of the published trials concerning methods, definitions and results of the trials in order to obtain more detailed and up-to-date information. The selected end-points for the meta-analysis were: rebleeding, mortality and chronic encephalopathy. Analysis of the results in the questionnaires was made using the method proposed by Collins. The pooled relative risk (i.e. the combined Odds ratio of each trial as an estimate of overall efficacy) of rebleeding was statistically reduced by DSRS (0.16; 95% confidence interval 0.10-0.27). Despite this, the overall risk of death following DSRS was only marginally decreased (0.78; 95% confidence interval 0.47-1.29); the lack of homogeneity in the results does not permit any significant conclusions on this end-point. However, in non-alcoholic patients, the decrease in risk of death was greater, and this without heterogeneity, following DSRS than EVS (0.59; 95% confidence interval 0.23-1.50). The overall risk of chronic encephalopathy was slightly increased after DSRS (1.86; 95% confidence interval 0.90-3.86). In conclusion, DSRS significantly reduced the risk of rebleeding compared to EVS without increasing the risk of chronic hepatic encephalopathy. However, DSRS did not significantly affect the overall death risk. Only in non-alcoholic disease did it seem to show an advantage over EVS.


Metallothionein concentration in the liver of patients with Wilson's disease, primary biliary cirrhosis, and liver metastasis of colorectal cancer. In patients with primary biliary cirrhosis and Wilson's disease liver copper concentrations become elevated during the evolution of the disorder. The accumulated copper is thought to be detoxified by metallothionein, a protein which binds copper and zinc. In liver metastasis of colorectal cancer, copper and zinc concentrations are usually decreased compared to normal liver tissue, but little is known about the concomitant metallothionein levels. In the present study metallothionein concentrations were determined in archival liver samples from patients with primary biliary cirrhosis and Wilson's disease, and in both normal and malignancy-containing liver samples from patients with metastasis from a colorectal adenocarcinoma. Twenty-seven control liver samples contained 3.98 +/- 1.55 mg metallothionein/g protein. From the 21 liver samples of patients with primary biliary cirrhosis, which had a mean metallothionein concentration of 6.06 +/- 5.03 mg/g protein, 6 were above the highest control level. Liver metallothionein concentrations for the 8 patients with Wilson's disease were significantly elevated (10.98 +/- 6.93 mg/g protein, p < 0.005 vs. controls and p < 0.05 vs. primary biliary cirrhosis). In the 11 liver metastases from colorectal adenocarcinomas metallothionein concentrations (1.17 +/- 0.90 mg/g protein) were significantly (p < 0.005) lower than surrounding normal liver tissue (4.25 +/- 1.75 mg/g protein). We conclude that in primary biliary cirrhosis and Wilson's disease increased liver metallothionein concentrations may detoxify the accumulated copper. Furthermore, liver metastasis of colorectal cancer contains less metallothionein than the surrounding normal liver tissue.


Persistent iron overload 4 years after inadvertent transplantation of a haemochromatotic liver in a patient with primary biliary cirrhosis. An iron-loaded liver from a 20-year-old man with occult haemochromatosis was inadvertently transplanted into a 64-year-old lady with primary biliary cirrhosis. Increased hepatic iron storage was observed in biopsy specimens undertaken at 18, 30 and 36 months after transplantation. Serum iron levels and transferrin iron saturation increased and remained elevated 4 years after surgery. Ferritin levels were also consistently increased. Iron absorption test, performed at 4 years after transplant, was increased at 38%. Our data suggest that an intrahepatic defect in haemochromatosis cannot be excluded, and casts some doubt on the assertion that a precirrhotic haemochromatotic liver can be transplanted without sequelae.


Ursodeoxycholate has no beneficial effect on liver function or histology in biliary cirrhosis in the rat. In different cholestatic conditions, the beneficial effects of the tertiary bile acid, ursodeoxycholate, have been described. It is unclear, however, whether ursodeoxycholate also affects the functional and structural alterations induced by chronic biliary obstruction. Therefore, we studied the effect of ursodeoxycholate (100 mg/kg/day) on microsomal function as assessed in vivo by the aminopyrine breath test, on portal hypertension and on the structural composition of the liver in rats with chronic (3-week) biliary obstruction. Hepatic composition was assessed stereologically. Ursodeoxycholate had no effect on any of the parameters measured. We conclude that this form of treatment does not affect advanced liver disease due to common bile duct obstruction. This finding supports one of the proposed mechanisms of action of ursodeoxycholate, namely that it interferes with the ileal absorption of more toxic endogenous bile salts.


Liver damage in Italian patients with hereditary hemochromatosis is highly influenced by hepatitis B and C virus infection. We evaluated the prevalence of hepatitis B virus (HBV) and hepatitis C virus (HCV) infection in 78 Italian patients with hereditary hemochromatosis as well as the relation between HCV antibody (anti-HCV) status, hepatitis B surface antigen (HBsAg) and liver histology. None of the patients had been transfused or ever consumed more than 60 g of alcohol per day. Eighteen showed histological signs of chronic hepatitis, active cirrhosis was present in 12, chronic active hepatitis in 4 and chronic persistent hepatitis in 2. Liver fibrosis or cirrhosis without inflammatory activity was observed in 31 subjects, whereas liver histology was normal except for iron overload in 18. The prevalence of HBsAg in the whole series was 5% and of anti-HCV was 20.5%. The prevalence of HBsAg and anti-HCV was significantly higher in the chronic hepatitis group than in the fibrosis/cirrhosis (p = 0.01) and the normal groups (p < 0.01). Fourteen of 18 hereditary hemochromatosis patients with chronic hepatitis were HBsAg (4) or anti-HCV (10) positive and all the latter subgroup had HCV-RNA in their serum as shown by the polymerase chain reaction. Although most of the patients with associated chronic hepatitis had cirrhosis, their serum ferritin levels and amount of mobilizable iron were significantly lower than those of the fibrosis/cirrhosis group (p < 0.01). This indicates that hepatitis viral infection acts synergistically with iron in accelerating the development of liver damage.


Tumor necrosis factor-alpha in liver transplantation and resection. No evidence for a key role in ischemia-reperfusion injury. Experimental studies have shown that liver ischemia-reperfusion induces Kupffer cell activation and tumor necrosis factor-alpha (TNF alpha) release. The aim of this work was to determine whether severe hepatic ischemia and subsequent reperfusion triggers TNF alpha release in man. Serum TNF alpha was measured before and 3, 10, 30, 60, 120 min after revascularization and postoperatively at day 1 and 2 in 11 patients with orthotopic liver transplantation (group 1) and 4 patients with liver resection with vascular occlusion (group 2). In group 1, TNF alpha levels decreased during the first few minutes of reperfusion, then increased slightly to peak at 120 min (40 +/- 13 pg/ml). Primary non-function occurred in 1 patient in whom low peroperative levels of TNF alpha levels were measured. In group 2, no significant changes in TNF alpha levels were observed. These data, in a small number of patients: (a) show that hepatic ischemia-reperfusion does not result in major TNF alpha production; (b) do not support a primary pathogenic role for TNF alpha in damage after ischemia-reperfusion in humans.


The effects of paroxetine, alone and in combination with alcohol on psychomotor performance and cognitive function in the elderly. Fifteen healthy male volunteers aged over 60 years received acute and repeated doses of paroxetine 20 mg or placebo, and acute doses of lorazepam 1 mg (as a positive internal control) with or without alcohol (0.6 g/kg of body weight) administered openly in a double blind balanced crossover study in which each subject acted as his own control. Psychomotor performance and cognitive function were assessed using a test battery which included critical flicker fusion, choice reaction time, compensatory tracking, Stroop and memory scanning tests. Subjective ratings of mood and sleep were recorded using line analogue rating scales. The pattern of results indicated that paroxetine had little or no effect on most of the test variables, and in some instances (critical flicker fusion thresholds) improved information processing ability. This was in marked contrast to the lorazepam verum which produced sedation and disruption of performance. Paroxetine had a slight antagonistic effect on alcohol induced sedation whereas impairment of performance with lorazepam was potentiated by co-administration of alcohol. The low behavioural toxicity of paroxetine in elderly volunteers has important implications for the pharmacotherapy of depression.


Comparison of light treatment with citalopram in winter depression: a longitudinal single case study. A woman with seasonal affective disorder (SAD) remitted within a week in each of six separate trials of light therapy. She remitted within 2 weeks of initiating citalopram treatment. Light treatment in the morning advanced and improved sleep, whereas citalopram delayed sleep and induced intermittent awakenings. These opposite patterns suggest that sleep deprivation or sleep shifts were not crucial for eliciting therapeutic response. Light and citalopram both selectively reduced intake of sweet carbohydrate parallel with improvement, implicating CNS serotonergic mechanisms in the interaction of mood and food in winter.


Positive and negative symptoms, depression and social disability in chronic schizophrenia: a comparative trial of bromperidol and fluphenazine decanoates. A 1 year double-blind trial of bromperidol decanoate and fluphenazine decanoate was conducted in the maintenance treatment of 47 outpatients with schizophrenia. Six patients relapsed on bromperidol decanoate and none on fluphenazine decanoate, a difference which is statistically significant. No significant differences in positive and negative symptoms, nor depression measures were found between treatment groups when comparisons were made for change in score from entry to last visit. However, patients on fluphenazine decanoate achieved significantly better changes on social disability (Morningside scale) compared to those on bromperidol decanoate. The incidence of extrapyramidal side-effects was similar in both groups, and no statistically significant differences emerged in body weight change between treatments.


Comparative study of the psychomotor and antistress effects of ritanserin, alprazolam and diazepam in healthy subjects: some trait anxiety-independent responses. The new potential anxiolytic ritanserin was studied in a double-blind manner vs. alprazolam, diazepam and placebo in 23 healthy subjects. The subjects belonged either to a high anxiety level group or a low anxiety level group, in order to study the effect of the anxiety level on the pharmacodynamic responses. The assessments included cognitive function (memory tests), psychomotor performance [Critical Flicker Fusion (CFF), Choice Reaction Time (CRT)], subjective ratings of alertness and overnight sleep and stress paradigm. Ritanserin (10 mg), alprazolam (0.75 mg), diazepam (10 mg) and placebo were given as single oral doses following a latin square design. Groups were well contrasted on the Cattell anxiety scale and were not overlapping. On no psychometric variable have there been any interactions between the anxiety level and the drug factor. At baseline an anxiety-related difference between the two groups was observed: lower CFF value in the high anxiety group (-1.4 Hz). Both benzodiazepines impaired psychomotor assessment and memory function and increased sleepiness. Ritanserin decreased CFF values without significantly affecting CRT on which nevertheless a trend to impairment was observed. Memory tests, and subjective ratings of alertness were unaffected by ritanserin. A trend to an antistress effect was observed on electrodermogram after ritanserin. Both benzodiazepines decreased central nervous system arousal and memory while ritanserin was inactive except on CFF. Recent data support the hypothesis that 5-HT2 blockers decrease pupil diameter which is a well known covariate of flicker frequency.


Changes in platelet aggregatory responses to collagen and 5-hydroxytryptamine in depressed, schizophrenic and manic patients. The changes in the aggregatory response of platelet rich plasma obtained from a group of depressed, schizophrenic and manic patients fulfilling the DSM-III-R criteria were compared with age and sex matched control subjects. The 5-hydroxytryptamine induced aggregatory responses were significantly decreased in the depressed and schizophrenic patients during the active phase of their illness but returned to normal following clinical recovery. The collagen induced aggregatory responses were decreased in the schizophrenic and manic patients and remained decreased despite clinical recovery. No changes were found in the aggregatory responses to adenosine diphosphate, noradrenaline or adrenaline. The results of this study suggest that changes in the polyunsaturated fatty acid composition of the platelet membrane (collagen effect) and the 5-hydroxytryptamine type 2 receptor (5-HT effect) may occur in these major psychiatric disorders.


The calcium channel antagonist nifedipine causes confusion when used to treat opiate withdrawal in morphine-dependent patients. Several animal studies have suggested that calcium channel antagonists may be clinically effective in the treatment of opiate withdrawal. In this study we aimed to examine whether the alpha 2-adrenoceptor agonist clonidine and the calcium channel antagonist nifedipine were equally effective in attenuating the naltrexone-precipitated opiate withdrawal syndrome. We planned to study 16 morphine-dependent in-patients in a double-blind trial. However, the study had to be abandoned after only four patients were entered into it because the first two patients treated with nifedipine became severely confused following naltrexone. The mechanism underlying the development of delirium in these two patients is uncertain, but might possibly relate to a large unopposed release of noradrenaline within the central nervous system. These findings suggest that the calcium channel antagonist nifedipine is not effective in the clinical treatment of opiate withdrawal. Whether other calcium channel antagonists also cause confusion when used in this clinical condition is uncertain at present, but in any future studies investigating their efficacy considerable care is required in their use.


Paroxetine in the treatment of melancholia and severe depression. Meta-analyses of the worldwide paroxetine database assessed the efficacy of this compound in the treatment of both DSM-III defined melancholia and hospitalised patients with severe depression (HAMD > or = 25). The analysis for melancholia included 178 paroxetine treated patients and 66 patients treated with placebo. Paroxetine was significantly superior to placebo in the treatment of melancholia and a clear dose-response relationship was established. The meta-analysis for severely depressed hospitalised patients included 109 paroxetine treated patients and 107 patients treated with a tricyclic/tetracyclic control. Paroxetine and active controls showed comparable efficacy in the treatment of severely depressed hospitalised patients.


Diagnosis and clinical use of bromperidol in HIV-related psychoses in a sample of seropositive patients with brain damage. We evaluated in an open trial the safety and effectiveness of a high-potency neuroleptic (bromperidol) for the treatment of AIDS-related organic mental syndromes. Eleven (nine men and two women) seropositive patients with psychotic features were included; six were intravenous drug users (IVDU) and five were not IVDU (NON-IVDU). On the basis of the achievement of a CGI score of 1 or 2 (much improved or very much improved) at the fourth week, nine patients were considered responders, one was a partial responder and one was a non-responder. From a clinical point of view, "positive" psychotic symptoms had a significant remission, while the "negative" ones seemed to be less sensitive or insensitive to bromperidol treatment.


[Through-bougie esophageal prosthesis intubation--a method and its evaluation]. A new method was developed for nonsurgical peroral positioning of an esophageal prosthesis by using bougie under X-ray control in 1983. I referred to it as "through-bougie esophageal prosthesis intubation". The external diameter of a bougie is equal to the internal diameter of an esophageal prosthesis, so intubation can be performed safely and smoothly. This method was carried out in 44 cases (40 cases of cancerous stenosis, and 4 cases of cicatrical stenosis), and insertion of an esophageal prosthesis was possible in all cases. The improvement rate of peroral feeding was 88.6%. This new method is useful for the patients, who have dysphasia due to inoperable stenosis of the upper gastrointestinal tract.


[Morbidity and mortality of coronary artery bypass surgery in patients 75 years of age or older]. A consecutive series of 30 patients 75 years of age and older who underwent isolated coronary artery bypass graftings during a 6 year period (from 1985 to 1990) was analyzed. This group was compared with a consecutive series of 512 patients under the age of 75 who underwent the same procedure during the same period. The elderly patients had a higher incidence of unstable angina pectoris, left main or triple vessel disease and depression of ejection fraction. There were no deaths in the hospital or within 30 days of operation (0%), but postoperative complication occurred in 26 cases (86.7%) in the elderly patients. Mean postoperative hospital stay was longer in the elderly patients than the younger ones (21.7 +/- 8.7 days, 18.9 +/- 5.9 days, respectively). The factors frequently noted in the elderly cases with major complications were emergency or urgent operation, history of congestive heart failure and diabetes. The factors associated with prolonged postoperative hospital stay in elderly cases were octogenarians, intraoperative blood transfusion, wound complications, perioperative myocardial infarction, pulmonary failure and low cardiac output state. It is concluded that CABG can be performed safely even in elderly patients by the proper postoperative management, in spite of having increased postoperative complications and resulting in a prolonged postoperative hospital stay.


[The effects of potassium concentration in reperfusion solution upon myocardial protection]. The effects of potassium in reperfusion solution (RS) and the influence of sodium on this effect were studied. Experimental time course was as followed: 20 min working perfusion, 3 min cardioplegic infusion with St. Thomas Cardioplegic Solution followed by global ischemia for 33 or 35 min at 37.5 degrees C, 15 min early Langendorff reperfusion with several different potassium concentration modified with Krebs Henseleit Bicarbonate Buffer (KHBB) containing 145 mM and 110 mM sodium and 5 min late reperfusion with KHBB, followed by 20 min working perfusion. Potassium in RS possessed bell shaped dose response nature with optimal concentration of 10 mM in the condition of 145 mM sodium but 6 m in the condition of 110 mM in terms of percent recovery of aortic flow. Although higher potassium reperfusion produced less Creatine Kinase leakage.


[Clinical use of the multi-purpose circuit with a soft reservoir built in inflow side in replacement of the descending thoracic aorta]. The temporary bypass circuit under centrifugal pumping is generally applied for the assisted circulation of the operation for the aneurysm of descending aorta. The estimation of the bypass flow to the abdominal viscera, however, sometimes showed inadequate when excessive bleeding happened during operation. In order to keep constant flow to the lower body, we developed a new circuit, that has soft reservoir built in inflow side of the bypass line. In 8 subjects using this circuit, we studied the usefulness of the circuit and the choice of bypass route based on changes in the hemodynamics during bypass and operative complications in relation to bypass technique. During bypass, perfusion pressure to the lower body was 70-110 mmHg and flow was maintained at more than 21/min even if massive hemorrhage occurred. Comparing arterial bypass with LV bypass, the diastolic pressure in the upper limb was significantly depressed in arterial bypass with reading of 40-50 mmHg. Furthermore, in one case of arterial bypass involving the ascending aorta, false aneurysm is found in the site of cannulation. The rectal temperature dropped with the lapse of time from 35.5 +/- 0.8 degrees C to 33.5 +/- 0.4 degrees c in 120 min. These results indicate that multi-purpose circuit is capable of promptly supplying the circulating volume and is excellent means of providing adequate circulation to the lower body even if massive hemorrhage occurred. And LV bypass should be selected first, because arterial bypass has the hazard of depressing the diastolic pressure in the upper limb and involving complications associated with the insertion of cannula.(ABSTRACT TRUNCATED AT 250 WORDS)


[Open-heart surgery without donor-blood transfusion--a clinical study]. Since October 1987, 80 patients underwent open-heart surgery without donor-blood transfusion. 50 (Group I) out of these 80 cases were selected to be paired with 50 patients (Group II) who underwent open-heart surgery with homologous blood transfusion in the same period. Twelve cases (Group III) underwent open-heart surgery without homologous blood transfusion but were transfused after surgery. To decrease the homologous blood requirements, ultra-filtration system as well as conservation and autotransfusion of autologous blood was employed. Peripheral blood count, blood chemistry for liver and renal function were analyzed and compared among these three groups. Although hematocrit of Group I was lower than that of Group II until the third postoperative day, there was no difference after the seventh postoperative day. The platelet count was more in Group I than in Group II or III on the first and the seventh postoperative day. The level of lactate dehydrogenase was higher in Group II than in Group I. Total bilirubin was more elevated in Group II than in Group I on the first and the fourteenth postoperative day. Direct bilirubin was also higher in Group II than in Group I till fourteenth postoperative day. Five cases in Group II fulfilled the criteria of the serum hepatitis. Blood urea nitrogen and creatinine were less in Group I than in Group II. The duration of the intra-tracheal intubation was shorter in Group I than in Group II or III. There was no difference in postoperative dosage or duration of catecholamines among three groups.(ABSTRACT TRUNCATED AT 250 WORDS)


[Myocardial structure and left ventricular function in aortic valvular diseases]. In this study 13 patients with aortic stenosis (AS) and 19 patients with aortic regurgitation (AR) were analyzed to investigate the correlation between myocardial structure and left ventricular (LV) function. LV end-diastolic dimension (Dd), LV end-systolic dimension (Ds), LV Mass Index (LVMI), FS, mVcf and the normalized rate of change of LV dimensions during systole and diastole (-V/Dd, +V/Dd) were assessed using M-mode echocardiography before and after aortic valve replacement. The myocardial structures were investigated from the biopsied specimen in the operation using both light and electron microscopes. Then muscle fiber diameter (Diameter), the degree of interstitial fibrosis (%Fibrosis) and the myocyte volume fraction (%MF, %MT, %SA) were quantitatively evaluated by using a computerized system. And semi-quantitative analysis was made with electron microscopic score (EM-score). The results were as follows. 1. AS group: Left ventricular myocardial degeneration was mild. Significant positive correlationships were found between preoperative LVMI and Diameter (p < 0.01), and between the former and the volume fraction of the myofibrils (%MF) (p < 0.05). And significant positive correlationship was seen between Diameter and %MF (p < 0.05). However, no significant correlationship was seen between preoperative LVMI and %Fibrosis. Both LV systolic and diastolic function (-V/Dd, +V/Dd) showed significantly negative correlationship to LVMI preoperatively (p < 0.01, p < 0.05) and postoperatively (p < 0.05, p < 0.05). And in the patients with preoperative LVMI larger than 300 g/m2 and Diameter larger than 30 microns, +V/Dd was irreversible postoperatively. 2. AR group: EM-score in AR was significantly higher than that in AS (p < 0.05). Preoperative LVMI showed significantly positive correlationship to %Fibrosis (p < 0.01). And postoperative LVMI showed significantly positive correlationship to fibrous content (p < 0.01). Both LV systolic and diastolic function -V/Dd, +V/Dd) showed significantly negative correlationship to LVMI preoperatively (p < 0.05, p < 0.01) and postoperatively (p < 0.01, p < 0.01). And in the patients with preoperative LVMI larger than 300 g/m2 and %Fibrosis larger than 16%, both -V/Dd and +V/Dd were irreversible postoperatively. The above mentioned results indicated that preoperative LVMI and the morphologic parameters were useful to predict the reversibility of the postoperative LV function in both AS and AR.


[Aortic valve replacement with fresh or cryopreserved aortic allograft--initial experience in Japan]. Aortic allograft valves were harvested from non-infected (bacterial or viral) cadavers within 24 hours of death with a family consent, and were sterilized by 4 degrees C antibiotic solution for 48 hours. Then, the allograft was preserved in the 4 degrees C nutrient medium (fresh; TC-199, calf serum and HEPES buffer) or in liquid nitrogen (-196 degrees C) after freezing to -80 degrees C by a programmed freezer. 10% dimethylsulfoxide (DMSO) was used for cryopreservation. Following germ-free confirmation, aortic allograft valves were implanted in 5 patients having aortic regurgitation with good results. Three fresh and two cryopreserved allograft valves were used. Although the follow-up term is very short (maximum 1 year) at the present time, the valve function is quite satisfactory, confirmed by cardiac catheterization and echocardiography. This is the first report in Japan with regard to cryopreservation of allograft valves and clinical use of fresh or cryopreserved valves. We believe that realization and progress of allograft preservation by cryo-technique and establishment of the tissue bank are important for the development of cardiovascular surgery in Japan.


[Metabolism of Ca2+ in myocytes and peroxidation products in ischemia-reperfusion injury under extracorporeal circulation]. The metabolism of calcium ion (Ca2+) in myocytes in ischemia-reperfusion injury under extracorporeal circulation (ECC) was studied by cytochemistry and electron microscopy. Ten mongrel dogs were under ECC with aortic cross-clamping for 120 minutes. A cold GIK crystalloid cardioplegic solution was infused via the aortic root intermittently during ischemia, and the myocardial temperature was maintained at 5-10 degrees C with ice slush. The morphological changes of Ca(2+)-ATPase activity in myocytes were estimated using the "lead citrate method". The activities of mitochondria, which had been temporarily decreased just before reperfusion, increased immediately after reperfusion and decreased again 60 minutes later. Electromicroscopy revealed swelling of mitochondria and laceration of myofibrils as well as intracellular edema 60 minutes after reperfusion. Immediately after reperfusion and 60 minutes later, creatine phosphokinase iso-enzyme (CK-MB) release in coronary sinus blood was significantly (p < 0.01) greater than that before the start of ECC. Anaerobic metabolism immediately after reperfusion was more active than that before aortic cross-clamping, as demonstrated by changes in excess lactate (delta XL) and redox potential (delta Eh) of lactate and pyruvate (delta XL, p < 0.05; delta Eh, p < 0.01). Thus, in ischemia-reperfusion injury, alterations of Ca(2+)-ATPase activity of mitochondria reflect the functional and morphological viability of the myocardium. Immediately and 60 minutes after reperfusion, the level of thiobarbituric acid was significantly (p < 0.01) higher and the level of alpha-tocopherol was significantly (p < 0.01) less than respective levels before the start of ECC.(ABSTRACT TRUNCATED AT 250 WORDS)


[A case of chondrosarcoma originating from the left third rib]. Chondrosarcoma of rib origin is rare in Japan. A 51-year-old man came to our hospital with chest pain and coin lesion in the left superior part of the chest X-ray film. It was suspected to be the posterior mediastinal tumor based on CT and MRI. Operation was done to remove the tumor and the histological diagnosis was chondrosarcoma. The tumor measured 2.5 x 2.6 x 2.2 cm arising from the posterior portion of the left third rib. Combined resection of descending aortic adventitia was done. The patient is doing well without symptoms of recurrence 15 months after operation.


[Nonfunctioning paraganglioma of the posterior mediastinum]. A 23-year-old man, complaining of a discomfort in the chest, saw a physician nearby and was pointed out chest abnormal shadow in chest X-ray. He was admitted to our hospital for surgery. As a result of a close check-up at this department, a giant tumor extending from above the right diaphragm to the posterior mediastinum was found. Physical findings in the preoperative examination and general examinations showed no abnormality. The operation was performed and was diagnosed as paraganglioma. This tumor is abundant in blood vessels. Thus, preoperative angiography and securing of the field of operation in treating the blood vessels were considered indispensable for the safety of operation.


[A ruptured thoracic aortic aneurysm with 4 cm diameter]. The size of a thoracic aortic aneurysm (TAA) is an important factor of the operative indication. We experienced a ruptured TAA the diameter of which was only 4 cm. A 71 years old man was admitted due to the severe back pain under the shocked condition. We diagnosed him a ruptured TAA by CT scan. Because he had no progressive anemia and the hemodynamics was very stable, we followed him conservatively. Two months later, the operation was performed. We resected the aneurysm and inserted an aortic prosthetic graft. From the operative findings, the aneurysm was certified as a true aneurysm, and the maximal diameter was only 4 cm. First choice for the treatment of ruptured TAA is the emergent operation. But when the hemodynamics is extremely stable and the anemia does not progress at all, a conservative therapy can be selected. Even if the aneurysm is very small, the control of hypertension is quite important.


[Two cases of the brachiocephalic artery avulsion due to blunt chest trauma]. Two young adult patients with brachiocephalic avulsion due to blunt trauma are reported. Both of them were brought to the emergency room of St. Marianna University Hospital with the blunt chest trauma and lung contusion due to the traffic accident. A widening of the superior mediastinum and mediastinal hematoma surrounding the major branches of the aortic arch were demonstrated on chest roentgenogram and contrast enhanced CT scan, however, these evidences were not valuable for the diagnosis. Aortogram revealed an aneurysmal dilatation at the origin of the brachiocephalic artery in the first case and at its distal portion in the second case. Emergency operation was performed under the simple cross clamp of the brachiocephalic artery without any adjunct means. In the first case, 10 mm knitted Dacron graft was interposed between the ascending aorta and distal segment of the brachiocephalic artery. In the second case, the brachiocephalic artery was replaced with 10 mm knitted Dacron graft. The postoperative course was uneventful and no neurological deficit was noted in these cases.


[A case of pulmonary leiomyosarcoma followed up for five years]. A 70-year-old woman with leiomyosarcoma, followed up for 5 years as tuberculoma, is described. The tumor, in the left lower lobe, had enlarged from 1.5 x 1.5 cm to 3.4 x 3.4 cm in 5 years, and doubling time was calculated to be 540 days. Another tumor (1.8 x 1.8 cm) was also recognized in the right lower lobe at the later time. Since not only a benign tumor but metastatic disease was suspected, thoracotomy was performed, and the intraoperative pathologic diagnosis was leiomyosarcoma. However, only partial lung resection was performed because of the low growth rate of the tumor, the patient's advanced age, limited lymphatic metastasis and favorable prognosis with only partial resection. DNA analysis of the tumor based on flow cytometry showed a diploid pattern, and this was thought to account for the long doubling time of the tumor. The postoperative course was satisfactory without any signs of recurrence at the operation site.


[A successful surgical treatment of postinfarction posterior ventricular septal defect through a right ventricular approach]. A 72-year-old man with acute postinfarction ventricular septal defect located posteriorly underwent successful operation through a right ventricular approach. Following cardiac catheterization revealed posterior ventricular septal defect with 82% left to right shunt ratio and coronary angiography showed three vessel disease, emergency operation was performed. The defect was exposed through anterior right ventriculotomy and closed by a teflon patch sutured right side of the interventricular septum, with added bypass grafting to left anterior descending artery. Postoperative course was uneventful and postoperative cardiac catheterization showed no residual shunt with patent bypass graft. He was discharged from our hospital about 2 months after operation.


[Two separate surgical repairs of post-infarction blowout rupture of the left ventricular free wall and subsequently developed subepicardial aneurysm]. A 69-year-old female patient with acute myocardial infarction was admitted to our hospital. After i.v. administration of the rt-PA, echocardiography disclosed pericardial effusion to which pericardial drainage was performed first through subxiphoid incision. Immediately after the drainage, electromechanical dissociation emerged and emergency thoracotomy was performed. There was a small blowout rupture of the left ventricular free wall that was successfully repaired using single suture buttressed with Dacron felt without cardiopulmonary bypass support. On the 38th day after the surgery, cineangiography disclosed ventricular aneurysm, to which aneurysmectomy was performed under the cardiopulmonary bypass and her post operative progress was uneventful. Histological study of the resected specimen revealed so called subepicardial aneurysm. Although blowout rupture of the left ventricular free wall used to be lethal, there might be a chance of life saving even without cardiopulmonary bypass support, if the left thoracotomy could be done as quickly as possible.


[A case report of tetralogy of Fallot associated with total occlusion of the right coronary artery and complicated with infective endocarditis]. A 31-year-old male with tetralogy of Fallot (TF) and total occlusion of the right coronary orifice complicated with infective endocarditis successfully underwent total repair of TF and coronary artery bypass graft (CABG). The patient had severely suffered from symptoms including breathlessness, palpitation (SVT) and chest pain. The coronary arteriography revealed occlusion of the right coronary orifice. The preoperative course was further complicated by endocarditis with vegetation of the aortic valve that did not respond to antibiotics. Concomitant surgical procedures consisting of TF repair, CABG to the right coronary artery with saphenous vein graft and vegetectomy of the aortic valve were carried out. The postoperative course was uneventful though he underwent cholecystectomy for symptomatic gall stones after TF repair. The patient is now in NYHA class II.


[Surgical repair of discrete subaortic stenosis complicated with prosthetic valve endocarditis--a case report]. A 46-year-old man was referred to our hospital because of prosthetic valve regurgitation. Eight years previously he had undergone aortic valve replacement because of aortic regurgitation due to infective endocarditis. At reoperation, we found prosthetic valve endocarditis and discrete subaortic stenosis. The obstructing fibrous tissue was resected and the aortic valve was replaced. Because discrete subaortic stenosis is usually located just below the aortic valve, the aortic valve cusps are liable to become thickened by the jet through the discrete stenosis and thus are vulnerable to infective endocarditis. It is pointed out that care must be taken not to overlook discrete subaortic stenosis in the presence of other associated cardiac disorders.


[Resection of a mediastinal teratoma that perforated the lung and combined with aspergilloma in the tumor cyst]. We hereby report a rare case of a mature type teratoma that perforated the lung and combined with aspergilloma in the tumor cyst. The patient was a 48-year-old female, who complained of coughing and sputum. The chest roentogenography and chest CT suggested aspergilloma. The patient was operated upon. From the intraoperative and pathological findings, a mature type mediastinal teratoma was found to have perforated the bronchus and lung, and combined with aspergilloma in the cyst of the tumor. The tumor was resected, the drainage bronchus was closed. The mediastinal teratoma and aspergilloma have not recurred for two years and four months since the operation.


[A case of Saber-sheath type tracheo-bronchomalacia]. A case of Saber-sheath type tracheo-bronchomalacia complicating bronchial asthma was treated by external fixation of Marlex mesh, and good results were obtained. The patient was a 43-year-old male who had been treated for bronchial asthma for over nearly 20 years. Since 4 years ago, dyspnea and a feeling of obstruction of the larynx developed and gradually aggravated. He lost consciousness twice and was hospitalized on an emergency basis. Pulmonary function tests performed during remission of asthma attacks revealed an obstructive disorder: FEV1.0% was 30.5% and peak flow was 4.11 L/sec. Bronchoscopy and tracheo-bronchography revealed Saber-sheath type tracheo-bronchomalacia in the trachea and the right main bronchus. The severity of the obstruction was, in terms of Johnson's classification, II. for the trachea and I. for the right main bronchus. In accordance with the method reported by Hanawa and Ikeda, external fixation was applied to the trachea and the right main bronchus; that is, Marlex mesh was applied around to the trachea and the right main bronchus, and additional Lyodura was applied over the Marlex mesh. The postoperative course was satisfactory. Both FEV1.0% and the peak flow improved, and constriction of the trachea and the right main bronchus at the time of coughing was also reduced.


[A case of congenital esophago-bronchial fistula communicated between esophageal diverticulum and left main bronchus in the adult--a review of 47 cases in the Japanese literature]. We experienced a successful repair of congenital esophago-bronchial fistula communicated between esophageal diverticulum and left main bronchus in adult case. The patient was a 60-year-old female. She had much wet cough on taking meals since 10 years ago. At the mass screening, a esophago-bronchial fistula was detected by upper GI series. Barium esophagography revealed a fistula between esophageal diverticulum and left main bronchus. The resection of diverticulum and fistula were undergone. In the operation, there exited no adhesion or inflammation around the fistula, therefore it was easy to isorate from the surrounding tissues. This case was categorized as Brainbridge type I esophago-bronchial fistula communicated to left main bronchus. Forty-six cases of congenital esophago-bronchial fistula with diverticulum were reported in Japan, but no cases which communicated with left main bronchus were reported. Then it is assumed that this is the first case in Japan.


[Apico-aortic conduit repair for the subaortic stenosis in the long-term period after correction of Taussig-Bing malformation]. Apico-abdominal-aortic bypass operation was successfully performed for the left ventricular outflow tract obstruction 17 years after correction of Tausig-Bing malformation. At the age of 14 months old, a 18-year-old patient underwent total correction of Taussig-Bing malformation according to Kawashima's intraventricular re-routing. The right ventricular hemodynamics were normal throughout, however, systolic ejection murmur due to aortic stenosis appeared 3 years after repair. Seventeen years postoperatively, marked aortic valve and subaortic obstruction was detected corresponding with the internal conduit made from the duplicated autopericardial baffle. A composite graft containing 23A-SJM valve was interposed between the left ventricular apex and infrarenal abdominal aorta. After the bypass operation, thickness of the posterior wall of the left ventricle and interventricular septum was significantly reduced and symptoms were remarkably improved. The present paper is concerned with the subaortic stenosis after repair of Taussig-Bing malformation and technique of apico-aortic bypass operation.


[An adult case of anomalous origin of the left coronary artery from the pulmonary artery with the coronary artery-bronchial artery anastomosis]. A case was 33 years old man who had complained chest pain during exercise. He was diagnosed anomalous origin of the left coronary artery from the pulmonary artery by coronary angiography. At operation, left main coronary artery originated from the posterior wall of the pulmonary artery. Numerous retrograde flow was seen through left coronary artery during aortic cross clamping. The left coronary ostium was closed, because sufficient extracardial anastomosis to coronary artery should be thought. The post operative course was uneventful and the patient is asymptomatic. The selective bronchial artery angiography was performed and it demonstrated collaterals between the bronchial artery and the left circumflex artery. The Thallium scintigraphy had showed ischemia of antrolateral wall of the left ventricle before operation, but postoperatively there was no ischemic redistribution.


[Accessory tricuspid valve--a report of two cases]. Accessory tricuspid valve is a rare cardiac anomaly. We describe two cases with accessory tricuspid valve. Case 1: A 7-year-old boy underwent repair of tetralogy of Fallot. Under deep hypothermic cardiopulmonary bypass, right ventricle was opened. An accessory tricuspid leaflet was noted to the right side of the VSD attaching to the infundibular septum from medial papillary muscle as a chordal origin. After excision of the accessory tricuspid leaflet, the VSD was closed with a Dacron patch followed by relieve of the right ventricular outflow obstruction and pulmonary valvotomy. Case 2: A 8-year-old boy had Rastelli operation to correct transposition of the great arteries. An accessory leaflet originated from the medial papillary muscle and was floating like a parachute in the way between VSD and aorta. There was no additional apparatus in the pathway between the VSD and aorta after excision of the accessory tricuspid leaflet. Intraventricular tunnel was created with a Dacron patch. Extracardiac conduit between the right ventricle and the distal pulmonary artery was constructed using a valved pericardial roll.


The role of interleukin 2 in the development of autoimmune thyroiditis. Interleukin 2 (IL-2) is a lymphokine that may disrupt immunological self-tolerance. While being incapable of interfering with intrathymic or peripheral clonal deletion, IL-2 may overcome functional antigen unresponsiveness in anergic T lymphocytes. Anergy of T helper cells of the inflammatory phenotype implies selective silencing of the transcription of the IL-2 gene and thus precludes autocrine IL-2/IL-2 receptor (IL-2R) mediated growth, as well as delivery of help to other T cells or B lymphocytes. Thus, IL-2 serves as a servomodulator regulating post-deletional self-tolerance. IL-2-producing and IL-2-receptive cells are present in a variety of autoimmune lesions, including spontaneous autoimmune thyroiditis developing in the Obese strain (OS) of chickens, in Hashimoto's struma lymphomatosa, and in Graves' disease. Whereas the OS is characterized by a hyperinducibility of the IL-2/IL-2R system that predisposes to the development of severe thyroid infiltration, the state of the IL-2/IL-R system in circulating lymphocytes of patients developing thyroid autoimmunity, or at risk of doing so, remains to be defined. The most frequent autoimmune side-effect of IL-2 treatment concerns the thyroid gland. IL-2 induces a lymphoid thyroiditis leading to primary hypothyroidism, especially in those patients that have pre-treatment antithyroid autoantibodies. The hypothesis is extrapolated that IL-2 induces autoimmune disease in those patients that bear undeleted thyroid-specific T cells, and in which the lack of manifest thyroiditis relies upon peripheral, post-deletional tolerance.


Draffin and his rods.

Draffin and his rods. Draffin's rods or bipods are now a well-known, internationally accepted ENT instrument. Before their invention in 1951, the attendant anaesthetist or nurse was obliged to support the mouthgag during tonsillectomy. Research into the life of their originator, David Alexander Draffin, reveals that in addition to his evident design skills, he was a surgeon of courage, wit and great charm.


Spontaneous healing of traumatic tympanic membrane perforations in man: a century of experience. Widespread controversy exists concerning the treatment of traumatic tympanic membrane perforations. To elucidate the issue, a reference value for the rate of spontaneous tympanic membrane closure in man, to which the healing rates following different techniques of early surgical repair should be compared, was established on the basis of a review of more than 500 texts covering a century's literature on the traumatically perforated tympanic membrane. The spontaneous healing rate appeared to be close to 80 (78.7 per cent) in 760 evaluable cases of traumatic tympanic membrane perforations of all sorts diagnosed within 14 days post injury. A relative, causal-related variation of spontaneous healing could be demonstrated, and a pathogenetic classification of direct traumatic tympanic membrane perforations into ruptures induced by air-pressure changes, heat or corrosives, solids, and water pressures, is of proved clinical value and may have medico-legal validity. There is an obvious need for clinically controlled studies on the spontaneous healing of all kinds of traumatic perforations of the tympanic membrane in humans, and important elements in the design of future studies are advocated.


Clinical and bacteriological profile of the ear in otogenic tetanus: a case control study. Twenty two patients presented with otogenic tetanus. Seventeen patients had acute histories with only a single episode of otitis media with otorrhoea. Fifteen patients had unilateral central perforations, five had bilateral central perforations and two had no perforations but had acutely congested tympanic membranes which were bulging suggesting the presence of purulent fluid behind them. All patients with perforations had a purulent pulsatile discharge. A coexisting aerobic infection was seen in 85 per cent of the cultures and 59 per cent of these were due to staphylococcus aureus (versus 25 per cent in the controls). Only one patient had received partial immunization. Tetanus resulting from otitis media is not an indication for surgery.


The otological status of patients with nasopharyngeal carcinoma after megavoltage radiotherapy. A middle ear effusion is a common complication of nasopharyngeal carcinoma both before and after radiotherapy. An effusion was found in 38 per cent of patients before radiotherapy and 9 per cent developed an effusion after the start of radiotherapy. Surgical treatment by myringotomy with or without grommet insertion was associated with a high incidence of otorrhoea (26 per cent) which was often refractory to treatment. In view of the frequency of this complication and the fact that a middle ear effusion may not be of concern to an adult patient with nasopharyngeal carcinoma, a 'wait and see' policy may be appropriate in the management of a middle ear effusion in these patients.


The midfacial degloving approach to sinonasal disease. The midfacial degloving approach was first described by Casson et al. in 1974 but despite a number of papers in the American literature advocating its use, it has not gained popularity in Europe. The advantages and application of the technique are presented in 36 patients, ranging from 7-78 years of age. The approach is ideally suited for extensive benign lesions in the nasal cavity, ethmoid and sphenoid sinuses and enables access to the nasopharynx and infratemporal fossa whilst avoiding an external incision. These lesions have included angiofibroma (13 cases), inverted papilloma (five cases), a variety of cysts (three cases) and six miscellaneous cases of benign pathology. Malignant lesions which have not breached the anterior cranial fossa may also be removed, up to and including bilateral maxillectomy (nine cases) and this can be combined with orbital clearance. The approach may be repeated if necessary and is associated with few significant complications though vestibular stenosis, oro-antral fistula, nasolacrimal damage and upward rotation of the nasal tip may occur. Strategies to avoid these problems can be undertaken and long-term cosmetic results are excellent.


Carcinoma of the maxillary antrum treated by pre-operative radiotherapy or radical radiotherapy alone. The results of pre-operative radical radiotherapy and subsequent maxillary resection are reported in 54 consecutive patients with carcinoma of the maxillary antrum treated at The Royal London Hospital from 1965 to 1989. The actuarial two and five year survivals were 50.3 per cent and 38.5 per cent respectively. Patients with adenocarcinomas fared better when compared with squamous and undifferentiated carcinomas (log rank p = < 0.01). Undifferentiated carcinoma and involved regional lymph nodes were both very poor prognostic factors. In those patients who were either unfit for or refused maxillary resection, radical radiotherapy alone was still an effective treatment, with only a slight disadvantage in terms of local control and survival.


A comparative study of calcium sodium alginate (Kaltostat) and bismuth tribromophenate (Xeroform) packing in the management of epistaxis. A prospective study was undertaken to compare the efficacy of calcium sodium alginate fibre (Kaltostat) to petrolatum gauze impregnated with bismuth tribromophenate (Xeroform) for the control of epistaxes that require hospital admission. Forty patients presenting with severe epistaxis requring hospital admission were treated with either Kaltostat or Xeroform nasal packs. Allocation to either treatment group was made randomly. The composition of each group in terms of age, sex distribution, aetiology of epistaxis and severity of bleed was not significantly different. There was no significant difference in the efficacy or patient acceptability of either therapeutic agent. It is concluded that calcium sodium alginate fibre should be considered as an acceptable alternative to traditional gauze packing.


Acute epiglottitis--25 years experience with nasotracheal intubation, current management policy and future trends. During a 25-year period 168 adults and 111 children in Copenhagen County were treated for acute epiglottitis. Four patients, two children and two adults died, of these the two children and one adult had a cardiac arrest on arriving at the hospital. Most children were treated by nasotracheal intubation while only some adults required nasotracheal intubation in order to secure the airway. Our data indicate that intubation of adults with epiglottitis is technically more difficult than in children. The fibrelaryngoscope, a new diagnostic tool, is advocated, and was in this study used to establish the diagnosis in 12 unclear cases of acute epiglottitis. The incidence of acute epiglottitis in children was calculated at 3.2/100,000 with a minor annual variation. As vaccination against Haemophilus influenzae type b becomes more common, the incidence will probably be markedly reduced, maybe even eradicated in children, but in adults the same reduction cannot be expected as the causative agent in this group is less frequently Haemophilus influenzae type b.


Fistulae in the inner canthus associated with ethmoiditis. A case of fistulae in the inner canthus arising from the ethmoidal air cell sinuses is presented. This type of complication is very rare, and to the best of our knowledge no similar case has been reported in the literature. Clinical findings, imaging, pathology and treatment are presented and discussed.


Nasopharyngeal tuberculosis.

Nasopharyngeal tuberculosis. Isolated nasopharyngeal tuberculosis is a rare disease with very few cases having been reported in recent years. We report a case presenting in the United Kingdom with unilateral otalgia and otorrhoea.


A rare congenital intranasal polyp: mesenchymal chondrosarcoma of the nasal region. A mesenchymal chondrosarcoma of the nasal region in a neonate is described. Problems of histological interpretation and management are discussed.


Nasal polyps in identical twins.

Nasal polyps in identical twins. Nasal polyps are multifactorial in aetiology but are associated with respiratory diseases, particularly late onset asthma. Several members of a family may be affected with nasal polyps but there is little evidence for a genetic basis for this. Some evidence to support a genetic predisposition comes from the development of polyps in identical twins.