Laparoscopic cholecystectomy in an infant. Use of the laparoscopic approach in traditionally open procedures has developed rapidly in recent years. Despite this intensive rate of evolution, most procedures have been done in adult patients, with pediatric patients largely excluded. This paper reviews a case report of a laparoscopic cholecystectomy in a 19-month-old male. This effort presents new data and techniques to encourage further investigation into minimally invasive surgery in the pediatric age group.


Laparoscopic sigmoid colostomy for perianal Crohn's disease. Fecal stream diversion is not an uncommonly used procedure in the treatment of symptomatic Crohn's disease of the rectum. We present a case report of a patient with documented Crohn's proctitis with multiple rectovaginal and perianal fistulas; an end sigmoid colostomy was performed as part of the management of her disease.


Laparoscopic retrieval of spilled stones. Spillage of gallstones during laparoscopic cholecystectomy is occasionally a problem. The use of a finger cut off of a size 9 sterile glove as an intraperitoneal sack facilitates the removal of these stones.


Splenic trauma as a complication of colonoscopy. Thirteen cases of splenic injury during colonoscopy have been reported. We report the first case associated with colonic perforation and discuss the risk factors and etiology.


Laparoscopic Nissen fundoplication.

Laparoscopic Nissen fundoplication. Laparoscopic Nissen fundoplication represents a minimally invasive surgical approach to symptomatic gastroesophageal reflux and may offer patients an attractive alternative to indefinite medical therapy. Fourteen patients with persistent gastroesophageal reflux and two with severe achalasia underwent a laparoscopically guided 360-degree or Nissen fundoplication. Both individuals with achalasia also had an extended distal esophagomyotomy. Two patients required conversion to open laparotomy because of difficulties in defining the anatomy of the posterior esophagus. All 16 patients reported complete relief of their symptoms. The average length of hospital stay was four days. These early results of laparoscopic Nissen fundoplication are encouraging and hopefully will stimulate further experience in this area.


Laparoscopic cholecystectomy: a review of 12,397 patients. We reviewed the cumulative experience with laparoscopic cholecystectomy reported in the surgical literature, including 12,397 patients selected to undergo laparoscopic cholecystectomy, 95% of which were performed on an elective basis. Although the indications for operation varied, 90% of patients had evidence of cholelithiasis and biliary colic. Conversion to open cholecystectomy was required in 534 patients (4%); of these, 52% were converted because of acute or chronic inflammation or adhesions. Laparoscopic cholangiography was attempted in 3,696 of 9,231 patients (40%) and was successful in 84%. The incidence of major bile duct injury, minor bile duct injury, bile leak, and overall morbidity was 0.3%, 0.1%, 0.4%, and 4%, respectively. The mortality rate was 0.08%. Results from individual reports indicate that 54% to 98% of patients were discharged on the 1st or 2nd postoperative day, and 77% to 98% returned to full activity within 7 to 14 days. The incidence of bile duct injury, overall morbidity, and mortality compare favorably with published reports for open cholecystectomy. The collective data would also indicate that laparoscopic cholecystectomy is a safe and efficacious procedure that offers a viable alternative to conventional cholecystectomy.


The laparoscopic approach to modified Taylor's procedure in the treatment of chronic duodenal ulcer: an improved technique. Laparoscopic modified Taylor's procedure for chronic duodenal ulcer was performed in three patients. A new, specially developed combination instrument allowed the operation to be performed easily, sometimes using only four introduction sites. Coagulation, suction, and rinsing can be performed at the same time, and the hook knife, scissors, or different forceps can be introduced through the operating channel of the instrument. An overcast seam to approximate the seromyotomy was done using the technique developed for transanal endoscopic microsurgery. Instead of the silver clips, specially handmade steel and titanium clips were used to fix the PDS suture. No major postoperative complications occurred. The gastric acid output under basal condition and stimulation showed a decrease ranging from 47% to 79%. Endoscopic examination performed on the 4th postoperative week showed complete recovery in all cases.


An experimental technique of laparoscopic bowel resection and reanastomosis. With the development of laparoscopic cholecystectomy, surgeons have been stimulated to develop techniques that allow many open surgical procedures to be performed laparoscopically. Appendectomy, hernia repair, and vagotomy have already been introduced clinically. Laparoscopic bowel resection, however, is somewhat more complicated. Bowel transection, mass tissue removal, and reanastomosis in the proper geometric fashion are critical to the success of this type of operation. The introduction of the Endo-GIA stapler (United States Surgical Corp., Norwalk, CT) will make this procedure feasible on a large-scale basis. The major problem with bowel resection is not transection or tissue removal, but, rather, reanastomosis. With intracorporeal anastomosis, manipulation of the bowel with proper orientation becomes difficult. This is less of a problem when performing low-anterior resection, however, because one of the bowel limbs is fixed. The purpose of this study was to develop a technique in the laboratory that would ensure proper orientation of the two bowel limbs, with minimal manipulation prior to performance of the anastomosis. The technique that we developed and describe herein does not require manual orientation during anastomosis. Improper bowel alignment with kinking and twisting is thereby avoided. The technique appears to be useful for small- and large-bowel resections, but not for low-anterior resection. For this technique to become a reality clinically, longer endoscopic staplers with taller staple height will be required.


Laparoscopic segmental resection for infiltrating endometriosis of the rectosigmoid colon: a preliminary report. The following is a description of the first series of laparoscopic partial proctectomies performed without a separate surgical incision. Sixteen women were treated for extensive endometriosis invading the rectal wall. This original series of patients tolerated the procedure well, with no major intraoperative or postoperative complications noted.


Laparoscopic cholecystectomy after unsuccessful shock-wave therapy. Extracorporeal shock-wave therapy of gallstones was begun at the Surgical Department of the University of Freiburg, Germany, in March 1988; 85 patients were treated up to September 1991. The stone-free rate differed with the gallstone group. Patients with solitary stones less than 20 mm in diameter showed a significantly higher rate after 18 months of lithotripsy and dissolution therapy than patients with multiple stones (p < 0.01), that is, 83% and 49%, respectively. Open cholecystectomy was necessary for seven patients with complications following fragmentation. After starting laparoscopic cholecystectomy, eight patients decided in favor of this procedure because of constant biliary symptoms. These patients had a mean duration of dissolution therapy of 19 months. The minimal invasive procedure is an alternative for patients with unsuccessful lithotripsy and lysis who initially demanded conservative treatment. Indication for shock-wave therapy is limited to only a small group of patients with solitary cholesterol gallstones less than 20 mm who reject laparoscopic surgery.


Postoperative respiratory function after laparoscopic cholecystectomy. Open cholecystectomy causes changes in pulmonary function test volumes; such changes can be related to respiratory complications of hypoxemia and atelectasis. Little data is available on lung volume changes after laparoscopic cholecystectomy. We measured preoperative and postoperative vital capacity (VC), functional residual capacity (FRC), arterial PO2, and chest X-ray atelectasis in 31 patients undergoing laparoscopic cholecystectomy and found small but significant decreases (p < 0.01) in VC (13 +/- 19%) and FRC (7 +/- 17%). The PO2 decreased from 89 +/- 11 mm Hg to 82 +/- 14 mm Hg, with only one patient's PO2 less than 60 mm Hg. Three patients demonstrated new segmental lobar collapse on postoperative chest X-ray. The postoperative changes in FRC (R2 = 0.40, p < 0.04) and atelectasis (R2 = 0.46, p < 0.03) could be predicted by multiple regression of risk factors, including obesity, smoking, use of narcotics, age, and symptoms of prior respiratory disease. We conclude that the respiratory changes after laparoscopic surgery are small in comparison to those expected after open cholecystectomy.


Complications of percutaneous endoscopic enterostomy tubes. Percutaneous endoscopic gastrostomy and jejunostomy tubes have been used clinically for approximately 10 years. They have been used predominantly in patients who cannot sustain their weight by oral intake, such as individuals with abnormalities of swallowing or intestinal peristalsis. The percutaneous endoscopic method of placement confers some advantages over classical surgical placement, especially in poor risk cases. Although several types of tube are commercially available, a substantial complication rate is still directly attributable to the tubes. In some series, complications are reported in 70% of cases. This report describes two complications of endoscopically introduced jejunostomy tubes used in patients with Roux-en-Y reconstructions after previous multiple gastric surgical procedures.


Laparoscopically assisted anterior resection for rectal prolapse. We report for the first time the treatment of rectal prolapse by laparoscopically assisted anterior resection. A 52-year-old woman, institutionalized for the last 10 years after diffuse cerebral injury secondary to toxic shock syndrome, developed rectal prolapse. A long life span is anticipated for this otherwise healthy middle-aged woman. Anterior resection was selected as treatment because of the low, long-term rates of recurrence of rectal prolapse. Approximately 2 1/2 ft of sigmoid colon and proximal rectum were resected. The anastomosis was constructed using a double-stapling technique. After surgery, the patient experienced virtually no pain and received only a single injection of pain medicine in the postoperative period. She was started on clear liquids on the first postoperative day and a regular diet on the second. She passed flatus on postoperative day 2 and stool on day 5. She was discharged 7 days after the operation. We believe that laparoscopically assisted anterior resection offers a promising new option for the treatment of rectal prolapse.


Laparoscopic-assisted abdominoperineal resection with pull-through (sphincter saving). The sphincter-saving pull-through operation for midrectal cancer has never been popularized because it has been considered to be against the principles of sound cancer surgery, because of its technical difficulty, and because of the assumption that sphincter mass is involved even in the early stages of cancer. We have observed, however, that even in far advanced midrectal cancer sphincter mass is rarely involved, primarily because of the basic difference in drainage systems (lymphatic and vascular) of the lower rectum and the midrectum. We believe therefore, that the pull-through operation for an early midrectal cancer (6-12 cm) is an acceptable procedure, especially for patients who adamantly refuse colostomy and have no gross findings of involvement of the sphincter mass. This paper presents our technique of laparoscopic assisted abdominoperineal resection with pull-through. The advantages of this technique are as follows: (a) it avoids colostomy and maintains continence of stool; (b) blind dissection is unnecessary and minimal bleeding occurs; (c) postoperative wound pain is lessened and time to recovery shortened; (d) exposure is excellent throughout the procedure.


Videoendoscopic pulmonary lobectomy for cancer. A videothoracoscopic right lower pulmonary lobectomy is reported. The excision was done in a 71-year-old man suffering from an adenocarcinoma of the right lower lobe, with an apparent absence of lymphnodal and systemic metastasis. The procedure has been performed using four 10-mm cannulas and a minimal inframammary thoracotomy (4 cm) by inserting a chip camera linked to the thoracoscope and connected to external monitors. The lobar hilar structures were dissected and then sutured-divided with Endo-GIA R shots. The specimen was extracted through the minimal thoracotomy. The postoperative course was uneventful with minimal postoperative pain, and the patient was discharged after complete surgical recovery with excellent functional and cosmetic results. This procedure in selected patients is a new and promising possibility in chest videoendoscopic surgery.


Laparoscopic splenectomy: operative technique and preliminary report. A technique of laparoscopic splenectomy was developed on animal models and subsequently applied in two human patients. After creation of a 15 mm Hg pneumoperitoneum, five trocars, two with 12-mm diameters, were introduced into the upper abdomen. The spleen was approached directly by dissection of the gastrosplenic ligament. The short gastric vessels and hilar vessels were individually ligated with metallic clips or a surgical stapler, depending on their size. A plastic bag was then introduced into the abdominal cavity and the spleen slipped inside. An umbilical incision measuring 2 to 3 cm was used for extraction after finger fracture of the spleen. After laboratory experience with seven animals, we used this operation on two patients. The first procedure had to be converted to open surgery because of hemorrhage; the second was successfully performed within 4 h. Knowledge of anatomic variations and meticulous surgical technique are necessary for the successful completion of splenic laparoscopic surgery.


Linear gastrectomy: an endoscopic staple-assisted anterior highly selective vagotomy combined with posterior truncal vagotomy for treatment of peptic ulcer disease. A technique of anterior highly selective vagotomy is described that uses an endoscopic stapling device to facilitate and speed the procedure. Further study is necessary to ascertain the long-term recurrence rate for this new procedure, but it shows great promise as a simplified procedure for laparoscopic application in peptic ulcer disease.


The technique of laparoscopic Billroth II gastrectomy. This report describes the technique of totally intra-abdominal Billroth II gastrectomy. Because the procedure is minimally invasive, patient recovery is remarkable compared with the conventional open technique. The development of this procedure completes the minimally invasive revolution in the management of peptic ulcer disease, which began with the introduction of laparoscopic vagotomy.


Laparoscopic gastropexy in a patient with chronic gastric volvulus. We report a case of chronic gastric volvulus that was successfully treated by laparoscopic gastropexy. This procedure is also considered applicable to operations for other gastrointestinal disorders requiring organ fixation.


The technique of laparoscopic Nissen fundoplication. Nissen fundoplication can be successfully carried out by the laparoscopic technique. Surgeons trained in laparoscopy are able to perform this procedure on selected patients with gastroesophageal reflux refractory to medical therapy. The technique is described in detail.


Biliary complications related to laparoscopic cholecystectomies: radiologic diagnosis and management. The purpose of this study was to review the radiologic presentations and management of biliary complications related to laparoscopic cholecystectomies. Additionally, a computed tomography (CT) evaluation of asymptomatic postsurgical patients was performed to determine the uncomplicated appearance of the gallbladder fossa. Over a 24-month period 23 biliary complications were seen in patients who underwent laparoscopic cholecystectomies (group 1). Twenty asymptomatic patients were examined with unenhanced CT examinations after laparoscopic cholecystectomy (group 2). Twenty patients in group I had bilomas located in the gallbladder fossa (n = 9), subhepatic (n = 7) and subphrenic (n = 2) spaces, and diffusely distributed in the peritoneal cavity (n = 2). The bile leaks were presumed to have been proved to be from the cystic duct (n = 19), right hepatic duct (n = 1), and common bile duct n = 3) injuries and leaks. Fourteen drains were placed percutaneously using CT (n = 12) or sonographic (n = 2) guidance, and in two cases drains were placed surgically. The duration of catheter drainage average 11.3 days. Six patients underwent endoscopic retrograde cholangiopancreatography (ERCP) procedures, including sphincterotomy (n = 6) and stent placement (n = 3). Patients who were treated with a drain or ERCP procedures or who were managed conservatively all recovered without the need for additional surgery. In five cases, the bile cultures were positive for multiple organisms. Three patients underwent surgical repairs for disrupted common bile ducts. In group 2 CT examinations showed minimal fluid densities in all patients. No evidence of distinct, well-demarcated fluid collection was seen in any of the 20 patients. (ABSTRACT TRUNCATED AT 250 WORDS)


The usefulness of intraoperative drip infusion cholangiography during laparoscopic cholecystectomy. Intraoperative cholangiography during laparoscopic cholecystectomy has been considered to be a necessary examination because incidental injury to the common bile duct must be avoided. We performed 93 intraoperative drip infusion cholangiographies among 103 laparoscopic cholecystectomized patients as simple examinations by using iotroxic acid. The best drip infusion time was determined to be 20 min and good pictures were obtained from 10 to 60 min after the end of the drip. Nine patients with liver dysfunction and a poor radiograph had poor cholangiograms. Clear cholangiograms were obtained in 79 patients: four had a long remnant cystic duct and, in one case, a common bile duct stenosis was found by endoclip. The findings in these five cases helped us to correct failures during operation.


Evaluation of pulmonary function in laparoscopic cholecystectomy. Historically, values of pulmonary function tests, when taken on the day after open upper abdominal surgery and cholecystectomy, show decreases of 45% to 60% compared with preoperative determinations. In a group of 54 consecutive patients in whom many pulmonary function parameters were studied, forced vital capacity (FVC) and forced expiratory volume in 1 s (FEV1), measured the morning after laparoscopic cholecystectomy, revealed a 22% decrease (3.31/2.59 L) and a 21% decrease (2.68/2.11 L), respectively, on average compared with preoperative values, demonstrating better pulmonary function after laparoscopic cholecystectomy. Furthermore, there was no difference between patients above or below 60 years of age and between smokers and nonsmokers. Improved pulmonary function after laparoscopic cholecystectomy may account for the observed reduced rate of pulmonary complications after laparoscopic cholecystectomy.


Laparoscopic appendectomy: a new opportunity for curing appendicopathy. It is strongly disputed whether the appendix is indeed the cause of chronic abdominal complaints, even when the pain is situated in the right lower quadrant. In 1976 the introduction of a new operative technique, the laparoscopic appendectomy, offered new insight by making it possible to remove an appendix that is not acutely inflamed through a second insertion in the right lower quadrant by using the open stump method. Between 1976 and 1989, this operation was performed on 1,214 patients in a regional population of about 75,000 people and was successfully performed in 85%. Two subgroups totaling 215 patients showed a success rate of greater than 80% with no major complications; after one year, the patients' scars were almost invisible. This high success rate of a somatic therapy for a so-called psychosomatic disease can be explained by the following possible pathological changes in the appendix: corpora aliena, parasites, kinking, adhesions, obliterations, viral follicular hypertrophy, fibrosis, and neural changes. Most of these conditions are postinfectious. The greater ability of female patients to handle infection results in differences between the two sexes in frequency, development, and behavior of the disease. Laparoscopy alone can reveal a herd of pathologic conditions in patients with pain of unknown origin. With the aid of the laparoscope, appendectomy can be added safely and more patients relieved from chronic abdominal complaints than previously thought possible.


Postoperative pain and nausea after laparoscopic cholecystectomy. Postoperative discomfort following cholecystectomy has diminished considerably since laparoscopic surgery was introduced. This study assessed the degree of postoperative pain and nausea when, during the operation, the trocar sites had been infiltrated with bupivacaine and antiemetics (ondansetron) had been administered. Postoperative pain intensity was moderate as 20% of the patients were managed without any opiates postoperatively and 88% did not require any opiates after discharge from the recovery room. Postoperative nausea and vomiting is known to be a problem that occasionally has been reported to delay discharge from the hospital. A single dose of ondansetron at the end of the operation seems to reduce postoperative nausea effectively. Two-thirds of the patients had no complaints of nausea, and the majority of the remainder experienced only mild and transitory nausea. We recommend that stab-wound sites be infiltrated with local anesthetics and that antiemetics be administered at the end of the operation.


Laparoscopic intraperitoneal marsupialization: report on a new treatment for lymphoceles. Lymphocele formation, a common complication of pelvic surgery, can produce considerable morbidity. Treatment is problematic, with no single procedure considered optimal. We recently treated a 67-year-old man with a symptomatic lymphocele by laparoscopic internal marsupialization. Total operative time was 45 min, and the patient was discharged home the same day with minimal need for pain medications. Total resolution of the symptoms occurred within 24 h. In comparison to other methods compiled and analyzed from the literature, this highly effective, minimally invasive procedure offers a significant advantage to the patient.


Laparoscopic hernioplasty using a self-expandable (umbrella-like) prosthetic patch. The umbrella-like repair of inguinal hernia via the laparoscope was performed without major complications in 25 patients. The technique involves the preperitoneal placement of a self-expandable patch of polypropylene that incorporates a nitinol wire. This innovation considerably reduces the difficulty of the laparoscopic hernioplasty procedure, saving time and technical effort for the surgeon without sacrificing any of the advantages of a laparoscopic operation for the patient.


Injury to an accessory bile duct during laparoscopic cholecystectomy. Anatomic variations of the bile duct system are frequent. Accessory cholecystohepatic ducts have been reported, but remain unrecognized in most patients. We present the case of an 53-year-old woman suffering from cholecystolithiasis. Five days after laparoscopic cholecystectomy, symptomatic bile collection in the peritoneal cavity was found. Endoscopic retrograde cholangio-pancreatography (ERCP) with papillotomy showed a bile leak in the gallbladder bed. During relaparoscopy, we were able to identify and to clip an accessory bile duct in the caudal part of the gallbladder bed. Symptomatic injury of an accessory bile duct is a rare complication of laparoscopic cholecystectomy and difficult to prevent. Intraoperatively we recommend the use of operative cholangiography to reveal anatomic variations. Postoperatively the leak can be identified by ERCP, but sphincterotomy should be done simultaneously. If necessary, however, the injury can be repaired by laparoscopic means.


A simple and rapid technique for suture ligation during laparoscopic cholecystectomy. During laparoscopic cholecystectomy, it is difficult to separate and resect an inflamed cystic duct. This difficulty derives mainly from the lack of a simple and rapid technique of manually ligating the cystic duct. We describe herein a technique that facilitates manual ligation using ordinary silk sutures.


Laparoscopic management of enlarged cystic duct. After laparoscopic exploration of the common bile duct, or when a patient has acute cholecystitis, the cystic duct is sometimes edematous and too large to be ligated safely with an Endoclip. In such cases, ligation of the cystic duct with an Endoloop offers a solution to the problem. The standard technique for application of an Endoloop consists of dividing the cystic duct and then applying the Endoloop. This becomes more difficult if, after the cystic duct is divided, loss of traction on the common bile duct results in retraction of the divided cystic stump outside of the laparoscopic field of view. To avoid this difficulty, the authors apply an Endoloop with the grasping forceps on the cystic duct before the duct is divided so that it cannot retract from operative view and for this task developed an instrument that allows simultaneous introduction of both grasping forceps and the Endoloop through a single port.


Simultaneous laparoscopic varicocelectomy and removal of an intrascrotal atrophic testicle. We report on the concomitant removal of an atrophic intrascrotal left testicle secondary to mumps orchitis and a right varicocelectomy for athenospermia done laparoscopically. The procedure proved to be quite simple to complete, avoiding the need for secondary incisions, which would have been required otherwise if a standard open approach was chosen. The convalescence period was uneventful with the patient returning to regular activities within 72 h of the procedure. We feel that in selected cases a laparoscopic orchiectomy offers distinct advantages to conventional open surgical approaches.


Mechanical retraction in laparoscopic surgery: cholecystectomy. Mechanical retraction in laparoscopic surgery results in stable exposure, dependable field of vision, and more efficient use of personnel. The steps required to use mechanical retraction in laparoscopic cholecystectomy are outlined in this report.


Intraperitoneal abscess after laparoscopic cholecystectomy. A case is presented of small bowel obstruction due to an intra-abdominal abscess as a complication of stones left behind during laparoscopic cholecystectomy. It is suggested that a concerted effort be made to remove all stones spilled in the peritoneal cavity and that a therapeutic course of broad-spectrum antibiotic be instituted.


Laparoscopic cholecystectomy in a patient with hemophilia B. Surgical procedures in hemophiliacs is a demanding challenge for the surgeon and hematologist. This report deals with a successful laparoscopic cholecystectomy in a young patient with hemophilia B. Despite a prolonged operation time, because of a partially intrahepatic gallbladder, no bleeding complications were registered and the patient recovered well. Laparoscopic cholecystectomy seems to be the method of choice in hemophiliacs, as it minimizes tissue trauma. Nevertheless, the procedure should be performed only in specialized centers with a fully equipped coagulation laboratory and a team of surgeons and hematologists familiar with the special problems of surgery in hemophiliacs.


Extraction of difficult gallbladders by laparoscopic cholecystectomy: development of a new retrieval system. The retrieval of elusive or torn gallbladders or of those with large stones and lost calculi is often difficult and time-consuming. We developed an extractor to recover these difficult gallbladders and have already used this extraction method successfully in 26 patients.


Rectus sheath hematoma: a complication of laparoscopic cholecystectomy. We describe a complication in laparoscopic cholecystectomy. The routine introduction of a midclavicular secondary trocar resulted in a large hematoma of the rectus sheath. The patient developed atelectasis and pneumonia and required extended hospitalization. This previously described complication is detailed with recommendations to prevent its occurrence.


Laparoscopic Ripstein procedure.

Laparoscopic Ripstein procedure. An endolaparoscopic technique to perform a proctopexy is reported. This procedure appears to be ideally suited for this approach and, furthermore, it can be performed safely and effectively. Long-term predictions of morbidity, mortality and recurrence rates cannot yet be made, but those parameters might not be different from what would be expected with the open approach.


Laparoscopic highly selective vagotomy: technique and case report. As the advantages of minimally invasive surgical techniques become more apparent, new applications are being identified. Here we describe the technique and our initial experience with laparoscopic highly selective vagotomy. The ability to perform this effective antiulcer operation laparoscopically with minimal resultant pain, reduced hospital time, less cost, and diminished morbidity may make surgical therapy a more attractive option in the management of peptic ulcer disease.


Laparoscopic-assisted sigmoid colectomy for sigmoid volvulus. A 75-year-old black man came to the emergency room because of nausea, vomiting, abdominal pain, and distension and obstipation. An abdominal radiograph revealed a sigmoid volvulus. This was nonoperatively reduced in the emergency room. Following a mechanical and antibiotic bowel preparation, the patient underwent elective exploration. We report, for the first time, operative treatment of sigmoid volvulus with a laparoscopic-assisted sigmoid colectomy and primary anastomosis. Because of dense fibrous scarring of the sigmoid mesentery produced by chronic mesosigmoiditis, the redundant sigmoid was exteriorized and resected extracorporeally. A stapled, side-to-side, functional end-to-end anastomosis was constructed. The patient experienced little postoperative pain and virtually no postoperative ileus. We believe that laparoscopic-assisted sigmoid resection may offer distinct advantages for the treatment of the typically elderly, debilitated patient in whom sigmoid volvulus develops. Furthermore, because of the characteristic mesosigmoiditis associated with sigmoid volvulus, we suspect that exteriorization and extracorporeal resection may prove the easiest and most rapid laparoscopic approach to this disease.


[Role of local peptide regulators in the maturation of ovarian follicles]. Follicular maturation and ovulation are triggered by pituitary hormones, specifically, follicle stimulating hormone (FSH) and luteinizing hormone (LH). Nevertheless ovarian response to gonadotropins is systematic and not targeted. Adequate physiological response, i.e. maturation of a single dominant follicle and a single ovulation, is dependent on local modulation of the response by local paracrine and autocrine regulators. Presently, we may conclude TGF alpha and IGF-I and II are implied in growth of cellular components of the follicles: granulosa and theca cells. TGF beta and activins stimulate cellular differentiation with production of estrogens and inhibins. TGF alpha is the single local factor which accelerates the meiotic competence acquisition. Finally, follistatin seems to be a powerful atretic factor for cohort follicles and luteinizing agent for dominant follicle.


[Toward a new definition of malignant histiocytosis in children]. The anaplastic large cell, CD30 positive lymphomas represent a heterogeneous group of lymphomas in which immunocytochemical and molecular investigations have demonstrated the existence of malignancies of T, B or undetermined origin. The recent identification, in a few cases of this group of a chromosomal 5q35 breakpoint may allow the individualization of a peculiar disease entity. In these cases, the 5q35bp has been found to be a permanent abnormality, present in five human permanent cell lines and associated with various translocations including t(2;5), t(1;5) and t(5;6). A primitive myelo-monocytic origin of these 5q35bp cell is suggested on the basis of the following arguments: they express the c-fms proto-oncogene which encodes the macrophage growth receptor (CSF-1-R) the c-fms is mapped on 5q33,34 close to the 5q35bp the express spontaneously CD68 the treatment by phorbol-diester of a 5q35bp cell line (DEL cell line) induces an immunodependent phagocytosis and a modulation of expression of c-fms, CSF-1 and TNF alpha. Because some 5q35bp cell lines also presents rearrangements for TCR-bêta, or IgF, these data suggest an ancestral stem cell origin, prior to the T, B and myelomonocytic differentiation. Whatever its origin, the 5q35bp abnormality has been mainly encountered in children's malignancies. It has been constantly associated with clinical and biological manifestations of a condition recognized by paediatricians as malignant histiocytosis. For this reason, the 5q35bp may today represent the best criterion for the identification of malignant histiocytosis in childhood.


[Cellular lesions in Alzheimer's disease: structural and molecular analysis]. Neurofibrillary tangles and senile plaques are the characteristic neuropathological lesions of Alzheimer's disease. Neurofibrillary tangles are composed of a microtubule-associated protein, the tau protein. This protein plays a role in the development of neuronal polarity and the stabilisation of microtubules. In Alzheimer's disease, tau proteins are abnormally phosphorylated on several sites. This abnormal phosphorylation might induce the modifications of the microtubule network observed in affected neurones. The main component of the senile plaque is an amyloid deposit made of a polypeptide (beta/A4 amyloid) which derives from a larger precursor. The overexpression of this precursor in experimental models or mutations of its gene leads to the development of neuropathological lesions. The relationships between cytoskeletal abnormalities and beta/A4 amyloid are further discussed.


[Current developments in psychiatry: current interest of works by A. Quételet and J. Guislain]. The influence of Adolphe Quételet and Joseph Guislain, born respectively in 1796 and 1797 in Gent, on the most recent developments of Psychiatry has a paradoxical character. Quételet was a mathematician and astronomer, but his interest in statistics led him to organize the standardized collection on data on an international basis and to initiate the measurement of social and pathological behaviours, two trends which dominate present day epidemiological, nosological and clinical research in Psychiatry. Although Guislain is rightly honoured as the organizer of a human system of treatment for the mentally ill in Belgium, his theoretical ideas about the nature of mental disorders, he considered as reactions to a basic disturbance, whose aspects were determined by the physical and psychological peculiarities of the individual, have been practically forgotten. But they provide an alternative to the now prevalent tendency towards a strictly categorical nosology, whose shortcomings are more and more apparent in empirical biological and clinico-epidemiological research.


[A royal ophthalmologist: Carl Theodor, Duke in Bavaria (1839-1090)]. History reveals that doctor Carl Theodor, Duke in Bavaria, was an exceptional man in many ways if we consider his professional qualities and his sense of responsibilities. Thoroughly humane, and desirous of living very close to his contemporaries, he had to overcome numerous obstacles which hampered his medical destiny. His humanitarian achievements are important and may have influenced his daughter, Her Majesty Queen Elizabeth, and developed her passion for healthcare concerning injured and sick persons. His scientific work, undertaken with prestigious masters in Vienna, Switzerland or Germany, reveals a searcher who always manifested a permanent concern for perfection in the accomplishment of his task.


Bacterial chemistry. VI. Biological activities and cytotoxicity of 1,3-dihydro-2H-indol-2-one derivatives. The biosynthetic pigment from Chromobacterium violaceum BB-78, 1,3-dihydro-2H-indol-2-one and its derivatives exhibit biological activities such as antimicrobial action, low hemolytic effects on red blood cells and in vitro trypanocide activity. A relatively high cytotoxicity on V-79 hamster fibroblast cells of the biosynthetic pigment was found, although with the methylol derivative the toxicity was almost eliminated. The methylol derivative exhibited similar toxicity as Nifurtimox, a known, commercial trypanocide compound.


Effects of stress upon plasma estradiol and progesterone levels and the rate of oviductal embryo transport in the rat. The possibility that changes in sex steroid levels associated with stress could alter the rate of oviductal embryo transport was investigated in the rat. To this end, the effect of cold-swimming and cold-restraint upon estradiol (E2) and progesterone (P) serum levels and embryo transport were assessed. Swimming in water at 16 degrees C for 10 min two or four times between 16:00 and 22:00 h on day 3 of pregnancy caused a modest acceleration of embryo transport that was not associated with decreased fertility. Restraint at 10 degrees C for 2 h between 13:00 and 15:00 h on the first 4 days of pregnancy did not affect embryo transport. Both stimuli increased corticosterone serum levels. Cold-swimming produced a severe hypothermia as compared to cold-restraint and increased serum E2, decreasing significantly the ratio P/E2. Cold-restraint increased the P/E2 ratio. When rats swam in cold water for 10 min twice and were rewarmed by immersion in water at 38 degrees C during 20 min, embryo transport was accelerated despite that no changes occurred in the blood levels of sex steroids. It is concluded that oviductal embryo transport is minimally affected by stress in the rat and that the effect of acute immersion may be independent of alterations in circulating sex steroid levels.


Effects of the diet consumed during the pregnancy on the lipids content in maternal and fetal rat lungs. This study was designed to determine if the quantity of lipids in the diet fed to pregnant rats would affect the deposition of fat in the fetal lung. Wistar rats were fed with two different diets during pregnancy: Standard Diet (StD; 4.000 cal/g) and High Fat Carbohydrate Free Diet (HFCFD; 6.000 cal/g). The rats consumed daily the same amount of calories from these different diets. The concentrations of triglycerides (TG), phospholipids (PL), total, esterified and free cholesterol (TC, EC and FC, respectively) were determined in serum and lung from pregnant rats as well as from their 19 day old fetuses. In the serum of rats fed with HFCFD, the cholesterol concentration increased in relation to that of rats fed with StD. In pregnant rat lung, the PL concentrations decreased and the TC, EC and FC concentrations increased with HFCFD in relation to StD. The triglycerides were not modified in any case. The lipidic composition of the sera and fetal lung were not changed by the two diets consumed by pregnant rats. This may be a biological protective mechanism to assure an adequate synthesis of alveolar surfactant.


Immunodetection of acrosin during the acrosome reaction of hamster, guinea-pig and human spermatozoa. Mammalian sperm acrosomes contain a trypsin-like protease called acrosin which causes limited and specific hydrolysis of the extracellular matrix of the mammalian egg, the zona pellucida. Acrosin was localized on hamster, guinea-pig and human sperm using monoclonal and polyclonal antibodies to human acrosin labelled with colloidal gold. This was visualized directly with transmission electron microscopy, and with light and scanning microscopy after silver enhancement of the colloidal gold probe. Four distinct labelling patterns were found during capacitation and the acrosome reaction in hamster and guinea-pig spermatozoa, and three patterns were found in human spermatozoa. In the hamster, acrosin was not detected on the inner acrosomal surface after the completion of the acrosome reaction, thus correlating with the observation that hamster spermatozoa lose the ability to penetrate the zona after the acrosome reaction. With guinea-pig and human spermatozoa, acrosin was still detected after the completion of the acrosome reaction, thus correlating with the observation that acrosome reacted guinea-pig spermatozoa bind to and penetrate the zona pellucida.


The evolutionary origin of the mammalian cerebral cortex. The origin of the mammalian neocortex in usually considered as an improvement in the structure of the brain. Alternatively, I suggest that the mammalian neocortex arose as a consequence of contingent adaptations in which there was no specific selection for more elaborate cognitive abilities. In primitive mammals, the adaptation to nocturnal life produced a reduction of the optic tectum (superior colliculus). In addition, the development of the olfactory system triggered the development of the cerebral cortex. It is proposed that, since both the optic tectum and the cerebral cortex are laminar structures, the growing cortex replaced the tectum in many integratory functions. When mammals reinvaded diurnal niches, the optic tectum did not redevelop, and the cerebral cortex remained the main integratory and perceptual system. This is a case of irreversible reduction of an organ. In reptiles and especially in birds, although there was also an increase in brain size (associated with higher cognitive capacities), the optic tectum grew in size and complexity and the forebrain grew largely as a nonlaminar structure (except the Wulst in birds). Therefore, the origin of the cerebral cortex resulted from the combination of adaptations to nocturnality and the development of olfactory-driven behavior, and its origin is not directly related to higher cognitive capacities.


Biological similarity theories: a comparison with the empirical allometric equations. Twelve biological variables were submitted to dimensional analysis in accordance with the MLT-system of physics (M, mass; L, length; T, time). Each of these variables has a characteristic numerical value for the exponents alpha for mass, beta for length, and gamma for time. By means of Newton's reduction coefficient (chi), the three dimensions (MLT) can be expressed as power functions of body mass (Mb); the exponent (b) is the result of the combination of the three dimensional exponents (alpha, beta, gamma). By linear regression analysis of 203 allometric exponents (betaE) obtained from the literature, the following equation was found for the regression exponent (bR) (equation: see text). The estimated numerical coefficients (ki) for the three exponents (alpha, beta, gamma) of the basic dimensions (MLT) do not agree with those of the prevailing theories of biological similarity.


Warfarin necrosis.

Warfarin necrosis. Skin and subcutaneous tissue necrosis is a rare complication of warfarin therapy. Although the incidence is low, with increased use of warfarin family physicians need to be aware of this potentially catastrophic event. This article reviews the history of warfarin necrosis and discusses its clinical presentation. The histologic findings with necrosed lesions are described, with emphasis on the possible pathogenesis of this disorder. Treatment options based on existing clinical experience as outlined in the literature are discussed.


Human gene therapy: a role for the primary care physician. Human gene therapy, once thought to be the unique province of specialized clinical centers, will be diffusing rapidly into primary care medicine. More than 10 medical centers in the United States and several centers world-wide are beginning to use this potentially curative therapy. Eleven trials of protocols are under way, nine are about to begin, and more than 12 protocols are nearing completion of the approval process. The diseases being treated are not the rare disorders found only in one in 100,000 patients, but instead include various types of cancer, diseases of the cardiovascular and pulmonary systems, and inborn errors of metabolism. Combined, these diseases affect more than half of the American population.


Revolution in real time. Physician practice management in the 21st century. Change in the health care system is stimulating the interest of physicians policymakers, and third-party payers in practice management activities. New analytic techniques and management concepts enable interested parties to obtain more and better information about the overall results of practice. These new techniques and concepts offer physicians an opportunity to exert more influence on the direction and productivity of practice than in the past. This report reviews the development of three emerging fields and projects their impact on practice management. Outcomes management technology involves adjusting for the differences in patient biology between practices and describes outcomes of patient interventions in standard ways. Medical informatics involves the conversion of data into information that allows the physician manager to direct outcomes, quality, and costs. Quality management involves empowering employees and physicians to participate in improving the overall performance of the practice. The use of techniques for analysis and intervention is changing the definition of practice management beyond its conventional preoccupation with billing and accounts receivable. In fact, a new science of practice management is emerging that describes the interactions between the health care organization and the outcomes of services to patients. These tools empower physicians to direct the performance of the practice, to match services to patient needs, and to manage the costs of practice operations. Thus, the new methods and technologies of practice management have the potential to bring substantial benefits to patients, office staff, and physicians.


American Medical Association Diagnostic and Treatment Guidelines on Domestic Violence. Physical and sexual violence against women is a public health problem that has reached epidemic proportions. An estimated 8 to 12 million women in the United States are at risk of being abused by their current or former intimate partners. This violence causes serious physical, psychological, and social sequelae for these women and their families.


Somatic consequences of violence against women. The rapidly growing literature on the somatic, nonpsychiatric effects of violence on women's health is reviewed, including rape, battery, and the adult consequences of child sexual abuse. The sequelae of these victimizations are summarized with consideration of acute effects (genital and nongenital injuries, sexually transmitted disease, and pregnancy), late consequences (chronic pelvic pain and other forms of chronic pain, gastrointestinal symptoms, premenstrual symptoms, and negative health behaviors), and long-term increases in the use of medical services. A recurrent theme across the literature is that the medical treatment of all types of victimized women can be improved by providing attention to the underlying cause of their symptoms. Achievement of this goal requires that physicians identify victimization history and provide access to appropriate support services. Because all forms of violence against women are prevalent among primary care populations, and victimization is clearly linked to health, health care providers cannot afford to miss this relevant history. The article concludes with suggestions for fostering and responding to disclosures of victimization.


Clinical competence of family physicians. The patient perspective. This study examines the attitudes and perceptions of patients regarding the clinical competence of family physicians. Telephone survey employing probability sampling (random-digit dialing). A sample of adults living in Kentucky. Data come from a sample of 650 completed calls (64% response rate). Ninety-three percent of the patients reported having a physician who provides primary health care. Only 1% of those with a physician listed a specialist as their source of care. Patients generally agree that family physicians are clinically competent to handle common medical problems. Of 11 investigated conditions, depression and heart disease were the conditions with the lowest reported patient confidence. A stepwise logistic regression model indicated that the quality of care provided by one's primary care physician was the only significant predictor of patient confidence in the competence of family physicians. These results suggest that patients believe family physicians are competent to treat a wide variety of common medical problems.


Patients' knowledge about fats and cholesterol in the Community Cholesterol Survey Project. The Community Cholesterol Survey Project assessed attitudes, knowledge, and behaviors relating to cholesterol. Survey. Six outpatient primary care practice sites (two urban, two suburban, and two rural) in northeast Ohio. Four hundred seventy-seven site-, age-, and gender-stratified adult patients were enrolled from a total of 604 approached (79% recruitment). Self-administered questionnaire and structured dietitian interview. A knowledge score derived from responses to multiple-choice questions and a knowledge rating given by the study dietitian. Motivation and dietary health were similarly measured. Subjects did worse than random guessing for seven of 12 knowledge questions regarding label reading, fats, and cholesterol. In particular, the meaning of "hydrogenated" and the relative energy content of fats was poorly understood. Knowledge scores and ratings were significantly correlated (r = .52). Knowledge ratings were higher in those who were receiving a cholesterol-lowering diet or who had received other advice or treatment from their physician for high cholesterol level. By analysis of variance, knowledge measures were found to have significant independent positive associations with higher social status (P < .001) and living in a suburban area (P < .05). Motivation and dietary health demonstrated similar relationships to social status. To make use of patients' motivation for change, it will be essential to provide education at an effective level. Instruction in label reading or creation of more meaningful food labels may have the greatest impact. A particular challenge is the education of less advantaged patients to promote healthy nutrition practices.


Substance use in rural Midwestern pregnant women. To determine the rate of prenatal use of cocaine, cannabis, amphetamines, opiates, and cigarettes in rural midwestern women by analysis of reported use of cigarettes, maternal urine drug screening at admission to labor and delivery, and newborn meconium screening. The cohort of all women presenting to labor and delivery and their newborns were screened by urine and meconium analysis. Demographic information was also collected and matched to the urine and meconium samples. Four primary care hospitals in rural Minnesota. Hospitals range in size from 66 to 140 beds, with 400 to 780 deliveries each year. All women presenting to labor and delivery for evaluation of term or preterm labor between April 4, 1991, and October 4, 1991. Overall, drugs not administered during labor were found in a mean (+/- SD) of 3.2% +/- 1.1% of all urine screens. Cannabis was found in 1.2% +/- 0.7% of maternal urine samples, amphetamines in 0.8% +/- 0.58%, opiates in 1.2% +/- 0.7%, and cocaine in 0% +/- 0.3%. Meconium samples were positive in 1.8% +/- 0.9% of cases. Cannabis was found in 1.1% +/- 0.7% of meconium samples, opiates in 0.6% +/- 0.5%, and cocaine in 0.1% +/- 0.1%. No urine samples were positive for more than one drug. One meconium sample tested positive for both cocaine and cannabis. Nearly 4% of patients had either a positive urine specimen or a positive meconium specimen. By history, 24.5% of women admitted to smoking during pregnancy. The use of cocaine, cannabis, opiates, and amphetamines was uncommon in this rural population. However, one quarter of the women admitted to smoking during pregnancy, exposing their fetuses to a dangerous substance.


Extrapulmonary tuberculosis. A review.

Extrapulmonary tuberculosis. A review. The increase in cases of tuberculosis that has occurred with the increasing number of individuals infected with the human immunodeficiency virus (HIV) has focused attention on the problems in diagnosing and treating tuberculosis. While it is primarily considered a pulmonary disease, tuberculosis has the potential to infect almost every organ system via lymphohematogenous dissemination during the initial pulmonary infection. Since 1984 the incidence of extrapulmonary tuberculosis has increased at an even faster rate than that of pulmonary tuberculosis. Extrapulmonary tuberculosis is considered a diagnostic criterion in the case definition of the acquired immunodeficiency syndrome. Immunocompromised individuals, such as patients with HIV, are at increased risk for extrapulmonary tuberculosis. The clinical manifestations are often nonspecific and insidious, and diagnosis may be delayed for years. Cases of miliary and meningeal tuberculosis are an exception, and they often constitute medical emergencies. Tuberculosis skin tests should be performed on all individuals suspected of having tuberculosis, but a negative test result does not exclude the diagnosis. Chest roentgenograms will often show signs of old or active pulmonary tuberculosis. Microscopic examination and culture of infected body fluids and/or tissue are necessary for definitive diagnosis. Treatment is with standard antituberculous medications. Short-course therapy (6 or 9 months) is probably adequate in most patients with extrapulmonary tuberculosis, but patients with human immunodeficiency viral infection need longer treatment. Extrapulmonary tuberculosis is a persistent problem in the United States and will become more prevalent as the number of patients with HIV increases. A high index of suspicion is needed to diagnose and treat extrapulmonary tuberculosis in a timely and health-preserving manner.


American Medical Association Diagnostic and Treatment Guidelines on Child Physical Abuse and Neglect. Child maltreatment has been endemic for generations. It is serious and life-threatening, affecting not only children but families and society as well. Every year, approximately 2 million children in the United States are seriously abused by their parents, guardians, or others, and at least 1000 children die as a result of their injuries.


Use of the Family CAGE in screening for alcohol problems in primary care. To establish the reliability and validity of the Family CAGE (an acronym indicating Cut down on drinking; Annoyed by complaints about drinking; Guilty about drinking; had an Eye-opener first thing in the morning), a four-item instrument intended to assess family alcohol-related problems. Two distinct cross-sectional studies using a survey, and in one study, retrospective chart review. A random sample of 172 adult patients presenting for nonurgent care to a network of family practice settings and a convenience sample of 107 patients who smoked presenting to a university family practice residency training setting. The Family CAGE was compared with alcohol-related variables and scales measuring psychosocial constructs. In the first study, these scales included the Family Stress and Coping Scale; Profile of Mood States; the Family Problems Checklist; and the Duke/University of North Carolina Mini-Health Profile. Chart review included medical utilization rates and prescription of medications. In the second study, a revised version of the Family CAGE was compared with other scales such as the standard CAGE questionnaire; an "Anomy" Scale; the Catchment Epidemiologic Study-Depression Scale; a global self-assessment of alcohol-related problems; and a self-report of lifetime history of major depression and recent self-limited depression. The Family CAGE showed strong internal consistency reliability, with Cronbach's alpha coefficients of .84 in the first study and .89 in the second. Construct validity was supported by Family CAGE correlations with family stress, family problems, depression, anxiety, individual stress, and marital dissatisfaction. The Family CAGE was strongly correlated with global assessment of family alcohol-related problems, and was superior to this variable in predicting help-seeking behavior. The Family CAGE was also significantly correlated with a higher sick visit rate and more medications prescribed (despite no difference in functional health status). The standard CAGE was correlated with a recent history of self-limited depression, while the Family CAGE was correlated with a lifetime history of major depression. Sensitivity and specificity rates vary depending on the criterion addressed, but a cutoff score of 2 or more appears to offer the best clinical information. The Family CAGE appears to be a reliable, valid, utilitarian measure of family alcohol problems. It offers more information than either a single-item global assessment regarding family alcohol-related problems or the standard CAGE questionnaire. The Family CAGE is strongly correlated with other important psychosocial problems, prescription of psychotropic medications, and health-care utilization. It is brief, understandable, and equally effective in interview and self-administered formats.


Childhood immunization practices of primary care physicians. To assess if immunization utilization practices differ between rural and urban primary care physicians in Kentucky. Survey of 200 primary care physicians. Pediatricians, family physicians, and general practitioners in Kentucky. Participants completed a 20-item questionnaire that surveyed selected demographics with regard to the physician and practice, immunizations offered to children, and reasons why the responding physicians did not offer immunizations and where they referred patients for this service. Physicians practicing in rural counties offered immunizations to their patients less frequently than did urban physicians (54% vs 77%). Rural and urban physicians cited immunization costs to patients as the chief reason that immunizations were not used more often and referred patients primarily to county health departments. Rising costs have limited physician use of immunizations in rural areas to a greater extent than that seen in urban areas. This may make access to immunizations more difficult for children living in rural areas.


Effects of differing nicotine-replacement doses on weight gain after smoking cessation. To prospectively assess effects of doses of a nicotine-replacement agent on weight gain in men and women after smoking cessation. Four-week, randomized, double-blind clinical trial. Outpatient medical clinic. Healthy volunteers who smoked at least 10 cigarettes per day. Pharmacologic: Random assignment to 0, 2, or 4 mg of nicotine polacrilex on a fixed-dose schedule (one piece per hour while awake). Behavioral: Brief, medical/behavioral counseling regarding smoking cessation. Weight change as a function of dose and gender only in participants abstinent for all 4 week. (Self-reported abstinence verified by breath carbon monoxide levels). Weight change in women abstinent for 4 weeks (n = 16) was +1.69, +0.33, and -0.26 kg in the placebo, 2-mg, and 4-mg groups, respectively, compared with +1.60, +1.45, and +1.18 kg for the men who were abstinent for 4 weeks (n = 19). Medication use did not differ as a function of dose or gender. Nicotine polacrilex suppressed, in a dose-related fashion, weight gain after smoking cessation in successfully treated women. Weight gain was not shown to be suppressed in men, possibly because of small sample size.


Dermatologic adverse drug reactions in a family medicine setting. To determine the prevalence of dermatologic adverse drug reactions in a family medicine outpatient practice setting, identify associated drug classes, and describe associated patient demographics and risk factors, we reviewed the charts of 557 patients in a university-based family medicine center who were diagnosed with a dermatologic condition. The study population included all patients diagnosed during a 1-year period. Thirty-five patients (6.3%) were identified as having dermatologic adverse drug reactions, of which the two most common types were exanthematous eruptions (n = 18 [51.4%]) and generalized erythroderma (n = 6 [17.1%]), with antibiotic use accounting for the majority (n = 21 [60.0%]) of reactions. Patient characteristics most commonly associated with a dermatologic adverse drug reaction were race (African-American), gender (female), and age (70 years and older). These data should provide insight into the types of cutaneous drug reactions commonly seen in community practice. Educational programs in all health-care disciplines, particularly medicine, pharmacy, and public health, that incorporate pharmacoepidemiologic strategies into their curricula are necessary to improve the overall process of monitoring and reporting of adverse drug reactions.


Who is providing ambulatory care to Medicaid beneficiaries with acquired immunodeficiency syndrome in New York State? This study examined the number of ambulatory care providers treating individuals with the acquired immunodeficiency syndrome who were Medicaid beneficiaries in New York State in 1988 and examined the distribution of this care across various practice settings. The study population was identified retrospectively in the New York State Medical HIV/AIDS Research Data Base and included a cohort of 5535 individuals with the acquired immunodeficiency syndrome who were enrolled in Medicaid in 1988 for at least 6 months after being diagnosed as having the disease and who had at least one ambulatory care encounter during the year. Ambulatory care for the study group was provided by more than 700 hospital or freestanding clinics and more than 3000 private physicians in 1988. Many sites had low caseloads; 47% of the clinics and 68% of the physicians treating this population saw only one or two patients with the acquired immunodeficiency syndrome who were enrolled in Medicaid. More than half the patients in the study group were seen most frequently in clinics for their ambulatory care during 1988. These data provide reassurance that a wide network of providers is involved in the care of patients with the acquired immunodeficiency syndrome who are Medicaid beneficiaries in New York.


Metoclopramide-associated tardive dyskinesia. An analysis of 67 cases. To summarize information regarding the frequency, risk factors, clinical characteristics, treatment, and course of metoclopramide hydrochloride-associated tardive dyskinesia obtained from an analysis of 67 case reports. All the case reports of metoclopramide-associated tardive dyskinesia involving human patients in the literature in English obtained by using Index Medicus and Med-Search. The indexing terms used were as follows: metoclopramide, tardive dyskinesia, dyskinesia, parkinsonism, and extrapyramidal side effects. For a patient to be included, the main published research criteria had to be met based on the information provided. These criteria included exposure to metoclopramide for at least 30 days before the onset of dyskinesia. Fifty-two patients met these criteria. One author independently extracted the data. The incidence and prevalence of tardive dyskinesia associated with metoclopramide have not been well studied. The mean (+/- SD) length of treatment with metoclopramide before the onset of symptoms was 20 +/- 15 months. The most common location of the dyskinetic movements was the face (28 [60%] of 47) followed by the tongue (21 [45%] of 47). In 15 (71%) of 21 patients on whom long-term follow-up was provided, the symptoms were still present 6 months or more after discontinuation of metoclopramide. Persistent tardive dyskinesia is a serious potential side effect associated with metoclopramide treatment.


The therapeutic use of albumin.

The therapeutic use of albumin. In this review, we condense and summarize the results of studies on the therapeutic use of human albumin to promote the more efficient use of this costly resource. Reports of major controlled and uncontrolled therapeutic trials, reviews, and summary articles published in English between 1972 and 1991 were identified through library and MEDLINE searches. Case series, prospective studies, and blinded therapeutic trials were identified from the bibliographies of these sources. All sources were critically evaluated for information about the comparative physiologic results and patient outcomes of the therapeutic use of albumin solutions, crystalloid solutions, and volume expanders other than albumin. The therapeutic use of albumin is of marginal benefit for many conditions for which it has been administered, apparently because of the body's capacity to quickly compensate for rapid colloid osmotic shifts. Human studies show little or no demonstrable value for albumin when it is administered for nutritional supplementation, wound healing, perioperative fluid replacement, treatment of early thermal injury, or therapy during extensive retroperitoneal surgery (including aortic aneurysm resection). Therapeutic albumin has well-defined value in several special circumstances: large-volume paracentesis in cirrhotic patients, acute nephrotic syndromes with diuretic resistance, organ transplantation, and plasmapheresis. Additional studies are needed to compare the efficacy of albumin with other volume expanders. For most purposes, balanced crystalloid solutions are satisfactory substitutes for colloid volume expanders and can be obtained at a fraction of the cost of colloid volume expanders.


Technology assessment. An American Medical Association perspective. The contemporary practice of medicine depends on the use of a wide array of technologies that did not exist 40 years ago. An exponential increase in our scientific knowledge base, and the subsequent application of this new information to clinical practice, have dramatically extended longevity, enhanced the quality of life, and improved the overall health status of the American public. Clinical medicine has become "a set of technologies for diagnosis, prevention, treatment, and rehabilitation."


Insulin effects on glucose kinetics in non-insulin-dependent diabetic patients with secondary failure to hypoglycaemic agents: role of different modes and rates of delivery. This study aimed at investigating the effects of pulsatile and continuous insulin delivery on glucose kinetics in non-insulin-dependent (type 2) diabetic patients with secondary failure to oral hypoglycaemic agents. Seven type 2 diabetic patients underwent a 585 minute glucose-controlled glucose intravenous infusion using the Biostator. The endogenous pancreas secretion was inhibited by somatostatin. Three experiments were performed in each patient on different days and in random order. In all cases, glucagon was replaced (58 ng/min). The amounts of insulin infused were: a) 0.15 mU/kg x min continuously; b) 0.20 mU/kg x min continuously and c) 1.0 mU/kg x min in 2 minute pulses every 13 minutes. D-[3-3H]-glucose infusion allowed determination of glucose kinetics. Infusion of identical amounts of insulin (A vs C) demonstrated that pulsatile insulin delivery exerted greater metabolic effects (higher glucose infusion rate and, mainly at the beginning of the experiment, lower endogenous glucose production) than continuous infusion; furthermore pulsatile insulin delivery (C) exerted metabolic effects similar to those of a greater dose of insulin (B) infused continuously. In type 2 diabetic patients with secondary failure to oral hypoglycaemic agents, pulsatile insulin delivery exerts greater metabolic effects than continuous hormone delivery.


Low-dose angiotensin converting enzyme inhibitors: effect on renal function in normo- and hypertensive type 1 diabetic patients. To investigate the effect of low doses of the angiotensin converting enzyme inhibitor enalapril on renal haemodynamics and albuminuria in normotensive and hypertensive type 1 (insulin-dependent) diabetic patients with incipient or overt nephropathy. Twenty-two type 1 (insulin-dependent) diabetic patients with persistent microalbuminuria or macroalbuminuria and normal serum creatinine were studied. Of all patients, 16 males and 6 females, age 45 +/- 13 years, diabetes duration 19 +/- 11 years, insulin dose 38 +/- 11 U/day, 10 were normotensive and 12 were hypertensive. After 3 months of run-in period the patients were assigned to treatment with 5 mg or 10 mg enalapril based on the presence of normotension or hypertension respectively. Before and after 6 months of treatment, renal function was assessed by evaluation of glomerular filtration rate (99m Tc-DTPA), renal plasma flow (131-I iodohippurate), filtration fraction and renal vascular resistance. Mean arterial pressure, albumin excretion rate, urinary urea excretion and glycated haemoglobin were also determined. Administration of enalapril resulted in both groups of patients in a significant fall in mean arterial pressure, albumin excretion rate, glomerular filtration rate, filtration fraction, and renal vascular resistance. Decreasing albumin excretion did not correlate with a drop in systemic blood pressure or filtration fraction. No significant variations were observed in renal plasma flow, in urinary urea excretion or in glycated haemoglobin. Our results suggest that low doses of enalapril are effective in influencing renal haemodynamics and reducing urinary albumin excretion in both normotensive and hypertensive type 1 (insulin-dependent) diabetic patients with incipient or overt nephropathy. The lowering effect of the angiotensin converting enzyme inhibitor on albuminuria seems to be independent of the action on systemic blood pressure and renal haemodynamic changes.


Enhanced secretion of tumour necrosis factor in patients with myocardial infarction. Recent evidence suggests that leukocyte infiltration of myocardial tissue may extend the area of necrosis during the acute phase of myocardial infarction. Since the activation of leukocytes depends on the action of cytokines, mainly tumour necrosis factor (TNF), we evaluated TNF secretion during myocardial infarction. The study included 12 patients with acute myocardial infarction as diagnosed on the basis of enzymatic and ECG criteria. Patients were admitted within 3 hours from onset of chest pain. Serum levels of TNF were measured by immunoradiometric assay on venous blood samples collected at time 0, and at 6, 12 and 18 hours and 1, 2, 4 and 7 days following myocardial infarction. Plasma levels of atrial natriuretic peptide-alpha (ANP) were also measured on the same samples. Mean TNF levels significantly increased during the myocardial infarction, with a peak within the first 24 hours (p < 0.01). They remained significantly elevated until day 4 (p < 0.05). The rise in TNF was positively correlated with creatinine kinase levels. ANP was also significantly increased with a delayed peak after that of TNF (p < 0.01). Even though limited to a small number of cases, this study shows that acute myocardial infarction is associated with increased TNF secretion. Because of its capacity of stimulating leukocyte infiltration in myocardial tissue, the increased levels of TNF might potentially have a negative prognostic significance.


Diabetes mellitus and bacteraemia: a comparative study between diabetic and non-diabetic patients. To compare the incidence, mortality, clinical characteristics and outcome between bacteraemias in diabetic and non-diabetic patients. A prospective study of all adult patients with bacteraemia admitted to a large Spanish teaching hospital during six consecutive years (1984-1990); 152 were diabetics and 1488 non-diabetics. Rates per 1000 admissions when bacteraemic diabetic patients were compared with non-diabetics (p < 0.001) were respectively as follows: incidence 26.8/15.5, acquisition in the community 18.4/6.2, urinary tract source 8.7/2.2, and E. coli aetiology 8.9/3.4. Diabetes mellitus type II was found in 138 episodes. Glycosylated haemoglobin levels were 13 +/- 3%. Bacteraemia developed in association with hyperosmolar status in 14.5% of patients and with ketoacidosis in 5%. Patients in the diabetic group developed septic shock in 22% of the episodes, acute renal failure in 40%, superinfections in 22% and had an inappropriate empirical antibiotic treatment in 6%, vs 15.6%, 20%, 11% and 25% respectively of the non-diabetic bacteraemic patients (p < 0.05 for all comparisons). Overall mortality and bacteraemia-related mortality were similar in both groups. Multivariate analysis showed that the association with fatal diseases, shock and renal insufficiency negatively influenced the outcome of diabetic patients, while the nephro-urologic source and an appropriate therapy were accompanied by a better prognosis. A higher incidence of bacteraemia, mainly of urinary source, community-acquired, and due to E. coli was found in the diabetic patients compared to non-diabetics. The common use of rapidly effective drugs for this predominant bacteraemia conditioned similar outcome and prognosis factors in both populations, in spite of the higher incidence of septic shock and acute renal failure in the diabetic population.


Interventional angiology.

Interventional angiology. Percutaneous transluminal angioplasty in peripheral artery occlusive disease by balloon catheters is the standard method in interventional angiology. For almost twenty years it has been recommended in the aorto-iliac region for arterial stenoses, and in the femoro-popliteal arteries for stenoses and short occlusions. Due to progress in technology of catheters and guide wires, a primary success rate of more than 90% is to be expected with favourable angiographic conditions. The long-term patency rate of some 90% on the aorto-iliac level exceeds that of 70-90% on the femoro-popliteal level. The patency rate decreases with increasing complexity of the lesions. Subacute/acute occlusions of the femoro-popliteal arteries by thrombosis or embolism are treated successfully in 80% of cases by catheter-thrombolysis and/or thrombus aspiration combined with percutaneous transluminal angioplasty if necessary. Several new techniques are under clinical evaluation, such as laser angioplasty, rotational catheters, atherectomy catheters and stents. Their application in clinical routine has up to now not been justified except for special situations such as obtaining biopsy material by Simpson catheter or maintenance of patency in balloon resistant lesions by stents.


Fibronectin in HIV-infected patients: a prospective study. Fibronectin, a non-specific opsonin involved in the clearance of microorganisms, is thought to play a role in various infectious disease processes. Its diagnostic value as a biological marker of infection and/or prognosis in human immunodeficiency virus (HIV) patients is questionable. We conducted a prospective study to evaluate plasma fibronectin levels in patients with HIV infection at different stages of the disease. Eighty-one consecutive HIV-infected patients seen in our department were evaluated clinically and biologically. Classifications according to the Centers for Disease Control (CDC) stages were: Group II (n = 22), Group III (n = 17), acquired immunodeficiency syndrome (AIDS) (n = 17) and AIDS related complex (n = 25). Plasma fibronectin levels were measured by a radial immunodiffusion assay. Plasma fibronectin levels were not different between HIV-infected patients (344 +/- 128 mg/L) and controls (n = 20, 335 +/- 45 mg/L). Among the 81 patients, plasma fibronectin levels were within normal value in 79%, with no significant difference of mean plasma fibronectin between the different CDC groups. No correlation was found between plasma fibronectin and other biological parameters including CD4+ cells, p24 antigen, beta-2-microglobulin. Furthermore, no correlation was noted between fibronectin and complement levels or presence of circulating immune complexes. These results suggest that plasma fibronectin is not a useful marker in patients with HIV infection.


Alternatives to randomization in surgical studies. The purpose of randomization is to provide unbiased estimates of treatment effects and valid probability statements for hypothesis tests in comparative studies. Difficulties with randomized allocation of patients in surgical studies include: patient selection--due to protocol limitations, possible changes in referral patterns, the need for patient consent, and physician co-operation; disruption of the patient-physician relationship; static protocol not responsive to changes as surgical skill evolves and experience regarding patient selection is acquired; the larger number of patients required causes a longer study and more patients receiving what may be a worse therapy. Moreover, for evaluating a new heart valve, the primary purpose should be estimation rather than comparison with a current device. This can be accomplished faster, in a more generalizable way and with more concern for patient care by using non-randomized comparison groups.


The United Kingdom Heart Valve Registry. The United Kingdom Heart Valve Registry project began in 1986 following discussions between the Department of Health (DOH) and the Society of Cardiothoracic Surgeons of the United Kingdom and Ireland. The intention was to establish a computerized database for valve replacement operations carried out in the UK Health Service cardiac units. This paper describes the experience gained over the first five years of this project. Around 30,000 patients were entered in the registry between 1986 and 1990. All Uk Health Service cardiac surgical units contribute their data, which is processed by the central Registry Office. The accuracy of the mortality data is ensured by tracking the registered patients through the Office of Population Census and Surveys (OPCS). The pattern of valve replacement surgery over the period 1986-90 revealed several interesting trends. Although the number of procedures remained static at around 5,000 valve transplants per year, the number of aortic replacements increased and the number of mitrals decreased. The use of prosthetic valves increased from 54% in 1986 to over 70% in 1990. The mean age of the patients increased from 58.31 years in 1986 to 60.97 years in 1990, with over 22% of the valve replacement operations in 1990 being performed on patients over 70 years of age. The five year survival rate for patients over 70 years at the time of the valve implant is significantly lower than for patients under 70 years (p < 0.005).


Mitral valve prolapse: etiology, clinical presentation and neuroendocrine function. Based on our experience and the experience of others, the following classification of patients with mitral valve prolapse has been proposed. Mitral valve prolapse - Anatomic includes patients with a wide spectrum of mitral valve abnormalities from mild to severe. Symptoms, physical findings and laboratory abnormalities in these patients are directly related to mitral valve dysfunction and progressive mitral regurgitation. Complications related to abnormal mitral valve include infective endocarditis, thromboembolic events, cardiac arrhythmias, progressive mitral regurgitation, rupture of chordae tendineae and congestive heart failure. Individuals with thick mitral leaflets and mitral systolic murmur are at higher risk of developing complications. The term mitral valve prolapse syndrome refers to the occurrence of symptoms such as palpitation, chest pain, fatigue, poor exercise tolerance, dyspnea, orthostatic phenomena and syncope or presyncope in patients with mitral valve prolapse which cannot be explained on the basis of mitral valve abnormality alone. The pathogenesis of these symptoms in patients with mitral valve prolapse syndrome appears to be related to metabolic neuroendocrine abnormalities. Preventing infective endocarditis is a major consideration in patients with mitral valve prolapse. Significant mitral regurgitation with the development of congestive heart failure often requires mitral valve surgery. The most important therapeutic approach in patients with mitral valve prolapse syndrome is to explain the mechanisms of symptoms and to reassure the patient.


Exercise tolerance and working capacity after valve replacement. Between 1978 and 1987, 1270 patients who survived single aortic or mitral valve replacement at the Rehabilitation Center in Bad Krozingen, Germany, underwent a comprehensive rehabilitation program. The preoperative diagnosis was isolated aortic stenosis in 425, isolated aortic regurgitation in 159, mixed aortic lesion in 211, isolated mitral stenosis in 208, isolated mitral insufficiency in 137 and mixed mitral lesion in 130 cases. Follow up examinations were carried out one and six months after surgery, and at yearly intervals thereafter. Exercise testing was performed with an electrically braked bicycle ergometer in the supine position, and the load was increased by 25 or 50 watts every two minutes until fatigue, severe angina, more than 0.3 mV ST-segment depression, or 80% of the age predicted maximum heart rate was achieved. Patients after aortic valve replacement had a better exercise performance one month after operation than did those after mitral valve replacement. Those with mitral stenosis showed more severe impairment of exercise tolerance than did the mitral insufficiency group. There was a steady increase in exercise tolerance between one and six months postoperatively, both in patients with aortic and those with mitral valve replacement, but the difference in performance between the two groups was still present (72% versus 57% of normal). The results of univariate and multivariate analyses showed that the preoperative employment status was the most important factor for postoperative return to work, followed by gender (male > female), exercise tolerance and valualar lesion (aortic > mitral).(ABSTRACT TRUNCATED AT 250 WORDS)


Aortic valve replacement in octogenarians. In a consecutive series of 1109 patients undergoing aortic valve replacement (AVR) between January 1988 and December 1990, there were 48 patients (33 female, 15 male) over 80 years of age (mean age 83.5 years, median 82.9 years). Of those, 33 had aortic stenosis and 15 combined aortic valve disease, with additional coronary artery disease being present in 36. Isolated AVR was performed in 25 patients, and it was combined with coronary venous bypass grafting, with 1-4 (mean 1.8) peripheral anastomoses in 23. Two patients died within 30 days (early mortality 4.2%). Non-fatal complications included one hemiparesis, four transient cerebral disorders, two cases of pneumonia which led to ventilatory assistance, three rethoracotomies because of postoperative bleeding, 15 tachycardias and one transient AV block. Late results were obtained after a median follow up time of 22 months. There were eight late deaths (four cardiac related, four not related) and a low incidence of non-fatal complications (two episodes of gastrointestinal bleeding while on oral anticoagulation, one cerebral transient ischemic attack and one acute left ventricular failure). Nine patients are in NYHA Class I, 12 in Class I-II, 11 in Class II, three in Class II-III and three in Class III. Of the surviving 38 patients, four are currently living in a home for the aged or a nursing home, while all the others are living in their own homes and are able to sustain a relatively independent life-style. We conclude that in very old patients with aortic valve disease, AVR can be performed with low mortality and few non-fatal complications.


Antibiotic prophylaxis and prosthetic valve endocarditis. Early onset prosthetic valve endocarditis is one of the most lethal complications after valve replacement. During the first year of operation of our new cardiac surgical program, we observed 10 cases of prosthetic valve endocarditis, the majority being caused by staphylococci, making an incidence of 10.6%. Subsequent investigations uncovered a very high prevalence of methicillin-resistant strains which led to a radical change in the antibiotic prophylaxis, from a cephalosporin-based protocol to a two drug regime of vancomycin and netilmicin. There were no cases of prosthetic infection among the 138 patients operated on in the one year period following the institution of this protocol. Because there were no other changes, either in the types of prostheses used or the techniques of implantation, the eradication of prosthetic valve endocarditis can be related only to this alteration in the prophylaxis. Therefore, we may conclude that the inter-institutional transfer of protocols is not adequate before a thorough investigation of the prevalent hospital pathogens and their sensitivity to antibiotics is carried out. We have not registered resistances to vancomycin and this drug remains the most important antimicrobial agent, both in the prophylaxis and in the treatment of prosthetic valve endocarditis.


Percutaneous mitral commissurotomy with the Inoue balloon for severe mitral stenosis during pregnancy. Percutaneous mitral commissurotomy using the Inoue balloon was performed in seven pregnant women between May 1990 and November 1991. The mean age of the group was 31.5 years (range 28-35 years). The mean gestation time was 29 weeks (range 20-38 weeks). All patients presented with severe symptoms; two had a recent history of pulmonary oedema, the rest exhibited marked shortness of breath, and mild exercise and paroxysmal nocturnal dyspnea. All were in sinus rhythm. Two patients had previously undergone closed mitral valvulotomy five and 14 years before their recent hospitalization. Echocardiographic examination revealed severe mitral stenosis, with the mitral valve area being less than 1.2 cm2 in all but one patient. None of the patients had left atrial thrombi or mitral regurgitation as seen on two-dimensional and Doppler echocardiography. Four patients (two with restenosis) had severe lesions of the subvalvular apparatus with thickening and marked shortening of the chordae, as assessed by echocardiography. Successful percutaneous mitral valvulotomy was completed in all seven patients using 25-28 mm Inoue balloons. There was one, transient maternal complications. Fetal complication did not occur. It is concluded that percutaneous, transseptal, mitral balloon valvulotomy during pregnancy with the Inoue balloon is a safe procedure, which can be recommended for suitable clinical cases.


Durability of glutaraldehyde-fixed pericardial valve prostheses: clinical and animal experimental studies. Bovine pericardium has been widely employed as a xenograft tissue for the manufacture of bioprosthetic valve substitutes. Early three-leaflet valve models showed poor tissue preservation and shortcomings in valve design, which accounted for tissue wear and prosthesis failure due to cuspal tear. Reducing the number of cusps in the unicusp pericardial valve has proved unsuccessful due to stretching of the single pericardial leaflet with consequent valvular incompetence. The new generation of pericardial xenografts present basic changes in valve design and optimal tissue preservation after industrial processing, with no evidence of leaflet tear at medium term follow up. However, clinical experience is limited and, similarly to porcine xenografts, dystrophic calcification still appears to be a major problem.


Mode of failure of the Mitroflow pericardial valve. A consecutive series of 188 Mitroflow pericardial bioprostheses were inserted in 166 patients between 1st January 1983 and 31st December 1985. Twenty-two valves had to be removed from 16 patients after a mean follow up period of 78 months (range 58-92 months) for aortic, 73 months (65-79 months) for mitral and 78 months (48-103 months) for double valve replacements. All but one reoperations for primary tissue failure were carried out as elective surgical procedures. The most important cause of failure was collagen degeneration, seen in all explanted valves. The areas of degeneration were the major sites of origin of calcification, which was seen in 11 valves (50%). Ten valves (45%) showed features suggestive of lipid infiltration, extensive fatty acid deposition being identified in one and a typical atheromatous reaction in another. In contrast to the Ionescu-Shiley valve, the mode of failure was tear originating at the top of the commissure, associated with major structural changes in the tissue. Excessive pannus ingrowth was observed in 11 valves (50%). The universal presence of tissue degeneration in the glutaraldehyde treated pericardial leaflets of the Mitroflow bioprostheses explanted and examined in this study questions the adequacy of the methods employed in the harvesting and/or processing and/or preservation of this valve. We have, therefore, discontinued using the Mitroflow bioprosthesis. However, the slow deterioration of the Mitroflow bioprosthesis permits elective reoperation; preventive removal of functioning valves is therefore not indicated.


Experimental evaluation of an autologous tissue heart valve. The goal of the autologous tissue heart valve (ATHV) prosthesis project has been the development of a non-antigenic, non-calcifying bioprosthesis of greater durability than heterograft or homograft bioprostheses. It is made in the operating room, at a sterile work bench, during surgery for heart valve replacement. Autologous pericardium is used for valve construction after a five minute immersion in 0.6 per cent glutaraldehyde buffered to pH 7.4 with phosphate. The stent-mounted trileaflet prosthesis can be made in five minutes with a semi-automated method that uses two concentric mating stents that substitute clamping for sewing of the tissue. In vitro testing, to include pulse duplicator, accelerated wear tester, static testing for leakage and tensile strength testing, has been performed with ATHVs made with glutaraldehyde-tanned bovine and ovine pericardium. Transvalvular pressure gradients were measured at 3.3-7.3 mmHg at flow rates of 4-5 l/min. Six valves have been tested beyond 800,000,000 cycles with full opening and closing at differential closing pressures of 125 mmHg. One of the valves developed a 2mm leaflet tear after 26,000,000 cycles but the remaining five survived intact. No fractures were seen in the Dacron covered Delrin stents. Six ATHVs were implanted in juvenile sheep for five months. One animal died after five months of infective endocarditis secondary to an unrecognized deep wound infection and the other five were electively sacrificed at the same time interval. Four valves were fully competent at terminal elective cardiac catheterization and one showed minimal insufficiency attributed to a paravalvular leak. The leaflet tissue was free of generalized calcification in all instances. There was no evidence of leaflet tissue thickening or shrinkage. The mean calcium content at necropsy of the 15 leaflets from the five valves was 8.357 mg/g of tissue. There is experimental evidence that an ATHV made of pericardium treated briefly with glutaraldehyde may achieve the goal of a non-calcifying, more durable bioprosthesis.


Aortic valve replacement with the Toronto SPV bioprosthesis. The Toronto SPV is a Dacron covered stentless porcine aortic prosthesis used for aortic valve replacement (AVR). We implanted this valve in 53 patients with a mean age of 58 years. The predominant valve lesion was aortic stenosis in 39 patients, insufficiency in 13 and a failed bioprosthesis in one. Six patients also had mitral valve disease and 18 had coronary artery disease. There was one operative death. Patients have been followed for four to 58 months, mean 27 months. There have been two late deaths but neither one was valve related. The actuarial survival at four years was 92% +/- 5%. Two patients required reoperation for reasons other than failure of the stentless aortic valve. There have been no thromboembolic complications. No patient had had infective endocarditis. Doppler echocardiographic assessment of the stentless valve revealed excellent effective valve areas and low transvalvular gradients. A few patients developed mild aortic insufficiency after implantation of the valve, but this problem has been practically eradicated by correct sizing of the prosthesis. AVR with the Toronto SPV provides excellent functional and hemodynamic results. This bioprosthesis seems to be associated with an extremely low rate of valve related complications. These findings justify its continued use, but further follow up is needed to determine its durability.


Aortic valve replacement with stentless xenografts. Between 15th June 1991 and 15th August 1992, 40 patients underwent aortic valve replacement with the newly designed Edwards stentless aortic bioprosthesis 2500. The patients' ages ranged from 24 years to 80 years (mean 60.3 years). Preoperatively, 17 patients presented with pure aortic stenosis, three with aortic regurgitation and 20 with mixed lesion. The operations were performed with normothermic extracorporeal cardiopulmonary bypass and cold cardioplegic arrest. The implanted valves ranged in diameter from 21 mm to 27 mm. Ten patients received a subcoronary implantation, with the lower row of sutures being interrupted and the upper being continuous. The so-called miniroot technique was used in the other 30, also involving lower interrupted and running upper sutures after adaptation of the coronary ostia to the preformed openings in the graft. The aortic cross-clamp time ranged from 51 minutes to 94 minutes (mean 71 minutes). There was no operative mortality but three patients died early after the operation due to cardiac tamponade, sepsis and pneumonia. There was no late mortality or morbidity in the surviving patients up to 16 months postoperatively. Echocardiography, performed at discharge and twice a year thereafter showed no signs of significant valve incompetence in any patient, and continuous wave Doppler measurements indicated that resting pressure gradients across the aortic valve were low or absent. Our preliminary experience with the stentless aortic xenograft shows improved hemodynamic function as compared to stent mounted xenografts or mechanical prostheses. Further studies are needed, however, to establish the long-term performance of this device.


Anatomically complete heterograft mitral valve substitute: surgical technique and immediate results. The use of a totally anatomical mitral valve heterograft as a mitral valve substitute has been proven to be technically feasible. A new stentless mitral porcine heart valve substitute was therefore developed to match the physiology and flow characteristics of the left ventricle and mitral valve complex, and tested in non-survival animal experiments. Having sought the approval of the Hospital Ethics Committee and the consent of each individual patient, this valve was implanted into 18 patients with diseased mitral valves. The duration of the procedure is approximately the same as for standard mitral valve replacement. The sizing of the valve and the anchoring of the sutures to the papillary muscle, although very straightforward, do require adherence to a protocol. The immediate clinical results are encouraging, although the first patient required a reoperation because of a patient/valve mismatch. All patients, including the patient reoperated, are in functional class I after four to 26 weeks of follow up. The patients will be followed by monthly clinical and Doppler echocardiographic examinations, as they have been so far, for the next 12 months, and annually thereafter.


Perforated aneurysm of the anterior mitral leaflet: late assessment with transesophageal echocardiography. We present a case study of a 54-year-old patient with a perforated aneurysm of the anterior mitral valve leaflet, diagnosed 13 years after an episode of bacterial endocarditis by transesophageal echocardiography. This report illustrates the superiority of transesophageal echocardiography in the diagnosis and management of valvular endocarditis.


Cluster analysis and related techniques in medical research. In this paper we review methods of cluster analysis in the context of classifying patients on the basis of clinical and/or laboratory type observations. Both hierarchical and non-hierarchical methods of clustering are considered, although the emphasis is on the latter type, with particular attention devoted to the mixture likelihood-based approach. For the purposes of dividing a given data set into g clusters, this approach fits a mixture model of g components, using the method of maximum likelihood. It thus provides a sound statistical basis for clustering. The important but difficult question of how many clusters are there in the data can be addressed within the framework of standard statistical theory, although theoretical and computational difficulties still remain. Two case studies, involving the cluster analysis of some haemophilia and diabetes data respectively, are reported to demonstrate the mixture likelihood-based approach to clustering.


Graphical displays.

Graphical displays. This paper selectively reviews the field of scientific and medical graphics. Examples are provided using world health statistics and several new methods of presenting multivariate data are introduced.


Statistical methods in diagnosis.

Statistical methods in diagnosis. Motivations are presented for exploring formal statistical methods for use in medical diagnosis and the advantages and disadvantages are discussed. A brief review is presented of classical linear discriminant analysis, quadratic discriminant analysis, logistic regression, nearest neighbour and kernel methods, recursive partitioning methods, the independence model, regularized discriminant analysis, structured conditional probability distributions, methods for categorical data, and other methods. Criteria on which a choice might be made are presented and methods for assessing diagnostic performance are outlined. Particular applications of screening and chromosome analysis are used as illustrations and available software is described.