Anatomically corrected malposition of the great arteries

We report the case of an infant with anatomically corrected malposition of the great arteries in solitus [S, L, D], associated with ventricular septal defect, patent ductus arteriosus, and right juxtaposition of the atrial appendages. The aortic pole was posterior to the tricuspid mitral line and the conus was bilateral. Successful surgical repair was undertaken by the Senning procedure with closure of ventricular septal defect and division of the ductus. Postoperative cardiac angiography demonstrated no hemodynamic obstruction or residual shunt.

Pulmonary veins in total anomalous pulmonary venous connection with obstruction: demonstration using silicone rubber casts

We studied the postmortem vascular anatomy of four patients with total anomalous pulmonary venous connection (TAPVC) with obstruction using a silicone rubber casting method. Two patients were studied clinically but died before therapeutic intervention, one died after corrective surgery, and another was not diagnosed before death. The morphologic types were supracardiac (2), infracardiac (1), and mixed (1). One of the supracardiac forms had a stenosis at the left vertical vein by a bronchoarterial vise, and a collateral channel to the right superior caval vein was also present. In the other supracardiac case, a left upper pulmonary vein was connected to the left vertical vein above the stenotic portion, resulting in postoperative pulmonary hemorrhage into the left upper lobe. The patient with infracardiac TAPVC had a tree-shaped descending vertical vein and small opening at the inferior caval vein. In the mixed type, a right upper pulmonary vein ran between the pulmonary artery and bronchus draining into the superior caval vein, and the rest of the drainage was to the portal vein.

Is natural progesterone the missing link in osteoporosis prevention and treatment?

Conventional treatment with vitamin D, calcium, and estrogen will delay but not reverse osteoporosis. The addition of fluoride may increase bone mass but fails to increase bone strength; fracture incidence is actually increased in non-vertebral bone by fluoride. Clearly, successful treatment of osteoporosis remains an unsolved problem. In women, osteoporosis coincides with menopause. The hypothesis that progesterone and not estrogen is the missing factor was tested in a clinical setting and was found to be extraordinarily effective in reversing osteoporosis.

A review of false negative mammography in a symptomatic population

A review of the mammograms of 871 patients with breast cancer from a symptomatic clinic performed at the General Hospital, Birmingham between 1980 and 1988 revealed an overall false negative rate of 8.6%. There has been a steady fall in the number of cancers missed per year from the commencement of review, and this reduction has been more consistent with improvements in radiographic equipment and technique, particularly the introduction of a radiographic grid. In half of the cases the tumour was missed because no radiological abnormality was detectable, even on reviewing the films, and this rate has remained remarkably stable over the study period, emphasizing the importance of a clinical examination in symptomatic women. Comparison of the histological diagnoses revealed similar percentages of ductal carcinomas, 89.6% in the true positive group compared with 85% in the false negative group. Of the false negative carcinomas, 5.5% were medullary tumours compared to 0.8% in the true positive group.

Incidence and prevalence of amyotrophic lateral sclerosis in Harris County, Texas, 1985-1988

The incidence of amyotrophic lateral sclerosis was determined in Harris County, Texas, for the period 1985 through 1988. Amyotrophic lateral sclerosis cases were ascertained from four sources: area neurologists, hospitals, death certificates, and the Muscular Dystrophy Association. The age-adjusted incidences of 1.27 per 100,000 person-years in males and 1.03 per 100,000 person-years in females were lower than recent rates in the northern US, Canadian, and northern European studies but higher than rates in southern European studies. Comparisons with other recent incidence studies show less uniformity in occurrence of amyotrophic lateral sclerosis, in both the overall rates and in the age- and sex-specific patterns, than was suggested by mortality studies. The incidence of amyotrophic lateral sclerosis among blacks and whites was similar. Hispanic males had incidences similar to white males, although a deficit of female Hispanic cases was found in Harris County. The prevalence of amyotrophic lateral sclerosis peaked in the 65- to 74-year age group at 33 per 100,000 population among males and 19 per 100,000 population for females.

Critical evaluation of the radial head-capitellum view in acute elbow with an effusion

The radial head-capitellum (RHC) view was performed in 125 patients following acute elbow trauma in which an elbow fat-pad effusion was visible on the standard antero-posterior and lateral projections. Seventy-four fractures were identified of which 63 (85%) involved the radial head. In only one case (1%) did the RHC view reveal a radial head fracture not seen on the standard two views. In eight cases (11%) the RHC view did not confirm a radial head fracture seen on the standard radiographs. Magnification blurring and the vertical orientation of the radial head fractures missed on the RHC view are responsible for this confusing situation. Routine use of the RHC view even in acute elbow trauma significant enough to produce an effusion is generally unhelpful and potentially misleading.

Effect of sodium hexanitrocobaltate (III) decomposition on its staining of intracellular potassium ions

The effect was examined of the chemical decomposition of the potassium stain sodium hexanitrocobaltate (III) (SHC), on its ability to produce stain granules of consistent size that could be used to estimate the K+ contents of stomatal guard cells. Stomata in detached epidermis from leaves of Vicia faba (fava bean) were stimulated to accumulate K+ by treating them with fusicoccin. Stomatal apertures and the fraction of guard cell area covered by K+ precipitate granules (K+ score) were measured by digitizing photographic enlargements, and K+ scores were correlated with the age of stain that had been stored either in open or closed containers. The ability of stain aged in open containers to produce consistent fractional cell coverage was compared to 1) the ability of identically treated stain to precipitate K+ from solutions of KCI, and to 2) the kinetics of decomposition of SHC. It was found that the fractional coverage of guard cells of stomata opened to the same apertures decreased with a first order rate constant of 2.3 x 10(-5)/sec. The mass of precipitate formed by treatment of KCl solutions was unchanged for 2 hr after initial preparation of the SHC, and decreased thereafter with a first order rate constant of 1.0 x 10(-5)/sec. When stored in tightly sealed containers, nearly 100 hr were required for an occasionally opened bottle of SHC to decay to the same efficacy as a solution left open to the air for 8 hr.

Immune response products alter CNS activity: interferon modulates central opioid functions

The present report provides evidence to support the hypothesis that peptides released during an immune response alter CNS activity and thus may provide a means for the immune system to transmit afferent signals into the brain. Specifically, it is demonstrated that recombinant interferon-alpha (rIFN-alpha), a peptide associated with the immune response to viral infection, can alter opiate withdrawal severity in a dose-dependent manner upon direct injection into brain areas essential for this phenomenon. These results are compared and contrasted with the effect of systemically injected rIFN-alpha upon opiate withdrawal. In addition, an electrophysiological investigation into the basis of the interaction of opioids and rIFN-alpha in brain structures essential for the expression of opioid activities is also presented. Finally, the effects of rIFN-alpha upon the functions of both the CNS and other systems is discussed in terms of the effects reported for other peptides associated with immune responses.

The importance of laparotomy in the diagnosis and management of intestinal bleeding of obscure origin

Thirty-seven patients who had had either a colonoscopy or a selective mesenteric angiogram while being investigated for severe or persistent gastrointestinal bleeding of obscure origin were reviewed. Failure to make a prompt diagnosis was partly responsible for the 16% hospital mortality in the series. Colonoscopy was diagnostic on 6 out of 38 examinations but detected 43% of lesions in the colon. Angiography achieved only 3 diagnoses in 17 examinations. Fourteen patients had an exploratory laparotomy which was diagnostic in 9. We believe that early laparotomy still has an important place in the diagnosis and treatment of intestinal bleeding of obscure origin.

Mammographic identification and biopsy of occult breast cancer

During a 9 year period we excised 70 suspicious non-palpable breast lesions detected by mammography. We found the most effective method of preoperative localisation to be insertion of a self retaining wire, and this procedure was facilitated by a Perspex grid incorporated in the mammography equipment. Thirty biopsies (43%) were found to be malignant, of which 14 contained invasive and 16 in situ carcinoma. The presence of malignancy could not be predicted from the mammographic appearance, although in situ cancer was always associated with microcalcification.

Combinations of laxatives for bowel preparation: are they necessary?

To determine whether combinations of saline and surface-acting laxatives have any superior action over saline laxatives alone in cleansing the colon, patients having double-contrast barium enema examinations were randomly allocated to magnesium citrate alone and magnesium citrate with either oral or rectal bisacodyl. The addition of bisacodyl conferred no benefit over magnesium citrate alone. A companion study of magnesium citrate and sodium picosulphate (Picolax) showed no benefit over magnesium citrate alone. It is concluded that it is unnecessary to add a contact or surface-acting laxative to 25 g of magnesium citrate for bowel preparation.

Variables in the preparation of the large intestine for double contrast barium enema examination

This study examines which methods are most appropriate for preparation of the large bowel for double contrast barium enema. Two proprietary laxatives, X-Prep and Picolax, mechanical colonic lavage, and dietary restriction were evaluated in a randomised study of 160 patients. Four alternative preparations were compared with or without dietary restriction. The four preparations were X-Prep alone, X-Prep plus lavage, Picolax alone, and Picolax plus lavage. Scoring of the radiographs was carried out on a double blind basis. Picolax proved superior to X-Prep overall (p less than 0.01) but this was almost entirely because of its greater effect in the right colon and transverse colon. Cleansing in the left colon and rectosigmoid was similar with both laxatives. Restriction of solid food improved bowel cleansing and gave better results than mechanical lavage. The addition of a colonic lavage in starved patients did not significantly improve the quality of bowel preparation with either laxative.

Diffuse histiocytic lymphomas of the gastrointestinal tract in the adult

Diffuse histiocytic lymphomas (Rappaport) are extranodal lesions frequently formed in the digestive tract. They are clinically different from lymphomas of nodal origin and are no longer considered to arise from histiocytes. They comprise from one-third to one-half of non Hodgkin's lymphomas and chiefly involve the stomach and duodenum. Identification of these tumors and their place in current systems of classification, at present, depends on sophisticated immunologic, histochemical and ultramicroscopic procedures not always suitable for clinical prognosis. Staging laparotomy, useful in Hodgkin's disease, does not always correlate with the prognosis of non Hodgkin's lesions. Radical removal of the affected organ may be curative. Nonresectable lesions may be treated with radiation and chemotherapy. Methotrexate, cyclophosphamide, vincristine, prednisone, nitrogen mustard, Adriamycin, bleomycin and other substances have been used in various combinations to obtain remission of the disease. While results have been favorable, the ideal therapeutic agent has not been found.

Gastric partitioning for morbid obesity

A consecutive series of 33 grossly obese individuals treated by gastric partitioning is described. There was no operative mortality. Weight loss at one year was 19% of original body weight and little loss occurred thereafter. Radiological assessment of the proximal compartment demonstrated progressive postoperative enlargement.

Routine use of hyoscine N butylbromide (Buscopan) in double contrast barium enema examinations

A retrospective analysis of the effect of oral and intravenous hyoscine N butylbromide (Buscopan) on the dimensions of the large bowel during double contrast barium enema (DCBE) examination was made and compared with corresponding measurements without Buscopan. It was found that 20 mg oral Buscopan did not alter colonic dimensions but 20 mg Buscopan intravenously allowed significantly greater distension of the large bowel. The colonic length was greater after intravenous Buscopan but not to a highly significant degree. It is concluded that Buscopan is not effective when given orally. No side effects have been observed with intravenous Buscopan, even in elderly patients. Buscopan given intravenously seems to be a safe and effective drug for use during DCBE examinations.

Assessment of anorectal function in selection of patients for ileorectal anastomosis in Crohn's colitis

Anorectal function has been assessed in 53 patients with Crohn's disease by measurement of resting and squeeze anal canal pressures and the maximum volume tolerated during distension of a balloon in the rectum. Radiographs of the rectum from barium enema examination were also reviewed to assess rectal capacity. Thirty-three patients have had a colectomy and ileorectal anastomosis for Crohn's colitis of whom 13 now have a stoma because they either required a protectomy (n=9) or where closure of a loop ileostomy had not been possible (n=4) because of severe anorectal disease. The maximum tolerated volume was less than 150 ml in 12 of 13 patients who now have a stoma compared with none of the 20 patients who have a functioning anastomosis. Although the correlation between a radiological assessment of rectal capacity and the maximum tolerated volume was poor, a severely contracted rectum was associated with the need for a stoma in six of seven patients compared with only two of 13 patients who did not have radiological signs of a narrow rectum.

A randomised trial to investigate X-prep, oral mannitol and colonic washout for double-contrast barium enema

Three methods of bowel preparation used prior to double contrast barium enemas were compared by a randomised trial in 60 patients. Evaluation was by radiological review and from a patient questionnaire. The preparations included X-Prep liquid with colonic washout, oral mannitol alone and oral mannitol with colonic washout. Adequacy of preparation as judged by faecal residue was significantly better after X-Prep than in either group receiving mannitol. The more severe purgation with mannitol did not result in better clearance of the large bowel and the addition of a colonic washout to mannitol did not reduce faecal residue. Side-effects and adverse comments were more common after mannitol. Diarrhoea was significantly less after X-Prep than after mannitol.

Peroperative frozen section and cytology to assess proximal invasion in gastro-oesophageal carcinoma

Peroperative frozen sections and cytological material have been obtained in 39 consecutive gastro-oesophageal resections between October 1978 and February 1980. Material from the proximal edge of the resected specimen was unreliable because of 3 false positive cytology results and 1 false positive frozen section report. Frozen section (no errors) was shown to be significantly more accurate than cytology (6 errors) when material was obtained from the distal oesophagus. Fatal anastomotic dehiscence occurred in only 1 of 30 resections when the excision was adequate. Where the results of frozen section were acted upon, in 5 of 9 patients with an inadequate excision, only 1 fatal dehiscence occurred compared with fatal dehiscence in all 4 patients where a second excision was not performed. These results indicate that frozen section of the distal oesophagus should be used to determine the extent of oesophageal resection in operations for gastro-oesophageal cancer.