Advances in the management of bile duct obstruction: percutaneous transhepatic cholangiography and endoscopic retrograde cholangiopancreatography

Jaundice can be diagnosed anatomically and frequently histopathologically without laparotomy by radiologic and endoscopic techniques, combined with biopsy or cytology. Benign and malignant causes of bile duct obstruction can be managed by endoscopic and radiologic methods with reduced morbidity and mortality, displacing abdominal operation for many entities. Even unresectable or inoperable lesions can be effectively palliated by these new techniques.

Percutaneous transluminal angioplasty for treatment of renovascular hypertension

Four patients with typical renovascular hypertension due to atherosclerotic stenosis (3 patients) and near occlusion (one patient) were treated with percutaneous transluminal angioplasty (PTA). Two patients had malignant hypertension by clinical standards. All had significant reduction in blood pressure following angioplasty, resulting in either a normotensive state, or management with significantly less antihypertensive medication. Patency and normal renin levels were achieved within two months in 2 patients. Clinical follow-up documented continued reduction in blood pressure. Advantages of the procedure include local anesthesia, relatively little discomfort, repeatability, and the fact that surgery is not precluded if angioplasty is unsuccessful.

Percutaneous transluminal angioplasty with the Grüntzig balloon catheter

The results of an ongoing five-year study of percutaneous transluminal angioplasty for the treatment of peripheral vascular disease are presented. A balloon catheter was used for iliac and superficial femoral and popliteal artery dilatation. Forty out of 43 procedures performed were considered to have initial success, with iliac angioplasty showing a greater success rate (96%) than superficial femoral angioplasty (90%). Complications requiring surgical intervention occurred in only 3 patients. Advantages of this technique include local anesthesia, early ambulation, reduced hospital stay, and reproducibility.

Percutaneous transluminal angioplasty (PTA) with the Grüntzig balloon catheter: technical problems encountered in the first forty patients

Forty patients have undergone percutaneous transluminal angioplasty (PTA) of the iliac or femoral-popliteal system with the Grüntzig balloon catheter. Technical problems ahve included experience with difficult antegrade puncture, production of intimal flaps, and loss of collateral vessels, as well as the need to develop an approach for recanalization of obstructions and for use of the balloon. Since problems in these areas may jeopardize the success of the procedure, they have been elucidated with some discussion of prevention. Preliminary results on the success of the procedure are included.

Transcatheter gelfoam embolization of posttraumatic bleeding pseudoaneurysms

Diagnostic angiography combined with transcatheter therapeutic embolization is a simple and effective means of treating complex clinical situations associated with posttraumatic hemorrhage. Bleeding pseudoaneurysms, even when large, can be readily managed by this combined modality with resultant decrease in morbidity and hospital stay. Five patients with posttraumatic pseudoaneurysms are presented. All five were treated by transcatheter therapeutic embolization with Gelfoam. Of these five cases, three involved extremities, one involved the retroperitoneal space, and the last was of renal origin. Two of the five cases still required surgical intervention after initial successful therapeutic embolization, one for recurrent bleeding from collaterals and the other for evacuation of a massive pseudoaneurysm which was causing distraction of fracture fragments. The early use of angiography in suspected cases of posttraumatic hemorrhage, together with careful evaluation of potential collateral supply, is stressed. The use of transcatheter therapeutic embolization in the extremities as presented here is yet another example of the ever-broadening applicability of this technique.

Transcatheter arterial embolization of a traumatic lumbar artery false aneurysm

The case of a false aneurysm of a lumbar artery secondary to penetrating trauma is presented. Problems of diagnosis are outlined, emphasizing the value of ultrasound, computerized tomography, and angiography. The early use of angiography is strongly advocated in cases of suspected post-traumatic bleeding. The use and value of therapeutic transcatheter embolization is discussed.

The analytic basis for the use of platelet estimates from peripheral blood smears. Laboratory and clinical applications

Estimation of the platelet count from examination of peripheral blood smears is a widely practiced procedure, but statistical validity to judge the accuracy of the technic has been lacking. More than 400 patients' platelet estimates and counts were analyzed to develop a simple working formula to permit a reasonably accurate platelet estimate. Smear-to-smear and technician-to-technician variabilities were defined, and the influences of different microscopes on the platelet estimates were demonstrated. Platelet estimates can be used as a rapid, convenient measurement suitable for providing useful information for clinical judgement of a patient's platelet status providing that the method's limitations are recognized.

Squamous cell carcinoma of the renal pelvis presenting with hypercalcemia

A case of hypercalcemia associated with documented squamous cell carcinoma of the renal pelvis without bony metastasis is reported. Pseudohyperparathyroidism was suspected strongly because of the radioimmunoassay values of parathormone. This was confirmed by the prompt decrease of serum calcium after removal of the neoplasm. The radiologic findings were non-specific.

Screening for breast cancer

Mammography is of real assistance to the surgeon in evaluating breast problems not associated with a breast mass. Use of mammography in the detection of early breast cancer in breast demonstration projects has brought forth the time honored value judgement of benefit vs risk. This report introduces an additional aspect in the consideration of benefit vs risk, the interval cancer. From the demonstration project at KUMC, 326 biopsies were performed and 65 proved to be cancer. However, 24 additional women developed cancer before their next recommended screening date. This reduces the accuracy of mammography and physical examination by trained nurses in screening for breast cancer to 73%.

Aortic stenosis: echocardiographic cusp separation and surgical description of aortic valve in 22 patients

Diminished echocardiographic aortic cusp separation is used as one indicator of the severity of aortic stenosis. To test the validity of this index, 22 patients--12 (55 percent) with isolated aortic valve disease and 10 (45 percent) with aortic stenosis associated with mitral or coronary artery disease--underwent M mode echocardiographic examination before aortic valve replacement. Tracings of diagnostic quality were obtained without difficulty from all 22 patients. Cardiac catheterization was performed in 21 patients. Echocardiographic cusp separation was measured from the apparent mid-systolic orifice and from the outer periphery of the anterior cusp to the outer periphery of the posterior cusp (maximal peripheral cusp separation). Mid-systolic cusp separation varied in nearly every patient, depending on the angle of leaflet presentation to the ultrasonic beam. Maximal peripheral cusp separation measured 16 mm in 18 of 22 patients (82 percent); it indicated neither the severity of the aortic stenosis as documented with cardiac catheterization nor the mobility of the cusps seen at operation. The surgical and echocardiographic descriptions of leaflet and aortic root calcification were similar. In situ examination of aortic cusp separation indicated that diseased aortic valves are not comparable with normal valves or valves with uncomplicated congenital obstruction. The aortic leaflets were curled, fused, calcified and deformed from their natural state of coaptation. Abnormal thickening and limited or eccentric mobility of the aortic leaflets were useful indicators of the cause of valve disease, but cusp deformity secondary to aortic stenosis invalidated mid-systolic cusp separation and maximal peripheral cusp separation as indicators of the severity of aortic stenosis.

Co-existent chronic lymphatic leukaemia with polycythaemia vera

A patient presenting with chronic lymphocytic leukaemia and iron deficiency anaemia who, following oral iron therapy, developed the clinical and pathological features of polycythaemia vera is reported. The relationship between these two diseases when co-existing is discussed.

Inhibition by glucocorticoids of prostaglandin release from adipose tissue in vitro

1 When rabbit chopped adipose tissue was incubated with a lipolytic agent (adrenocorticotrophic hormone, ACTH1-24, 0.1 microng/ml) in Krebs solution, prostaglandin E2 was formed in the tissue and about the same amount was found in the medium. 2 In the presence of indomethacin (1 microng/ml) the appearance of prostaglandin E2 was almost abolished both in the tissue and in the medium. 3 When the incubation was carried out in the presence of hydrocortisone or betamethasone (1-10 microng)ml) the concentration of prostaglandin E2 leaking or carried into the medium was significantly reduced, whereas that remaining in the tissue was significantly increased. This action of the steroids was not reversed by increasing substrate (arachidonic acid) concentration in the medium. 4 The steroids did not affect lipolysis, nor did they influence prostaglandin metabolism since such activity was not detectable in the adipose tissue. 5 Anti-inflammatory steroids therefore did not reduce prostaglandin formation but increased the tissue/medium ratio, which supports the view that they inhibit the release of prostaglandins after these have been synthesized.

Efficacy of albendazole against Haemonchus, Nematodirus, Dictyocaulus, and Monieza of sheep

Albendazole was highly efficacious in the removal of monospecific and mixed infection of Haemonchus contortus, Nematodirus spathiger, and Dictyocaulus filaria from sheep. A dose level of 5 mg/kg removed nearly all gastrointestinal nematodes, and 10 mg/kg removed all lungworms. Tapeworms of the genus Moniezia were completely removed by a dose level of 10 hg/kg.

Pulmonary nocardiosis in an orangutan

Pulmonary nocardiosis was diagnosed in an adult male orangutan (Pongo pygmaeus) being maintained in an outdoor facility. Periodically, the orangutan had had clinical signs of an upper respiratory tract infection, as evidenced by slight nasal discharge and cough. At the terminal stage, the orangutan had acute respiratory embarrassment, with epistaxis, and died before diagnosis could be made and treatment initiated. Gross necropsy findings included fibrosis of the pulmonary parenchyma as well as evidence of air sac infection, extensive pneumonia, and extensive chronic pleuritis. Microscopically, some of the lung sections had alveoli filled with polymorphonuclear cells, with other sections being diffusely fibrotic; the areas of fibrosis contained interspersed foci of polymorphonuclear cell infiltration. Many of the latter areas contained organism colonized in the form of granules that resembled those seen in actinomycosis. These organisms were gram-positive and branched, and measured close to 1 mum in diameter. Nocardia asteroides was isolated from the pulmonary tissue.

Chromobacterium violaceum infection in a nonhuman primate (Macaca assamensis)

Chromobacteriosis caused by Chromobacterium violaceum was diagnosed as an Assam macaque, Macaca assamensis, that died 4 days after receipt of the Yerkes Primate Center, It was received from a primate facility in Florida where it has been housed with a group of rhesus monkeys for 5 years. The animal died suddenly without showing any signs of clinical illness. Necropsy findings included extensive hepatic necrosis with the formation of multiple large cavitary lesions. Foci of necrosis were also found in the lungs and lymph nodes. Numerous gram-negative bacilli were demonstrable in the lesions and Chromobacterium violaceum was isolated from the blood, liver, lungs, spleen and kidneys.

Electron microscopy of albumin synthesis

Albumin molecules appeared to be synthesized in the light hepatocytes of rats by bound polysomers on rough and endoplasmic reticulum and the nuclear envelope. The molecules were discharged directly into the cytosol, then to the external cellular spaces. This conclusion failed to support the current theory from biochemical studies that albumin is synthesized by bound ribosomes, discharged into the cisternae of rough endoplasmic reticulum, and transported to the smooth endoplasmic reticulum and then to the Golgi apparatus. In addition to the liver, positive syntheic activities were observed in the aorta, kidney, and hepatoma cells of rat. Earlier investigators have reported that only liver cells can synthesize albumin.

Disseminated oesophagostomiasis in the rhesus monkey

Disseminated oesophagostomiasis was diagnosed at necropsy of 5 rhesus monkeys (Macaca mulatta). Nodular lesions were in visceral organs as well as in the colon and mesentery. Lesions varied greatly with respect to degree of organ involvement and damage due to parasite invasion. In 2 monkeys, nodular lesions were in the colon, mesentery, liver, kidneys, abdominal wall, urinary bladder, and uterus; in 1 of these 2 monkeys, a nodular lesion inhabited by a parasite was in a lung. The ectopic nodules in the less severely affected monkeys were scattered in the liver, kidneys, and abdominal wall.

Limited form of Wegener's granulomatosis in ulcerative colitis

The limited form of Wegener's granulomatosis is described as a complication in 2 cases of chronic ulcerative colitis. The coexistence of ulcerative colitis and the limited form of Wegener's granulomatosis raises the question of a common etiologic basis, possibly an immunologic defect. Awareness of such an association may help shed further light on the etiology of both disorders.

The radiologic diagnosis of spontaneous mesenteric venous thrombosis

Spontaneous mesenteric venous thrombosis is a distinct clinicopathologic entity that typically presents as abdominal pain of obscure origin. Pathologically, thrombosis of multiple small tributaries of the superior mesenteric vein causes segmental congestion, edema, hemorrhage and ultimately mucosal necrosis. Characteristic radiologic changes were found in 10 of 12 cases.

PMN-kinin and kinin metabolizing enzymes in normal and malignant leucocytes

1. Studies have been carried out on the kinin-forming and kinin destroying activity of rabbit macrophages obtained from the lung before and after BCG injection and from the peritoneal cavity following mineral oil injection. A similar study was carried out with L-1210 leukaemic cells obtained from the peritoneal cavity of mice.2. The macrophages and leukaemic cells contain enzymes that form kinins from purified kininogen substrates at acid pH. The kinin-forming activity is not limited to the lysosomal fraction of the cell since it is found in extralysosomal compartments. Delta-guanidovaleryl benzyl ester partially inhibits the kinin-forming activity. Trasylol does not inhibit the kinin-forming activity of these cells, but does inhibit the kininases of these cells. The lack of effectiveness of this agent as a general anti-inflammatory agent is thus explained.3. The kininases of the normal and malignant cells are also inhibited by chloromethyl ketones such as tosyl-lysine chloromethyl ketone (TLCK) and tosyl-phenylalanine-chloromethyl ketone (TPCK) as well as by copper salts. Hydroxyquinoline has no inhibitory action on these cells, indicating that they differ from the plasma kininases.4. Investigation of the kinins produced by enzymes in rabbit and human polymorphonuclear (PMN) cells has demonstrated the formation of a kinin that differs from bradykinin and other known mammalian kinins in its pharmacological properties, molecular weight, and amino-terminal end group. This peptide has been named PMN-kinin.5. Overall, the investigation has demonstrated the importance of white cells in contributing to the formation and destruction of "extra-plasma" sources of kinins by enzymes which differ from plasma enzymes. Anti-inflammatory agents may have different actions on these cell enzymes from those on plasma enzymes.