[Non-iatrogenic trauma of the brachial artery]

Brachial artery trauma are treated quite frequently in the emergency units. Between January 1987 and December 1990 we studied prospectively 50 patients with brachial artery trauma at the Hospital das Clinicas, of University of Sao Paulo. The patients mean age ranged from 2 to 64 years. Males were predominant with 46 patients. Most of them were white (66%). Penetrating injuries were the most frequent. Most of these injuries were caused by gunshot wounds or stabing. Absence of distal palpable pulses was the predominant finding among the clinical features (94%). 74% of the patients do not present important ischemia. The right side was more affected (34 patients). 14 patients had concomitant nerve injury. 35 patients (70%) were submitted to arterial reconstruction with saphenous vein. 12 patients (24%) had end-to-end vascular anastomoses. 3 patients (6%) were submitted to brachial artery ligation. 2 patients underwent simultaneous median nerve repair. In 3 patients we used fasciotomy. 6 patients developed arterial occlusion following vascular reconstruction and in one of them it was necessary to perform amputation. 2 patients had wound infection with saphenous vein repair disruption. Both were treated with brachial artery ligation and one underwent amputation. One patient died on the post operative period owing to associated lesions. Limb preservation was achieved in 47 patients (94%). 33 (70.2%) had no neurological deficit and 14 (29.7%) had some degree of neurological deficit. None of the patients had venous hypertension at the time of discharge.

Survival after reduced-size liver transplantation is dependent on pretransplant status

Orthotopic liver transplantation (OLT) in children is characterized by unique problems including a shortage of compatible-size donors resulting in long waiting periods, significant deterioration while waiting, and death before transplantation. To improve the chances of obtaining an organ for the sickest patients, reduced-size liver transplantation (RSLT) was offered to all hospital-bound children starting in July 1988. Since then, 68 OLTs were performed in 58 children. Thirty-six RSLTs were done in 30 children (42% of total 86 OLT, 53% since 1988). The mean weight of the RSLT patients was 13.5 +/- 10.4 kg versus 23.8 +/- 21.9 kg in the full-size (FSLT) group (P < .05). Twenty-five of 39 transplants (71.4%) done in children < 10 kg were RSLTs in comparison to only 10 of 47 (21.3%) in patients > 10 kg (P < .0005). Since 1988, 25 of 34 (73.5%) of all transplants in children < 10 kg have been RSLTs. Average donor to recipient weight ratio in the RSLT group was 4.21:1 versus 1.17:1 in the FSLT group (P < .0001). RSLT was done as a primary procedure in 26 patients and as a retransplant in 10. Mean blood product replacement was significantly higher in the RSLT group both intraoperatively (515.7 +/- 490.9 v 177.2 +/- 278.3 mL/kg, P < .005) and during the first 24 hours postoperation (50.5 +/- 81.8 mL/kg v 16.4 +/- 28.5 mL/kg, P < .05).(ABSTRACT TRUNCATED AT 250 WORDS)

[Survival after aorto-femoral shunt with Dacron prosthesis]

The purpose of this paper is to establish the survival rate of patients submitted to aorto-femoral bypass grafting and compare it with the general mortality rate of the population in the State of São Paulo. The records of 210 patients with aorto-femoral bypass grafts and mean age of 54 years were analysed according the Kaplan and Meyer method. The survival curves of the normal population with the age of 55 and 70 years were used for comparison. Our results are comparable with those reported in the international literature. The aorto-femoral atherosclerotic disease Hás the same features wherever lives the patient. The death is caused mainly by cardiac disease. In our patients, however, the infection of the prosthesis was also an important factor in the fatal outcome of the disease. After ten years about half of the patients submitted to an aorto-femoral bypass grafting are still alive.

[Surgical treatment of telangiectasis]

The surgical treatment of telangiectasis synchronous to sclerotherapy is presented in this paper. Two female patients with extensive telangiectasis of the lower limbs comprise our report. They were considered typical cases for application of the proposed technique: abolishing venous reflux. The adjacent veins were resected through skin incisions of about 2 mm with crochet hooks, under local anesthesia, immobilized with adhesive tape. Sclerotherapy was performed simultaneously. The cosmetic result was excellent in both cases, with complete removal of the telangiectasis. This procedure should be considered the method of choice in the treatment of telangiectasis resulting from obvious venous reflux.

In vitro vascular reactivity of the rat utero-feto-placental unit

OBJECTIVE

To evaluate the vascular reactivity to vasoconstrictor drugs and the local role of angiotensin I-converting enzyme in the rat utero-feto-placental unit.

METHODS

The experiments were carried out in vitro on a new model of the isolated perfused uterine horn from 19 nonpregnant and 16 pregnant rats.

RESULTS

Norepinephrine, angiotensin II, and angiotensin I induced concentration-dependent vasoconstriction in non-pregnant uteri (50% effective concentration = 271 +/- 63, 9.9 +/- 3.7, and 1.7 +/- 0.8 x 10(-9) mol/L, respectively; n = 4-5, mean +/- standard error of the mean). In pregnant uteri, the maximum vasoconstrictor effects of norepinephrine (increase in perfusion pressure 132 +/- 6 versus 186 +/- 20 mmHg in pregnant and nonpregnant, respectively) and angiotensin II (37 +/- 9 versus 89 +/- 4 mmHg), but not angiotensin I, were significantly lower. The vasoconstrictor effect of angiotensin I was inhibited by saralasin, an antagonist of the angiotensin II receptors, and by ramiprilat, a converting-enzyme inhibitor.

CONCLUSION

The isolated perfused rat utero-feto-placental unit is a useful experimental model for studying uterine vascular reactivity during pregnancy. Our in vitro results confirm vascular refractoriness to norepinephrine and angiotensin II during pregnancy and demonstrate local angiotensin II synthesis in the rat uterine vascular bed.

Oral acyclovir and recurrent genital herpes during late pregnancy

OBJECTIVE

To assess plasma acyclovir levels in pregnant women given oral acyclovir during late gestation and to determine the role and effect of oral acyclovir on asymptomatic shedding of virus in cases of recurrent genital herpes.

METHODS

Five pregnant women with proven genital herpes isolate (herpes simplex virus [HSV] 2) after 37 weeks' gestation were studied. Oral acyclovir was administered every 8 hours at dosages of 300, 400, and 300 mg in two subjects, and 200 mg five times daily in the other three until delivery. Plasma acyclovir peak and trough levels were determined. Viral cultures were obtained from both the mothers and neonates at delivery.

RESULTS

There was no difference in acyclovir plasma levels among the patients. Furthermore, acyclovir levels were comparable to those of nonpregnant adults. The drug failed to suppress asymptomatic shedding of virus and transmission of HSV 2 to the neonate in one of five of the patients.

CONCLUSION

Our study suggests that asymptomatic shedding of virus is not prevented by use of oral acyclovir during late gestation in proven recurrent genital herpes even though plasma acyclovir levels were within the normal range.

Cervical tuberculous vertebral osteomyelitis: case report and discussion of the literature

We report a case of tuberculous vertebral osteomyelitis of the first and second cervical vertebrae with extensive adjacent soft-tissue involvement and extension into the mediastinum and bilateral flanks. The clinical presentation of tuberculous vertebral osteomyelitis depends on the vertebrae involved. The characteristic syndrome, Pott's disease, reflects the consequence of infection of the lower thoracic and lumbar spine, the most common site of tuberculous vertebral osteomyelitis. Cervical involvement is unusual: tuberculosis affects the cervical vertebrae in approximately 0.03% of all cases. Tuberculosis of the atlas and axis is even more rare. Characteristic symptoms reported on presentation include fever, weight loss, night sweats, and neck pain and stiffness. Patients may have no neurological manifestations, but findings can range from single nerve-root compression to quadriplegia. Abscess may extend into the retropharynx, mediastinum, and posterior triangles and along the epidural space. Computerized tomography and magnetic resonance imaging are the most useful imaging procedures. Therapy should consist of administration of antimycobacterial antibiotics and--if indicated by the degree of subluxation, by neurological signs, or by cervical instability--surgical debridement and stabilization.

The subepithelial connective tissue graft for treatment of gingival recession

A technique has been described for areas of single or multiple root coverage, especially in the maxilla, for coverage of existing crown margins, and for areas requiring a combination of ridge augmentation and root coverage. The success of the subepithelial connective tissue graft is attributed to the double blood supply at the recipient site from the underlying connective tissue base and the overlying recipient flap. The donor site is a closed wound, which produces less postoperative discomfort. In addition, an excellent color blend can be achieved.

[Surgical treatment of infections involving arterial prosthesis in aorto-femoral position]

This article is to evaluate the results of surgical treatment of aorto-femoral graft infections. The records of 20 patients with aorto-femoral graft infections were reviewed. The patients were submitted mostly to a combination of surgical procedures. They were: a) conservative treatment; b) partial removal of the infected graft and c) total removal of the infected graft. The removal of the prosthesis, partial or total, was followed by a new arterial reconstruction in some patients. The final treatment was: total removal of the infected graft in 11 (55%) patients, total removal plus arterial reconstruction in six, partial removal in two and partial removal plus arterial reconstruction in one. The results of treatment were presented as the survival rate and the effective palliation (patient alive, lower limbs preserved and infection cured). The survival rates after one month, 12, 24, 36 and 48 months were respectively: 80%, 60%, 53%, 42% and 27%. The effective palliation rates after one month and after 48 months were respectively 50% and 27%. The highest effective palliation rate was obtained when the infected prosthesis was removed and a new arterial reconstruction performed. We conclude that the treatment of choice of aorto-femoral graft infections seems to be the total removal of the graft followed by new arterial reconstruction.

Ischemic rest pain of the lower extremities. Treatment with peripheral nerve crush

The authors report the results obtained from peripheral nerve crushing in the treatment of ischemic rest pain and/or trophic lesions of toes and feet. They studied retrospectively 102 patients who were submitted to peripheral nerve crushing at the "Hospital das Clínicas da Universidade de São Paulo" during a sixteen-year period, from March 1971 to April 1987. These patients had no other choice, either clinical or surgical. The results were evaluated under three aspects: elimination of pain, evolution of trophic lesions and postoperative complications. The follow-up period varied from 1 month to 6 years (mean of 18 months). The results showed immediate elimination of pain in 94% of the patients. The remaining 6% were reoperated on within 24 to 48 hours, due to technical failure in identifying some of the nerves during the first operation. Regarding the trophic lesions, in 71% of the patients the results were good and the remaining underwent amputation at leg or thigh. The worst results were obtained in patients with necrotic lesions (p < 0.05). Three patients presented surgical wound dehiscence. The authors conclude that peripheral nerve crushing constitutes a valid alternative for a select group of patients with uncontrollable ischemic rest pain in the feet.

[Infection involving arterial prosthesis: clinical picture, etiology, and predisposing factors]

Thirty patients were operated for arterial reconstruction with synthetic grafts. They presented one of the following complications: 1) prosthesis exposed by a cutaneous fistula; 2) prosthesis in communication with a hollow viscus; 3) prosthesis involved by pus; 4) positive culture of a fragment of the prosthesis or of the surrounding secretion. The clinical manifestations were cutaneous fistula in 21 patients (70%), external bleeding in 14 (47%), exposition of the prosthesis in five (17%), anastomotic aneurysm in five (17%), and enteric fistula in four (13%). The infection became evident during the first postoperative year in half of the patients. The most important agents of infection were staphyilococci and Gram negative bacteria.

Dental implants: a review

The present article is a review presenting an update on the field of dental implants since the World Workshop in Clinical Periodontics in July 1989. Areas that are discussed include following: 1. Biomaterials and the implant interface, and the interaction of these with the environment. 2. Periodontal considerations including data supporting a perimucosal seal of implant to soft tissue and discussion of the endosseous interface between the bone and the implant. 3. Newer techniques of diagnostic imaging and their determination of bone types are related to the future practice of dental implants. 4. Implant selection and the surgical techniques involved in implant placement. 5. Current ideas of implant prosthodontics, implant maintenance, and the treatment of implant failures. 6. Finally, the use of dental implants in the United States and Sweden.

Post-transplant recurrent hepatitis B viral liver disease. Viral-burden, steatoviral, and fibroviral hepatitis B

Recurrence of hepatitis is a well-documented complication of hepatitis B liver disease, post-transplantation. It is well established also that the earliest hepatocellular change is the appearance of hepatitis B viral (HBV) markers and that the disease is rapidly progressive. In this article on 17 liver transplants in 16 HBV positive patients with long-term follow-ups (100-1234 days), the distinctive pathologic features of this disease are emphasized: the extreme viral load, the steatosis, and/or fibrosis. An attempt to quantitate the magnitude of the viral burden was made and the result was a staggering figure. In one patient, an estimated 10(18) HBV core particles were present in the liver. One of two patterns of progression were noted. In four patients in addition to the massive nuclear hepatitis B core antigen (HBcAg) and cytoplasmic hepatitis B surface antigen (HBsAg) positivity, superimposed hepatitic changes led to diffuse hepatic fibrosis (fibroviral hepatitis B); and in another six patients, extraordinary hepatocellular viral marker positivity and steatosis were the hallmarks (steatoviral hepatitis B). Steatosis is not usually considered a feature of HBV liver pathology. These results suggest that more than one type of posttransfusion recurrent hepatitis B liver disease exists pathologically.

[Abdominal aortic mycotic aneurysm due to Salmonella: case report and review of literature]

A 59 year old female patient was admitted to the hospital complaining of lower back pain and fever for four months, with worsening of symptoms during the last two weeks. A painful pulsatile abdominal mass was the only positive sign at her physical examination. Her CT-Scan showed a periaortic hematoma and a rupture of the aortic wall while the Aortography disclosed a false aneurysm below the renal arteries. All blood cultures were negative. The patient was operated on and had her aneurysm resected and her aorta reconstructed with an in situ bifurcated aorto-femoral Dacron graft. The bacteriological examination of the aortic wall revealed a Salmonella type B, which confirmed the clinical hypothesis of abdominal aortic mycotic aneurysm. It was not possible to maintain a prolonged antibiotic therapy and the patient had to be submitted to a second operation three months later because of an infected graft; when the aorto-femoral graft was removed and an axillobifemoral bypass prosthesis was done. After a three years follow-up period the patient is doing well and has no signs of recurrences. We conclude, based on the literature review and our personal experience, that: 1) the symptomatologic triad presented by the patient is highly suggestive of those diagnosis; 2) blood cultures may not be positive; 3) the CT-Scan and aortography are the best examinations for the diagnosis of abdominal aortic mycotic aneurysm; 4) either the in situ or the extra-anatomical arterial reconstruction may be employed with good results. Higher infection rates are reported with the in situ grafts; 5) life-long antibiotic therapy is recommended whatever reconstruction procedure is selected.

[Arterial reconstruction of the iliofemoral segment by eversion endarterectomy]

From October 1985 to December 1988, 31 iliofemoral eversion endarterectomies were performed in 29 patients with arteriosclerosis. The surgical procedure was carried out for trophic lesions in 74% of the patients and for ischemic rest pain in the remaining 26%. In 11 operations the endarterectomy was associated with profundoplasty, and in eight with saphenous vein femoropopliteal bypass. There were six immediate failures, four of them submitted to successful reoperations, and two to above knee amputations. In cases with good immediate patency no complications occurred during the follow-up periods which ranged from one to 34 months. With one post-operative death the mortality rate was 3.2%. Two patients displayed later severe ischemic manifestations in the opposite limbs and were both submitted to the same type of operation with good result. It may be concluded that iliofemoral eversion endarterectomy is an appropriate alternative procedure to the aortoiliofemoral reconstruction surgery in patients with severe ischemia of the lower limbs.

[Femoral artery compression test: a non-invasive method for detection of obstructive injury of the internal iliac artery]

For non-invasive detection of obstructive disease in the internal iliac artery, the femoral compression test was devised. This test consists in the compression of the inguinal arcade of the patient with the examiner's thumb, until the disappearance of the arterial beats in this region and peripherically in the correspondent lower limb, while one auscultates the sound in the dorsal penial artery with ultrasonic stethoscope and measures the penial pressure. The test was considered positive when there was abolition of sound in the penial artery, or reduction superior to 15% in the penial pressure. The test was negative when there was no abolition or reduction of sound and pressure, as referred respectively. In 15 normal individuals the 30 tests, one for each inguinal region, were negative. In 23 patients with ischemia of lower limbs registered by the analysis of angiographies to which they were submitted, there were 39 tests, one in each inguinal region, in which there was femoral pulsation. There was abolition of sound in the penial dorsal artery in 20 of 22 tests in which the arteriography showed obstruction of the homolateral internal iliac artery. In 15 tests, in which there was reduction of penial pressure, the arteriography showed presence of unique or multiple stenosis in the internal homolateral iliac artery. In two cases of patency of the internal homolateral iliac artery, the test was negative. The positivity of the test was significantly higher in patients with obstructive lesions of internal iliac artery when compared to normal individuals (p < 0.001, chi-square test).(ABSTRACT TRUNCATED AT 250 WORDS)

Early experience with reduced-size liver transplants

Scarcity of small donors results in a high mortality rate for children on liver transplant waiting lists. To alleviate this problem, we have recently started to reduce the size of livers from older donors to use in children. In the last year, a total of 20 liver transplants were performed in 17 patients, including seven reduced-size liver transplants (RSLT) in six children. Mortality on the waiting list has been reduced to negligible amounts compared with a mortality rate of 25% before starting RSLT in patients with acute liver failure or those whose weight was less than 10 kg. Children undergoing RSLT weighed 10.8 +/- 8.5 kg compared with 20.9 +/- 20.3 for all others (NS). Cold ischemia time was significantly longer in the RSLT group (9.5 +/- 3.0 v 6.0 +/- 2.8 hours, P less than .05) as was intraoperative blood loss (9.4 +/- 9.4 v 3.0 +/- 3.5 blood volumes). There was no significant difference in postoperative aspartate aminotransferase and prothrombin time between the two groups. Four children received a RSLT as a primary procedure and three have survived with good liver function. Two patients were retransplanted with RSLT after a failed first transplant and both died of nonhepatic complications. This compares with 11 of 13 survivors in the whole liver transplant group. Causes of death in children who died after RSLT include cytomegalovirus sepsis (2) and myocardial infarction(1).(ABSTRACT TRUNCATED AT 250 WORDS)

Dental implants used for periodontal patients

For those performing implant treatment, continued research and reports of long-term successful results are essential to evaluating the validity of implants, especially when variables such as design and surface treatment are introduced. The dental profession has enthusiastically embraced the clinical results of implant treatment and its benefits to the patient. However, just as patients who undergo periodontal and restorative treatment must continue a regular long-term routine of maintenance therapy to ensure their dental health, so must those patients who receive dental implants. Both the periodontist who places the implants and the dentist who fabricates the prosthetic replacement must work cooperatively to deliver a healthy restoration that will function for many years.

Mycobacterial subcutaneous arteritis

The authors report three patients with subcutaneous erythematous nodules in different phases of development, unspecific systemic symptoms, positive PPD test, and normal chest X-rays. The histopathological study of the older nodules showed a granulomatous arteritis with a few acid-fast bacilli in the vascular wall. The nodules at an early phase showed an unspecific panniculitis with some acid-fast bacilli in apparently normal cutaneous vessels. These findings suggest that the mycobacterium has a vascular tropism and may cause a primary granulomatous arteritis.

Selective or total shunts for variceal bleeding

Shunt surgery remains an important therapeutic option in the management of variceal bleeding, and both total and selective shunts have a role to play. The distal shunt is associated with a lower long-term encephalopathy rate and may yield better survival in the nonalcoholic patient; it is, therefore, the preferred shunt in the elective situation. The total shunt is technically easier to perform and more widely available; it is, therefore, preferred in the emergency situation. Ordinarily, the side-to-side and end-to-side shunts have similar outcomes; however, in patients with hepatic venous outflow obstruction and patients with intractable ascites, the side-to-side shunt should be used.

Delta and conjugated bilirubin as complementary markers of early rejection in liver-transplant recipients

For 51 liver allograft recipients, we evaluated whether serum profiles of delta (Bd) and conjugated bilirubins (Bc) could be used to diagnose rejection during the first 30-50 postoperative days, in comparison with histology as the "gold standard." Daily measurements of aspartate aminotransferase, alkaline phosphatase, total bilirubin, Bd, and Bc were made, the last two by liquid chromatography. In 34 patients without any biochemical or histological evidence of rejection, within seven to 10 postoperative days Bd increased to greater than 40-50% of total bilirubin, while Bc decreased to less than 10%. In patients with severe rejections resulting in death, Bc increased rapidly to greater than 50%, while Bd remained less than 30%. In 24 histologically proven episodes of rejection in 17 patients there was either a rapid decrease in Bd or its persistence at 30%, plus either a steep increase in Bc, or its remaining at greater than 50% total bilirubin. Treatment of rejection resulted in a prompt reversal of these trends. Individually promising as prognostic adjuncts to existing liver-function markers, Bd and Bc also complemented each other, rendering the diagnosis of liver rejection much more incisive.

Delta and conjugated bilirubin as complementary markers of early rejection in liver-transplant recipients

For 51 liver allograft recipients, we evaluated whether serum profiles of delta (Bd) and conjugated bilirubins (Bc) could be used to diagnose rejection during the first 30-50 postoperative days, in comparison with histology as the "gold standard." Daily measurements of aspartate aminotransferase, alkaline phosphatase, total bilirubin, Bd, and Bc were made, the last two by liquid chromatography. In 34 patients without any biochemical or histological evidence of rejection, within seven to 10 postoperative days Bd increased to greater than 40-50% of total bilirubin, while Bc decreased to less than 10%. In patients with severe rejections resulting in death, Bc increased rapidly to greater than 50%, while Bd remained less than 30%. In 24 histologically proven episodes of rejection in 17 patients there was either a rapid decrease in Bd or its persistence at 30%, plus either a steep increase in Bc, or its remaining at greater than 50% total bilirubin. Treatment of rejection resulted in a prompt reversal of these trends. Individually promising as prognostic adjuncts to existing liver-function markers, Bd and Bc also complemented each other, rendering the diagnosis of liver rejection much more incisive.

Liver transplantation in children: the initial Toronto experience

The Hospital for Sick Children's initial 2-year experience with pediatric liver transplantation is reviewed. Patients are divided into high- and low-risk groups according to certain criteria. The high-risk group includes patients under 10 kg in weight, those with extrahepatic biliary atresia (EHBA), those with portal vein atresia or thrombosis, and those in hepatic coma. All others were considered low risk. Twenty-nine patients were assessed for transplantation: 18 were transplanted and 6 (21% of total referred) died while on the waiting list. Eighteen patients received 23 transplants. Of the 18 recipients, nine had EHBA, four had fulminant hepatic failure, two had tyrosinemia, one had glycogen storage disease, one had Indian childhood cirrhosis, and one had idiopathic cirrhosis. Seven of the 13 patients in the high-risk group survived (55% survival) with 1 to 23 month follow-up. Survival was significantly higher (80%) in the low-risk group (P less than 0.05). Four patients were retransplanted and two survived. Early deaths occurred from prolonged warm ischemia, recurrent portal vein thrombosis, and brain death in a patient who had been transplanted in hepatic coma. Late deaths occurred from cytomegalovirus (CMV) disease (2 patients), acute rejection (1 patient), and myocardial infarction (1 patient). The incidence of primary nonfunction was 4.3% (1 of 23) and of arterial thrombosis was 13% (3 of 23). Survival in patients transplanted for EHBA (67%) was slightly higher than it was for the rest of the group, although not as good as it was in the low-risk group.(ABSTRACT TRUNCATED AT 250 WORDS)

Treatment of primary liver graft nonfunction with prostaglandin E1

Primary nonfunction following orthotopic liver transplantation is characterized by rapidly rising serum transaminases, minimal bile production, and severe coagulopathy, which can progress to hypoglycemia, hepatic encephalopathy, and acute renal failure. Untreated it has a mortality of over 80% and to date the only treatment has been retransplantation. As a result of the beneficial effect of Prostaglandin E1 infusion in patients with fulminant hepatic failure, this trial was conducted to determine whether PGE1 would be of value in primary nonfunction. We have encountered 16 cases of primary nonfunction in 94 liver transplants, an incidence of 17%. Initially in the program, there were 6 occurrences of nonfunction that did not receive PGE1; 3 underwent retransplantation (2 survivors), 2 died awaiting another liver, and in one recovery of hepatocellular function occurred with supportive care but the patient died of cytomegalovirus infection. Ten patients received PGE1 within 4-34 hr of transplantation. Within 12 hr of treatment, 8 patients responded with a significant fall in the AST (129 U/hr) whereas, in the untreated group, the AST continued to rise (267 +/- 102 U/hr) at the same rate as prediagnosis (337 +/- 95 U/hr). At the conclusion of the infusion (4-7 days) in the 8 responders, there were significant decreases in AST (4386 +/- 546 U/L to 102 +/- 21 U/L), prothrombin time (22 +/- 2 to 12 +/- .4 sec) and partial thromboplastin time (45 +/- 3-29 +/- 4 sec), and significant increases in coagulation factor V (26 +/- 8 to 95 +/- 12%) and factor VII (10 +/- 5 to 61 +/- 4%). No serious side effects occurred, although 2 patients developed diarrhea, and abdominal cramps. Two patients treated with PGE1 were retransplanted at 10-36 hr and were considered nonresponders. Graft survival was 80% in the PGE1-treated group and 17% in the untreated group (P less than 0.05) and patient survival was 90% and 33%, respectively. This study suggests a potential benefit of PGE1 in the treatment of primary nonfunction.

[Prevention of cytomegalic inclusion disease in leukemia patients with a cytomegalovirus hyperimmune globulin preparation]

In a randomised study the efficacy of a cytomegalic hyperimmune globulin preparation (CMV-HIGP) which had been treated with beta-propiolactone was analysed. The study included 85 patients with acute lymphoblastic leukemia (ALL) and Non-B-Non-Hodgkin-lymphoma (NHL) who were treated initially or underwent a relapse therapy. During the intense chemotherapeutical period within leukemia treatment the patients were passively immunised by the intravenous route with CMV-HIGP (1 ml per kilogram of body weight) every two to three weeks at the latest. In the initial stages the basic immunisation protection was achieved by the application of double dose CMV-HIGP. The Frankfurt patients were recruited from the BFM-ALL- and the NHL-study since october 1982. When they were admitted their CMV serostatus was determined by means of the ELA-ELISA or IFA-method. Seronegative patients were given the passive immunisation immediately or 48 hours after the first blood transfusions at the latest. The patients who had become CMV-IgG-positive by passive immunisation were randomised when reaching long-term therapy according to the protocol. Because of a 30% cytomegaly disease incidence rate in our patient population a randomisation was unwarrantable at the beginning of leukemia treatment. During randomisation one group of patients were immunised by the intravenous route with CMV-HIGP (2 ml per kg body weight one time in four weeks), the second group was a control group.(ABSTRACT TRUNCATED AT 250 WORDS)

Surgical research: its importance in the evolution of the specialty of general surgery

General surgery is a specialty that has gradually been defined by the evolution of surgery in general, the major events being the identification and separation of subspecialties. Advances in knowledge brought about by research have been the major determinants in allowing the development of these subspecialties. Research has played a major role in the redefinition of general surgery, which has now in its own right become both the parent specialty and a subspecialty: the parent specialty because of its continued concern with disease states of a general nature, such as trauma, critical care, nutrition, transplantation, oncology; a subspecialty because of its focus on specific areas of surgery, particularly gastrointestinal surgery. Future developments in general surgery depend on fostering research in both the general and specific areas, and also across the whole spectrum from the most basic to applied clinical research.

Monocyte/macrophage procoagulant activity as a measure of immune responsiveness in Lewis and brown Norway inbred rats. Discordance with lymphocyte proliferative assays

In vitro lymphocyte proliferative assays were performed using Lewis (Lew) and Brown Norway (BN) rats, and compared to induction of monocyte/macrophage procoagulant activity (PCA) in a mixed lymphocyte culture and by endotoxin (LPS) (E. Coli 0111:B4). Splenic mononuclear cells from Lew rats had significantly greater mitogen-induced proliferation to concanavalin A (P = .002) and phytohemagglutinin (P = 0.007). The Lew cells also showed greater allogeneically induced proliferation by BN cells in a one-way MLC in comparison to the reciprocal BN proliferative response (P less than 0.04). PCA induction in peripheral blood mononuclear cells (PBM) by allogeneic stimulation in MLC or total content PCA by LPS did not vary significantly between the 2 strains (P greater than 0.5). Induction of PCA by LPS was rapid, with a moderate rise over basal activity at 3 hr and maximal activity at 6 hr. Two-way allogeneic induction of PCA in PBM from BN and Lew rats resulted in PCA elevation by 3 hr, which became maximal at 18 hr. One-way MLC with Lew or BN cells as responders resulted in moderate increases in PCA by 3-6 hr, with equivalent maximal activities recorded at 18 hr. Viable PCA accounted for 26-32% of total content PCA in both Lew and BN rats. Maximal allogeneic PCA induction by MLC was 14-18% of PCA induced by LPS and required a longer incubation for its expression. Our results indicate that in vitro PCA expression by Lew and BN PBM following allogeneic or endotoxin stimulation shows little interstrain variability in comparison to lymphocyte proliferative responses. Thus PCA appears to more closely reflect the observed in vivo responses of these strains to allogeneic challenge.

Listeria monocytogenes cholecystitis

Listeriosis usually manifests at the extremes of age, during pregnancy or among immunocompromised individuals as an acute meningoencephalitis with or without associated septicemia. Localized infections are rare. We investigated the incidence of Listeria monocytogenes cholecystitis using the data of the Listeria reference laboratory of the University of Würzburg/FRG. Out of 467 culture proven L.m-infections in the years 1986 and 1987, two cases were localized infections of the gall bladder. Although studies of the microbiology of gallbladder infections have not demonstrated the recovery of Listeria monocytogenes as a pathogen in acute or chronic cases of cholecystitis, these two cases substantiate the existence of this rare form of listeriosis as an entity and support the theory of the importance of the gastrointestinal tract in the pathogenesis of Listeria infections.