Impact of human immunodeficiency virus type 1 on tuberculosis in rural Haiti

We conducted a case-control study to determine the relative and attributable risk of HIV seropositivity for bacillary-positive (smear and/or culture) pulmonary tuberculosis in Haiti. There were 274 patients with tuberculosis and an equal number of control subjects. Antibodies to HIV were present in 67 (24%) patients and eight (3%) control subjects. Odds ratios suggested that the risk of pulmonary tuberculosis was 15.7 times as great (95% confidence interval, 4.8 to 5.0; p less than 0.05) in patients 20 to 39 yr of age who were HIV-seropositive than in HIV-seronegative patients. In contrast, the relative risk in those 40 to 59 yr of age was elevated (3.0 times), though not significantly (lower 95% confidence interval, 0.8). In the 20- to 39-yr age group, 31% of tuberculosis was attributable to HIV infection (95% confidence interval between 23 and 39%). HIV-seropositive and HIV-seronegative patients did not differ with respect to sputum smear positivity. HIV-seronegative patients were twice as likely to be infected with resistant organisms, though this was not significant. We conclude that HIV infection is a major risk factor for pulmonary tuberculosis in young adult residents of Haiti. This, together with the fact that similar proportions of HIV-seropositive and HIV-seronegative patients were potentially infectious, suggests that without vigorous counteraction tuberculosis will become a greater problem for Haiti.

The chest roentgenogram in pulmonary tuberculosis patients seropositive for human immunodeficiency virus type 1

To determine the impact that co-infection with HIV has on the radiographic presentation of pulmonary tuberculosis, we examined the chest roentgenograms obtained before treatment in 225 HIV-tested adult Haitians with bacillary (smear or culture or both) positive pulmonary tuberculosis. There were 67 HIV-seropositive and 158 HIV-seronegative patients. Intrathoracic adenopathy alone was more common and parenchymal infiltrates less common in HIV-seropositive patients (p less than 0.05). Although a parenchymal infiltrate was less likely to be cavitating in the HIV-seropositive group (p less than 0.05) when cavitary parenchymal disease was present, HIV seropositivity did not affect the number of cavities (single or multiple) or the size of the largest cavity. Patients with AIDS were significantly more likely to have a chest radiographic pattern consistent with primary tuberculosis (80 percent) than HIV-seropositive patients without AIDS (30 percent), and the latter were significantly more likely to have such a pattern than HIV-seronegative patients (11 percent) (p less than 0.05). The HIV-seropositive patients were equally infectious, regardless of the pattern of disease (primary vs postprimary). Even though pulmonary tuberculosis in an HIV-seropositive adult probably results from reactivation of dormant foci or reinfection, the pattern on the chest roentgenogram often suggests primary disease, especially if the patient has AIDS.

[Studies on immunoregulation and hypersensitivity of secretary otitis media]

Sixty patients with secretary otitis media (SOM) and 50 control cases were studied for their cellular immunity and hypersensitivity. Most of patients revealed that total T or T cell subpopulations were below those of the control. Eighty percent of patients had high serum IgE level and 81.2% as Positive in intradermal skin tests on inhalant allergy, but only 51.7% of patients had clinical symptoms of allergy. It was found immunologically that SOM occurred more frequently in allergic patients and most of them had abnormality of immunoregulation, and that there was a subclinical allergy for some of the patients. Allergy might play a significant role in the etiology of this disease. Authors suggest that it is necessary for patients with SOM to have some tests and treatment of immunology.

Antituberculous drug resistance in central Haiti

To determine the prevalence of antituberculous drug resistance in Haiti, we conducted a 1-yr survey in a central district. From a bacillary positive (smear and/or culture positive) case rate of 80/100,000, there were 282 patients from whom Mycobacterium tuberculosis was cultured. Each isolate was packaged and delivered to Canada where speciation and drug susceptibility testing were performed. Reported resistances are those using the proportions method (Laboratory Center for Disease Control, Ottawa, Canada). Resistance to one or more drugs was found in 22% of isolates. Age was the most important predictor of resistance in Haiti; resistance rates for age groups less than 14, 14 to 29, 30 to 44, greater than or equal to 45 were 8, 19, 22, and 31%, respectively. In patients not known to have received antituberculous drugs in the past, resistances were isoniazid (19%), streptomycin (5%), ethambutol (2%), ethionamide (2%), rifampin (1%). We conclude that antituberculous drug resistance is prevalent in Haiti, especially in older age groups, and that in persons with no known antituberculous drug use in the past, resistance to isoniazid is significant.

Serotypes of Pseudomonas aeruginosa from human and animal sources

Forty human isolates and twenty-eight animal isolates of Pseudomonas aeruginosa from Prince Edward Island area (Atlantic Canada) were serotyped using a kit consisting of 4 polyvalent O-group antisera and 17 monovalent O-type (serovar) antisera, in accordance with the International Antigenic Typing Scheme. The results showed a difference between humans/dogs (50%/48% group I) and pigs (71% group IV). Whereas O-serovar 9 and 1 appeared to be most involved in human and canine infections, O-serovar 3 was the predominant type in porcine infections.

The relation of flow cytometry to clinical and biologic characteristics in women with node negative primary breast cancer

Flow cytometry (FC) analysis including DNA index (ploidy status) and cell kinetics (%S and %S + G2/M) was done on frozen tissue of the primary lesions of 101 women with node negative (N-) breast cancer who were studied prospectively. Currently, 19% (19/101) of the patients have recurred. No significant relations have been found between recurrence or survival and age, estrogen/progesterone receptor status, tumor size, and tumor type. The DNA index (ploidy) was not related to any clinical variable, time to recurrence, or survival. Aneuploid tumors did, however, have significantly higher %S phase activity. Patients with %S activity less than or equal to the median value were significantly different from those patients with %S above the median. They were older and had a higher frequency of ER/PR positive and well- or moderately differentiated tumors. Patients with %S + G2/M greater than the median value showed shorter time to recurrence (P = .055) and shorter survival (P = .006), whereas %S alone was significantly associated only with survival. Multivariate analysis showed that neither DNA index nor cell kinetics was significantly associated with time to relapse. DNA index was not significantly associated with survival; %S was of borderline significance whereas %S + %G2/M was a significant independent predictor of survival. Although FC data may provide independent information related to survival in N-women, additional research in a larger number of patients is needed to define its precise role in patient management.

Chronicity. Adjustment differences of Vietnam combat veterans differing in rates of psychiatric hospitalization

The study focuses on the frequency of inpatient care for patients with Posttraumatic Stress Disorder (PTSD). This factor, termed "chronicity," is, perhaps surprisingly, largely overlooked in many PTSD studies. The significance of chronicity was addressed through administration of Minnesota Multiphasic Personality Inventory (MMPI) to Vietnam Theater and Era veterans in an inpatient psychiatry service. MMPI scores were analyzed for two main effects: combat exposure and chronicity (i.e., number of inpatient psychiatry admissions). The results replicated research showing combat exposure is associated with greater maladjustment (i.e., higher MMPI scores). Moreover, chronicity also emerged as a significantly important variable: of all groups compared, Vietnam combat veterans higher in chronicity scored higher on MMPI clinical scales, particularly on scales Paranoia, Psychasthenia, and Schizophrenia, thereby (a) empirically establishing (a) the methodological point that number of admissions must be controlled and (b) the substantive point that chronicity is important in studies of PTSD.

Tuberculous pericarditis: long-term outcome in patients who received medical therapy alone

A conservative approach to operative intervention in the treatment of active tuberculous pericarditis was adopted and only 4 of 16 consecutive patients underwent pericardiectomy, all within 2 months of diagnosis. One patient died of constrictive pericarditis despite pericardiectomy, and one died of acute bronchopneumonia after 8 months of otherwise successful medical management. All 14 long-term survivors were reevaluated to exclude chronic constrictive pericarditis and other potential sequelae of tuberculous pericarditis. Reevaluation included physical examination, chest radiograph, electrocardiogram, M-mode and two-dimensional echocardiogram, computed tomography (CT) scan, and in patients less than or equal to 75 years of age, incremental cycle exercise to maximum oxygen consumption. None were found to have chronic constrictive pericarditis or convincing evidence of other recognized complications of tuberculous pericarditis. Our results suggest that when pericardiectomy is not required for the relief of cardiac compression during the acute phase of tuberculous pericarditis and patients are treated with medical therapy alone, an excellent long-term outcome may be anticipated.

Treatment of canine aspiration pneumonitis: fluid volume reduction vs. fluid volume expansion

The aspiration of gastric acid causes pulmonary edema and hypoxemia. One approach to the management of this syndrome is to raise cardiac output (Qt) and O2 delivery (QO2) to ensure tissue oxygenation (VO2) at the risk of increasing the edema. Another approach reduces the edema by reducing pulmonary microvascular pressure (Pmv) at the risk of reducing QO2 and VO2. We compared these approaches in 24 anesthetized, ventilated dogs with pulmonary wedge pressure (Ppw), a clinical approximation of Pmv, of 12.5 mmHg. Before and again 1 h after endobronchial instillation of 0.1 N HCl, we measured Qt, QO2, VO2, venous admixture, and in vivo extravascular lung liquid. The dogs were then randomly divided into four equal groups: 1) 12.5 mmHg Ppw, high Qt; 2) 7.5 mmHg Ppw, intermediate Qt; 3) 4.5 mmHg Ppw, low Qt; and 4) 4.5 mmHg Ppw plus dopamine, intermediate Qt. Measured values were followed for 4 more h, after which the lungs were excised to compare wet weight-to-body weight ratios (W/B). When plasmapheresis reduced Ppw at 1 h, edema did not increase further and W/B of groups 2 (21 +/- 3), 3 (18 +/- 3), and 4 (22 +/- 3) were significantly less than in group 1 (27 +/- 3) (P less than 0.001). Although Qt decreased with Ppw, increased hematocrit and reduced venous admixture maintained QO2 in group 2 but not in group 3. In group 4 an intermediate Qt maintained QO2 even at 4.5 mmHg Ppw but edema increased to the group 2 level presumably because Pmv rose with Qt on dopamine. VO2 remained constant over time in each group. These data demonstrate that canine HCl-induced pulmonary edema, measured in vivo or gravimetrically, is very sensitive to reductions in Pmv. Moreover, the lowest Pmv (and QO2) was well tolerated because an O2 supply dependency of VO2 was not observed.

Anatomical analysis of frontal cortex sites at which carbachol induces motor seizures in the rat

High amplitude spiking representative of seizures, accompanied by an unusual motor behavior pattern of rearing and forelimbic clonus resembling "boxing," was elicited by microinjection of the cholinergic agonist, carbachol, 4 micrograms, into the medial prefrontal cortex of the rat. A rating scale devised to score the behavior revealed a motor pattern elicited by carbachol from the medial anterior cortex which was similar to that described by Racine for electrical stimulation of the amygdala. Topographical analysis of the areas surrounding the medial anterior cortex region revealed that the motor manifestations of seizures were elicited over a wide region of the anterior cortex, with scores significantly lower at carbachol microinjection sites greater than 1 mm rostral, 2 and 3 mm caudal, and 2 mm lateral to the standard medial prefrontal cortex site. Unilateral microinjection of carbachol yielded motor seizures primarily from the contralateral forepaw, suggesting involvement of a crossed pathway. Retrograde tracing with fast blue dye, combined with immunostaining for choline acetyltransferase and NADPH-diaphorase, found that the cholinergic neurons innervating the standard microinjection site were the dorsolateral tegmental cells, as previously reported, which have been shown to also contain substance P and corticotropin releasing factor. In addition, cholinergic neurons of the nucleus basalis of Meynert region were found to innervate the standard microinjection site. These findings implicate cholinergic innervation of the rostral cortex in classical limbic seizures.

The effects of indomethacin on edema and gas exchange in canine acid aspiration

Previous studies have suggested that prostaglandin synthesis inhibition might alter lung water accumulation in low pressure pulmonary edema. Therefore we studied the effects of indomethacin administration on edema formation, hemodynamics, and gas exchange in canine acid aspiration. Fourteen pentobarbital anesthetized dogs received 1 ml/kg of 0.1 N HCl intratracheally and then 7 received indomethacin (5 mg/kg) and 7 served as time controls. Lung liquid was measured in vivo by a double indicator technique and at the end of the experiment by gravimetric determinations. Following HCl administration, venous admixture (Qva/Qt) increased in both groups. Over the succeeding 4 h Qva/Qt decreased after indomethacin administration by 4.1 +/- 14.2%, but increased in the control group by 10.9 +/- 11.5% (P less than 0.05). Cardiac index remained constant in the control group but decreased after indomethacin from 232 +/- 89 ml X kg-1 X min-1 to 167 +/- 75 ml X kg-1 X min-1. Lung liquid accumulation, however, was similar between both groups. We believe that the changes in Qva/Qt associated with indomethacin can be explained by the known observations that decreases in cardiac output are associated with decreases in intrapulmonary shunt.

Artificial ventilation of a canine model of bronchopleural fistula

The authors studied the abnormalities of gas exchange and lung mechanics in a canine model of bronchopleural fistula during intermittent positive pressure ventilation (IPPV) and high-frequency oscillatory ventilation (HFOV). The left lower lobe bronchus was opened to atmosphere and it was determined that end expired volume was best maintained at frequencies of 45-50 breaths/min. during IPPV. Comparing alternating periods of IPPV and HFOV in six dogs (Group I) at matched airway opening pressure (Pao), we found that Pao2 decreased significantly to 68 +/- 14 mmHg and 69 +/- 24 mmHg, respectively, on opening the fistula. In a second group of six dogs (Group 2), when Pao was increased by additional bias flow into the ventilatory circuit during both IPPV and HFOV, Pao2 increased significantly to 89 +/- 12 mmHg and 87 +/- 8 mmHg, respectively. Repeating Group 2 studies after induction of oleic acid low-pressure pulmonary edema demonstrated that conventional IPPV was associated with large intrapulmonary shunts. HFOV, however, maintained gas exchange at near baseline values. For both Group 1 and Group 2, the calculated gas flow through the fistula was significantly less at all levels of airway pressure during HFOV. The authors conclude that HFOV offers advantages over conventional IPPV in the maintenance of oxygenation and in the reduction of gas leak through the fistula.

Hôpital Albert Schweitzer and the Republic of Haiti

The Hôpital Albert Schweitzer was established near the village of Deschapelles in Haiti in 1956 by Dr. and Mrs. William Larimer Mellon of Arizona. The hospital currently has 162 acute care beds and provides inpatient and outpatient services to a district of about 160,000 people. In 1983, visits to the hospital and its dispensaries totaled 39,163. Since its founding the hospital has evolved into a tertiary care facility but has also established primary care programs through seven satellite dispensaries. Health agents and midwives play an important role in the hospital's field programs. Outreach programs concentrate on health and nutrition education, immunizations, supplementary food programs, tuberculosis screening, oral rehydration for infants with diarrheal diseases and cord cutting clinics for the prevention of neonatal tetanus. This paper describes the principal causes of morbidity and mortality in this area of Haiti, the functioning of the hospital and both its medical and non-medical programs. The latter include agricultural irrigation and well digging projects, and wood working, weaving and ceramic facilities to encourage local artisans.

The effects of surgical and chemical lesions on striatal [3H]threo-(+/-)-methylphenidate binding: correlation with [3H]dopamine uptake

The specific binding of [3H]threo-(+/-)-methylphenidate to membranes prepared from rat striatum was significantly reduced following either surgical lesions of the medial forebrain bundle or intracerebroventricular administration of 6-hydroxydopamine. The decrease in the density of [3H]threo-(+/-)-methylphenidate binding sites in striatum following chemical or surgical denervation was highly correlated with the decrease in [3H]dopamine uptake. In contrast, intracerebroventricular administration of 5,7-dihydroxytryptamine, AF64A, or chronic parenteral administration of reserpine did not alter either the number of apparent affinity of [3H]threo-(+/-)-methylphenidate binding sites. These data suggest that the specific binding sites for [3H]-threo-(+/-)-methylphenidate in striatum are localized to dopaminergic nerve terminals, and may be associated with the dopamine transport complex.

Repair of urinary tract fistulas with bulbocavernosus myocutaneous flaps

Urinary tract fistulas resulting from severe trauma or pelvic irradiation are often associated with extensive tissue loss, scar formation, and fibrosis. Two cases, one with a urethro-vaginal fistula secondary to trauma and one with a vesico-vaginal fistula secondary to irradiation, are presented. In neither case could the bladder, urethra, or vagina be repaired primarily. Using a bulbocavernosus myocutaneous "island" flap, the fistulas were successfully repaired. The anatomy of the graft and the operative procedure are described. This new procedure should be considered in urinary tract fistulas in which there is extensive tissue loss and scarring.

Role of nitrosation in the mutagenic activity of coal dust: a postulation for gastric carcinogenesis in coal miners

The mutagenicity of coal dust solvent extracts with and without nitrosation was studied using the Salmonella/microsome assay system. Coal dust solvent extracts were either non-mutagenic or very weakly mutagenic with S9 activation. High mutagenic activities, however, were found when extracts of bituminous, subbituminous, and lignite coal dusts were reacted with nitrite under an acidic condition. Formation of mutagens from coal dust extracts by nitrosation was highest at pH 3.2 and decreased with increasing pH in the reaction mixture. Mutagenic activity appeared to be independent of metabolic activation. The mutagens formed from nitrosation of coal dust extracts induced frameshift mutations. The results reported here may have possible implications for the explanation of an elevated incidence of gastric cancer in coal miners.

Upper extremity neuropathies following median sternotomy

The status of 958 patients who underwent median sternotomy between January, 1978, and May, 1981, was analyzed. Fifty-four patients had an upper extremity neuropathy. Among 38 patients who underwent further evaluation, motor and sensory nerve conduction studies localized the injury to the level of the elbow in 13, to the brachial plexus in 10, and to both locations in 6. Ninety-two percent of these 38 patients were asymptomatic 3 months after operation.

Intractable diarrhoea in a patient with vasoactive intestinal peptide-secreting neuroblastoma. Attempted control by somatostatin

A 1 1/2 year old child developed profuse watery diarrhoea, shown to be due to excessive plasma vasoactive intestinal peptide (VIP) levels, whilst on treatment for metastatic neuroblastoma. Because it was unresponsive to alternative treatment, an attempt was made to control the diarrhoea with a somatostatin infusion. The attempt failed despite the fact that serum VIP levels were substantially reduced. Possible reasons for failure are discussed and the importance of plasma VIP as a marker for maturation in neuroblastoma emphasised.

Lack of difference in digoxin urinary excretion with two intravenous infusion rates

Ten normal subjects were given 0.4 mg digoxin intravenously by bolus injection over 3 to 5 min and by constant-rate infusion for 1 hr. Urinary excretion of digoxin over the next 6 days, as measured by radioimmunoassay, was similar after both the rates of intravenous injection. In one subject, who excreted substantial amounts of digoxin reduction products, no difference was apparent in the amount of reduced metabolites excreted. These results are not in agreement with previous reports of an effect of intravenous infusion rate on urinary digoxin excretion.

Autogenous tunica vaginalis graft for Peyronie's disease: an experimental study and its clinical application

Tunica vaginalis autografting was done after patches of tunica albuginea of the penis were excised in 5 dogs. Examination of these grafts 4 to 12 weeks later showed that they were well accepted. A selected group of 5 patients with Peyronie's disease underwent excision of Peyronie's plaques and autogenous tunica vaginalis grafting with satisfactory results in all cases.

Causes of perioperative myocardial infarction: their identification and prevention

Despite major technical advances in coronary bypass surgery and myocardial preservation, perioperative infarction remains a serious problem. The authors review the pathogenesis of the two different types of myocardial injury, occlusion necrosis and reperfusion necrosis. These two entities can be distinguished clinically by radioisotope scanning. Experimental studies have demonstrated that reperfusion necrosis can be prevented pharmacologically. Since the majority of perioperative infarcts are probably due to reperfusion, the importance of distinguishing between these two entities is evident.

Differentiation between reperfusion and occlusion myocardial necrosis with technetium-99m pyrophospate scans

Although infarct-avid scanning is used to diagnose myocardial infarction, no distinction is made between two very different mechanisms of myocardial cell death. These are occlusion necrosis and reperfusion necrosis. The former is the major form of cell injury after a sustained occlusion of a coronary artery; the latter occurs immediately after reperfusion of ischemic myocardium. The present study examines whether the technetium pyrophosphate scan becomes positive more rapidly with one form of injury rather than the other. Myocardial damage was produced in dogs by either sustained coronary occlusion (Group I, 6 dogs) or reperfusion (Group II, 18 dogs). Infarct-avid myocardial scans obtained with technetium-99m pyrophosphate were positive in only one of six animals in Group I when isotope was injected 4.5 hours after sustained coronary occlusion. In contrast, 12 or 13 animals (Group IIa) with reperfusion necrosis had a positive scan when isotope was injected 3.5 hours after reperfusion. When isotope was injected only 30 minutes after the onset of reperfusion (Group IIb), only two of five scans were clearly positive. The results indicate that if the interval between myocardial injury and a positive scan is known, inference can be made concerning the predominant type of injury.

Renin-angiotensin-aldosterone system, electrolyte homeostasis and blood pressure in alloxan diabetes

The effect of a chronic glucose osmotic diuresis on electrolyte homeostasis was evaluated in alloxan diabetic rats with urine volumes greater than 150 ml/day and glycosuria of 4 to 10 gm/day. Results were compared with control rats for periods up to 84 days. Sodium and potassium intake and urinary losses were significantly higher in diabetic animals throughout the study periods. Negative Na balance, however, persisted for only four days, and negative K balance for only 18 days. Blood volumes were elevated probably secondary to the osmotic effect of hyperglycemia (serum glucose greater than 600 mg %). Plasma renin activity decreased progressively, in part because of an early decrease in renin substrate at a time when renin concentration was normal. Despite hyperkalemia, mean plasma aldosterone was not increased compared with that in control rats, suggesting diabetic rats had relative hypoaldosteronism. Although three diabetic rats became hypertensive, no significant difference in mean blood pressure was observed between the groups. The results suggest that diabetic rats have losses of Na and K early in their diabetes, following which mechanisms to conserve Na and K are activated preventing further electrolyte depletion despite continuation of the osmotic diuresis. Decreased renin activity with inadequate stimulation of aldosterone would contribute to K conservation. Maintenance of Na balance must be explained by increased Na intake and other renal Na conserving mechanisms.

Renin-angiotensin system in phlorhizin compared with alloxan diabetes in the rat

In alloxan-treated diabetic rats, plasma renin activity (PRA) is decreased. One possible mechanism that may explain the decreased PRA is an increased delivery of sodium to the macula densa produced by the glucose osmotic diuresis, resulting in decreased renin release. To evaluate this possible mechanism, rats with phlorhizin diabetes, which produces a glucose osmotic diuresis without hyperglycemia, were studied and compared with rats with alloxan-induced diabetes. Whereas phlorhizin-treated rats had low blood glucose and alloxan-treated rats had elevated glucose, the glucose osmotic diuresis was similar in the two groups. PRA and plasma renin concentration (PRC) were significantly increased in the phlorhizin group. In the alloxan group, PRA was decreased and angiotensin II sensitivity increased, both significantly. Plasma renin substrate (PRS) remained adequate in each group. These results suggest that the decreased PRA in alloxan-induced diabetes is due neither to factors associated with the glucose osmotic diuresis including changes in renal tubular sodium not to decreased PRS.

Steroid priming of the luteinizing hormone response to luteinizing hormone releasing hormone

Perifusion experiments were performed to study the stimulatory effects of luteinizing hormone releasing hormone (LH-RH) on the release of LH from anterior pituitary tissue. Exposure of pituitary tissue from normal male rats to LH-RH (5 ng/ml for 5 min) induced a small release of LH; in tissue from ovariectomized rats receiving no pretreatment, the release was more than three times greater and in tissue from gonadectomized male or female rats pretreated with oestradiol benzoate and progesterone, the release was six times greater than that observed in normal rats. Further exposure of pituitary tissue from gonadectomized steroid-pretreated male and female rats to LH-RH (5 ng/ml) induced an increase in the level of LH even greater than that seen after the initial exposure (priming action of LH-RH); in tissue from ovariectomized rats receiving no pretreatment, less LH was released than after the first exposure to LH-RH and in tissue from normal male rats the response was unchanged.

Management of uremic pericarditis: a report of 11 patients with cardiac tamponade and a review of the literature

Uremic pericarditis remains a significant cause of morbidity and mortality in most hemodialysis programs. A review of the literature and out own experience show that uremic pericarditis should be vigorously treated when detected. Usually an increase in the dialysis program with regional heparinization is sufficient to control the pericarditis. When signs of pericardial effusion are manifested, patients often progress rapidly to cardiac tamponade. A surgical anterolateral pericardiectomy is the most satisfactory measure in controlling pericardial effusion and preventing fatal cardiac tamponade. Although these patients have severely impaired renal function, the operation can be performed safely with a low morbidity and mortality.

Pericardiectomy for uremic tamponade

Pericardial tamponade developed in 29 patients with uremia. The clinical presentation varied, some patients having no symptoms whereas others sustained circulatory collapse. Pericardial friction rub, elevated central venous pressure and a paradoxical pulse were the most common physical findings. Serial chest radiography and echocardiography were most useful procedures in confirming this diagnosis. Two patients were treated conservatively and died despite repeated pericardiocentesis. The remaining 27 patients underwent partial pericardiectomy. One patient died of cardiorespiratory failure and a second from brain damage related to cardiac arrest before pericardiectomy. The other 25 patients reported immediate relief of symptoms and no recurrence of pericarditis. Pericardiectomy is the treatment of choice in uremic pericardial tamponade.