Clinical and molecular profiling of AML patients with chromosome 7 or 7q deletions in the context of TP53 alterations and venetoclax treatment

Deletions in chromosome 7 (del(7)) or its long arm (del(7q)) constitute the most common adverse cytogenetic events in acute myeloid leukemia (AML). We retrospectively analyzed 243 treatment-naive patients with AML and del(7) (168/243; 69%) or del(7q) (75/243; 31%) who did not receive any myeloid-directed therapy prior to AML diagnosis. This is the largest comprehensive clinical and molecular analysis of AML patients with del(7) and del(7q). Our results show that relapse-free survival was significantly longer for AML patients with del(7q) compared to del(7), but the overall survival and remission duration were similar. TP53 mutations and del5/5q were the most frequent co-occurring mutations and cytogenetic abnormalities, and conferred worse outcomes in del(7) and del(7q) patients. Venetoclax-based treatments were associated with worse outcomes in TP53 mutated AML patients with del(7) or del(7q), as well as del(7) with TP53 wildtype status, requiring further investigation.

Partial trisomy 3p and partial monosomy 11q associated with atrial septal defect, cleft palate, and developmental delay: a case report

Unbalanced translocation involving both chromosome 3p duplication and 11q deletion in the same patient is extremely rare; only 1 live-born case was reported previously. This karyotype was also detected during prenatal diagnosis of 2 different pregnancies in a Taiwanese family which were both terminated. In all 3 cases, only standard karyotyping was done to detect the abnormal karyotypes. Here, we report a 4-year-old boy with cleft palate, atrial septal defect, and hypotonia with gross and fine motor delay. Oligonucleotide-based array comparative genomic hybridization showed copy number gain from 3pter to 3p24.2 (approximately 24.5 Mb) and copy number loss from 11q25 to 11qter (approximately 5.8 Mb). This de novo unbalanced translocation event involving a terminal 3p duplication and a terminal 11q deletion provides candidate genes for further investigation of dosage effect leading to the patient's multiple phenotypic abnormalities. Genotype-phenotype correlation is difficult to make in this case due to the large number of genes involved. However, the description of such cases together with precise gene-level mapping of chromosomal breakpoints will add to further refinement of candidate genes to be investigated for terminal imbalances in 3p and 11q when more similar cases are reported.

Natural history of trachomatous scarring in The Gambia: results of a 12-year longitudinal follow-up

PURPOSE

The sight-threatening complications of trachoma are trichiasis and corneal opacity, and these remain the world's most common cause of preventable blindness. The aim of the study was to investigate the rate of progression of trachomatous conjunctival scarring to trichiasis and corneal opacity and to investigate risk factors for such progression.

DESIGN

A 12-year, longitudinal study of the incidence and risk factors for the development of trichiasis and corneal opacity in a cohort of patients initially identified with trachomatous scarring in The Gambia.

PARTICIPANTS

Six hundred thirty-nine subjects with some degree of trachomatous scarring were identified from the 1986 survey, and attempts were made to trace all these subjects.

METHODS

Successfully traced subjects were interviewed, examined, and graded for trachoma.

MAIN OUTCOME MEASURES

(1) Twelve-year rates of progression. (2) Risk factors for progression of disease.

RESULTS

Three hundred twenty-six of six hundred thirty-nine (51%) subjects were traced and examined, 108 (17%) had died, and 205 (32%) were lost to follow-up. After 12 years, 6.4% (95% confidence interval [CI], 4.0-9.97) of scarred subjects had trichiasis develop, 5.96% (95% CI, 3.67-9.42) had corneal opacity develop, 16.51% (95% CI, 12.71-21.13) had visual impairment/blindness develop, and 2.5% (95% CI, 1.2-5.0) had corneal visual impairment/blindness develop. Mandinka ethnicity was a risk factor for trichiasis (odds ratio [OR], 4.3; 95% CI, 1.3-14.4), and trichiasis at baseline was a risk factor for corneal opacity (OR, 8.4; 95% CI, 1.8-39.2). History of lid surgery for trichiasis was associated with corneal opacity at follow-up (OR, 4.4; 95%CI, 1.4-14.0). Older age was a significant risk factor for development of trichiasis, corneal opacity, and visual loss (OR, 1.07; 95% CI, 1.01-1.12). Bilateral cataract was present in 40% of traced subjects and was associated with the incidence of visual impairment/blindness (OR, 9.4; 95%CI, 4.5-19.6)

CONCLUSIONS

This is the first study to demonstrate the link between trichiasis and future corneal opacity, and it provides the rationale for performing lid rotation surgery on patients with trichiasis who do not yet have corneal opacity. The association between corneal opacity at follow-up and previous surgery among trichiasis patients suggests late presentation as a problem. The planning of surgical services will be aided by the incidence figures generated by this study.

Comparison of deltamethrin tablet formulation with liquid deltamethrin and permethrin for bednet treatment in The Gambia

The study aim was to compare three formulations, tablet deltamethrin, liquid deltamethrin and liquid permethrin, for their impact on vector behaviour and persistence. Product acceptance, perceived side-effects and user's perceptions of effectiveness were also investigated. At the beginning of the 1998 rainy season, 255 nets in a Gambian village were dipped in one of the three insecticides. Chemical residue analysis immediately after dipping showed that the target doses were reached for the liquid insecticides, but tablet deltamethrin deposited significantly less. Insecticide persistence at 5 months, however, was highest for the tablet formulation. Susceptibility tests established that Anophelines in this area were sensitive to both insecticides. All three formulations appeared effective as very few live Anophelines, or other mosquitoes, were caught under the treated nets. This conclusion was supported by the bioassay data with both deltamethrin formulations giving over 90% mortality soon after dipping and at 3 months, and at 5 months 70.8 and 79.6% were obtained for deltametrin liquid and tablet, respectively. Permethrin appeared less effective at all times (72.4, 86.8, 59.0%). There were no serious side-effects reported by the villagers following dipping. All three treatments were perceived as effective by the majority (92%) of users and most (93%) wanted to use the insecticide again. Deltamethrin tablets thus appear as good as permethrin for treating bednets in The Gambia. In addition, a tablet formulation is considerable easier to pack and distribute.

Myelodysplasia syndrome and acute myeloid leukemia in patients with congenital neutropenia receiving G-CSF therapy

Granulocyte colony-stimulating factor (G-CSF) has had a major impact on management of "severe chronic neutropenia," a collective term referring to congenital, idiopathic, or cyclic neutropenia. Almost all patients respond to G-CSF with increased neutrophils, reduced infections, and improved survival. Some responders with congenital neutropenia have developed myelodysplastic syndrome and acute myeloblastic leukemia (MDS/AML), which raises the question of the role of G-CSF in pathogenesis. The Severe Chronic Neutropenia International Registry (SCNIR), Seattle, WA, has data on 696 neutropenic patients, including 352 patients with congenital neutropenia, treated with G-CSF from 1987 to present. Treatment and patient demographic data were analyzed. The 352 congenital patients were observed for a mean of 6 years (range, 0.1-11 years) while being treated. Of these patients, 31 developed MDS/AML, for a crude rate of malignant transformation of nearly 9%. None of the 344 patients with idiopathic or cyclic neutropenia developed MDS/AML. Transformation was associated with acquired marrow cytogenetic clonal changes: 18 patients developed a partial or complete loss of chromosome 7, and 9 patients manifested abnormalities of chromosome 21 (usually trisomy 21). For each yearly treatment interval, the annual rate of MDS/AML development was less than 2%. No significant relationships between age at onset of MDS/AML and patient gender, G-CSF dose, or treatment duration were found (P >.15). In addition to the 31 patients who developed MDS/AML, the SCNIR also has data on 9 additional neutropenic patients whose bone marrow studies show cytogenetic clonal changes but the patients are without transformation to MDS/AML. Although our data does not support a cause-and-effect relationship between development of MDS/AML and G-CSF therapy or other patient demographics, we cannot exclude a direct contribution of G-CSF in the pathogenesis of MDS/AML. This issue is unclear because MDS/AML was not seen in cyclic or idiopathic neutropenia. Improved survival of congenital neutropenia patients receiving G-CSF therapy may allow time for the expression of the leukemic predisposition that characterizes the natural history of these disorders. However, other factors related to G-CSF may also be operative in the setting of congenital neutropenia. (Blood. 2000;96:429-436)

The Gambian National Impregnated Bed Net Programme: evaluation of effectiveness by means of case-control studies

Two case-control studies, one on mortality and the other on malaria morbidity, were carried out in order to evaluate the impact of the Gambian National Insecticide Bed Net Programme during the second year of intervention and to explore the feasibility of such a study for the evaluation of programme effectiveness. For the mortality study, children 1-9 years old who died during the 1993 rainy season were matched by age and sex with 2 healthy controls from the same village. For the morbidity study, children 1-9 years old attending Fatoto or Jahalia Health Centres in The Gambia and who had fever and parasitaemia > or = 5000/microL were matched by age with a child attending the health centres without fever or parasitaemia. An additional healthy control was recruited from the case's village. No impact of insecticide-treated bed nets on mortality was detected and this was in keeping with the results obtained by prospective surveillance. A protective effect of insecticide-treated nets on malaria morbidity was detected when cases were compared with controls recruited at the health centres. However, this disappeared when cases were compared with controls recruited from the cases' villages. The mortality case-control study suggested that reducing the time between onset of disease and treatment may have an important impact on childhood mortality. In order to calculate programme cost-effectiveness, important for informed resource allocations to be made by health managers, it is essential to obtain evidence of effectiveness. This can be done by means of case-control studies, which are easier to carry out and require fewer resources than prospective surveillance. Nevertheless, it is necessary to be conscious of their pitfalls, particularly of the bias involved in the choice of cases and controls. The measurement of insecticide on the nets of the cases or controls is essential for such studies.

The impact of charging for insecticide on the Gambian National Impregnated Bednet Programme

During the second year of the Gambian National Impregnated Bednet Programme (NIBP) charges for insecticide ($0.50 per net) were introduced into the half of the primary health care villages in the country where insecticide have been provided free of charge the previous year. Free insecticide was provided in the remaining villages that had acted as controls during the previous year. In villages where insecticide was provided free, 77% of nets were treated with insecticide. In contrast, in villages where charges were made coverage was only 14%. During the first year of the NIBP, mortality in children was significantly lower in villages where insecticide was provided free than in the control villages. Introduction of a charge for insecticide into the first group of villages and the provision of free insecticide in the latter abolished this difference. The cash income of rural Gambians is very limited and payment of even $2-3 for insecticide treatment for all the bednets in a household represents a substantial outlay. Further education on the benefits of treatment of nets and/or the provision of cheaper insecticide will be required before the full benefits of this powerful new malaria control measure can be fully realised in the Gambia.

Ruptured aortic dissection into the left atrium which presented as congestive heart failure and was diagnosed by transoesophageal echocardiography

A 72 year old man was admitted with severe dyspnoea. Ten days before he had had intense thoracic pain with loss of consciousness that was followed by increased dyspnoea. A continuous murmur was heard in the precordial and the left infrascapular regions. Lung auscultation showed stasis over the lower half of both lungs. Transthoracic echocardiography showed a bicuspid aortic valve and a dissection of the proximal aorta, which was considerably enlarged. Transoesophageal echocardiography confirmed dissection of the proximal aorta and showed a communication from the false lumen of the aortic dissection to the left atrium; and colour flow Doppler showed a continuous shunt to the left atrium. After transoesophageal echocardiography the patient had emergency surgical repair, which was successful. He had no complications in the post-operative period.

[Prosthetic duplication of the ascending aorta]

A simple implantation technique for multiple bypass of the ascending aorta with cervico-encephalic and infradiaphragmatic targets is reported. A conduit made by termino-terminal suture of two bifurcated grafts is anastomosed latero-laterally to the ascending aorta. The procedure is easy to perform and provides a suitable trajectory to the grafts.

The protein CD63 is in platelet dense granules, is deficient in a patient with Hermansky-Pudlak syndrome, and appears identical to granulophysin

The levels and expression of the proteins CD63 and granulophysin in platelets from control and from a Hermansky-Pudlak syndrome subject (a condition characterized by dense granule and lysosomal deficiencies and the accumulation of ceroid-like material in reticuloendothelial cells) were examined. Immunofluorescence studies indicated that anti-CD63 and anti-granulophysin antibodies recognized similar numbers of granules; coapplication of antibodies did not identify more granules than the individual antibodies. Significantly fewer granules were recognized in Hermansky-Pudlak syndrome platelets than in control using either antibody. Immunoblotting studies demonstrated that anti-CD63 and anti-granulophysin antibodies apparently recognize the same protein, which was deficient in Hermansky-Pudlak platelets. Analysis by fluorescence-activated cell sorter (FACS) showed biphasic expression of CD63 and granulophysin after thrombin stimulation of control but not Hermansky-Pudlak platelets. Anti-CD63 effectively blocked detection of the protein by anti-granulophysin using immunofluorescence, ELISA, immunoblotting, and FACS analysis. Amino-terminal sequencing over the first 37 amino acids revealed that granulophysin was homologous to CD63, melanoma antigen ME491, and pltgp40. These results suggest that granulophysin and CD63 are possibly identical proteins. This is the first report of a protein present in platelet dense granules, lysosomes, and melanocytes, but deficient in a patient with Hermansky-Pudlak syndrome.

Diagnosis and management of catheter-related infected intracardiac thrombosis in premature infants

Infected right atrial thrombosis is an uncommon but severe complication of the use of central indwelling catheters in children. Massive thrombi around a right atrial catheter were seen in two critically ill premature infants after 3 weeks of parenteral nutrition. A catheter-related sepsis had previously occurred and had been treated by antibiotics. Subsequently, protracted thrombocytopenia, fluctuating hepatomegaly, and increasing respiratory distress were found in both cases. A right atrial mass was detected by 2 dimensional echocardiography. Cardiotomies for removal of the infected thrombus were performed with success in both cases. In one infant, weighing only 900 gm, surgical removal was accomplished with the aid of inflow stasis. Premature infants with catheter-related sepsis appear at greater risk for intracardiac thrombosis and should undergo echocardiography as part of their evaluation. Infected atrial thrombi can be safely removed by cardiotomy even in the very small premature infant.

Platelet dense granule membranes contain both granulophysin and P-selectin (GMP-140)

We recently reported the characterization of a platelet granule membrane protein of molecular weight (mol wt) 40,000 called granulophysin (Gerrard et al: Blood 77:101, 1991), identified by a monoclonal antibody (MoAb D545) raised to purified dense granule membranes. Using immunoelectron-microscopic techniques on frozen thin sections, this protein was localized in resting and thrombin-stimulated platelets. In resting platelets, labeled with antigranulophysin antibodies and immunogold probes, label was localized to the membranes of one or two clear granules per platelet thin section. D545 also labeled dense granules in permeabilized whole platelets and isolated dense granule preparations examined by whole-mount techniques. Expression of granulophysin on the platelet surface paralleled dense granule secretion as measured by 14C-serotonin release under conditions in which lysosomal granule release, as measured by beta-glucuronidase secretion, was less than 5%. After thrombin stimulation, both the surface-connected canalicular system and the plasma membrane were labeled, demonstrating redistribution of granulophysin associated with degranulation. Double labeling experiments with D545 and antibodies to the alpha-granule membrane protein, P-selectin, demonstrated labeling of both P-selectin and granulophysin on dense granule membranes. Distribution of both proteins on the plasma membrane after platelet stimulation was similar. The results demonstrate that granulophysin is localized to the dense granules of platelets and is redistributed to the plasma membrane after platelet activation.

Nonsurgical intervention in the resolution of acquired neonatal bronchial stenosis

A stricture of the right main bronchus developed in an 1100 gm premature (first delivered twin female) infant being mechanically ventilated for approximately 1 month. The stricture resolved with treatment consisting of three consecutive daily obturations with angiocatheters avoiding the use of a balloon inflation technique provoking a local dilation. The catheters were placed with a guide wire under fluoroscopic control. The clinical protocol advanced for the dilation of acquired bronchial stenosis was well tolerated by the patient. A 9-month clinical radiologic review confirmed normal pulmonary structures and functions. Catheter dilation is described as a new technique for treatment of bronchial stenosis in the very small infant.

Diaphragmatic pacing in the treatment of chronic respiratory insufficiency of quadriplegic patients

Following our experience with diaphragmatic pacing in 2 quadriplegic patients with bilateral diaphragmatic paralysis, we here present the indication for and the surgical technique of bilateral implantation of a diaphragmatic pacemaker. This mode of artificial ventilation appears to be superior to positive pressure ventilation for longterm ventilatory assistance of these patients.

Diagnostic and therapeutic value of thoracotomy in advanced pulmonary neoplasms

This study analyses retrospectively 100 consecutive thoracotomies performed for lung cancer before end 1986. Chest CT scan assessed mediastinal lymph node disease, chest wall invasion and mediastinal invasion, with an overall accuracy of 75, 93 and 91 per cent respectively; mediastinal lymph node disease was significantly more underestimated in the stage III group. Characteristics, type of surgical and adjuvant therapy and follow-up were analysed in the T3 (16 patients) and the N2 (18 patients) group. Complete resection was possible in only a minority of the cases: 3 in the T3 group and one in the N2 group. Of the T3 group, 3 patients have survived more than 3 years and 3 are actually still alive. Of the N2 group, only 2 patients are still alive. Most deaths were due to generalization of the disease.

A patient with two chronic posttraumatic aneurysms of the thoracic aorta

A case of successful replacement of two coexistent chronic post-traumatic aneurysms of the thoracic aorta is presented. Presumably, these aneurysms at the aortic isthmus and the descending thoracic aorta resulted from two different deceleration traumas.

Muscular fibrosis due to chronic intramuscular administration of narcotic analgesics

Chronic intramuscular injections, particularly of narcotic analgesics, are an uncommon cause of myopathy. We report two patients with pentazocine- and meperidine-related myopathy. Narcotic-induced muscular fibrosis and contractures must be considered in patients with a pattern of muscle involvement that does not conform to any recognized myopathy, but allows for self-administration of injections. Trauma due to needle puncture, repetitive infections and a local myotoxic effect of the drugs probably contribute to these lesions.

Posttraumatic rupture of the thoracic aorta

Ten patients with traumatic lesions of the thoracic aorta were seen in a hospital. Most were victims of traffic accidents and presented severe associated lesions along with their vascular trauma. We found that the vascular injuries were clinically manifest in only a minority of patients. The remaining ruptures were discovered through CT-scanning of the mediastinum or angiography. We believe that in every major trauma victim aortic lesions should be actively sought for by complimentary examinations to guarantee maximum survival of the patients.

Comparison of auscultation, continuous wave Doppler imaging, intravenous digital subtraction angiography and conventional angiography in diagnosis of carotid artery disease

The reliability of auscultation, continuous wave (CW) Doppler imaging, and intravenous digital subtraction angiography (IV DSA) in the assessment of carotid artery disease has been evaluated in comparison with conventional angiography in 30 patients. With auscultation, specificity and sensitivity for internal carotid artery (ICA) stenosis of 50% or more were 81% and 67% respectively. CW Doppler imaging detected ICA stenosis of 50% or more with a sensitivity of 83% and a specificity of 92% and ICA occlusion with a sensitivity of 60%. The specificity of IV DSA was 95% and the sensitivity for ICA stenosis of 50% or more and ICA occlusion were 75% and 100% respectively. Combining CW Doppler and IV DSA findings raised sensitivity for ICA stenosis of 50% or more and ICA occlusion to 89% and 100% respectively and specificity to 95%. The combination of CW Doppler and IV DSA is a safe and accurate test battery in the detection and categorization of carotid disease.

Transaxillary thoracotomy for treatment of spontaneous pneumothorax

This study reports the retrospective analysis of operative treatment of 20 cases of spontaneous pneumothorax during the last 4 years. Surgical indications included recurrence, recollapse of the lung on clamping the chest tube, nonexpansion of the lung despite adequate drainage or persistent air leak, and giant bulla. A transaxillary thoracotomy was used in all cases to treat sites of air leak and subpleural blebs by resection (14 cases) or oversutering (4 cases) combined with pleural abrasion (19 cases) or apical pleurectomy (1 case). This approach has met with excellent results without major morbidity or mortality.

Repair of pericardial rupture by abdominal transphrenic approach solely

The abdominal transphrenic approach enabled us to repair a left lateral pericardial rupture on a polytrauma patient who also had a rupture of the spleen and a retroperitoneal hemorrhage. A pericardial exploration was necessary because of a sudden upper venous congestion syndrome during operation, suggestive of a cardiac tamponade.

Posterior mediastinal sarcoidosis

We report two cases of enlargement of the posterior mediastinal lymph nodes due to sarcoidosis. Bilateral hilar enlargement, pulmonary parenchymal involvement, or extrathoracic manifestations of sarcoidosis were absent. A diagnostic thoracotomy had to be performed in both instances.

Femorofemoral bypass grafting in high-risk patients

A total of 37 extra-anatomic femorofemoral bypasses were inserted for severe unilateral iliac artery stenosis or a thrombosed graft limb of an aorto-bifemoral bifurcation graft. All patients were severely debilitated and at high risk for direct aorto-iliac reconstruction. 30% suffered severe claudication; 70% had ischemic restpain or trophic lesions. 43% died during a mean follow-up period of 17 months. This study demonstrates that the extra-anatomic femoro-femoral bypass procedure is an effective alternative therapeutic modality for high-risk patients with an acceptable operative mortality (5.4%) and morbidity to improve the quality of life.

Fibromuscular dysplasia of the internal carotid artery

An observation on symptomatic fibromuscular dysplasia of the internal carotid artery, surgically treated by graduated internal dilatation is presented. Fibromuscular dysplasia is a segmental, nonatheromatous disease of small to medium-sized arteries, affecting mainly renal arteries. Involvement of the internal carotid artery is often an incidental angiographic finding in asymptomatic patients, but can be associated with specific neurologic symptoms requiring surgical treatment. The histopathologic character, the pathogenesis, the clinical manifestation, the diagnosis and the therapeutic possibilities of this affection are discussed.

Recurrent pulmonary embolism: importance, diagnosis, management and prevention

Pulmonary emboli, even small, cause irreparable lung damage. Recurrent pulmonary emboli further increase the amount of non functional lung tissue and may result in incapacitating respiratory disease or death. It is therefore mandatory that the disease be correctly diagnosed and adequately treated. As prevention is better than cure, every patient presenting with clinical signs of deep venous thrombosis (DVT) should be correctly explored. The site and size of thrombosis must be visualized preferably with contrast venography with imaging of the veins of the limbs, iliac veins and vena cava. Risk factors such as obesity, immobilization etc. must be taken into account. Underlying disease such as heart disease and venous insufficiency must be treated. Malignancy must be looked for as in a recent series of patients with primary DVT which were studied, 15% presented with an up till then unknown malignant disease. In patients presenting with recurrent DVT this percentage rose to 20%. When a patient presents with DVT of the femoro-iliac vena cava axis, aggressive treatment must be adopted. Fibrinolysis or if this is contra-indicated, thrombectomy will be used. A vena cava filter may be necessary and longterm anticoagulation is mandatory. The same rationale is applicable in cases of pulmonary embolus whether it is a primary event or a recurrence.

Small artery syndrome in women

During the past four years, 106 women underwent aortography and peripheral runoff studies for peripheral vascular disease. Eleven patients presented with "small vessels" and were selected for this study. They were significantly younger than the rest of the group (a mean age of 52 versus 66 years). A clear history of claudication was elicited in all patients. Rest pain was present in four patients. Most patients were small in stature but not obese. Weak or absent femoral and distal pulses and abdominal or femoral bruits were common. Angiography demonstrated a narrow infrarenal aorta, narrow iliac and common femoral arteries and a straight course of iliac arteries. Atherosclerotic lesions involved mainly the aortoiliac segment, but were confined to the superficial femoral artery in two patients. Reconstruction was achieved by endarterectomy or transluminal angioplasty in segmental aortoiliac disease and aortobifemoral or aortobi-iliac graft in diffuse disease. Femorpopliteal or iliopopliteal graft or lumbar sympathectomy was performed in patients with significant femoral disease. In one patient, an acutely occluded femoral segment was replaced by a venous interposition graft. Two patients were treated conservatively. There were no operative deaths. Nine patients were markedly improved at follow-up examination. Graft thrombosis occurred in one patient with combined aortobi-iliac and iliopopliteal graft. The high incidence of single bifurcating lumbar arteries at the fourth and fifth lumbar vertebrae supports the hypothesis that aortic hypoplasia may result from embryonic overfusion of the dorsal aortas. Lipid abnormalities existed in 54 per cent of the patients. All women were heavy smokers and 73 per cent had a positive family history of cardiovascular disease.

[Systematic research on an etiology in apparently primary deep venous thrombosis. Apropos of 59 cases]

Primary deep vein thrombosis was confirmed by phlebography in 59 cases between Jan. 1981 and Jan. 1984 in the department of Cardiovascular Surgery of the Academic Hospital of the V.U.B. Brussels. Investigations conducted in all patients included blood and urine analyses, chest radiography, electrocardiogram, gynecologic or urologic examinations and abdominal and pelvic ultrasound imaging. Findings demonstrated one or more risk factors in 92% of cases, the principal ones being obesity, a history of thromboemboli and, in women, the use of oral contraceptives. Nine patients had cancer and 4 of these received combined surgery-chemotherapy. All cases of so-called primary deep vein thrombosis should be investigated routinely for risk factors, because of the need and possibilities for treatment in some of them, particularly since procedures are non-invasive, of low cost, and easily performed during initial heparin therapy.

Surgical management of spontaneous pneumothorax

Spontaneous pneumothorax is a common surgical problem. Although the general principles of drainage of the pleural space and of prevention of recurrence seem well known, the literature shows differences in success rates concerning the treatment of a first pneumothorax and of the eventual recurrences. This is probably due to some technical factors and different views on the therapeutical strategy. In this retrospective review of 62 patients with spontaneous pneumothorax, 8 were treated by bed rest for their not enlarging and less than 20% pneumothorax, and 54 were treated by closed chest tube thoracostomy with an early success rate of 93.5% at the first admission. The simultaneous use of scarifying agents and closed chest drainage appears useful for the treatment of immediate or first recurrence. Sixteen patients were readmitted later for ipsilateral recurrence. According to the magnitude of their pneumothorax, they were treated by bed rest or tube thoracostomy with scarifying agents. Four of these patients needed thoracotomy with oversuturing of subpleural blebs and pleurodesis. The total thoracotomy rate of the initial patient population was 12.9% after an average follow up period of 24.8 months.

Disposition of and clinical response to salicylates in patients with rheumatoid disease

The disposition of salicylic acid (SA) and its metabolites and the clinical response to long-term aspirin treatment at varying doses were assessed in patients with rheumatoid disease. Steady-state kinetics of SA (total and unbound), salicyluric acid (SUA), gentisic acid (GA), and clinical status were estimated weekly in 10 patients with rheumatoid arthritis. Eight received a soluble aspirin form and two received an enteric-coated form. The starting dose of aspirin in each patient was 1.8 gm (soluble) or 1.95 gm (enteric-coated) daily. Weekly increments in dose were made until a satisfactory clinical outcome was achieved. The final aspirin dose range was 3.6 to 8.1 gm daily, which resulted in mean steady-state plasma SA concentrations (CpSA) from 56 to 375 mg/l. Since the mean total CpSA increased approximately proportionately over the dose range, there was little change in total SA clearance. By contrast, increasing aspirin dosage resulted in decreased clearance and disproportionate increases in unbound SA (CpuSA). The maximum velocity of conversion of SA to SUA (Vm) increased significantly, from 57.3 +/- 11.7 mg/hr at an aspirin dose of 1.8 gm/day to 71.4 +/- 19.4 mg/hr at the next highest dose (2.7 to 3.6 gm/day), with no further change with increasing dosage. Km ranged from 0.4 to 1.2 mg/l for CpuSA and from 5.5 to 17.2 for total CpSA. Renal clearance of SUA (ClSUA) ranged from 124 to 893 ml/min and correlated with creatinine clearance. ClGA ranged from 23 to 164 ml/min, and ClSA ranged from 0.1 to 17.1 ml/min; neither correlated with creatinine clearance.(ABSTRACT TRUNCATED AT 250 WORDS)

[Endarterectomy of the superficial femoral artery using an oscillating loop]

A short series of half closed endarterectomies of superficial femoral artery with oscillating ringstripper is presented. The technique used is described, and major problems are discussed. Results are published and confrontated with the clinical events. Three criteria are withheld for indication of this procedure: the superficial femoral artery has to be completely occluded and not calcifiated; the popliteal artery has to be angiographically normal; two out of three arteries below knee have to be permeable. The authors advocate oral anticoagulation for a relatively long postoperative period.

[Myxomas of the right atrium. Apropos of 3 cases. Review of the literature]

The authors report 3 cases of right atrial myxoma and review 88 other cases in the literature managed by surgery. The first personal case, in a 74 year old patient, illustrate the dramatic consequences of tumour engagement in the tricuspid orifice, in this instance cardiac arrest during catheterisation justifying emergency surgery. The second case exemplifies the diagnostic value of echocardiography: the correction of an erroneous diagnosis of pericarditis. The third case shows that some forms may be totally asymptomatic, the tumor being diagnosed on clinical examination and confirmed by echocardiography. In their review of the literature, the low overall incidence of primary cardiac tumours, of which myxoma is the most common, is emphasised. A right atrial localisation is found in only 25% cases. 88 surgical reports have been published since Bahnam's original attempt at surgical cure under cardiopulmonary bypass. Myxoma may occur at any age but it usually presents between the ages of 30 and 60. Some familial forms have been reported. The presenting symptoms are protean but usually point to an obstacle in the right heart chambers. They may be summarized as follows: 1. Isolated right ventricular failure without left heart disease may be observed in large tumours (reported in 50% of cases). 2. Simulating pericarditis (25% of cases) with a low grade pyrexia (25% of cases). 3. Paroxysmas of cardio respiratory distress of variable severity (a few cases). Clinical examination, chest x-ray and ECG are not diagnostic but do show non-specific changes which are of value in drawing attention to the heart and leading to echocardiography. This confirms the diagnosis by showing abnormal mobile echos in the right atrium prolapsing into the right ventricle in diastole. Angiography serves only to confirm these appearances. Surgery is the treatment of choice, and preferably with the shortest possible delay. It offers definitive cure at a minimal risk to the patient.

Complete replacement of the ascending aorta with reimplantation of the coronary arteries: new surgical approach

Thirty patients had total replacement of the ascending aorta with reimplantation of the coronary arteries, 20 for a fusiform aneurysm of the ascending aorta and 10 because of a dissection of the ascending aorta, of which there were acute. All had associated aortic insufficiency. The technique consists of implantation, within the aneurysmal sac, of a Dacron prosthesis containing a Björk-Shiley aortic valve. The coronary orifices are anastomosed to the tubular Dacron prosthesis by means of a second smaller Dacron tube. The aneurysmal pouch is then closed over the entire appliance and a fistula between the aneurysmal sac and the right atrial appendage is created to drain oozing from the prosthesis. The operative mortality was 10% (three deaths) and the late mortality has been 14.8% (four deaths). The deaths, early and late, have been confined to the first 10 cases, during which time the technique was being developed. There has been no mortality among the last 20 patients. The 23 survivors followed for an average of 19 1/2 months (range 6 months to 5 1/2 years) are in NYHA Functional Class I (21) or II (two). The technical modifications utilized in this series have simplified the operation and permit the proposal of this technique for aneurysm involving the entire ascending aorta.

[Coronary endarterectomy associated with coronary artery bypass in severe coronary artery disease. 50 cases]

The surgical indications of coronary endarterectomy were defined from a study of 50 cases in which endarterectomy was associated with aorto-coronary bypass surgery. This total represented 6 p. 100 of all the aorto-coronary bypass operations performed in the same period. Coronary endarterectomy was performed "on principal" for the right coronary artery, and "of necessity" for the left anterior descending artery. The special techniques of endarterectomy on the left anterior descending artery are described. Endarterectomy does not increase the operative risk and enables revascularisation of vessels unsuitable for bypass surgery. 85 p. 100 patients are asymptomatic with an average follow up period of 2 years after endarterectomy and aorto-coronary bypass graft of the right coronary artery.

The prevention of myocardial ischaemia by the method of profound selective myocardial hypothermia during open heart surgery

A new method of myocardial protection, profound selective myocardial hypothermia has been employed in order to avoid the effects of cardiac ischaemia during aortic cross clamping in the course of operations undertaken under extracorporeal circulation. It consists of the irrigation of the aortic root immediately after cross clamping with 4 liters of Ringer Lactate at 4 degrees C which perfuses the entire coronary bed and induces complete uniform profound coling of the intrapericardial mass to a temperature of approximately 10 degrees C with resultant flat electrocardiogram and cessation of all electrical activity of the myocardium. This inactivity remains complete until the aorta is unclamped permitting reoxygenation and rewarming of the heart with resumption of its function. This method has been used in the course of 250 cardiac procedures involving the use of extracorporal circulation including 177 valve replacements, either aortic or mitral and aortic, 54 saphenous vein bypass procedures, either simple or with valve replacement and 19 other assorted procedures including cardiac transplantation and complex congenital malformations. Thermal, electrocardiographic, hemodynamic, histologic, histochemical and enzymatic observations have proven the minimal significance of the ischemic lesions produced in hearts protected in this manner. The total mortality was 6.4% which proves the value of this method and its superiority over the 2 techniques most often used at the present time, coronary perfusion or topical myocardial hypothermia according to Shumway's method.

[Mitral valve insufficiency due to ballooning. A surgical series of 70 cases]

The authors report 70 cases of mitral regurgitation due to ballooning. For the surgeon this is the most frequent cause of degenerative mitral regurgitation in patients around 60-years-old. The aetiology still remains unknown. There are two opposing theories--the congenital and the acquired. The appearances at operation are characteristic--a localised or diffuse ballooning of one or both cusps with elongation of the chordae attached to the ballooned portion. Two histological features are noted--myxomatous degeneration of the cusp and the absence of any inflammatory process. Ballooning may be asymptomatic and bening for a long time before evolving progressively or suddenly into important mitral regurgitation. The pre-operative diagnosis is aided by left ventricular angiography and echocardiography. Surgical treatment, guided by the findings at operation, usually involves mitral valve replacement or, less frequently, mitral valve repair.

[Deep selective myocardial hypothermia (author's transl)]

This new method of myocardial protection was used to prevent complications of cardiac ischaemia during clamping of the aorta. 4 litres of Ringer lactate at 4 degrees C are used to perfuse the coronary arteries and produce a total, uniform and deep fall of all the pericardial and myocardial system. This results in a flat electrocardiogram, i.e. the interruption of electrical activity of the cardiac cells. This effect persists until the aortic clamp is released which results in reoxygenation, a rise in temperature and the restoration of function. The method has been used in more than 250 operations with extracorporeal circulation (valves, bypass procedures, transplants). Up until the present, it has proved superior to techniques of coronary perfusion or hypothermia obtained using Shumway's technique.

[Aneurysms of the ascending aorta; total replacement with reimplantation of the coronary arteries (author's transl)]

The replacement of the entire aorta and the aortic valve is the procedure of choice in aneurysms involving the aortic annulus. This method, which necessitate the reimplantation of the coronary arteries, is, however, sometimes difficult and carries a greater operative risk of bleeding problems. Our experience of 15 such cases lead us to propose some modifications (such the use of an independent coronary conduit and the atrial drainage of the peri prosthetic space) in order to make the operation simple and safer.