Prominence of Terahertz Acoustic Surface Plasmon Excitation in Gas-Surface Interaction with Metals

The current understanding of the dynamics of gas-surface interactions is that all of the energy lost in the collision is transferred to vibrations of the target. Electronic excitations were shown to play a marginal role except for cases in which the impinging particles have energies of several electronvolts. Here we show that this picture does not hold for metal surfaces supporting acoustic surface plasmons. Such loss, dressed with a vibronic structure, is shown to make up a prominent energy transfer route down to the terahertz region for Ne atoms scattering off Cu(111) and is expected to dominate for most metals. This mechanism determines, e.g., the drag force acting on telecommunication satellites, which are typically gold-plated to reduce overheating by sunshine. The electronic excitations can be unambiguously discerned from the vibrational ones under mild hyperthermal impact conditions.

Conservative Surgical Approach for Reduction of Macrocheilitis Caused by Massive Injection of Liquid Silicone

Cosmetic lip augmentation, regardless of the filling agent, is nowadays one of the most requested aesthetic procedures. Liquid silicone injections were used in the past, but after reports of severe late complications their use has been discontinued, ending with a permanent ban in most western countries. In this report we describe clinical presentation, diagnostic pathways and surgical reconstruction of six patients presenting with macrocheilia due to previous liquid silicone augmentation. Patients showed chronic inflammation of the lower third of the face, lip eversion, various degrees of asymmetry and functional impairment of the lips. All patients underwent preoperative soft tissue High Frequency Ultrasound (HFUS) and Magnetic Resonance Imaging (MRI) of the of the face to obtain evidence of the filler material and to ascertain its diffusion within the soft tissues of the perioral region. Conservative surgery was carried out to remove foreign material and to restore symmetric aesthetically pleasing lips. Histology confirmed the siliconoma diagnosis. HFUS and RMI allowed to clearly identify the silicone within the soft tissues. The conservative surgery restored the harmonious relationship between the lips, with an improvement in lip functionality at long term follow-up. Healing was complete and uneventful in all of the patients.

A survey on knowledge and perceptions regarding head lice on a sample of teachers and students in primary schools of north and south of Italy

High rates of pediculosis are found in every part of the world. The age-range most affected is between 3 and 12 years. No-nit policies are ineffective in preventing infestations. On the other hand, misdiagnosis and overuse of pediculicides, increase resistance to treatment. Lack of information leads people to consider this kind of infestation to be associated to low social classes and immigrants. This research has been implemented to find out about the information level on pediculosis on a sample of students (722) and teachers (408) of some primary schools in northern and southern Italy, and to highlight the role of personal aspects such as age, gender, cultural level, geographical position which may influence this topic and, eventually, allow the use of the correct knowledge in developing appropriate procedures within the school district. Data was obtained through a questionnaire containing 21 multiple choice questions for the teachers and 14 for the students. Standard descriptive statistics were computed. chi2 tests were applied to highlight statistical association among observed variables; test for the difference of two proportions were applied to confirm significant differences among the observed proportions. The level of information for students seems to be, approximately, the same both for northern and southern Italy. There was a slight prevalence of correct answers from southern teachers, probably because the phenomenon of pediculosis has a positive trend of growth in the south. The number of correct answers was, for all, on average about 60.0%; a negative result in itself considering the simplicity of the questions. Knowledge about the biology of the louse was virtually absent. The area of prevention showed lack of information and need for improvement. Most of the teachers believe that there are specific products that can prevent infestation by louse. Most of the teachers have information which does not come from scientific sources. Students receive some short and incomplete information from their parents. Deficiencies in teachers' knowledge indicate that they are inadequately equipped to manage lice infestation. Educational interventions with teachers and families and, as a consequence, with students should be taught at school to allow a correct understanding of the pediculosis, increasing the teachers' competence and, consequently, as soon as the infestation should manifest, a rapid alert of the Health Service so that proper treatment could be provided.

Microbial community structure and dynamics in the largest natural French lake (Lake Bourget)

We investigated the dynamics and diversity of heterotrophic bacteria, autotrophic and heterotrophic flagellates, and ciliates from March to July 2002 in the surface waters (0-50 m) of Lake Bourget. The heterotrophic bacteria consisted mainly of "small" cocci, but filaments (>2 microm), commonly considered to be grazing-resistant forms under increased nanoflagellate grazing, were also detected. These elongated cells mainly belonged to the Cytophaga-Flavobacterium (CF) cluster, and were most abundant during spring and early summer, when mixotrophic or heterotrophic flagellates were the main bacterial predators. The CF group strongly dominated fluorescent in situ hybridization-detected cells from March to June, whereas clear changes were observed in early summer when Beta-proteobacteria and Alpha-proteobacteria increased concomitantly with maximal protist grazing pressures. The analysis of protist community structure revealed that the flagellates consisted mainly of cryptomonad forms. The dynamics of Cryptomonas sp. and Dinobryon sp. suggested the potential importance of mixotrophs as consumers of bacteria. This point was verified by an experimental approach based on fluorescent microbeads to assess the potential grazing impact of all protist taxa in the epilimnion. From the results, three distinct periods in the functioning of the epilimnetic microbial loop were identified. In early spring, mixotrophic and heterotrophic flagellates constituted the main bacterivores, and were regulated by the availability of their resources mainly during April (phase 1). Once the "clear water phase" was established, the predation pressure of metazooplankton represented a strong top-down force on all microbial compartments. During this period only mixotrophic flagellates occasionally exerted a significant bacterivory pressure (phase 2). Finally, the early summer was characterized by the highest protozoan grazing impact and by a rapid shift in the carbon pathway transfer, with a fast change-over of the main predators contribution, i.e., mixotrophic, heterotrophic flagellates and ciliates in bacterial mortality. The high abundance of ciliates during this period was consistent with the high densities of resources (heterotrophic nanoflagellates, algae, bacteria) in deep layers containing the most chlorophyll. Bacteria, as ciliates, responded clearly to increasing phytoplankton abundance, and although bacterial grazing impact could vary largely, bacterial abundance seemed to be primarily bottom-up regulated (phase 3).

An endogastric capsule for measuring tumor markers in gastric juice: an evaluation of the safety and efficacy of a new diagnostic tool

BACKGROUND

In gastric juice, high levels of the carcinoembryonic antigen (CEA) and the carbohydrate antigen 19-9 (CA 19-9) have been found to correlate with precancerous lesions and gastric cancer. So far, sampling of gastric juice has required upper endoscopy. In place of this invasive procedure, we investigated a new tool for the quantitation of tumor markers in gastric juice.

MATERIALS AND METHODS

The study population consisted of healthy controls and consecutive subjects with suspected gastric cancer or dyspepsia/epigastric distress. Patients were asked to swallow a small gelatine capsule (14 mm in length and 5 mm in diameter) containing a pierced plastic cover and surrounding a piece of absorbent paper. The capsule was left in the gastric cavity for 60 min to allow saturation of the absorbent paper with gastric juice. A 45-50 cm length of nylon thread connected to the inner capsule was used to remove the device from the gastric cavity. After processing the absorbent paper for radioimmunoassay, CEA and CA 19-9 levels were correlated to the findings of upper endoscopy and biopsies of gastric mucosa or suspected lesions.

RESULTS

The endogastric capsule did not cause any side-effects and 62 participants were fully compliant to the procedure. Assessable gastric juice samples were taken from 23 patients with gastric cancer, 15 patients with intestinal metaplasia or dysplasia, 12 patients with gastritis and 12 controls without gastric diseases. In the 12 samples of gastric juice from control patients, mean values of CEA and CA 19-9 were 1.1 +/- 0.9 ng/ml and 16 +/- 7.5 ng/ml, respectively. The mean levels of both markers were found to increase according to the severity of gastric lesions and in patients with cancer, mean CEA and CA 19-9 levels were 513 +/- 627 ng/ml and 545 +/- 510 ng/ml, respectively. Patients with precancerous lesions and cancer showed higher levels of CEA and CA 19-9 than patients with normal findings or gastritis (P <0.001).

CONCLUSIONS

The endogastric capsule is a simple, non-invasive tool for the measurement of CEA and CA 19-9 levels in gastric juice. These values may discriminate between normal or minor pathologic changes and precancerous lesions or carcinomas. Further investigations are warranted, since this may represent a new method for gastric cancer screening.

Microsurgical reconstruction of wide simple and compound foot defects

BACKGROUND

A mutilated foot as a result of traumas or resection for tumours or ulcers, is a serious physical and social handicap for the patient, because it impairs deambulation and affects his selfgovernment. The evolution of microsurgical techniques has allowed us to utilize such methods to reconstruct wide simple and composite losses of substance of the foot, usually treated conservatively or radically with amputation and prosthesization. Functional, cosmetic and social outcome has been evaluated.

METHODS

We evaluated 23 patients affected by cutaneous (19) and osteocutaneous (4) losses of substance of the foot (11 of rearfoot, 5 of forefoot, 4 of the sole, 1 of middlefoot, 1 of the dorsum, and 1 of the malleolus). We performed 23 microsurgical reconstructions harvesting 24 free flaps (14 radial flaps, 4 latissimus dorsi, 3 fibula, 1 scapular flap, 1 lateral arm, 1 iliac crest).

RESULTS

Cutaneous and muscular flaps healed in 3 weeks, while osteocutaneous flaps healed in 10 to 12 weeks. Deambulation was restored in all patients but 1, within 6 months from surgery, and all patients went back to their work and social life. We observed in the early follow-up 2 cases of partial skin necrosis, which solved spontaneously and 1 case of total necrosis (overall complication = 4.3%). Donor area morbidity was rated as fair. Overall success rate was 95.7% at a mean follow-up of 3 years.

CONCLUSIONS

Free microsurgical transfers allowed us to obtain a satisfactory and long-lasting morpho-functional restoration of wide superficial and deep losses of substance of the foot, guaranteeing the patient a fast psycho-physical and social rehabilitation.

Correction of hypospadias with a vertical preputial island flap: the Göteborg experience of 47 patients

We report the follow-up of 47 patients with penile hypospadias who were treated by the Scuderi procedure between 1988 and 1998 at Sahlgrenska University Hospital, Göteborg, Sweden. Forty of the patients (85%) had had no previous operations, while the remaining seven had had meatotomy with chordectomy only, or an unsuccessful Dennis-Browne procedure. Hypospadias was distal in 35 (74%), mediopenile in 8 (17%), and proximal in 4 (9%); 21 (45%) showed signs of curvature. After a Scuderi urethroplasty one patient developed a fistula (2%) and 4 developed mild stenosis. The early success rate was therefore 42/47 (89%) and this later increased to 46/47 (98%) after non-surgical treatment of the stenoses. The results support the use of the Scuderi procedure for correction of primary and secondary penile hypospadias with a low complication rate.

[Simultaneous bilateral pneumothorax. Case report]

A case report of a 44 year-old white man admitted to the surgical unit for a bilateral simultaneous pneumothorax is presented. The pneumothorax occurred on day one after a surgical operation for discal hernia; in the past the patient already presented a right spontaneous pneumothorax at 32 years of age and a left pneumothorax at 37 years of age, both treated with a pleural drainage. A thoracic drain was bilaterally positioned with a good result only in the right side. The persistence of the left pneumothorax induced the authors to perform a postero-lateral thoracotomy bullae excision and pleurectomy with a good postoperative course. After a few months a new right pneumothorax occurred and the patient was treated with a right postero-lateral thoracotomy, bullae resection and pleurectomy. On the basis of the case reported, the authors consider the different opportunities in the treatment of spontaneous pneumothorax in relation to the present knowledges and technologies. Surgical procedure is to be preferred in case of persistence of pneumothorax despite a pleural drain and in case of pneumothorax in high risk subjects. Even if thoracoscopy seems to give better results regarding postoperative pain, it is not always possible with such a method to perform a careful pleurectomy neither to obtain it in all cases (above all in secondary pneumothorax). Every case must then be carefully studied to choose the best treatment at present available.

Comparative evaluation of traditional, ultrasonic, and pneumatic assisted lipoplasty: analysis of local and systemic effects, efficacy, and costs of these methods

Recently ultrasound assisted liposuction (UAL) and pneumatic assisted liposuction (PAL) have been introduced as an attempt to improve the results and reduce the pitfalls of standard liposuction (SAL). Until now no studies comparing, at the same time, UAL, PAL, and SAL have been published. The aim of this study was to analyze these methods from the surgeon's point of view, focusing not only on aesthetic results but also on local and systemic trauma, efficacy, handling, and cost. Forty-five cosmetic patients affected by local lipodystrophy, divided into three equal groups, have undergone liposuction with the three above-mentioned techniques. Quantitative and qualitative analysis of lipoaspirates, together with blood chemistry, local and systemic complications, time to aspirate 100 cm3, distress, fatigue, and costs of the procedures, has been recorded. Our results showed bloodier lipoaspirates in SAL and a higher percentage of triglycerides in UAL lipoaspirates. Blood tests revealed a slight decrease in the postoperative Hb in SAL only. Early complications observed were four erythemas in PAL, three ecchymoses in SAL, and one long-lasting edema in UAL. Aesthetic results rated by independent viewers were similar for all methods. Efficacy was higher in the PAL group (4 min x 100 cm3 fat aspirated) than in SAL (7 min x 100 cm3 fat) and UAL (10 min x 100 cm3 fat). Surgeon's distress was higher in PAL than in SAL and UAL. Surgeon's fatigue was much lower in the PAL group than in the others. Costs expressed as multiples of 1 unit (1 unit = $500 U.S.) were highest for UAL, low for PAL, and lowest for SAL. In conclusion, PAL and UAL caused reduced vascular injury, UAL being more selective for adipocyte removal. Complications of UAL and PAL were mostly related to the longer learning curve of these methods. The UAL procedure was much more expensive than PAL and, especially, SAL. PAL proved to be a handy technique, with the most favorable cost/benefit ratio, and seems to be the best option for busy liposuction practices or fast office procedures, even though the choice of the ideal technique always depends on the surgeon's preference.

[Surgery of large ventral hernias. Personal experience in 1990-1997]

BACKGROUND

The surgical treatment of large wall defects conventionally defined as an extension over 10 cm is discussed. The difficulty to contain the bowels that have lost law of domicile in the abdominal hollow, constitutes motive for notable increase of the endo-abdominal Pressure with serious consequences in the postoperative course and this leads to the use of prothesis meshes that allow the closing of the abdominal hollow with the Tension-Free technique.

METHODS

Personal experience embraces 45 patients, with large wall defects, divided into 21 patients with overumbilical location, 14 with umbilical location, 10 with periumbelical location; a simple suture has been used in 7 cases, the reconstruction of the wall according to Stoppa in 36 cases and the apposition of Goretex net internally and Marlex net externally in 2 cases.

RESULTS

There have been neither mortality, neither recidivists of illness, but only some complications: 9 cases of superficial infection, 1 case of intestinal occlusion and 2 of subcutaneous seroma.

CONCLUSIONS

According to their experience and wide literature review, the authors draw some conclusions: an accurate toilet and a careful evaluation of the respiratory functionality are fundamental; it's necessary to postpone surgical intervention in presence of local inflammation and, where this is improrogable it's opportune to avoid the use of prothesis meshes or refold on readsorbible prothesis; special care must be taken to the hemostasis and an aspirative drain for 24-48 hrs preserves from the risk of postoperative hematomas and following local infections. The submuscular mesh permits a Tension-Free suture and for this reason it would have nowdays a more extensive use. Finally it's pointed out the choice of a PTFEe mesh in contact with the intestinal skein.

Assessment of CABG-related risk in patients with CAD and LVD. Contribution of PET with [18F]FDG to the assessment of myocardial viability

BACKGROUND

Previous studies have demonstrated that hibernating myocardium can be assessed by [18F]fluorodeoxyglucose ([18F]FDG) and positron emission tomography (PET). This study evaluated the use of [18F]FDG-PET for CABG related risk assessment in patients with coronary artery disease (CAD) and left ventricle dysfunction (LVD).

METHODS

We retrospectively evaluated 241 to patients candidate CABG presenting with signs and symptoms of congestive heart failure (CHF) prevailing over ischemic signs. Of the 241 patients, 153 had undergone [18F]FDG-PET as well as conventional assessment: 110 out of 153 (group A) were operated because of PET evidence of hibernation. Of the 241 patients, 88 had not undergone [18F]FDG-PET: 86 out of 88 (group B) were operated on. The outcome of surgical patients was evaluated by considering all major perioperative complications including the use of mechanical and pharmacological support and in-hospital mortality. After hospital discharge, each patient was examined at 1, 4 and every 6 months thereafter.

RESULTS

Perioperative use of mechanical supports and inotropic drugs, was significantly lower for the PET selected group (A) than for the non PET selected group (B). Mortality within 30 days of surgery was 0.9% in group A and 19.8% in group B. The only predictors of perioperative outcome were the presence of hibernating tissue and the ejection fraction.

CONCLUSIONS

[18F]FDG-PET prior to CABG can be crucial for the assessment of perioperative risk in patients with CAD.

Positron emission tomography for the assessment of myocardial viability: a synopsis of methods and indications

An improvement of regional and global left ventricle dysfunction can be achieved in patients with coronary artery disease either by coronary revascularization with percutaneous transluminal coronary angioplasty or coronary artery bypass grafting. Several techniques have been developed to identify dysfunctional but viable myocardium. In the last decade, positron emission tomography (PET) with 18F-fluorodeoxyglucose (18F-FDG) has been used for the detection of hibernating myocardium. It can accurately predict the recovery of abnormal wall motion in hibernating segments prior to surgery. In particular, assessment of viability with 18F-FDG is indicated in high-risk surgical candidates being considered for revascularization or transplantation. Moreover, patient selection criteria and economic consideration are also relevant for cost-effective use of the technique.

Myocardial metabolism studied during warm blood antero-retrograde reperfusion in ischaemic human hearts

We propose modified warm blood antegrade-retrograde reperfusion (WBARR) of arrested hearts as a metabolic model with which to study substrate exchange and energy metabolism during the recovery phase after 90 min of ischaemia in man. Eleven anaesthetized patients undergoing aorto-coronary bypass were studied during WBARR. The protocol was designed as follows: period 1, a warm blood reperfusion with potassium (3 min); period 2, a warm blood reperfusion without potassium (2 min). The perfusion flow rate averaged 250+/-2 ml/min at the beginning of period 1 and 218+/-19 ml/min at the beginning and at the end of period 2; the perfusion was performed antegradely and retrogradely in the arrested hearts. Samples were simultaneously taken from the coronary venous sinus (CVS) and from the aortic root needle (AR). At the beginning of WBARR lactate release was 85+/-44 micromol/min and at the end it had significantly decreased to 21+/-99 micromol/min (P<0.03). Simultaneously, non-esterified fatty acids (NEFA) and beta-hydroxy-butyrate were initially released (71+/-61 and 22+/-66 micromol/min, respectively), while at the end of the WBARR there was an uptake of both NEFA (20+/-22 micromol/min; P<0.01) and beta-hydroxy-butyrate (12+/-35 micromol/min; P=0.290). Alanine, glycerol and branched chain amino acid balance across the heart did not significantly change. In summary after 90 min of ischaemia the heart energy metabolism is mainly anaerobic and based on glucose consumption, with lactate, NEFA and amino acids, which are mainly released. After 5 min of WBARR (recovery from ischaemia), lactate release is significantly reduced and NEFA becomes the energy supply of the heart. In conclusion, (1) WBARR is a valuable method with which to study myocardial metabolism in anaesthetized humans and may be combined with the use of tracers; (2) the study of myocardial metabolism in arrested hearts eliminates the imprecisions arising from the noncontinuous coronary blood flow; (3) NEFA become an important source of energy utilized by human hearts in the recovery phase from ischaemia.

Relation between left ventricular function and oxidative stress in patients undergoing bypass surgery

OBJECTIVE

To determine whether preoperative left ventricular ejection fraction (LVEF) is related to the degree of myocardial oxidative stress during bypass surgery in man.

DESIGN

Observational study.

SETTING

Tertiary care centre.

PATIENTS AND INTERVENTIONS

31 patients (LVEF range was 20% to 68%) undergoing elective coronary bypass surgery with blood cardioplegic reperfusion were studied. Arterial and coronary sinus blood was collected before aortic cross clamping (T0) and at 0 (T1), 15 (T2), and 30 (T3) minutes after unclamping. Transmural left ventricular biopsies were also obtained from 15 patients at T0 and at T1.

MAIN OUTCOME MEASURES

Glutathione and adenine nucleotides were measured in myocardial biopsies, while coronary sinus-artery differences for glutathione, nucleotides, and products of lipid peroxidation were calculated from blood specimens. Creatine kinase (myocardial band; CK-MB) was measured in plasma at four and 12 hours after operation.

RESULTS

Myocardial glutathione and adenine nucleotides were correlated (p < 0.02) with preoperative LVEF both at T0 (r = 0.909 and 0.672) and T1 (r = 0.603 and 0.605). Oxidised glutathione released from the heart during reperfusion was inversely correlated with LVEF (r = -0.448, -0.466, and -0461 at T1, T2, and T3, p < 0.01), while reduced glutathione (r = 0.519 and 0.640 at T1 and T2) and glutathione redox ratio (r = 0.647, 0.714, 0.645, and 0.702 at T0, T1, T2, and T3) showed a direct correlation (p < 0.01). Lipid peroxidation at T1 was negatively related to LVEF (r = -0.492). CK-MB was also negatively related to LVEF (r = -0.440 at 4 h and -0.462 at 12 h).

CONCLUSIONS

The capacity to counterbalance oxidative burst following ischaemia and reperfusion appears to be related to the functional ability of the heart.

Role of leucocytes in free radical production during myocardial revascularisation

OBJECTIVE

To evaluate the role of leucocytes in free radical production in patients with depressed or normal ejection fraction undergoing coronary bypass.

DESIGN

Two randomised control trials.

SETTING

Tertiary care centre.

PATIENTS AND INTERVENTIONS

In the first study, 22 patients with ejection fractions of < or = 40% received blood cardioplegic reperfusion with (n = 11) or without (n = 11) leucocyte depletion. In the second study, 22 patients with ejection fractions > or = 45% received either leucocyte depleted (n = 11) or blood cardioplegia (n = 11).

MAIN OUTCOME MEASURES

Glutathione, hypoxanthine, and lipid peroxidation products were measured in coronary sinus blood and plasma before aortic cross clamping and at 0, 15, and 30 minutes after unclamping. Haemodynamic variables and creatine kinase MB isoenzymes were monitored on the first postoperative day. Comparison between treatments was performed on difference (delta) between measurements at time 0 and at baseline, and on slopes obtained by fitting measurements after unclamping with a linear regression model.

RESULTS

At unclamping no difference in delta for plasma glutathione redox ratio (oxidised/total glutathione, %) was observed between treated and control groups with low ejection fraction (delta = 16 (SD 8.39) and 24 (7.0) redox ratio %, respectively). Baseline value recovery rate (redox ratio %/min) was significantly faster in treated v control patients (slope -0.912 (0.380) v -0.158 (0.200), P < 0.005, respectively). Cardiac index showed a trend to greater improvement in the treated group (slope 0.04 (0.03) v 0.003 (0.002) 1/min/m2/h, P < 0.02, treated v controls, respectively). In patients with normal ejection fraction, leucocyte depletion did not result in significant improvement v controls.

CONCLUSIONS

Leucocyte depletion seems to provide benefit only in patients with left ventricular dysfunction.

Six-and-half years' experience with the St. Jude BioImplant porcine prosthesis

BACKGROUND AND AIMS OF THE STUDY

In this study, we reviewed our experience in heart valve replacement with the St. Jude BioImplant heart valve, which is a low-profile, low-pressure glutaraldehyde-fixed porcine prosthesis mounted on a flexible Delrin stent.

METHODS

During the period May 1989-January 1996, 117 patients were implanted with 132 BioImplant prostheses; three patients were lost to follow up and excluded from the series. Mean age was 67.5 +/- 9.8 years (range: 19 to 82 years); myocardial revascularization was performed in 22 (19.3%) patients. In-hospital mortality rate was 6% (7/117 patients). By January 1996, 114 patients (53 males, 61 females), in whom 59 aortic, 35 mitral, 15 mitro-aortic and five tricuspid prostheses had been implanted, were eligible for the analysis. Mean follow up was 40.4 +/- 21.7 months (range: 1 to 76 months).

RESULTS

The survival probability of survivors was 72.1 +/- 6.5 at 77 months. Seventeen patients died during follow-up. The mean NYHA class improved from 3.1 +/- 0.6 preoperatively to 1.4 +/- 0.6 postoperatively. The freedom probabilities were respectively 89.5 +/- 5.3% from thromboembolism, 93.2 +/- 3.7% from infective endocarditis, 84.5 +/- 10.3% from structural dysfunction, 99.1 +/- 0.9% from non-structural dysfunction, and 80.1 +/- 10.2% from reoperation. The freedom probability for valve-related events was respectively 75.3 +/- 12.3%, 98.0 +/- 1.9% and 67.2 +/- 17.2% for patients who underwent mitral, aortic and mitro-aortic heart valve replacement (p = 0.05 comparing only patients who underwent mitral or aortic replacement); moreover the freedom probability from valve-related events was 71.6 +/- 11.2% in patients aged < or = 65 years and 90.2 +/- 6.6% in patients aged > 65 years (p = 0.006).

CONCLUSIONS

The BioImplant heart valve, in our experience, seems to be a valuable device which shows a mid-term performance similar to that of other porcine prostheses.

[Use of an anesthetic cream in the surgical treatment of phimosis]

The authors present their technique of local anaesthesia in the surgical treatment of phimosis using a cream composed of an eutectic mixture of lidocaine and prilocaine (Emla). This cream, unlike injectable local anaesthetics, allows surgical procedures to be performed on the prepuce without pain.

Pectus excavatum in adults: destructive surgery or simple correction of an aesthetic defect?

Pectus excavatum, a congenital depressive malformation of the sternum, is described since 1594 by Johannes Schenk and has successively been the subject of many studies because of its various inherent problems. The repercussions on the respiratory and cardiac dynamics caused by the compression on the mediastinal structures and by the reduction of the respiratory volume have only recently been valuated completely with the application of the latest techniques to diagnosis, cardiology and radiology. The aesthetic defect, often the first aspect to attract the attention of patient and doctor, has serious psychological implications, especially for what concerns the affective life and relationships in general. The surgical therapy consists in radical interventions with large sternocostal resections and repositioning of the sternum (turnover), or in interventions with a less invasive technique to correct only the aesthetic defect. In this study have been examined 7 cases of patients affected by pectus excavatum who were operated at the Institute of General Surgery IV and the Department of Plastic surgery of the University of Rome "La Sapienza" between 1983 and 1993. The patients were divided in two groups: a first group of 4 patients who underwent a sternal turnover, and a second group of 3 patients who were operated with conservative methods to correct the aesthetic defect. In both groups the results were good without any post-operatory complications. The experience gained during these years consents us to propose radical interventions for patients who have a severe malformation with evident physiopathological implications; this intervention is especially indicated if the patient is young, to prevent further disabling complications. Less invasive methods, on the other hand, should be applied to all other cases, considering the higher degree of tolerance of the intervention, the absence of postoperatory complications and the minor cost, thanks to a shorter hospital stay.

Accessory slip of the palmaris longus muscle

We discuss the case of a patient presenting an accessory slip of the palmaris longus (PL) muscle, which caused symptoms of median nerve compression on his left forearm. An asymptomatically anomalous distal PL belly contralaterally is also reported, and the clinical relevance and diagnosis of PL anomalies are discussed.

Relation between dobutamine trans-thoracic echocardiography, 99Tcm-MIBI and 18FDG uptake in chronic coronary artery disease

The relationships between rest conditions of myocardial asynergy, response to dobutamine administration, perfusion and glucose metabolism were examined in 12 patients with chronic coronary artery disease and left ventricular dysfunction. We evaluated (1) rest and stress myocardial perfusion by 99Tcm-methoxyisobutylisonitrile (MIBI) and single photon emission tomography (SPET), (2) rest myocardial segmental wall motion by trans-thoracic echocardiography and low-dose dobutamine, and (3) myocardial metabolism by [18F]-2-fluoro-2-deoxy-D-glucose (18-FDG) and positron emission tomography (PET), in the fasting state. The analysis was carried out on 16 left ventricular myocardial segments. The SPET studies were analysed semi-quantitatively by normalization to the peak activity. Wall motion was assessed by a visual score. An 18FDG index was determined as the tissue/blood pool radioactivity ratio in each segment. The results showed: (1) remarkably good agreement between the number of dobutamine responsive segments and 18FDG positive segments among those that were only moderately hypoperfused and hypokinetic; (2) a smaller number of dobutamine responsive segments than 18FDG positive segments among those that were hypoperfused and akinetic; and (3) the presence of 18FDG in 50% of the segments that were severely hypoperfused and akinetic or dyskinetic and without improvement with dobutamine. These results indicate that in severely hypoperfused and akinetic or dyskinetic segments, trans-thoracic echocardiography under inotropic stimulation provides little additional information compared with that obtained with rest echocardiography and perfusion studies; the assessment of 18FDG uptake provides information that is complementary to that obtained by perfusion assessment, rest and dobutamine trans-thoracic echocardiography.

Results of surgical treatment of arthrofibrosis after ACL reconstruction

We prospectively studied 31 knee arthrolyses performed for loss of motion after intra-articular anterior cruciate ligament (ACL) reconstruction. The arthrolysis was performed on average 10.6 months after the reconstruction (range 4-25). Seven knees were localized forms. They were treated with arthroscopic removal of a fibrous nodule and scar tissue anterior to the ACL, which was preserved. Twenty-four knees were global forms and treated arthroscopically (14) or in open procedure (10). Suprapatellar, medial, and lateral gutter adhesions were sectioned, and fibrous tissue was removed from the anterior compartment. A posteromedial and/or posterolateral capsulotomy was necessary in 7 knees. The ACL graft was nonfunctional and/or malpositioned in 19 knees. The results were evaluated with the IKDC form with an average follow-up of 3.5 years (range 1.5-7). Preoperatively the localized forms had an average extension loss of 11 degrees and an average flexion loss of 14 degrees compared to the opposite knee. At follow-up all the knees were satisfactory for symptoms. All except one achieved a satisfactory motion (within 5 degrees of extension loss and 15 degrees of flexion loss) and a satisfactory final result. Global forms had a greater preoperative flexion loss (average 34 degrees) and extension loss (average 17 degrees). At follow-up 58% were satisfactory for symptoms and 71% for arc of motion. However, the final result was satisfactory in only 37%. In conclusion, local forms have a good prognosis. In global forms motion may be improved by surgery, but the final result is downgraded by symptoms. Arthrolyses performed within 8 months from index operation had a better outcome.

Myocardial protection with and without leukocyte depletion: a comparative study on the oxidative stress

We tested the hypothesis that controlled reperfusion with leukocyte-depleted blood could improve myocardial protection by reducing the oxidative stress in patients undergoing myocardial revascularization. Thirty-four patients receiving antegrade/retrograde blood cardioplegia were divided into: group A: 11 patients with ejection fractions (EF) less than 35%, treated with leukocyte-depleted controlled blood reperfusion, group B: 11 patients with EF less than 35% in whom no leukocyte depletion was performed, group C: 6 patients with EF more than 45% treated as group A and group D: 6 patients with EF more than 45% without leukocyte depletion. To asses the oxidative stress, we evaluated total, total oxidized (GSSX), and reduced glutathione (GSH) in coronary sinus plasma, immediately before cross-clamping the aorta (T0), and at 0 (T1), 15 (T2) and 30 (T3) min after unclamping it. In groups A and B a significant shift towards oxidation of redox status of glutathione (GSH/GSSX) at T1 vs T0 was observed. Glutathione redox ratio remained low in group B while in group A it returned to the basal value at T2 with a significant difference from group B at T2 and T3. No differences were observed between groups C and D. In conclusion, our data show that leukocyte-depleted reperfusion can afford a better myocardial protection in patients with left ventricular dysfunction, while it seems unnecessary in patients with normal EF.

Identification of hibernating myocardium: a comparison between dobutamine echocardiography and study of perfusion and metabolism in patients with severe left ventricular dysfunction

The distinction between fibrotic and viable myocardium is a key issue in patients with coronary artery disease and left ventricular dysfunction. Metabolic imaging with positron emission tomography (PET) and labeled tracers, along with the study of myocardial perfusion, is now available to identify hibernating myocardium. However, PET imaging of myocardial metabolism is a high-cost and time-consuming technique, and requires an on-site cyclotron. The aim of this study is to test the reliability of dobutamine echocardiography (DE) compared with PET imaging, for the identification of hibernating myocardium. In 16 patients, scheduled for myocardial revascularization, left ventricular shapes were divided in eight segments both for echocardiographic and nuclear study evaluation. All patients underwent a technetium 99m MIBI single-photon emission tomography stress-rest study of perfusion, a fluorine-18-labeled deoxyglucose (FDG(/PET study of metabolism, and a DE test (baseline, at a 5 micrograms/kg/min infusion of dobutamine for 8 minutes and at a 10 micrograms/kg/min dose for additional 8 minutes). Neither myocardial ischemia nor arrhythmia occurred during the DE test. Baseline echocardiograms showed 90 segments with wall motion abnormalities: wall motion impairment was decreased or reversed in 33 of 90 segments; it remained unchanged in 57 of 90 segments. In 32 of 33 segments considered viable on the basis of DE and in 21 of 57 segments with unchanged kinesis, some degree of FDG was detected. Thus, sensitivity and specificity of DE compared with nuclear studies was 60% and 97% respectively. Moreover, a good correlation and agreement (kappa = 0.51) between DE and the presence of FDG were found. We conclude that DE is a safe and reliable test for the screening of hibernating myocardium in patients with chronic coronary artery disease and left ventricular dysfunction.

Assisted circulation in postcardiotomy heart failure: experience with the Bio-Medicus centrifugal pump in ten patients

Between January 1990 and September 1992, ten patients required assisted circulation for postcardiotomy heart failure which was unresponsive to inotropic drugs and aortic counterpulsation. All patients were supported by a Bio-Medicus centrifugal pump (biventricular assist in five, left ventricular in three, right ventricular in two); six had ischaemic heart disease, two a congenital ventricular septal defect, one an acute mitral valve incompetence and one an aortic type 'A' dissection. The mean duration of circulatory support was 5.1 days (range 2 hours to 8 days). Six patients were weaned from the device and four were discharged; the perioperative deaths among the patients weaned from support were the result of cerebral haemorrhage and multiorgan failure respectively. No late deaths occurred at a mean follow-up of 15 months. Common complications were bleeding (40%), acute renal failure (30%) and sepsis (30%). All patients who developed renal failure died. The high incidence of haemorrhagic complications makes the use of pre-heparinized circuits desirable as these patients do not then require additional anticoagulation.

Measurement of cardiac troponin T and myosin to detect perioperative myocardial damage during coronary surgery

This study evaluated the use of monitoring blood levels of the isoenzyme of creatine phosphokinase, troponin T (tnT) and myosin in the detection of perioperative myocardial damage after coronary artery surgery. Serial blood samples were collected in 24 patients undergoing myocardial revascularization. The patients were retrospectively divided into three groups: group A with no changes in their electrocardiogram; group B showing non-specific signs of perioperative myocardial infarction such as deep and permanent T wave inversion; and group C with definite electrocardiographic signs of perioperative myocardial infarction (new persistent Q-waves and loss of R-waves). Group A (n = 17) demonstrated a mean(s.d.) troponin T peak blood level of 0.64(0.35) ng/ml at 12-24 h after surgery, a myosin peak of 1030(670) mu units/l at 3-6 days afterwards, and a creatine phosphokinase isoenzyme peak of 25.8(10.6) units/l. In group B (n = 5), mean(s.d.) troponin T levels were elevated to a peak of 4.8(3.9) ng/ml 24 h after intervention, while myosin rose to 2074(340) mu units/l 3-6 days after surgery and creatine phosphokinase isoenzyme reached 57.8(38) units/l. Group C (n = 2) had a mean(s.d.) troponin T peak of 4.8(2.6) ng/ml, a myosin peak of 2404(392) mu unit/l and a creatine phosphokinase isoenzyme peak of 88.5(20) units/l. Peak values of troponin T and myosin in groups B and C were statistically different from those in group A (P < 0.001). These results suggest that troponin T and myosin are reliable indicators of perioperative myocardial damage. In particular, troponin T may allow the differentiation of reversible from irreversible myocardial injury.

[Autoantibodies against oxidised low density lipoproteins in patients with coronary disease]

OBJECTIVES

Evidence has been obtained indicating that oxidation of low-density lipoproteins (LDL) plays a relevant role in the pathogenesis of atherosclerosis and it has been proposed that, due to the antigenic properties of oxidized LDL, the anti-oxLDL antibody titre could represent a useful index of in vivo LDL oxidation.

METHODS

Sixty-nine control subjects and 64 patients scheduled for selective coronary revascularization were investigated before surgery.

RESULTS

The coronary disease patients had a higher level of total plasma cholesterol, LDL cholesterol and triglycerides, and a lower level of HDL cholesterol. Plasma anti-oxLDL antibody titre was measured as the ratio of antibody binding to CuSO4-oxidised LDL versus native LDL. The antibody ratio was higher in coronary patients as compared with control subjects (1.56 +/- 0.5 vs 1.0 +/- 0.3, p < 0.01). A ratio higher than 1.34 (mean of controls +/- one standard deviation) was present in 60% of the coronary patients. Subclass analysis indicated that the presence of diabetes mellitus and hypercholesterolaemia (but not of hypertension, generalized arteriosclerosis, myocardial infarction and cigarette smoking) increased the anti-oxLDL antibody ratio to 1.72 +/- 0.4 and 1.68 +/- 0.3 respectively.

CONCLUSION

The results obtained indicate that a) a high titre of anti-oxLDL antibodies is present in plasma of patients with coronary atherosclerosis, b) in these patients LDL oxidation takes place in vivo and probably plays a critical role in the development and progression of atherosclerosis.

Myocardial revascularization with bilateral internal thoracic artery in patients with left main disease or left ventricular dysfunction: an incremental risk?

Although long-term patency of the internal thoracic artery (ITA) is well stated, there is still some concern about its perioperative performance. We considered 122 consecutive patients, 63 with left main disease (LMD; mean age 60 years) and 59 with left ventricular dysfunction (LVD; mean age 59 years) who underwent coronary artery bypass grafting in our Institute from March 1988 to September 1992. Patients with LMD were divided into 2 groups: LMD I: 29 patients receiving only ITA grafts on the left coronary system and LMD II: 34 patients having a single ITA graft on the left coronary system. Patients with LVD were divided into: LVD I: 44 patients operated with bilateral ITA and LVD II: 15 patients receiving a single ITA graft. Perioperative complications in LMD I and LMD II patients were respectively: myocardial necrosis in 2 (6.9%) versus 3 (8.8%), use of intra-aortic balloon pump (IABP) in 2 (6.9%) versus 2 (5.9%); no death occurred in both groups. Perioperative results in groups LVD I and LVD II were: death in 1 patient (2.2%) versus 1 (6.7%), myocardial necrosis in 2 (4.5%) versus 1 (6.7%) and IABP in 4 (9.1%) versus 2 (13.3%). In our experience the use of bilateral ITA grafts in patients with LMD and LVD was not related to an incremental risk. We conclude that LMD and LVD should not be considered as contraindications to the extensive use of arterial conduits.

Myocardial revascularization in patients with severe ischaemic left ventricular dysfunction: a clinical experience

The benefits of myocardial revascularization in patients with ischaemic left ventricular dysfunction are widely reported. However, myocardial revascularization in such cases is associated with higher mortality and morbidity rates. Sixty patients with severe left ventricular dysfunction underwent myocardial revascularization at the authors' institution. Ejection fraction was assessed by angiocardioscintigraphy before and at 3 months after surgery. All patients underwent elective surgery and received complete myocardial revascularization. Myocardial protection was achieved using Buckberg's protocol. One perioperative death occurred. Weaning from cardiopulmonary bypass required inotropic drug therapy in 22 cases and aortic counterpulsation in nine. Perioperative myocardial infarction occurred in three patients with no further haemodynamic impairment. The mean postoperative ejection fraction was 41.0%, compared with a mean preoperative value of 26.5%. The extent of left ventricular functional improvement was greatest in those patients having the worst preoperative left ventricular function. It is concluded that, with this technique, myocardial revascularization can be achieved in patients with severe left ventricular dysfunction with an acceptable operative mortality.

Myocardial revascularization with bilateral internal thoracic artery in patients with left main disease: an incremental risk?

Although the long-term patency of the internal thoracic artery (ITA) has been well proved, there is still some concern about its preoperative performance. We considered 80 patients with left main disease (mean age 60.2 years) who underwent coronary artery bypass grafting in our institute from March 1988 to September 1992. Patients with left main disease were divided into 2 groups: group I-38 patients receiving only ITA grafts on the left coronary system and group II-42 patients having a single ITA graft together with saphenous vein grafts on the left coronary system. No patients in group I received a saphenous graft on the left coronary system and three patients with right coronary artery involvement received total arterial myocardial revascularization with the use of the inferior epigastric artery. Perioperative complications in group I and group II patients were, respectively: myocardial necrosis in 2 (6.9%) and 3 (8.8%), use of intraaortic balloon pump in 2 (6.9%) and 2 (5.9%). No death occurred in either group. In our experience, the use of bilateral ITA grafts in patients with left main stenosis was not related to an incremental risk. We conclude that left main disease should not be considered as counterindication to the extensive use of arterial conduits.

Identification and revascularization of hibernating myocardium in angina-free patients with left ventricular dysfunction

We examined 17 angina-free patients with left ventricular dysfunction, referred for surgical decision-making, who presented with no or few signs and symptoms of myocardial ischemia according to treadmill stress test. On cardiac catheterization they were affected by severe multi-vessel coronary artery disease; the mean left end-diastolic pressure of this population was 26.3 +/- 5.5 mm Hg (mean +/- SD) and their mean ejection fraction was 27.6 +/- 4.9% (mean +/- SD). They all were investigated for the presence of viable myocardium by the combined assessment of cardiac perfusion and metabolism using single photon emission tomography with [99mTc] labelled hexakis-2-methoxy-isobutyl-isonitrile [99mTc]MIBI/SPET) and positron emission tomography with [18F]-2-fluoro-2-deoxy-D-glucose ([18F]FDG/PET), respectively. Patients were considered for coronary surgery when [18F]FDG was detectable in at least two cardiac segments with wall motion abnormalities and perfusion defects. Nine patients were operated on, six were medically treated and two were scheduled for heart transplantation. We recorded no in-hospital mortality. At a mean follow-up of 28.4 +/- 9.8 (mean +/- SD) months all surgical patients were alive and their NYHA functional classes have improved, except in one case. Among the patients refused for bypass surgery, three are in stable conditions, three have worsened clinical statuses and two died while waiting for heart transplantation. In conclusion, for patients with bypassable coronaries, left ventricular dysfunction and lack of angina, successful coronary revascularization may be predicted by the presence of viable myocardium demonstrated with positron emission tomography.

Myocardial function in early hours after coronary artery bypass grafting: comparison of two cardioplegic methods

The theoretical advantages of retrograde blood cardioplegia combined with anterograde blood cardioplegia and warm reperfusion before aortic unclamping during coronary surgery were evaluated in 41 patients (group 2). The early postoperative myocardial function of this group was compared with that of 55 patients (group 1) in whom cold crystalloid cardioplegia was administered. The following variables were measured and analyzed by multivariate statistical analysis: heart rate, left atrial pressure, systemic arterial pressure, cardiac index, left ventricular stroke work index, ventricular function, oxygen delivery, hemoglobin, partial oxygen pressure in mixed venous blood, arteriovenous oxygen difference, carbon dioxide production per square meter, and cardiac isoenzyme of creatine-kinase. The myocardial function improved progressively and cardiac enzymatic release was low for both groups 9 hours after admission to the intensive care unit. However, group 2 had significantly higher oxygen delivery, carbon dioxide production per square meter, cardiac index, left ventricular stroke work index, and ventricular function and significantly lower left atrial pressure and mean systemic arterial pressure than that of group 1. The best separation of group 2 from group 1 occurred at the ninth hour, with a probability of correct recognition of 92.1%.

Specificity of autoantibodies against oxidized LDL as an additional marker for atherosclerotic risk

BACKGROUND

LDL oxidation is a crucial step in the development and progression of atherosclerotic lesions. The detection of an increase in the anti-oxidized LDL antibody titre may thus represent a biological marker of enhanced LDL oxidation in vivo.

METHODS

The occurrence of anti-oxidized LDL autoantibodies was investigated in control patients, in patients with atherosclerotic coronary artery disease, in those without clinically relevant signs of atherosclerosis, but considered at risk, and in patients with chronic alcohol-related liver disease.

RESULTS

Anti-oxidized LDL autoantibodies were present in the plasma of the majority of patients with overt coronary atherosclerosis. An increased antibody titre can also be detected well before the onset of clinically relevant signs of the atherosclerotic disease in patients classically considered at risk, indicating the occurrence of in-vivo LDL oxidation during atherosclerosis development. The specificity of molecular targets (LDL) for oxidative modifications is supported by the demonstration that anti-oxidized LDL autoantibodies are absent in the plasma of alcoholic patients who exhibit a marked increase in biological markers of oxidative stress but do not classically develop atherosclerosis.

CONCLUSION

These data demonstrate that the occurrence of anti-oxidized LDL autoantibodies could be specifically related to the promotion and progression of atherosclerosis and is not a simple epiphenomenon of any oxidative process occurring in vivo.

Mitral valve prosthetic endocarditis: development of left ventricular-coronary sinus fistula following replacement

We report the history and course of a patient in whom a left ventricular-coronary sinus fistula developed following mitral valve replacement due to prosthetic endocarditis. Six months after the intervention the patient suddenly presented with deterioration of her symptoms, holosystolic murmur and signs of congestive heart failure. Transesophageal echocardiography showed a left-to-right shunt but did not show its exact location. At surgery, exploration of the right atrium revealed a left ventricular-coronary sinus communication due to discontinuation of the left ventricular free wall next to the coronary sinus; repair of the defect was successfully performed by direct suture. The postoperative course was uneventful and the patient recovered quickly. This case is reported to stress that debridement of the mitral annulus and removal of an old prosthesis must be very carefully performed and to facilitate the diagnosis of this rare but severe complication of repeated mitral valve replacement.

Total arterial myocardial revascularization

The superiority of the internal thoracic artery (ITA) compared with venous conduits in terms of late graft patency is nowadays well documented. The inferior epigastric artery (IEA) was recently proposed as an alternative conduit for coronary artery surgery with good early clinical and angiographic results. To improve the benefits from myocardial revascularization, we expanded the use of these arterial conduits. From June 1988 to December 1991, 615 patients underwent coronary surgery in our institute. In 138 of them (22.4%) we performed total arterial myocardial revascularization placing 2 or more coronary anastomoses. An average of 2.37 anastomoses per patient were placed with the maximum number of 6 in one case. Only one patient died of cardiac related causes (0.72%). Perioperative morbidity included myocardial infarction and sternal dehiscence in 5 patients each (3.6%). No stroke or reoperation for bleeding occurred. No rectus muscle necrosis was recorded. Accurate preoperative planning of graft placement allows for the performance of as many as 6 distal anastomoses using bilateral ITA and single IEA grafts only, thus completely revascularizing most of the hearts with three-vessel disease. In our series this procedure was not reflected in an increase in the perioperative morbidity. We choose an elective total arterial revascularization in younger (under 65 years) patients who, while showing a lower incidence of complications in our study, are likely to derive the highest benefits from the good durability of ITA and hopefully IEA grafts.

Presurgical identification of hibernating myocardium by combined use of technetium-99m hexakis 2-methoxyisobutylisonitrile single photon emission tomography and fluorine-18 fluoro-2-deoxy-D-glucose positron emission tomography in patients with coronary artery disease

We tested the possibility of identifying areas of hibernating myocardium by the combined assessment of perfusion and metabolism using single photon emission tomography (SPET) with technetium-99m hexakis 2-methoxyisobutylisonitrile (99mTc-MIBI) and positron emission tomography (PET) with fluorine-18 fluoro-2-deoxy-D-glucose (18F-FDG). Segmental wall motion, perfusion and 18F-FDG uptake were scored in 5 segments in 14 patients with coronary artery disease (CAD), for a total number of 70 segments. Each subject underwent the following studies prior to and following coronary artery bypass grafting (CABG): first-pass radionuclide angiography, electrocardiography gated planar perfusion scintigraphy and SPET perfusion scintigraphy with 99mTc-MIBI and, after 16 h fasting, 18F-FDG/PET metabolic scintigraphy. Wall motion impairment was either decreased or completely reversed by CABG in 95% of the asynergic segments which exhibited 18F-FDG uptake, whereas it was unmodified in 80% of the asynergic segments with no 18F-FDG uptake. A stepwise multiple logistic analysis was carried out on the asynergic segments to estimate the postoperative probability of wall motion improvement on the basis of the preoperative regional perfusion and metabolic scores. The segments with the highest probability (96%) of functional recovery from preoperative asynergy after revascularization were those with a marked 18F-FDG uptake prior to CABG. High probabilities of functional recovery were also estimated for the segments presenting with moderate and low 18F-FDG uptake (92% and 79%, respectively). A low probability of functional recovery (13%) was estimated in the segments with no 18F-FDG uptake.(ABSTRACT TRUNCATED AT 250 WORDS)

[Staplers and pulmonary surgery]

The Authors report their experience with staplers (model T.A. 30) in lung surgery: 152 stapled sutures were, in fact, performed in the IV Surgical Department of the University "La Sapienza" of Rome, during the period 1980/90. The use of staplers assures a perfect closure and prevents granulomas due to suture materials in typical as well as atypical lung resections.

[Current aspects and controversies in reconstructive surgery after esophagectomy: personal experience]

The authors report their series of 184 esophagectomies performed both for benign (44) and malignant (140) diseases. On the basis of their experience and supported by Literature data, it is believed restoration of digestive continuity offers two main points of discussion: choice of the intestinal tract for the interposition and type of anastomosis to perform. The nature of the lesion and its level seems to play the most important role in the choice.

Aortic valve replacement in Cogan's syndrome

Cogan's syndrome is a systemic vasculitis of autoimmunologic origin. The main disturbances involve the eye, the ear and the heart, but many other structures can also be affected. Nonspecific abnormal laboratory findings are also present. The disease usually involves a cranial nerve, followed by aortitis which can affect the aortic valve and, more rarely, the cusps of the valve. Aortic lesions strongly influence the course of the disease and therefore the prognosis. When choosing the type of valve replacement, long-term corticosteroid therapy and the age and sex of the patient must be taken into account.

[Correlation between electrocardiographic and echocardiographic findings in chronic aortic insufficiency]

Echocardiographic indices of left ventricular volume and mass and electrocardiographic indices of left ventricular hypertrophy have evaluated in 25 patients with chronic aortic regurgitation and in 10 normal subjects. When the patients with aortic regurgitation were subdivided in three groups with increasing evidence of left ventricular hypertrophy, the echocardiographic measures of left ventricular dimension and mass were also found to be increased, with statistically significant differences between patients and controls and among the three groups of patients as well. A specially constructed cumulative electrocardiographic index of left ventricular hypertrophy (Sokolow and Lyon's index plus Lewis' index plus strain pattern) is correlated with the left ventricular end-diastolic diameter (r = 0.65; P less than 0.001), cross-sectional area (r = 0.65; p less than 0.001) and mass (r = 0.75; p less than 0.001) better than the isolated electrocardiographic indexes.