Nonsteroidal anti-inflammatory drug hypersensitivity syndrome. A multicenter study. I. Clinical findings and in vitro diagnosis

BACKGROUND

We present the results obtained from the largest series of in vitro diagnostic tests ever reported in patients with clinically validated hypersensitivity to acetylsalicylic acid (ASA)/nonsteroidal anti-inflammatory drugs (NSAID) compared with various categories of controls tolerating ASA/NSAIDs. This multicenter study, which was performed within the framework of the European Network for Drug Allergy (ENDA) group, showed that the basophil activation test (BAT), particularly when used with the 3 NSAIDs aspirin (ASA), diclofenac (DIC), and naproxen (NAP), allows us to confirm the diagnosis of NSAID hypersensitivity syndrome. The results of the cellular allergen stimulation test (CAST) frequently correlate with those of the BAT, although not always. An unexpected finding was that basophil activation by NSAIDs is not an all-or-nothing phenomenon restricted to clinically hypersensitive patients, but that it also occurs in a dose-related manner in some NSAID-tolerant control individuals.Therefore, NSAID hypersensitivity appears as a shift in the normal pharmacological response to NSAIDs. These findings allow us to formulate a new rational hypothesis about the mechanism of NSAID hypersensitivity syndrome, a mechanism that most authors continue to describe as "unknown."

METHODS

We enrolled 152 patients with a history of hypersensitivity to NSAIDs and 136 control participants in 11 different centers between spring 2003 and spring 2006. Flowcytometric BAT was performed.

RESULTS

The most noteworthy results of our study were that 57% of 140 patients presented very clear-cut positive BAT results to multiple NSAIDs, and 16% were entirely negative. In about 27% of cases, positive results were obtained with 1 or 2 concentrations of a single NSAID. There is clearly a correlation between the results of BAT and CAST.

CONCLUSIONS

BAT seems particularly indicated in patients with a clinical history of NSAID intolerance, and in whom a provocation test is not advisable for ethical, clinical, or other reasons. Clear-cut positive results can be considered as confirming a history of NSAID hypersensitivity, although negative results may not exclude it.

A filamentous growth response mediated by the yeast mating pathway

Haploid cells of the budding yeast Saccharomyces cerevisiae respond to mating pheromones by arresting their cell-division cycle in G1 and differentiating into a cell type capable of locating and fusing with mating partners. Yeast cells undergo chemotactic cell surface growth when pheromones are present above a threshold level for morphogenesis; however, the morphogenetic responses of cells to levels of pheromone below this threshold have not been systematically explored. Here we show that MATa haploid cells exposed to low levels of the alpha-factor mating pheromone undergo a novel cellular response: cells modulate their division patterns and cell shape, forming colonies composed of filamentous chains of cells. Time-lapse analysis of filament formation shows that its dynamics are distinct from that of pseudohyphal growth; during pheromone-induced filament formation, daughter cells are delayed relative to mother cells with respect to the timing of bud emergence. Filament formation requires the RSR1(BUD1), BUD8, SLK1/BCK1, and SPA2 genes and many elements of the STE11/STE7 MAP kinase pathway; this response is also independent of FAR1, a gene involved in orienting cell polarization during the mating response. We suggest that mating yeast cells undergo a complex response to low levels of pheromone that may enhance the ability of cells to search for mating partners through the modification of cell shape and alteration of cell-division patterns.

Gastric dilatation syndrome associated with chronic nephropathy, hypergastrinemia, and gastritis in mice exposed to high levels of environmental antigens

Gastric dilatation (GD) has been observed in Tac:(SW)fBR surveillance mice, with mean age of 10 months, that are exposed to high levels of environmental antigens during routine exposure to dirty bedding. The aim of the study reported here was to determine whether GD was associated with other systemic conditions affecting mice. Three groups of nine animals including-surveillance mice not exposed to dirty bedding (control), surveillance mice with out GD (NGD), and surveillance mice with GD (group GD)-had mean stomach weight with ingesta of 0.5 +/- 0.02 g, 1.09 +/- 0.07 g (P < 0.0001), and 2.54 +/- 0.4 g (P < 0.0001), respectively. Mean serum creatinine concentration was significantly higher in GD (1.6 +/- 0.25 mg/dl), compared with NGD (0.17 +/- 0.22 mg/dl, P < 0.0001) and control (0.2 +/- 0.16 mg/ dl, P < 0.0001) mice. In addition, lesions consistent with severe chronic nephropathy and mild gastritis were common in GD, compared with NGD and control mice. Finally, serum amidated gastrin concentration was significantly high in GD (179.37 +/- 53.86 pM, P < 0.03) and NGD (264.89 +/- 115.89 pM, P < 0.009), compared with control (60.77 +/- 8.39 pM) mice. Gastric dilatation syndrome is associated with chronic nephropathy, hypergastrinemia, and gastritis in surveillance mice exposed to high levels of environmental antigens.

Typhlocolitis in NF-kappa B-deficient mice

Activation of inflammatory gene expression by the transcription factor NF-kappaB is a central pathway in many inflammatory disorders, including colitis. Increased NF-kappaB activity has been linked with development of colitis in humans and animal models, thus it was unexpected when NF-kappaB-deficient mice developed spontaneous typhlocolitis. To further characterize this finding, we induced typhlocolitis in rederived NF-kappaB-deficient mice using intragastric infection with Helicobacter hepaticus. At 6 wk postinfection (PI), severe colitis with increased type 1 cytokine expression was seen in infected mice that lacked the p50 subunit of NF-kappaB and were also heterozygous for the p65 subunit of NF-kappaB(p50(-/-)p65(+/-)). Mice lacking the p50 subunit alone (p50(-/-)) were less severely affected, and wild-type mice and p65(+/-) mice were unaffected. T cell development in NF-kappaB-deficient mice was normal. These data indicate that p50 and p65 subunits of NF-kappaB have an unexpected role in inhibiting the development of colitis.

E2F4 is essential for normal erythrocyte maturation and neonatal viability

The retinoblastoma protein (pRB) plays a key role in the control of normal development and proliferation through the regulation of the E2F transcription factors. We generated a mutant mouse model to assess the in vivo role of the predominant E2F family member, E2F4. Remarkably, loss of E2F4 had no detectable effect on either cell cycle arrest or proliferation. However, E2F4 was essential for normal development. E2f4-/- mice died of an increased susceptibility to opportunistic infections that appeared to result from craniofacial defects. They also displayed a variety of erythroid abnormalities that arose from a cell autonomous defect in late stage maturation. This suggests that E2F4 makes a major contribution to the control of erythrocyte development by the pRB tumor suppressor.

Pheromone-regulated genes required for yeast mating differentiation

Yeast cells mate by an inducible pathway that involves agglutination, mating projection formation, cell fusion, and nuclear fusion. To obtain insight into the mating differentiation of Saccharomyces cerevisiae, we carried out a large-scale transposon tagging screen to identify genes whose expression is regulated by mating pheromone. 91,200 transformants containing random lacZ insertions were screened for beta-galactosidase (beta-gal) expression in the presence and absence of alpha factor, and 189 strains containing pheromone-regulated lacZ insertions were identified. Transposon insertion alleles corresponding to 20 genes that are novel or had not previously been known to be pheromone regulated were examined for effects on the mating process. Mutations in four novel genes, FIG1, FIG2, KAR5/ FIG3, and FIG4 were found to cause mating defects. Three of the proteins encoded by these genes, Fig1p, Fig2p, and Fig4p, are dispensible for cell polarization in uniform concentrations of mating pheromone, but are required for normal cell polarization in mating mixtures, conditions that involve cell-cell communication. Fig1p and Fig2p are also important for cell fusion and conjugation bridge shape, respectively. The fourth protein, Kar5p/Fig3p, is required for nuclear fusion. Fig1p and Fig2p are likely to act at the cell surface as Fig1:: beta-gal and Fig2::beta-gal fusion proteins localize to the periphery of mating cells. Fig4p is a member of a family of eukaryotic proteins that contain a domain homologous to the yeast Sac1p. Our results indicate that a variety of novel genes are expressed specifically during mating differentiation to mediate proper cell morphogenesis, cell fusion, and other steps of the mating process.

Implantation of cardioverter defibrillator and pacemaker using the same pectoral quadrant

We implanted a cardioverter defibrillator (ICD) together with a pacemaker system in three patients with ventricular tachycardia and bradyarrhythmias. Both systems (ICD and pacemaker) were implanted in the same left pectoral quadrant using a single skin incision and the subclavian and/or the cephalic vein. The ICD was implanted deep to the pectoralis major muscle, the pacemaker was placed subcutaneously in a more medial pocket. There were no technical difficulties during implantation or complications during follow-up.

Single pass lead VDD pacing in children and adolescents

Implantation of permanent pacemakers in children and adolescents is possible but usually is limited to single chamber generators. The natural growth of these patients may require physiological pacing, but until recently two leads were required for this type of pacing. The single pass lead VDD pacing mode makes possible physiological pacing by using only one lead, for both atrial sensing and ventricular sensing and pacing. The feasibility of VDD pacing using endocardial lead was evaluated in 16 children and adolescents with congenital or postsurgical atrioventricular block. Their mean age was 7.9 +/- 4.9 years (range 1-16 years) and the smallest patient's weight was 8.2 kg. In all the patients, a single pass pacing lead with atrial sensing rings and bipolar ventricular pacing and sensing capability was implanted through the left or right subclavian vein. The pacemaker generator was implanted in a rectopectoral position. The mean atrial electrogram during the implantation was 4.2 +/- 2.1 mV and 2.6 +/- 1.9 mV after a mean of 1 week. The ventricular pacing threshold was 0.5 +/- 0.2 V; the ventricular pacing impedance was 560 +/- 95 omega; and the ventricular electrogram amplitude was 9.9 +/- 2.1 mV. This is a first report to demonstrate the feasibility of atrial synchronous ventricular endocardial pacing using a single pass lead in a relatively large group of children and adolescents.

Single lead VDD pacing: multicenter study

Optimal treatment for patients with AV block and normal sinoatrial node (SA) function entails atrial sensing and ventricular pacing (VDD mode). Single-lead VDD pacing preserves AV synchrony, precludes the need to insert two leads, and makes the implanter's work simpler and quicker. Our objectives were to verify the performance of the Thera VDD pacing system (medtronic, Inc., Minneapolis, MN, USA), and evaluate the effectiveness of its atrial sensing and its ventricular sensing and pacing. In 165 patients, 150 adults (mean age 62 +/- 18 years) and 15 children (mean age 7 +/- 5 years) with 1 degree-3 degrees AV block and normal SA node function, a Thera VDD system (Models 8948 or 8968) was implanted. Intraoperative ventricular electrical measurements were not significantly different from those of VVI pacemakers. The mean amplitude of the atrial signal during implantation was 4.1 +/- 1.9 mV. Optimal atrial signals during implantation were usually obtained in the mid or lower part of the right atrium by using a special technique. Adequate atrial measurements remained stable throughout 24 months. There was no difference between serial measurements of atrial signal amplitudes at predischarge and during follow-up visits. Reposition of the lead was done in 2 patients (1.4%), and reprogramming to VVI in 7 patients: due to atrial fibrillation in 3 (1.8%) and due to atrial undersensing in 4 patients (2.4%). Thera VDD pacing is reliable and easy to manage with dependable atrial sensing and ventricular pacing. The survival rate of VDD pacing at 2 years was 96%.

Geometric reconstruction in left ventricular aneurysm. Surgical aspects and early results

The early results of 79 patients who underwent left ventricular aneurysmectomy with geometric and circular reconstruction in a seven-year experience are analyzed. The most common indication for operation was congestive heart failure (78.4%), either isolated (25.3%) or with angina (53.1%). Sixty patients (76%) were in NYHA class III and 10 (12.6%) in NYHA class IV at the time of surgery. Fifty-eight (73.4%) underwent coronary artery by-pass graft surgery. Hospital mortality was 5.1%, in patients older than 60 (12%), in NYHA class IV (20%), with poor left ventricular function (EF < 0.30-20% and LVED > 25) (14%), and with extensive coronary artery disease (10%) were under increased risk. Low cardiac output and use of intra-aortic balloon pump were also associated risk factors. Other risk factors mentioned in the literature are discussed. There were no deaths from isolated left ventricular aneurysmectomy. The early results of this study and the early and late results of others using the same technique are better than the results obtained in previous studies of different types of correction, suggesting that this is the procedure of choice for treating left ventricular aneurysm.

Cardiomyoplasty review: physiological principles and characteristics of electrically stimulated skeletal muscle. II. A therapeutic option

Chronic heart failure continues unsolved as ever despite recent advances in cardiac surgery and pharmacological new armamentarium and remains a significant cause of death, regardless of etiology. Cardiomyoplasty (CMP), a new form of biomechanical ventricular support, has given new life to the field of mechanical circulatory support, providing a "bridge" to transplantation and serving as a possible alternative to surgical treatment. The geographic distribution of world experience in 401 patients shows that 80% were centralized in Europe (50%) and South America (30%). This review of the data analysis, documented improved changes in patients clinical status, further clarifies and appropriate patients population indications for DCMP as well as that more than 80% survival probability for NYHA class II & III and an early procedure related mortality of 8 to 10%.

Plasticity in spinal opioid control of lower urinary tract function in paraplegic cats

Spinal cord injury disrupts micturition reflexes, which produces morbidity. The contribution of endogenous opioid systems to urinary retention were assessed in chronic spinal cats by administering the opioid receptor antagonist, naloxone (5-500 micrograms kg-1, i.p.), to unanesthetized paraplegic cats while monitoring lower urinary tract function and observing hind limb reflexes. While naloxone had no overt effect in acute spinal cats, in chronic spinal cats naloxone induced the release of large volumes of urine and produced marked hind limb hyper-reflexia. Prominent tachyphylaxis and tolerance to the effects of naloxone were evident. Immunohistochemical studies indicated a marked increase in leucine enkephalin and dynorphin in sacral spinal neurons. Together, these data indicate hyperactivity of the endogenous spinal opioid system following recovery from spinal cord injury and, furthermore, suggest that the spinal neural circuitry may become 'dependent' upon elevated levels of endogenous opioid peptides.

Localization of peripheral pulmonary nodules for thoracoscopic excision: value of CT-guided wire placement

OBJECTIVE

One of the indications for the rapidly expanding use of thoracoscopic surgery as an alternative to thoracotomy is the excision of peripheral lung nodules. Nodules judged too small or too far from the pleural surface to be seen or palpated during thoracoscopy must be localized beforehand. The purpose of this study was to evaluate the feasibility and effectiveness of percutaneous placement of spring hookwires to localize such nodules before video-assisted thoracoscopy.

SUBJECTS AND METHODS

Under CT guidance, 17 nodules in 14 patients were preoperatively localized with the Kopans breast lesion localization system. Three patients who had solitary nodules had thoracoscopic resections for diagnosis because a previous transthoracic needle or transbronchial biopsy had been unsuccessful. Four patients who had lesions less than 8 mm in diameter had thoracoscopic biopsies because transthoracic fine-needle aspiration biopsy was not likely to be diagnostic. Seven patients, who had a total of 10 nodules, had therapeutic wedge resections of either limited metastases or a second bronchogenic carcinoma. Mean nodule diameter was 10 mm (range, 3-20 mm). The mean distance from nodule to costal pleura was 9 mm (range, 0-25 mm). At the end of the procedure, wire placement was confirmed by CT scanning. After thoracoscopy, the surgeons were questioned about the stability and utility of each hookwire localization.

RESULTS

In all 17 procedures, a hookwire was placed successfully. In one case, the wire dislodged before thoracoscopy (after a 6-hr preoperative delay and severe bending of the wire during induction of anesthesia). In 16 of the 17 resections, the surgeon thought that thoracoscopic identification of the lesion would not have been possible without hookwire localization. Only one localization, across a major fissure, required placement of a second wire to localize a nodule. Wire-related complications included two instances of serious pain, five cases of clinically insignificant pneumothorax, and one large pneumothorax requiring drainage before a second nodule in the same lung was localized. CT scanning showed presumed local pulmonary hemorrhage in six cases without hemoptysis or hemothorax.

CONCLUSION

CT-guided hookwire localization is easily and safely performed and permits thoracoscopic resection of lung nodules, which might otherwise be impossible.

Seven years of left ventricular pacing due to malposition of pacing electrode

The case report is presented of a patient in whom an uncomplicated left ventricular transvenous pacing produced right bundle branch block (RBBB). A diagnostic echocardiography, confirmed by cine cardiovascular computed tomography, showed that there was no rupture of the right ventricle and diagnosed a left ventricular pacing, due to malposition of the pacing electrode. The patient was treated with aspirin and dipyridamole during the last 6 years of follow-up, without any complications, including 1 year of pacing, prior to admission.

Alterations in afferent pathways from the urinary bladder of the rat in response to partial urethral obstruction

Afferent pathways from the urinary bladder were examined with axonal tracing techniques in normal female Wistar rats and in those with partial urethral ligation. Following injection of wheat germ agglutinin-horseradish peroxidase (HRP) into the bladder wall, HRP was detected in lumbosacral dorsal root ganglion cells and in afferent projections to the L6-S1 spinal cord at sites in laminae I, II, V-VII, and X known to receive visceral afferent input. Partial urethral ligation (6 weeks) produced a sixfold increase in bladder weight and altered the morphology of bladder afferent pathways. Changes included an increase in the average cross-sectional area of labelled neuronal profiles in L6 and S1 dorsal root ganglia in obstructed (766 +/- 378 microns 2, P less than 0.001) compared to control rats (528 +/- 189 mu 2). The cross-sectional area of the largest profiles also increased by approximately 40%. The mean number of labelled dorsal root ganglion cell profiles was similar in ligated (837 +/- 198) and control (883 +/- 352) groups. When compared to control animals the obstructed animals exhibited a 60% increase in the area of the labelled afferent terminal field in the intermediolateral region of the L6-S1 spinal cord. This increased labelling was even more remarkable given that the volume of tracer per bladder weight injected into the hypertrophied bladder was 87% less than controls. These results provide evidence that bladder afferents project to regions of the spinal cord known to regulate micturition and that these afferents can undergo morphological alterations and/or changes in axoplasmic transport in response to urethral ligation. Changes may occur in response to increased target organ mass, increased neural activity, or alterations in the levels or activity of neurotrophic factors.

Neonatal hepatitis and extrahepatic biliary atresia associated with cytomegalovirus infection in twins

Prenatally acquired cytomegalovirus infection in twins was temporally associated with a discordant development of neonatal hepatitis and extrahepatic biliary atresia. This case presents evidence suggesting an association between perinatal cytomegalovirus infection and selected extrahepatic biliary atresia and neonatal hepatitis. Congenital cytomegalovirus infections and cytomegalovirus hepatitis are also discussed.

Postnatal development of opioid regulation of micturition in the kitten

Endogenous opioids tonically regulate micturition in adult mammals. The present study sought to determine if opioids regulate micturition in neonatal kittens. Naloxone (up to 2 mg/kg given i.p. or i.v. to unanesthetized/ketamine-anesthetized or chloralose-anesthetized kittens, respectively), an opioid receptor antagonist, produced no effects in unanesthetized, ketamine-anesthetized, or chloralose-anesthetized kittens that had been prepared for bladder pressure recording, until 3 weeks of age. This indicates that endogenous opioids are not tonically regulating micturition in neonatal kittens. From 3 weeks up to at least 6 weeks of age, naloxone (100 micrograms/kg i.p. or i.v.) weakly facilitated bladder activity by transiently increasing the amplitude and/or duration of bladder contractions, but no effects on frequency of contractions was recorded. Morphine (up to 2 mg/kg given i.p. or i.v. to unanesthetized/ketamine-anesthetized or chloralose-anesthetized kittens, respectively), an opioid agonist, did not inhibit bladder contractions in unanesthetized or ketamine-anesthetized neonatal kittens, but it did inhibit (at a threshold dose of 100 micrograms/kg) and completely abolished (at a dose of 300 micrograms/kg) bladder activity in chloralose-anesthetized kittens in a dose-dependent, naloxone-reversible manner. Surprisingly, following morphine administration to unanesthetized or ketamine-anesthetized neonatal kittens, naloxone now produced an adult-like enhancement of bladder activity. These latter results indicate that opioid receptors, whose inhibitory effects are anesthetic-dependent, are present along the micturition reflex pathway in neonates. Immunohistochemical studies of the sacral spinal cord revealed that opioid peptides are distributed similarly in neonatal and adult cats.

Morphological plasticity in efferent pathways to the urinary bladder of the rat following urethral obstruction

Partial urethral ligation in female Wistar rats produces changes in the neural control of the lower urinary tract including bladder hyperactivity and facilitation of a spinal micturition reflex pathway. To gain insight into the mechanisms underlying these changes, axonal tracing studies were conducted to examine the postganglionic efferent limb of the micturition reflex pathway which originates in the major pelvic ganglion (MPG). Forty microliters of the tracer Fluoro-Gold (4%) were injected into the right side of the bladder in urethral-obstructed (n = 10) and control (n = 4) rats 6 weeks after urethral ligation or sham surgery. As a control Fast blue (40 microliters, 5%) was injected into the colon to label neurons in the MPG innervating the intestine. Obstructed rats exhibited a 6-fold increase (p less than 0.001) in bladder weight (0.848 gm) compared to controls (0.148 gm). A significant increase (p less than 0.001) in the size of labeled bladder postganglionic neurons in the MPG was noted in obstructed rats (576.4 microns 2, n = 4) as compared to controls (299.6 microns 2). However, labeled, colon postganglionic neurons in the MPG in obstructed (312.9 microns 2) rats were not enlarged compared to controls (359.4 microns 2). Neuronal hypertrophy was not associated with a change in the number of labeled MPG neurons in control and obstructed groups.(ABSTRACT TRUNCATED AT 250 WORDS)

Safety precautions in the management of patients with pacemakers when electrocautery operations are performed

The hazards related to ten patients who underwent 11 urologic surgical procedures during a 36 month period were taken into consideration. Electrocautery was used in all instances and there were no complications. All of the pacemakers were preset for ventricular pacing and sensing inhibited or multiprogrammable and were reprogrammed during the operation to ventricular pacing fixed rate mode or magnet mode, with very satisfactory outcome. To avoid life-threatening situations arising from pacemaker inhibition or ventricular fibrillation during cautery for transuretheral resection, three basic factors were considered: 1, appropriate type of pacemaker; 2, the proper grounding of all medical electronic equipment used during the procedure, and 3, the directing of the complete flow of the electrocautery circuits substantially below the level of the pacemaker unit.

Polymorphous ventricular tachycardia and atrioventricular block

Nine patients are presented who had polymorphous ventricular tachycardia (PMVT) occurring during atrioventricular (AV) block. There were five men and four women with a mean age of 80 +/- 9 years. Five patients had organic heart disease and the remaining four had primary conduction disease (bundle branch block). AV block was complete in four patients (2:1 in three, and paroxysmal in two). The mean ventricular cycle length (of the AV block rhythm) was 1567 +/- 203 ms. The mean QT interval was 0.64 +/- 0.09 s and the mean QTc was 0.51 +/- 0.06 s. When compared to a similar control group with AV block but without PMVT, the ventricular cycle length was similar but the QT and QTc were significantly longer. PMVT was usually of short duration (eight beats to 12 s) and in seven of these nine patients, frequent premature ventricular beats (PVBs) were recorded at various times from the occurrence of PMVT. This is in contrast to the control patients in whom PVBs were detected in one patient only. In conclusion, patients with AV block who develop PMVT usually have longer QT intervals and have detectable PVBs on routine ECGs, unlike similar patients with AV block but without PMVT. In a patient with AV block, a QT interval above 0.60 s and PVBs on the ECG seem to indicate an increased risk for the development of PMVT.

Closed pericardial drainage for relief of pericardial tamponade

The method of continuous catheter drainage for pericardial tamponade as used in 108 patients is described. The efficacy of this procedure in relieving tamponade resulting from a variety of diseases is demonstrated. Blood clot in the pericardium probably constitutes a contraindication to catheter drainage.

Use of the Shaw Scalpel in pacemaker operations

Pacemaker carriers are at risk when undergoing operations involving the use of diathermy. The Shaw Scalpel utilizes a method by which the cutting edge of the blade is heated to a selected temperature that seals blood vessels as they are cut. No electrical currents are passed to or through the patient and there is no sparking or electrical arcing to the tissue. This apparatus was used as the sole method of thermal coagulation in 20 patients undergoing replacement of pacemaker batteries.

A simple method for insertion of a left atrial catheter in congenital heart disease

A relatively simple and safe method is described for the insertion of a left atrial pressure line in patients undergoing operation for repair of congenital heart defects. This method has been utilized successfully in 12 patients undergoing repair of a ventricular septal defect and tetralogy of Fallot.

A simple method for closure of patient ductus arteriosus in elderly patients

A relatively simple and safe method for closure of the patient ductus arteriosus in the elderly patient is described. It has been done successfully in 4 patients.

Haemopericardium as a late complication in anticoagulant therapy following mitral valve replacement

Two patients, who suffered from pericardial tamponade in the course of prophylactic anticoagulant treatment, are reported. The mitral valve had been replaced by a prosthesis in both cases. The diagnosis was suspected clinically and radiologically and proven by pericardiocentesis. One of the patients was treated by a percutaneously inserted small polyethylene tube for continous drainage and the other by thoracotomy and partial pericardiectomy. Both patients recovered and are at present asymptomatic. Th mechanism of bleeding patients receiving anticoagulant therapy is briefly discussed.

Ureteral substitute by fallopian tube. Experimental study

Experimental substitution of a long segment of ureter by a fallopian tube was performed in dogs. Three different techniques of proximal and distal anastomosis for reconstruction of the urinary tract were used in three groups of animals. Based on this, it is believed that the fallopian tube, as a pedicle graft, could serve in female dogs as the most approximate ideal substitute for ureter because of (a) anatomic proximity to the ureter permitting blood supply to the tube, (b) the fallopian tube's mucosa lining is not affected by urinary excretions, (c) does not allow absorption of electrocytes, (d) has a muscular wall with peristaltic activity, and (e) avoids the problems of antigenicity and/or foreign body reaction.