Surgical treatment of the severely ischaemic leg: I. Survival rates

Over a 10-year period, 411 patients with atherosclerotic major artery disease causing severe ischaemia of the legs were treated by surgery. Their survival rate, assessed by the life table method, was 80 per cent at 1 year and 50 per cent at 5 years. Early and late survival rates were significantly worse in elderly patients, and in patients with extensive gangrene. Late survival rates were significantly worse in diabetics, and in patients with clinical myocardial ischaemia. Patients treated by arterial reconstruction showed a better survival rate than those treated by sympathectomy or amputation, though the latter groups contained more poor risk patients. Survival rates were not influenced by the technique of reconstruction.

The effect of smoking on the late patency of arterial reconstructions in the legs

In a retrospective study of 217 patients, smoking habits were related to the late patency rates of arterial reconstructions performed for ischaemia of the legs. Patients who had stopped smoking or who smoked no more than 5 cigarettes per day after the operation had late patency rates of approximately 90 per cent for aortofemoral reconstructions and 80 per cent for femoropopliteal vein grafts. Patients who continued to smoke more than 5 cigarettes per day were approximately three times more likely to block an aortofemoral reconstruction and four times more likely to block a femoropopliteal vein graft. The results were similar for males and females, for various age groups, for claudicants and patients with severe ischaemia and for aortofemoral endarterectomy and Dacron grafts. The late patency rate was approximately inversely proportional to the number of cigarettes smoked per day after the operation. There was no such correlation with the number smoked per day before the operation.

Improved colorimetric determination of aspirin and salicylic acid concentrations in human plasma

An improvement in a previously described method for the determination of plasma salicylic acid and aspirin levels in humans is described. The procedure was simplified by employing only one plasma sample for both salicylates. More accurate estimation of salicylates, particularly aspirin, was achieved by using two different calibration curves. Salicylic acid was estimated by reaction with an aqueous solution of the Folin-Ciocalteu phenol reagent. Absorbance of the blue-colored complex, which formed on addition of sodium hydroxide, was measured at 670 nm. The influence of alkalinity in the formation of the colored complex is discussed. The average recovery of aspirin added to plasma was 94.61%; it was 214.72% by the previous method.

Aneurysm formation in an expanded microporous polytetrafluorethylene graft

Microporous expanded polytetrafluoroethylene (PTFE) has recently been proposed as an arterial graft. Although excellent graft patency rates have been achieved both experimentally and clinically, aneurysm formation of the graft has occurred in a small number of cases. This report describes a further case of aneurysm formation in a PTFE graft five months after insertion. We discuss the possible causes of graft aneurysm formation and a newly developed reinforced form of PTFE graft.

Mixed bacterial meningitis: a complication of ventriculo- and lumboperitoneal shunts

Infectious complications of ventriculo- and lumboperitoneal shunts in two patients are presented. Cerebrospinal fluid infection due to aerobic and anaerobic enteric flora was characteristic of each case. Both infections occurred several months after shunt surgery and were associated with colonic perforation by the distal limb of the peritoneal catheter. These cases emphasize this unusual hazard of peritoneal shunts and demonstrate methods for diagnosis and effective therapy.

Carotid cavernous fistula in pregnancy

A carotid-cavernous fistula in pregnancy is not rare. Increasing pain and worsening of the proptosis made prompt operative intervention necessary. The fact that other known cerebrovascular lesions lend themselves to surgical attack without undue risk during this time8--11 prompted us to proceed with surgery. There was no adverse effect on the pregnancy, other than premature delivery. Both the mother and child are doing well 4 years after surgery.

Changes in role perceptions by first-year dental students

Dental education combines the learning of technical skills with the professional role of health care provider. The investigation compared first-year dental students perception of themselves, dental practitioners, dental school upper-class students, and patients. The study indicated that first-year students are more likely to identify with upper-class students than with dental practitioners. They also tended to see themselves as clearly different from dental patients. It is suggested that dental educators should recognize this fact in order to avoid the depersonalization of dental care delivery.

Pleuroscopy and cautery control of intrathoracic hemorrhage with a flexible fiberoptic bronchoscope

Intrathoracic hemorrhage from adhesions torn by a spontaneous pneumothorax is relatively uncommon. Continued hemorrhage from such adhesions after the evacuation of 1,500 ml of blood would usually require thoracotomy for control. Through a flexible fiberoptic bronchoscope, we confirmed the source of hemorrhage and cauterized the bleeding point. This case illustrates another application for pleuroscopic examination, further broadening the use of the flexible fiberoptic bronchoscope.

Descending thoracic aortofemoral bypass for distal aortic reconstruction after removal of an infected dacron prosthesis

A simplified technique of descending thoracic aortofemoral bypass is presented. This technique was employed successfully in a patient in whom an infected aortofemoral Dacron bypass was removed and an axillofemoral reconstruction had failed.

Changes in intra-vascular complement and anti-treponemal antibody titres preceding the Jarisch-Herxheimer reaction in secondary syphilis

Six patients with secondary syphilis and one control subject were observed over a period of up to 8 hr following the administration of either penicillin or erythromycin. Serial clinical observations were made and blood samples obtained for complement and serological analysis. The patients showed Jarisch-Herxheimer reactions (JHR) of varying intensity which were found to be preceded by and to parallel in degree certain changes in complement and syphilitic antibody titres. Falls in total haemolytic complement, in C4, C3, C6 and C7 and a marked drop in C1INH were observed. There was no change in total GBG/GGG or evidence of conversion of GBG to GGG. Associated falls occurred in the titres of the QFTA and the QTPHA antibodies but not of the QVDRL or QTPI antibodies. C3 conversion was found in the two patients that suffered severe reactions. Immune complexes were not detected and it is suggested that complement activation occurred in the extra-vascular body compartment. The significance of these changes in relation to other plasma enzyme systems and to the development of the full clinical picture of the JHR is discussed.

Ruptured iliac aneurysms

Iliac aneurysms are uncommon as compared with aneurysms of the abdominal aorta. Rupture is the most serious complication of aneurysms of both vessels. Considerable attention has been focused on the management of ruptured abdomonal aortic aneurysms, but ruptured iliac aneurysms have received little notice. The problems in the management of ten ruptured iliac aneurysms, seen over the last five years, together with the rarity of other reports of this condition, have stimulated this review.

The management of popliteal aneurysms

Twenty-three patients with 34 popliteal aneurysms were treated between 1963 and 1974. Nearly half of the aneurysms were the site of thrombosis when they first presented, and of these nearly half required a major amputation. Surgical treatment of aneurysms in which the popliteal artery was patent was satisfactory; the only failure occurred when a Dacron graft became occluded after eight years. A small group of patients was observed for an average of one year, during which time the thrombus in one aneurysm embolized and one aneurysm became occluded, necessitating an amputation. The results of this series suggest that the prognosis for a limb with popliteal aneurysm depends on the patency of the popliteal artery at the time of the initial presentation, and lends support to the belief that popliteal arteries with aneurysms are best reconstructed before the onset of a serious complication.

Response decrement as a function of effort

Albino rats were given acquisition training on a 6 ft. enclosed straight alley runway which could be adjusted for inclinations of 0°, 20°, and 40°. After receiving equal training on each of the three effort conditions, three groups of subjects were given massed extinction trials for 30 min. on only one effort condition. Results indicated fewer responses during extinction under the greater effort conditions. These results support a relation between effort and response decrement in extinction, consistent with the predictions of Hull's theory of reactive inhibition.