The educational value of ward rounds as a learning and teaching opportunity for house officers, medical officers, and registrars in Sudanese hospitals: a multi-center cross-sectional study

BACKGROUND

Ward rounds are a cornerstone in the educational experience of junior doctors and an essential part of teaching patient care. Here, we aimed to assess the doctors' perception of ward rounds as an educational opportunity and to identify the obstacles faced in conducting a proper ward round in Sudanese hospitals.

METHOD

A cross-sectional study was conducted from the 15^th to the 30^th of January 2022 among house officers, medical officers, and registrars in about 50 teaching and referral hospitals in Sudan. House officers and medical officers were considered the learners, while specialist registrars were considered the teachers. Doctors' perceptions were assessed using an online questionnaire, with a 5-level Likert scale to answer questions.

RESULTS

A total of 2,011 doctors participated in this study (882 house officers, 697 medical officers, and 432 registrars). The participants were aged 26.9 ± 3.2 years, and females constituted about 60% of the sample. An average of 3.1 ± 6.8 ward rounds were conducted per week in our hospitals, with 11.1 ± 20.3 h spent on ward rounds per week. Most doctors agreed that ward rounds are suitable for teaching patient management (91.3%) and diagnostic investigations (89.1%). Almost all the doctors agreed that being interested in teaching (95.1%) and communicating appropriately with the patients (94.7%) make a good teacher in ward rounds. Furthermore, nearly all the doctors agreed that being interested in learning (94.3%) and communicating appropriately with the teacher (94.5%) make a good student on ward rounds. About 92.8% of the doctors stated that the quality of ward rounds could be improved. The most frequently reported obstacles faced during ward rounds were the noise (70%) and lack of privacy (77%) in the ward environment.

CONCLUSION

Ward rounds have a special value in teaching patient diagnosis and management. Being interested in teaching/learning and having good communication skills were the two major criteria that make a good teacher/learner. Unfortunately, ward rounds are faced with obstacles related to the ward environment. It is mandatory to ensure the quality of both ward rounds' teaching and environment to optimize the educational value and subsequently improve patient care practice.

Chemical features mining provides new descriptive structure-odor relationships

An important goal in researching the biology of olfaction is to link the perception of smells to the chemistry of odorants. In other words, why do some odorants smell like fruits and others like flowers? While the so-called stimulus-percept issue was resolved in the field of color vision some time ago, the relationship between the chemistry and psycho-biology of odors remains unclear up to the present day. Although a series of investigations have demonstrated that this relationship exists, the descriptive and explicative aspects of the proposed models that are currently in use require greater sophistication. One reason for this is that the algorithms of current models do not consistently consider the possibility that multiple chemical rules can describe a single quality despite the fact that this is the case in reality, whereby two very different molecules can evoke a similar odor. Moreover, the available datasets are often large and heterogeneous, thus rendering the generation of multiple rules without any use of a computational approach overly complex. We considered these two issues in the present paper. First, we built a new database containing 1689 odorants characterized by physicochemical properties and olfactory qualities. Second, we developed a computational method based on a subgroup discovery algorithm that discriminated perceptual qualities of smells on the basis of physicochemical properties. Third, we ran a series of experiments on 74 distinct olfactory qualities and showed that the generation and validation of rules linking chemistry to odor perception was possible. Taken together, our findings provide significant new insights into the relationship between stimulus and percept in olfaction. In addition, by automatically extracting new knowledge linking chemistry of odorants and psychology of smells, our results provide a new computational framework of analysis enabling scientists in the field to test original hypotheses using descriptive or predictive modeling.

An important issue in olfaction sciences deals with the question of how a chemical information can be translated into percepts. This is known as the stimulus-percept problem. Here, we set out to better understand this issue by combining knowledge about the chemistry and cognition of smells with computational olfaction. We also assumed that not only one, but several physicochemical models may describe a given olfactory quality. To achieve this aim, a first challenge was to set up a database with ~1700 molecules characterized by chemical features and described by olfactory qualities (e.g. fruity, woody). A second challenge consisted in developing a computational model enabling the discrimination of olfactory qualities based on these chemical features. By meeting these 2 challenges, we provided for several olfactory qualities new chemical models describing why an odorant molecule smells fruity or woody (among others). For most qualities, multiple (rather than a single) chemical models were generated. These findings provide new elements of knowledge about the relationship between odorant chemistry and perception. They also make it possible to envisage concrete applications in the aroma and fragrance field where chemical characterization of smells is an important step in the design of new products.

Mechanisms of microthrombosis and microcirculatory constriction after experimental subarachnoid hemorrhage

Microcirculatory dysfunction may contribute to delayed cerebral ischemia after subarachnoid hemorrhage (SAH). This study investigated structural changes in microvessels and their relationship to brain injury after SAH. We used 15 mice (n = 5 for each group) to create sham, saline-injected (100 μl 0.9% NaCl) or SAH (100 μl autologous blood) model by injection into the prechiasmatic cistern. We sacrificed mice 2 days after surgery and examined the brains using scanning electron microscopy (SEM), transmission electron microscopy (TEM), and immunohistochemical staining of fibrinogen. We assessed neuronal apoptosis by terminal deoxynucleotidyl transferase dUTP (deoxyuridine triphosphate) nick end labeling (TUNEL). Nitric oxide (NO) was measured with 4,5-diaminofluorescein-2-diacetate. TEM and SEM demonstrated that mice with SAH had significantly more of them arterioles with lesion characteristics consistent with microthrombi. Microthrombi number correlated with the number of apoptotic neurons and decreased NO in the brain. In conclusion, SAH causes microthrombosis and constriction of arterioles, which correlates with neuronal death and decreased NO. These data suggest NO depletion may contribute to the formation of microthrombosis and arteriolar constriction, which in turn results in neuronal cell death.

Pharmacologic reduction of angiographic vasospasm in experimental subarachnoid hemorrhage: systematic review

Animal models have been developed to simulate angiographic vasospasm secondary to subarachnoid hemorrhage (SAH) and to test pharmacologic treatments. Our aim was to evaluate the effect of pharmacologic treatments that have been tested in humans and in preclinical studies to determine if animal models inform results reported in humans. A systematic review and meta-analysis of SAH studies was performed. We investigated predictors of -translation from animals to humans with multivariate logistic regression. Pharmacologic reduction of vasospasm was effective in mice, rats, rabbits, dogs, nonhuman primates, and humans. Animal studies were generally of poor methodologic quality, and there was evidence of publication bias. Fresh blood injection to simulate SAH (vs. clot placement) and evaluation of vasospasm more than 3 days after SAH were independently associated with successful translation. We conclude that reduction of vasospasm is effective in animals and humans, and that injection of fresh blood and evaluation of vasospasm more than 3 days after SAH may be preferable for preclinical models.

Pharmacologic reduction of angiographic vasospasm in experimental subarachnoid hemorrhage: systematic review and meta-analysis

Animal models have been developed to simulate angiographic vasospasm secondary to subarachnoid hemorrhage (SAH) and to test pharmacologic treatments. Our aim was to evaluate the effect of pharmacologic treatments that have been tested in humans and in preclinical studies to determine if animal models inform results reported in humans. A systematic review and meta-analysis of SAH studies was performed. We investigated predictors of translation from animals to humans with multivariate logistic regression. Pharmacologic reduction of vasospasm was effective in mice, rats, rabbits, dogs, nonhuman primates (standard mean difference of -1.74; 95% confidence interval -2.04 to -1.44) and humans. Animal studies were generally of poor methodologic quality and there was evidence of publication bias. Subgroup analysis by drug and species showed that statins, tissue plasminogen activator, erythropoietin, endothelin receptor antagonists, calcium channel antagonists, fasudil, and tirilazad were effective whereas magnesium was not. Only evaluation of vasospasm >3 days after SAH was independently associated with successful translation. We conclude that reduction of vasospasm is effective in animals and humans and that evaluation of vasospasm >3 days after SAH may be preferable for preclinical models.

Effects of timed artificial insemination following estrus synchronization in postpartum beef cattle

The objectives of this study were to evaluate estrus response and pregnancy rates resulting from timed artificial insemination (AI) following estrus synchronization using CIDR in postpartum beef cattle. A total of 100 cows were randomly divided into three groups. Groups 1, 2 and 3 were artificially inseminated at 48-50 h (n=30), 53-55 h (n=30) and 58-60 h (n=40) after CIDR removal, respectively. Estrus synchronization was carried out using a CIDR containing 1.38 mg progesterone. All cows were given 2 mg estradiol benzoate, intramuscularly on the day of CIDR insertion (D 0). The CIDR was removed after 8 days and 125 μg of prostaglandin F2α (PGF2α) was injected intramuscularly. One day after CIDR removal all cows were given 1 mg of estradiol benzoate intramuscularly (D 9). Cows were observed visually for estrus after removal of CIDR. Between 30 and 32 days after timed AI, pregnancy was determined using transrectal ultrasonography. The first estrus observation which is approximately 32 h after CIDR removal showed no significant difference (P>0.05) among the three groups. The onset response of estrus after 32 h removal of CIDR was less than 10% in all three groups 6.6% (G1), 6.8% (G2) and 7.3% (G3). Furthermore, percentages of estrus response (D 10) following CIDR removal were 76.6%, 75.0% and 77.5%. The difference between on D 9 and D 10 estrus response were statistically significant (P<0.05). The pregnancy rates were 23.3% (G1), 26.6% (G2) and 37.5% (G3), which were not significant (P>0.05).

Dissociation of Vasospasm and Secondary Effects of Experimental Subarachnoid Hemorrhage by Clazosentan

Background and Purpose—

Endothelin receptor antagonists such as clazosentan decrease large-artery vasospasm after experimental and clinical subarachnoid hemorrhage. We used clazosentan to gain insight into the pathophysiology of subarachnoid hemorrhage by determining if decreasing vasospasm is associated with alleviation of other secondary complications of subarachnoid hemorrhage such as oxidative stress, endothelial nitric oxide synthase dysfunction, microthromboembolism, and neuronal injury.

Methods—

Mice were subjected to subarachnoid hemorrhage by injection of blood into the chiasmatic cistern. They were treated with clazosentan or vehicle by continuous intraperitoneal infusion for 48 hours. Middle cerebral artery vasospasm, superoxide anion radical, peroxynitrite, microthromboemboli, endothelial nitric oxide synthase uncoupling, cerebral blood flow, neuronal injury, and mortality were assessed.

Results—

Clazosentan preserved cerebral blood flow, alleviated vasospasm, and decreased mortality but did not affect superoxide anion radical, peroxynitrite, or microthromboemboli in the brain. Endothelial nitric oxide synthase uncoupling and neuronal injury also were not reduced by clazosentan.

Conclusions—

This study shows large-artery vasospasm is pathophysiologically independent of some other effects of subarachnoid hemorrhage. The findings have implications for development of treatments for this disease.

Anterior circulation mouse model of subarachnoid hemorrhage

A model of subarachnoid hemorrhage (SAH) first described in rats where blood is injected into the prechiasmatic cistern was adapted to mice. The hypothesis was that such an anterior circulation SAH model would produce vasospasm of greater severity and longer duration than other mouse models. The goal was to create a mouse model that could then be used in transgenic and knockout animals in order to further knowledge of SAH and vasospasm. A needle was inserted stereotactically into the prechiasmatic cistern and 100 microl autologous arterial blood injected over seconds (n=10). Effects were compared to injection of saline (n=10) or to sham operation (n=7). Monitoring of cerebral blood flow by laser Doppler showed a statistically similar decrease during injection in both groups. 7 days after SAH there was vasospasm of the middle and anterior cerebral arteries (51% reduction in MCA radius in SAH compared to saline-injected group, P<0.009, Student's t-test). In order to determine if SAH in this model was associated with neuronal injury, brains were examined for TUNEL and fluoro-jade-positive cells. 60% of SAH but not saline-injected mice exhibited TUNEL-positive cells in the cerebral cortex and 30% of the SAH but no saline-injected mice had fluoro-jade positive cells in the cortex, hippocampus and dentate gyrus. The model is simple to perform and may be useful for investigating the pathophysiology of SAH.

Neuronal and astrocytic apoptosis after subarachnoid hemorrhage: a possible cause for poor prognosis

Clinical evidence suggests that factors other than cerebral vasospasm, such as delayed neuronal and astrocytic cell death, may play a role in the poor prognosis of patients with subarachnoid hemorrhage (SAH). Here we examined this using immunohistochemistry and confocal microscopy in 3 different brain areas in a dog model of SAH. Using antibodies against neuronal marker neuronal nuclear protein (NeuN) and astrocyte marker glial fibrillary acidic protein (GFAP) in conjunction with apoptosis marker (cleaved caspase-3), we quantified neurons and astrocytes to monitor the degree of apoptosis in both groups. Experimental SAH group showed 44 +/- 1% caspase-3 positive neurons in comparison to the 2.0 +/- 0.1% in the control group (P < 0.001, 6 animals each group). For astrocytes, a total 25 +/- 1% were caspase-3 positive in day 7 SAH group, as compared to 0.40 +/- 0.01% for controls (P < 0.001). Regional analysis revealed that neuronal caspase-3 immunoreactivity in all 3 regions were significantly higher (P < 0.001) in SAH animals than that in the control animals. However, the analysis of total area, size and signal co-localization of GFAP with caspase-3 indicated that astrocytic reactivity and proliferation are seen primarily in the hippocampal area, with the least changes detectable in the brainstem. We conclude that in the dog model, there was a significant increase of neuronal and astrocytic cleaved caspase-3, possibly reflecting apoptosis, following SAH induction. These changes coupled with neurological deterioration seen in patients may present a possible reason for the poor outcome in SAH patients.

CYP121, CYP51 and associated redox systems in Mycobacterium tuberculosis: towards deconvoluting enzymology of P450 systems in a human pathogen

An extraordinary array of P450 (cytochrome P450) enzymes are encoded on the genome of the human pathogen Mycobacterium tuberculosis (Mtb) and in related mycobacteria and actinobacteria. These include the first characterized sterol 14alpha-demethylase P450 (CYP51), a known target for azole and triazole drugs in yeasts and fungi. To date, only two Mtb P450s have been characterized in detail: CYP51 and CYP121. The CYP121 P450 shows structural relationships with P450 enzymes involved in synthesis of polyketide antibiotics. Both P450s exhibit tight binding to a range of azole drugs (e.g. clotrimazole and fluconazole) and the same drugs also have potent effects on growth of mycobacteria (but not of e.g. Escherichia coli). Atomic structures are available for both Mtb CYP51 and CYP121, revealing modes of azole binding and intriguing mechanistic and structural aspects. This paper reviews our current knowledge of these and the other P450 systems in Mtb including recent data relating to the reversible conversion of the CYP51 enzyme between P450 (thiolate-co-ordinated) and P420 (thiol-co-ordinated) species on reduction of the haem iron in the absence of a P450 substrate. The accessory flavoprotein and iron-sulfur proteins required to drive P450 catalysis are also discussed, providing an overview of the current state of knowledge of Mtb P450 redox systems.

Attentional modulation in the detection of irrelevant deviance: a simultaneous ERP/fMRI study

Little is known about the neural mechanisms that control attentional modulation of deviance detection in the auditory modality. In this study, we manipulated the difficulty of a primary task to test the relation between task difficulty and the detection of infrequent, task-irrelevant deviant (D) tones (1,300 Hz) presented among repetitive standard (S) tones (1,000 Hz). Simultaneous functional magnetic resonance imaging (fMRI)/event-related potentials (ERPs) were recorded from 21 subjects performing a two-alternative forced-choice duration discrimination task (short and long tones of equal probability). The duration of the short tone was always 50 msec. The duration of the long tone was 100 msec in the easy task and 60 msec in the difficult task. As expected, response accuracy decreased and response time (RT) increased in the difficult compared with the easy task. Performance was also poorer for D than for S tones, indicating distraction by task-irrelevant frequency information on trials involving D tones. In the difficult task, an amplitude increase was observed in the difference waves for N1 and P3a, ERP components associated with increased attention to deviant sounds. The mismatch negativity (MMN) response, associated with passive deviant detection, was larger in the easy task, demonstrating the susceptibility of this component to attentional manipulations. The fMRI contrast D > S in the difficult task revealed activation on the right superior temporal gyrus (STG) and extending ventrally into the superior temporal sulcus, suggesting this region's involvement in involuntary attention shifting toward unattended, infrequent sounds. Conversely, passive deviance detection, as reflected by the MMN, was associated with more dorsal activation on the STG. These results are consistent with the view that the dorsal STG region is responsive to mismatches between the memory trace of the standard and the incoming deviant sound, whereas the ventral STG region is activated by involuntary shifts of attention to task-irrelevant auditory features.

Biodiversity of cytochrome P450 redox systems

P450s (cytochrome P450 mono-oxygenases) are a superfamily of haem-containing mono-oxygenase enzymes that participate in a wide range of biochemical pathways in different organisms from all of the domains of life. To facilitate their activity, P450s require sequential delivery of two electrons passed from one or more redox partner enzymes. Although the P450 enzymes themselves show remarkable similarity in overall structure, it is increasingly apparent that there is enormous diversity in the redox partner systems that drive the P450 enzymes. This paper examines some of the recent advances in our understanding of the biodiversity of the P450 redox apparatus, with a particular emphasis on the redox systems in the pathogen Mycobacterium tuberculosis.

[Canine leishmaniasis in the Rif mountains (Moroccan Mediterranean coast): a seroepidemiological survey]

A sero-epidemiological survey has been conducted in several localities of the province of Nador to investigate canine leishmaniasis in the North-Eastern slope of the Rif mountains (Mediterranean coast of Morocco). Serum samples collected from 257 dogs were analysed using indirect fluorescent antibody test (IFAT) and enzyme-linked immunosorbent assay (ELISA) to detect anti-Leishmania infantum antibodies. Forty eight (18.7%) of the screened dogs were IFAT positive and 54 (21.0%) were ELISA positive; the concordance of the two methods was 96.1%. The prevalence of infection is significantly higher in dogs more than four years of age whereas no significant difference in prevalence of infection was seen between males and females. The frequent symptoms observed in seropositive dogs were the enlargement of lymph nodes (57.4%), emaciation (51.9%) and skin involvement (25.9%). However, 38.9% of those dogs showed no one of the major symptoms of visceral leishmaniasis. Leishmania isolated from three of the examined dogs was identified as L. infantum MON-1. These results show that the North-Eastern slope of the Rif mountains is one of the most active Mediterranean areas of visceral leishmaniasis and confirm that the dog is the main reservoir of L. infantum.

Effects of sequential and temporal probability of deviant occurrence on mismatch negativity

The mismatch negativity (MMN) increases in amplitude as the probability of deviant occurrence decreases. It is unclear whether the determining variable is sequential probability (i.e. the probability of a deviant within a number of standards) or temporal probability (i.e. the probability of a deviant within a period of time). Eight subjects heard a train of frequently occurring 1000 Hz standard tones. The probability of a 1100 Hz pitch deviant was manipulated. In one condition the stimulus-onset-asynchrony (SOA) was 150 ms, with temporal probability of deviant occurrence being either 1/9.00, 1/4.50, 1/2.25, or 1/1.125 s (sequential probability being 1/60, 1/30, 1/15, or 1(deviant)/7.5(standards), respectively). In another condition the SOA was 600 ms, with temporal probability being either 1/9.00, 1/4.50, or 1/2.25 s (sequential probability being 1/15, 1/7.5, or 1/3.75, respectively). In a final condition, the SOA was 2400 ms with temporal probability being 1/9.00 s (sequential probability 1/3.75). Both sequential and temporal probabilities had a marked effect on the MMN. When a deviant occurred every 2.25, 4.50, or 9.00 s, the MMN increased as temporal probability decreased. When a deviant occurred once every 7.5 or 15 standards, the MMN was larger for lower sequential probability, but the effect was not significant. Nevertheless, when temporal probability was held constant at 1/9.00 s, the MMN increased as sequential probability decreased. At rapid rates of stimulus presentation, the MMN was largest. However, it was attenuated when the probability of deviant occurrence was very high perhaps due to the refractoriness of its generator. At the slowest rate, the MMN was diminished perhaps due to memory decay for the standard stimuli.

A confluence of contexts: asymmetric versus global failures of selective attention to stroop dimensions

In 6 experiments probing selective attention through Stroop classification, 4 factors of context were manipulated: (a) psychophysical context, the distinctiveness of values along the color and word dimensions; (b) set size context, the number of stimulus values tested; (c) production context, the mode used to respond; and (d) covariate context, the correlation between the dimensions. The psychophysical and production contexts mainly caused an asymmetry in selective attention failure between colors and words, whereas the set size and covariate contexts contributed primarily to the average or global magnitudes of attentional disruption across dimensions. The results suggest that (a) Stroop dimensions are perceptually separable, (b) J.R. Stroop's (1935) classic findings arose from his particular combination of contexts, and (c) stimulus uncertainty and dimensional imbalance are the primary sources of task and congruity effects in the Stroop paradigm.

The mismatch negativity to frequency deviants during the transition from wakefulness to sleep

This study examines the changes in the Mismatch Negativity during the transition from a waking, conscious state to one of sleep and unconsciousness. Auditory event-related potentials were recorded from eight participants during the sleep onset period. A 1,000 Hz-standard stimulus was presented every 600 ms. At random, on 20% of the trials, the standard was changed to either a large 2,000-Hz or a small 1,100-Hz deviant. During wakefulness, the large deviant elicited a larger, long-lasting MMN than the small deviant. Following the large deviant during relaxed wakefulness and Stage 2 sleep, the MMN continued to be elicited although it was reduced in amplitude. No significant MMN was recorded for either deviant in Stages 1 and slow wave sleep. The loss of consciousness therefore appears to have a marked effect on the MMN.

Mismatch negativity to inclusions and omissions of stimulus features

Two experiments were run to determine the effects of addition or removal of a stimulus feature on mismatch negativity (MMN). In the first experiment, a deviant stimulus was constructed by adding a click to a white noise standard stimulus. In the second experiment, the deviant was constructed by subtracting the click from the standard. In different conditions, the intensity of the click was varied. When the deviant was constructed by the addition of a click, a significant MMN was evident in those conditions in which click-to-noise ratio exceeded 1.0. When the deviant was constructed by the subtraction of the click, a significant negativity was found only when the click-to-noise ratio was very large. However, this negativity was accompanied by only a small polarity inversion at the mastoid. The MMN is thus best elicited when the deviant stimulus contains a new afferent element not present in the standard stimulus.

Muslims with non-insulin dependent diabetes fasting during Ramadan: treatment with glibenclamide

OBJECTIVE

To compare the efficacy of two glibenclamide regimens in patients with non-insulin dependent diabetes who were fasting during Ramadan and regular glibenclamide treatment in the non-fasting group.

DESIGN

Non-randomised control group of patients who did not fast during Ramadan and two groups of patients who fasted randomised equally to one of two regimens: to take their usual morning dose of glibenclamide in the evening and their usual evening dose before dawn; or to follow this pattern but to reduce the total dose by a quarter.

SETTING

Two university hospitals, one private hospital, and two private clinics in Casablanca and Rabat, Morocco.

SUBJECTS

591 diabetic patients (198 men, 391 women, two unspecified) with similar duration of diabetes and length and amount of glibenclamide treatment, of whom 542 completed the study.

MAIN OUTCOME MEASURES

Serum fructosamine and total glycated haemoglobin concentrations and number of hypoglycaemic events.

RESULTS

At the end of Ramadan there were no significant differences between the groups in fructosamine concentration (400 mumol/l in controls and 381 mumol/l and 376 mumol/l in the fasting groups); percentage of glycated haemoglobin (14.7%, 14.0%, and 13.6%); or number of hypoglycaemic events during Ramadan (11, 14, and 10).

CONCLUSION

Glibenclamide is effective and safe for patients with non-insulin dependent diabetes who fast during Ramadan. The easiest regimen is to take the normal morning dose (together with any midday dose) at sunset and any evening dose before dawn.

3-Nitropropionic acid-exogenous animal neurotoxin and possible human striatal toxin

3-Nitropropionic acid (3-NPA)--a suicide inhibitor of succinate dehydrogenase--is a widely distributed plant and fungal neurotoxin known to induce a damage to basal ganglia, hippocampus, spinal tracts and peripheral nerves in animals. Recent reports from Northern China indicate that 3-NPA is also likely to be responsible for the development of putaminal necrosis with delayed dystonia in children after ingestion of mildewed sugar cane. This article discusses the role of 3-NPA in the causation of the disease in China, its neurotoxic effects in animals and the potential role for this compound as a probe of selective neuronal vulnerability.

Undesirable effects of hemometakinesia induced by vascular reconstruction

Hemometakinesia, the borrowing of blood by one part of the body for use by other parts or tissues, is a well regulated physiologic mechanism involving selective vasodilation and vasoconstriction. It has been shown, however, that diversion of blood flow following vascular reconstruction may impoverish tissues from which the blood flow is borrowed, causing ischemia in these vascular beds. Observations on 12 patients out of a group of 100 who had undergone vascular reconstruction of a limb deterioration. It is suggested that the type and site of the vascular disorder and the expected diminution of blood flow in other involved arterial circuits should be considered in selecting the most appropriate vascular surgical procedure. Searching for and recognizing the hemodynamic significance of a silent lesion in the carotid or gastrointestinal circuit or in a contralateral limb may avert a vascular crisis after the primary lesion has been successfully treated.