Eruptive milia.

Milia are small subepidermal keratin cysts. They may arise either spontaneously or in the course of bullous diseases or trauma. We describe an unusual case of multiple eruptive milia on the posterior neck and back and review the classification of milia.

Kaposi's sarcoma. Epidemiology, pathogenesis, histology, clinical spectrum, staging criteria and therapy.

The acquired immunodeficiency syndrome (AIDS) epidemic has had a profound impact on our understanding of Kaposi's sarcoma (KS). Epidemiologic features suggest a sexually transmitted cofactor in the pathogenesis of AIDS-associated KS (AIDS-KS), and several putative agents have received intense scrutiny. Cell culture studies suggest that the angiogenesis of AIDS-KS is stimulated by both human immunodeficiency virus proteins and growth factors that may be involved in the development and progression of AIDS-KS, thereby providing a rationale for new therapeutic interventions. The dermatologist is uniquely qualified to provide care for the majority of patients with KS, as many patients have cutaneous lesions amendable to local therapy (cryotherapy, intralesional therapy, simple excision). Patients requiring more aggressive local therapy (radiation therapy) or systemic therapies (interferon, chemotherapy) can be easily recognized. Standardized staging criteria provide assistance for determining appropriate local or systemic therapy and for evaluating and comparing responses to new therapies. This article reviews the epidemiology, pathogenesis, histologic features, clinical spectrum, staging criteria, and treatment of KS.

A radiation hybrid map of 18 growth factor, growth factor receptor, hormone receptor, or neurotransmitter receptor genes on the distal region of the long arm of chromosome 5.

The distal portion of the long arm of human chromosome 5 contains an impressive number of genes encoding growth factors, growth factor receptors, and hormone/neurotransmitter receptors. The order of and relative distance between 18 of these genes was determined by radiation hybrid mapping. There is only a single gap in a contiguous radiation map from 5q22-5q35. For this set of radiation hybrids, one map unit (centiray) corresponds to 20-50 kb of DNA. Close physical proximity for several pairs of loci was predicted by the map. Two sets of these were found to be contained in single YAC clones. The physical map produced by radiation hybrid mapping should prove useful in efforts to identify four disease genes that have been assigned to distal 5q by linkage studies.

Early clinical results of long coronary arteriotomy, endarterectomy and reconstruction combined with multiple bypass grafting for severe coronary artery disease.

Within a 2.5-year period between 1985 and 1988, long coronary arteriotomy, endarterectomy and reconstruction (principally left anterior descending artery) and multiple bypass grafting (mean graft rate was 9) were performed in 130 of 329 patients (40%) with severe diffuse coronary artery disease to ensure complete myocardial revascularization. Ninety-two percent of the patients who underwent exercise testing had abnormal (greater than 1 mm ST) depression and/or positive results on scintigraphy. Long coronary arteriotomy (5 to 12 cm), endarterectomy and reconstruction of the left anterior descending artery and its branches, were performed in 121 patients; of the left circumflex artery and its branches in 13 patients; and of the right coronary artery and its branches beyond the crux in 18 patients. Single endarterectomy and reconstruction was performed in 109 patients, double in 20 and triple in 1. The operative mortality was 2.3% and the perioperative infarction was 1.5%. Twenty-four patients (among them 38% who had undergone greater than 1 previous bypass operation) were randomly selected and studied within 20 days after surgery. This group comprised a total of 69 coronary conduits of which 68 (99%) were patent, and a total of 206 coronary anastomoses of which 202 (98%) were patent. Thirty-two of 33 conduits (97%) to endarterectomized and reconstructed arteries were patent. One hundred and twenty-six of 127 patients were followed up for a mean of 20 months; 120 of the 121 patients (99%) were in angina class I by Canadian Cardiovascular Society classification, and 63 of 71 patients (89%) had a normal treadmill exercise stress test.(ABSTRACT TRUNCATED AT 250 WORDS)

Comparative use of cold blood potassium cardioplegia in coronary bypass patients necessitating long (2.5-6 h) versus short (less than 1.5 h) aortic cross-clamp times.

In symptomatic patients with severe diffuse multivessel coronary disease undergoing bypass surgery, complete revascularization with multiple bypass grafts using saphenous vein and internal mammary conduits, and multiple endarterectomies may be necessary. Such complex surgeries may require long aortic cross-clamp times in excess of 2.5 h. To evaluate the myocardial preservation provided by cold potassium blood cardioplegia, two groups of consecutive patients using nearly similar surgical techniques were compared. Group A consisted of 100 patients who received an average of 3.8 grafts per patient and had a mean aortic cross-clamp time of 66 (range 15-90) min. Group B was comprised of 100 patients who received an average of 9.3 grafts per patient and had a mean cross-clamp time of 187 (range 150-351) min. Operative mortality and perioperative myocardial infarction were low (0-2%) and were not significantly different between the groups. In addition, the postoperative creatine kinase-MB isoenzyme levels, use of pharmacologic and/or mechanical (i.e., intra-aortic balloon) support, and follow-up exercise treadmill tests were not significantly different in the two groups. These findings suggest that cold potassium blood cardioplegia is equally protective of the myocardium during surgical revascularization in patients with short aortic cross-clamp times (less than 1.5 h) as in those with severe diffuse multivessel coronary artery disease requiring long cross-clamp times exceeding 2.5 h and up to 6 h.

Multiple (more than eight) bypass grafts in severe diffuse coronary disease: improved exercise tolerance and functional classification in seventy-seven consecutive patients.

During a 43-month period (May 1981 to December 1984), 77 consecutive patients underwent multiple (eight or more) coronary artery bypass procedures using saphenous vein conduits for severe diffuse triple-vessel coronary artery disease. Patients received from 8 to 14 grafts (average 9). All coronary arteries and branches that were at least 1.5 mm in diameter and greater than 50% obstructed were bypassed. The operative mortality rate was 1.3%. Seventy-six of 77 (98.7%) patients are alive at a mean follow-up of 2 years. According to the Canadian Cardiovascular Society Angina Criteria, before surgery 5 patients (6%) were classified class I, 8 (10%) class II, 43 (56%) class III, and 21 (27%) class IV. After surgery all 76 patients were class I. Of 59 patients who had undergone bypass surgery who were followed by exercise testing according to the modified Bruce protocol, 47 exercised to greater than or equal to 85% heart rate. Among these patients, 44 (94%) had a normal exercise test result and only 3 had greater than or equal to 1 mm ST segment depression. Thus, patients with severe diffuse coronary disease can undergo multiple (eight or more) bypass grafting procedures with low mortality rates and improved exercise tolerance and functional classification.

Sternal dehiscence: pericostal guy wires equals sternal stability.

Our five-year clinical experience with 11 patients treated with pericostal guy wires has uniformly established sternal stability, primary bone healing, and rapid resolution of infection. The stable anterior chest wall helps abolish cardiopulmonary complications (i.e., progressive pulmonary insufficiency, atelectasis, and low cardiac output) commonly associated with sternal dehiscence.

Improved stress test results after multiple coronary grafting.

Compared with previous reports that have addressed the issue of preoperative and postoperative stress testing in coronary artery bypass grafting, our results show a 30 percent improvement in the conversion rate from abnormal to normal. In a group of patients with severe coronary artery disease, we have been able to obtain normal stress test results postoperatively. Modern surgical techniques, including the use of blood cardioplegia and other methods of myocardial preservation, have allowed for safety in doing adequate grafting. From our population, we identified a select group of patients (approximately 30 percent) who require 6 or more grafts for complete revascularization. Although our follow-up of 30 months is relatively short, we are encouraged by the results so far. We believe that more than 90 percent of patients can be converted to normal postoperative stress test results after adequate coronary artery bypass grafting.