Role of revascularization to treat chronic nonhealing fractures in ischemic limbs.

The contribution of chronic limb ischemia to long-term nonunion of a lower extremity fracture was suggested in a single published case report from our group 13 years ago. We have since encountered three additional patients with nonunited lower extremity fractures occurring in limbs with arterial ischemia. In each of these four patients limb revascularization was undertaken in an effort to stimulate healing of the fracture. These patients had chronic (mean 6 months) nonunion of tibial (three) or femur (one) fractures associated with severe lower extremity ischemia (ankle/brachial index m = 0.33; range 0.24 to 0.5). All patients had histories of chronic lower extremity ischemia before the fracture (ischemic rest pain, 2; claudication, 2). All patients underwent angiography followed by lower extremity revascularization. Restoration of normal arterial supply to the fracture site was followed by healing of the fracture in all patients. To our knowledge, this represents the first reported series of patients undergoing elective limb revascularization to stimulate healing of the fracture. Widespread appreciation of this relationship by orthopedic surgeons may be of considerable clinical importance.

Treatment of infected abdominal aneurysms by extraanatomic bypass, aneurysm excision, and drainage.

Five patients with infected abdominal aortoiliac aneurysms were treated. The diagnosis was made preoperatively based upon fever, leukocytosis, positive blood culture findings, and presence of an aneurysm in all five patients. Two patients had salmonella species, two had staphylococcus species, and one had bacteroides species cultured from the blood and aneurysm contents. All patients were treated with appropriate antibiotics and a single operative procedure consisting of preliminary extraanatomic bypass followed by complete aneurysm excision and posterior drainage of the retroperitoneum. There were no operative deaths and no instances of aortic stump disruption, persistent retroperitoneal sepsis, or graft thrombosis. All patients were alive and well on last follow-up 15 months to 5 years postoperatively.

Effects of E. coli endotoxin on rat plasma angiotensin converting enzyme activity in vitro and in vivo.

Angiotensin converting enzyme (ACE), a glycoprotein, is found in high concentration in pulmonary capillary endothelial cells. Several investigators have studied the relationship between various direct and indirect pulmonary insults and ACE activity and in some cases have found conflict. In an attempt to clarify this relationship we have examined the effect of endotoxin on rat plasma ACE activity in vitro and in vivo. We used the synthetic ACE substrate 3H-BPAP and the assay described by Catravas and Gillis [J Pharmacol Exp Ther 217:263-270, 1981]. In vitro, a statistically significant concentration-dependent reduction in ACE activity was demonstrated (p less than .005). In vivo an intravenous dose of endotoxin (20 mg/kg) alone resulted in no significant change in plasma ACE activity. However, the combination of intravenous endotoxin (20mg/kg) and mild hemorrhage (5-10% of blood volume) caused a statistically significant reduction in plasma ACE activity by 15 min as compared to control rats with hemorrhage only (39% vs. 66%, p less than .005). This reduction persisted at 30 and 60 min. However, by 180 min ACE activity was no longer statistically different from control values. We have demonstrated an acute reduction of plasma ACE activity in the endotoxemic rat that appears to be dependent on the amount of circulating endotoxin and the presence of mild blood loss.

Diagnosis and management of Hirschsprung's disease. A 25 year perspective.

The demographic data and the distribution of the extent of involved bowel in Hirschsprung's disease have remained unchanged over the past 25 years and are similar to those reported by others. The age at which the diagnosis was established decreased initially but increased in the last 10 year period. This increase has been accompanied by an increase in the number of breast-fed infants. Definitive operation for Hirschsprung's disease is now usually performed in children less than 18 months of age. The procedures used were selectively applied in the most recent 10 years. Arbitrary dependence on a single procedure is no longer appropriate and individualized judgment should be used in the application of specific treatment alternatives in the surgical management of Hirschsprung's disease. Mortality after definitive operation is now confined to problems other than Hirschsprung's disease. The patient with undiagnosed Hirschsprung's disease may not survive enterocolitis despite aggressive contemporary resuscitative treatment.

Improving the outcome in gallstone ileus.

A 32 year retrospective review of 24 cases of gallstone ileus from the hospitals of Oregon Health Sciences University has been presented. Nineteen patients (79 percent) were female and 18 (75 percent) were more than 70 years of age. Fifty-four percent of the patients had a correct preoperative diagnosis that correlated well with the roentgenographic findings. Enterolithotomy was the most frequently employed operation, and cholecystoduodenal fistulas were positively identified in 61 percent of the patients. Most obstructions occurred in the distal ileum (48 percent). Wound infections occurred in six patients (26 percent), and there were three deaths for a mortality rate of 13 percent. Of note, the incidence of wound infections and mortality is found to be decreasing. This is related to the more frequent use of prophylactic antibiotics. The controversy regarding performing an enterolithotomy alone versus a one stage procedure has been reviewed and several interesting and atypical cases have been briefly discussed.

The financial viability of rural primary health care centers.

Primary health care centers have been proposed to meet the health care needs of rural America. Some centers become financially "self-sufficient", receiving their entire budgets from direct patient or third-party payments; others shut down when external funding is withdrawn. An explanation for this difference is important, because funding agencies may not wish to subsidize centers whose financial futures appear bleak. This study identifies the correlates of financial self-sufficiency. A survey conducted in late 1976 or 164 rural clinics provided 101 usable responses. Multiple regression analysis of the data shows that the longer a center has been in operation, the more self-sufficient it will become. Hospital control of the center and provision of laboratory tests increase self-sufficiency; outreach services and nonprofit status reduce it. Two variables related to financial self-sufficiency are separately examined. Clinics with a faster growth rate of patient visits are more self-sufficient, and smaller clinics tend to grow faster. More self-sufficient clinics experience less difficulty in keeping professional staff. The presence of a state Area Health Education Center (AHEC) program also eases the problem of staff retention.