Placement of a Greenfield filter in the superior vena cava.

A 75-year-old man with a Greenfield filter in the inferior vena cava for previous pulmonary emboli had recurrent pulmonary emboli. He was unable to take anticoagulants due to gastric ulcer disease. Contrast studies revealed a large thrombus in the left brachiocephalic vein. A Greenfield filter was placed in the superior vena cava through the right internal jugular vein using the femoral insertion apparatus.

The third time coronary artery bypass graft: is the risk justified?

Twenty-one patients undergoing a coronary artery bypass graft operation for the third time were retrospectively reviewed to assess the factors of importance in the management of these patients. The study spans 5.8 years and represents 6.2% of coronary bypass reoperations and 0.6% (21/3500) of total bypass operations during that time. The indication for reoperation was disabling angina pectoris not responsive to medical treatment in 20 patients (95%) and unstable angina pectoris with an intraaortic balloon pump present in one patient (5%). Median sternotomy was used in all and cardiopulmonary bypass in all but one who had an interposition vein graft without cardiopulmonary bypass. Internal mammary artery grafting was used in 86% of patients. There were no operative deaths. One patient died 12 months after his operation. Four patients (19%) required intraaortic balloon pump support postoperatively for up to 6 days. There were no reexplorations for bleeding. One patient required sternal rewiring for an early dehiscence (5%). Respiratory failure occurred in eight patients (38%). Average stay was 4.4 days in the intensive care unit and postoperative hospital stay was 13.7 days. No new Q waves were noted postoperatively. Detailed follow-up was obtained on 18 of the 20 survivors (90%). The two remaining are alive but declined interview efforts. All patients interviewed reported feeling subjectively better than before operation; however 61% of these interviewed continue to have some degree of angina pectoris. One patient has had a late myocardial infarction. This report suggests that the third time coronary bypass can be done with good results when myocardial revascularization is indicated.

Cefamandole versus cefonicid prophylaxis in cardiovascular surgery: a prospective study.

We randomized 400 patients who were scheduled for an elective cardiovascular operation involving median sternotomy to receive cefamandole nafate or cefonicid in a prospective double-blind study. Three hundred fifty-seven patients were evaluable for prophylactic efficacy. Chest wound and donor site infections and early prosthetic valve endocarditis occurred more frequently with cefonicid (11 patients, 6.3%) than with cefamandole (4 patients, 2.2%) (p = 0.05). Three patients, all in the cefonicid group, required sternal debridement to control postoperative deep wound infections. Twenty-five miscellaneous postoperative infections (urinary tract infection, pneumonia, intravenous site infection, bacteremia, sepsis, Clostridium difficile diarrhea) occurred in 16 patients (9.19%) in the cefonicid group and four in 4 patients (2.19%) in the cefamandole group (p = 0.003). These data indicate that cefamandole is superior to cefonicid in preventing both surgical wound infections and miscellaneous nonsurgical infections after cardiovascular operations.

Spontaneous rupture of the esophagus: a 30-year experience.

This retrospective review of 34 patients with spontaneous rupture of the esophagus, which spans a 30-year period, attempts to identify areas in diagnosis and therapy that might alter the dismal prognosis. The diagnosis and definitive surgical repair of Boerhaave's syndrome were frequently delayed. Delay resulted in a significant increase in complication rates. Pain (85%) and vomiting (71%) were the only common historical events suggesting the diagnosis. Physical examination was of aid in the diagnosis in only the 9 patients (27%) who demonstrated cervical or mediastinal emphysema. The initial chest roentgenogram was abnormal in 97% of the patients, but was interpreted as "compatible with perforation of the esophagus" in only 27%. Esophagography was diagnostic in 23 of 24 patients in whom it was used. Thoracentesis was of little diagnostic aid, but pleural fluid pH was measured in only 15% of the patients. Prompt surgical repair, regardless of time after onset, appears to be the indicated therapy.

Application of electron microscopy in the interpretation of fine-needle aspiration biopsies.

A series of 31 fine-needle aspiration biopsies were studied ultrastructurally in order to evaluate the usefulness of electron microscopy in the diagnosis of aspiration biopsies. In seven cases, the electron microscopic findings were crucial to the diagnosis. In the remaining cases, electron microscopy helped to confirm the light microscopic diagnosis. In addition, in a number of cases the diagnosis rendered following electron microscopy was much more precise and specific than was possible with light microscopy alone. It is concluded that electron microscopy has a definite place in the diagnosis of fine-needle aspiration biopsies and should be increasingly utilized on a selective basis.

Mesenteric lymphatic obstruction in Crohn's disease.

The lymphatic drainage of diseased and normal bowel was studied in 21 patients undergoing surgery for Crohn's disease. Mesenteric lymphatic obstruction was a consistent feature, identified in areas of small bowel macroscopically affected by Crohn's disease. This finding was also observed in some areas of apparently unaffected small bowel. Subsequent examination of these areas confirmed the presence of early Crohn's disease. This method of study may prove to be of value for determining the extent of operative resection in patients with Crohn's disease. Experimental lymphatic obstruction in animals failed to produce pathological changes of Crohn's disease, suggesting that this feature is an epiphenomenon and is not of primary importance in the pathogenesis of regional enteritis.

Digital simulation of the membrane voltages and currents in nerve and muscle fibers.

This paper describes digital computer simulations of the membrane voltages and currents in axons and muscle fibers. The simulations, which allow calculations ona nonuniform fiber, are based on the discrete Hodgkin-Huxley and Falk-Fatt equations. An efficient algorithm is used to solve the set of equations generated. Calculations are made of the voltage and current at the natural end of a muscle fiber and the results are compared with measurements by other investigators.