Combined carotid endarterectomy and coronary artery bypass in a community hospital.

A study examining combined carotid endarterectomy and coronary artery bypass (CAB) outside the metropolitan or university hospital setting was performed. Over a 5-year period, 52 patients underwent carotid endarterectomy and CAB under a single anesthetic. Twenty-two patients (42%) had unstable angina and 23 (44%) had previous neurologic symptoms. There were two postoperative strokes (4%), one ipsilateral and one contralateral to the endarterectomy site. No ipsilateral neurologic events occurred after discharge (mean follow-up 25 months). There were four deaths (8%), all of which were cardiac related. Three of the four deaths were in patients with a recent history of congestive heart failure, a subgroup with a high mortality rate (three of seven; 43%). Over the same period, 2421 patients underwent CAB alone with stroke and mortality rates of 1.4 and 2.0% respectively, while 344 patients had carotid endarterectomy alone with stroke and mortality rates of 0.6 and 0.6% respectively. It is concluded that the combined procedure can be performed in a community setting with morbidity and mortality rates similar to those for major centers. Although stroke and mortality rates for the combined procedure were higher than those for the isolated operations, this group has a high incidence of cardiac symptoms, including unstable angina and congestive heart failure. Patients with recent congestive heart failure had the highest mortality rate of any subgroup and these patients should be carefully examined with regard to selection for the combined procedure.

Silent cirrhosis in patients with hepatocellular carcinoma. Implications for screening in high-incidence and low-incidence areas.

We assessed the frequency of silent (i.e., clinically asymptomatic) cirrhosis among 305 patients with hepatocellular carcinoma (HCC) and cirrhosis in relation to the patients' country of birth, the cause of the cirrhosis, clinical features, and hepatitis B surface antigen (HBsAg) status. Overall, 56% of the patients had silent cirrhosis, but this occurred significantly more frequently among those born in areas of the world where HCC is common (64% compared with 36%), those who were HBsAg-seropositive (75% compared with 25%), and those who had cryptogenic cirrhosis (71% compared with 29%). Previously recognized ("known") cirrhosis was more common among those from low-incidence areas (52% compared with 36%) and the cause of the cirrhosis was more often alcoholic (44% compared with 10%). The clinical features at the time of presentation with HCC did not differ between the two groups. During the 10-year period of the study (1978 to 1988), 448 patients with HCC were seen (including those without cirrhosis and those in whom the presence or absence of cirrhosis could not be determined). Overall, therefore, cirrhosis was recognized before presentation with tumor in only 30% of the patients. The screening of cirrhotic patients can only have a limited impact on the early detection of HCC.

Operative management of bilateral internal iliac artery aneurysms.

A case of bilateral internal iliac artery aneurysms in association with an infrarenal abdominal aortic aneurysm is presented. The implications of surgical repair of these lesions are considered, particularly with reference to interruption of pelvic blood flow. Reimplantation of the inferior mesenteric artery is recommended when internal iliac artery flow is compromised during aortic reconstruction.

External carotid endarterectomy under direct vision.

At the conclusion of standard carotid endarterectomy in 50 consecutive patients, we examined flow in the external carotid artery using a continuous-wave Doppler probe. In two patients (4 percent), flow was absent in the distal external carotid artery. In both patients, opening the external carotid artery through a separate incision revealed an obstructing intimal flap that was removed easily under direct vision, and external carotid endarterectomy was accomplished without interrupting flow through the internal carotid artery. This simple manuever allows for salvage of external carotid arteries that are occluded during standard blinded external carotid endarterectomy.

Hepatocellular carcinoma in immigrants to the United Kingdom.

Analysis of the origin of patients with hepatocellular carcinoma admitted to the Liver Unit between 1970 and July 1985 showed an increase in frequency of this tumour in immigrants to the United Kingdom from none between 1970 and 1973, to 15 per cent between 1981 and 1985. The 19 immigrant cases had resided in this country for between four and 28 years and when compared with a group of 30 patients born in the United Kingdom three striking differences emerged. Firstly, the immigrants were significantly younger. Secondly, although the frequency of underlying cirrhosis (approximately 80 per cent) was similar the aetiology differed with HBV-related disease being the largest group (93 per cent) in the immigrants and alcohol or cryptogenic cirrhosis in the other patients amongst whom HBV markers were detected in only 20 per cent. Thirdly, whilst signs and symptoms attributable to hepatocellular carcinoma represented the first evidence of liver disease in 89 per cent of the immigrants, symptoms of cirrhosis in patients born in the United Kingdom had been evident for several years before tumour development.

Risk factors in development of hepatocellular carcinoma in cirrhosis: prospective study of 613 patients.

In a prospective study of 613 patients with cirrhosis of different aetiological types increasing age, male sex, and non-UK nationality were found to be significant independent risk factors for the progression of cirrhosis to hepatocellular carcinoma. Seropositivity for hepatitis B surface antigen and the duration and aetiology of cirrhosis were not related to the development of the disease. Age and sex were also found to be significant risk factors when UK patients alone were considered. Seropositivity for hepatitis B surface antigen may be associated with hepatocellular carcinoma only because hepatitis B virus infection is a common cause of cirrhosis.

The in vitro effect of the thymic factor thymopoietin on a subpopulation of lymphocytes from severely malnourished children.

Several investigators have shown that the proportion of T cell lymphocytes was greatly reduced while that of the B cell lymphocytes was virtually unaffected; thus the relative proportion of null cells was significantly increased in severely malnourished patients. Other studies have demonstrated that extracts of bovine thymus will induce an increase in the proportion of T cell rosettes from patients with various disorders. This study has demonstrated that peripheral blood lymphocytes from severely malnourished patients with secondary infections contain a subpopulation of lymphocytes which will respond in vitro in the presence of thymopoietin by increased numbers of E rosettes. These results also support the concept of a finite population of responder cells and indicate that other thymopoietin insensitive subpopulations of null cells are increased when the proportion of T cells are greatly suppressed. Further characterization of the lymphocyte subpopulation(s) affected by thymopoietin is needed.

Depression of cell-mediated immunity in cholera.

Cholera toxin may depress cell-mediated immunity by stimulation of adenyl cyclase and production of cyclic AMP in cellular systems or when given parenterally to experimental animals. Whether or not similar effects might be found during clinical infection with Vibrio cholerae was the subject of this study. Delayed hypersensitivity reactions to skin test antigens were found to be markedly depressed in Bengali patients with cholera 24 h after fluid repletion. Skin test response rates were lower in children and in adults with the disease than in both normal adults and children or in adults with an equivalent degree of malnutrition. Patients with equal degrees of dehydration due to noncholera diarrhea were significantly less immunosuppressed. Concurrent depression of other manifestations of cell-mediated immunity was not found.

Enhanced T-cell rosette formation in shigellosis by the in vitro use of thymopoietin.

The results from this study suggest that the large nul cell lymphocyte population seen in patients with Shigella dysentery, does contain a sub-population of cells that will respond in vitro to thymopoietin, a bovine thymic extract, by increased E-rosette formation. It is felt that this sub-population is in fact immature T-cells. A previous study has shown that an unusual leukaemoid reaction develops in a substantial number of patients with Shigella dysentery. The leukaemoid response was primarily granulocytic in nature but there was also a substantial increase in the mean number of lymphocytes. The proportion of the various populations of lymphocytes from leukaemoid and non-leukaemoid subjects were altered, B-cells remained constant, while the T-cells were depressed with a corresponding rise in the proportion of nul cells. The cumulative results of this and other studies demonstrate that the T-cell arm of immunity is compromised in shigellosis. Indeed the degree of compromise may ultimately be the decisive factor in determining the severity of this disease.

Sub-populations of peripheral lymphocytes from patients with shigella bacillary dysentery with associated leucocytosis.

In this study we ascertained the proportion and absolute number of T, B and nul cell peripheral lymphocytes from Shigella dysenteriae type I patients and compared these results with those from age matched controls. Single blood samples were collected from 13 Bangladeshi children who complained of symptoms for one or more weeks. Patients were divided into two categories, with and without a leukaemoid response. The leukaemoid response was primarily granulocytic in nature, but there was a substantial increase in the mean number of lymphocytes. Over one third of the lymphocytes were nul cells. These cells rose proportionally to the decrease of T-cells, as the proportion of B-cells remained within normal range. One leukaemoid patient died. The absolute number of lymphocytes was normal and the B-cells were normal in respect of both proportions and absolute numbers. T-cell percentage and numbers were well below normal values.

Spontaneous hemorrhage due to pseudocysts of the pancreas.

Spontaneous hemorrhage caused by erosion of major arteries by a pseudocyst of the pancreas is a rare condition. We have encountered three cases, one involving the abdominal aorta and two the superior pancreaticoduodenal artery. It is important to keep in mind that pseudocyst of the pancreas may cause massive gastrointestinal or intraabdominal bleeding. Operative treatment offers a better chance of survival than more conservative management.

T and B rosetting lymphocytes in the blood of smallpox patients.

The proportion of T and B cells in the peripheral blood of smallpox patients was determined. The average initial percentage of T cells was depressed (41 +/- 8.4%) in comparison with uninfected controls (65 +/- 7.6%), while the initial B cell counts averaged 26 +/- 11.4% and 28 +/- 5.1%, respectively. However, initial B cell percentages in four infected patients (two of whom died) were between 9 and 14, which are considerably lower than any control value, the lowest of which was 19%. Review of the literature emphasizes the both cellular and serological immunity play a role in recovery from pox disease; the two patients who had the highest initial nul cell (lymphocytes not identified as either T or B cells) counts died, while none of five patients who had consistently low nul cell counts died.

The surgical management of catheter injuries of the brachial artery.

In 84 patients the wrist pulses were lost after diagnostic left heart catheterization via the brachial artery. Sixty-six of these patients underwent surgical exploration of the brachial artery for restoration of pulsatile arterial flow to the hand. This aim was achieved in 64 instances. In all cases, the artery was found to be occluded by fresh thrombus. In 36 patients, balloon thrombectomy and accurate arterial closure were successful. In the remainder, in addition to thrombectomy, indentification of an area of damage to the arterial wall required additional surgical measures, usually in the form of resection and anastomosis. The surgical approach to this problem and the importance of the recognition and treatment of arterial wall damage by the catheter are stressed in this paper.

Left colon gangrene after acute inferior mesenteric artery occlusion.

We report here an experience with five patients, aged 58 to 70, suffering gangrene of the left colon after spontaneous inferior mesenteric artery occlusion. All cases were the result of arteriosclerosis; in two, small aortic aneurysms were present and might have been responsible for emboli to the inferior mesenteric artery. The dead bowel was resected in all patients; three patients survived. No primary anastomoses were done and they are not recommended. Because ligation of the patent inferior mesenteric artery has been done so often without ill effects during aortic surgery, the collateral circulation to the left colon can be considered excellent. Gangrene is therefore rare and requires major interference with collateral circulation by emboli or arteriosclerotic occlusion. The clinical symptoms and signs may be confusing.