Cephalic vein grafts for lower extremity revascularization.

From 1980 to 1989 infrainguinal revascularization was performed with cephalic vein grafts in a consecutive series of 34 patients (35 limbs) whose saphenous veins were either inadequate or already had been harvested for previous coronary (N = 16, 47%) or ipsilateral lower extremity bypass (N = 19, 56%). Surgical indications included ischemic rest pain or focal tissue necrosis in 25 limbs (71%), disabling claudication in six (17%), and popliteal aneurysms or prosthetic femoropopliteal graft infections each in two (6%). Preliminary arteriovenous fistulas were constructed in the arms of 23 patients (68%) to enhance the diameter of their cephalic veins, and 24 (69%) of the 35 infrainguinal procedures in this series were performed with use of cephalic vein alone. The distal popliteal artery was used for the outflow anastomosis in 10 limbs (29%), a tibial vessel was used in 12 (34%), and the peroneal artery was used in 13 (37%). Fourteen graft occlusions (40%) and six amputations (17%) have occurred during follow-up intervals of 1 to 107 months (mean, 28 months; median, 27 months). At 3 years the cumulative primary patency rate is 40%, the secondary patency rate is 46%, and the limb salvage rate is 82%. Despite their relative inconvenience, cephalic vein grafts appear to be preferable to prosthetic materials for infrainguinal revascularization below the knee.     

Survey of difficult to contain and treat children and adolescents

Child psychiatrists and paediatricians are faced by a number of disturbed children and adolescents who become a major treatment challenge due to a combination of their dangerous and/or disruptive behaviour and the unavailability of resources. Paediatricians and psychiatrists in one regional health area were questioned about the number of such children and adolescents under 18 years of age seen over a 20 month period. The response rate was 44% (86/194 specialists approached). A total of 72 children and adolescents were identified. For a health district with a total population of 200,000, this represents nearly five children (about one of these identified by paediatricians and one with associated learning disability). The majority of cases were adolescents with chronic problems (over one month's duration) but most cases reported by paediatricians were acute in preadolescents. Conduct disorders, autistic spectrum, and psychotic disorders were the most common clinical problems. Seriously disruptive behaviour had been present in two thirds and marked problems with behaviour that was a physical risk to others and to the self were present in over half and nearly a third of cases respectively. Services had been universally stretched by these children's difficulties. Clinicians thought the needs of these children would have been best met either through psychiatric day hospital type facilities or in combined paediatric/child psychiatric inpatient units.     

EFFECTS OF PROSTAGLANDIN E2 ON RENAL FUNCTION AND LUNG LIQUID DYNAMICS IN FOETAL SHEEP

1. The aim of the present study was to determine the effects of prolonged prostaglandin E₂ (PGE₂) administration on the function of the foetal kidneys and lungs in order to gain a greater understanding of the role played by PGE₂ in the control of foetal fluid balance. By studying the effects of PGE2 at two gestational ages, we have also been able to examine the influence of age. 2. We studied the effects of 26 h PGE2 infusion on foetal sheep at a mean (±SEM) of 120.0 ± 0.6 (n= 6) and 139.0 ± 0.8 (n= 4) days of gestation. In both groups, foetal urine production was significantly inhibited throughout the infusion period (P < 0.05). In younger, but not older foetuses, urine production returned to control values within 24 h of ending the infusion (P < 0.05). This PGE2-induced anti-diuresis was associated with foetal hypoxaemia and acidaemia, a reduction in free water clearance and an increase in foetal plasma arginine vasopressin concentrations (P < 0.05). 3. During PGE₂ infusions, foetal breathing movements were inhibited, the effect being greater and more sustained in older foetuses (P < 0.05). 4. Infusions of PGE₂ led to increased lung liquid production at both ages (P < 0.05); lung liquid volumes were reduced in older foetuses (P < 0.05), but were unchanged in younger foetuses. The reduction in lung liquid volume in older foetuses may have been due to inhibition of foetal breathing. 5. We conclude that increased circulating levels of PGE2 have profound effects on foetal renal and lung function which, if sustained, could compromise foetal lung development and perinatal well-being.     

Antibody response in an ABO-incompatible blood transfusion. Antigen specificity and immunoglobulin class

The anti-A response in a group B patient accidentally given 1 unit transfusion of A1 blood is described. The antibody response is characterized both with conventional agglutination techniques and with radioimmunoassay using pure group A antigens with different core saccharide structures (type 1, 2, and 4 chains) and class-specific second antibodies. The anti-A titer rose to a maximum Days 11 to 14 after the incompatible transfusion. The antibodies involved were mainly of the IgG and IgA types, while the IgM response was moderate. The IgA antibodies seemed to be nonselective with respect to group A antigen type, while the IgG antibodies showed a specificity against type 2 chain group A antigens.     

Avascular necrosis versus other diseases of the hip: sensitivity of MR imaging

Magnetic resonance (MR) imaging of the hip has been useful in the examination of patients for the presence of avascular necrosis (AVN). In the detection of AVN, MR imaging is more sensitive than computed tomography or nuclear scintigraphy. This study assessed the usefulness of MR imaging in the differentiation of AVN from other hip diseases. Twenty-two cases of non-AVN hip disease were matched with 23 biopsy-proved cases of AVN and ten normal controls. MR images were rated in a blinded manner by five experienced radiologists, and receiver operating characteristic (ROC) analysis was performed on the data. In the discrimination of AVN from other hip diseases or from normality, the A(z) value (the area under the ROC curve) was 98.6. With a specificity of 98%, MR imaging was 97% sensitive in the differentiation of AVN from normality, 85% sensitive in the differentiation of AVN from non-AVN disease, and 91% sensitive in the differentiation of AVN from both conditions. MR imaging may therefore help discriminate between AVN and other hip diseases.     

Psychosocial adjustment of adult survivors of a paediatric dialysis and transplant programme

The social adjustment of 45 young adult renal patients who commenced treatment for end stage renal disease (ESRD) as children and of 48 age and sex matched controls were compared. Renal patients were less socially mature than controls. More lived with their parents, fewer had an intimate relationship outside the family, they had fewer school qualifications, and there was more unemployment among them. The majority, however, were in employment and the level of subjective stress and support derived from most of these areas was comparable in renal patients and in controls. Having a close relationship with a member of the opposite sex was the only domain in which renal patients reported more stress than controls. Early start of illness and current health problems were associated with poorer social outcome. A lifelong history of ESRD leads to suboptimal or delayed social functioning on conventional indicators. However this does not lead to increased overall distress in the patients about their social circumstances and quality of life does not appear to be substantially impaired.