Result of bypass grafting for upper limb ischemia

Bypass grafting in the treatment of upper extremity ischemia is required far less frequently than it is in the lower extremity. The present study was undertaken to evaluate functional results and long-term patency of such grafts. Between 1978 and 1984, 33 bypass grafts were performed to relieve hand and forearm ischemia in 27 patients. The indication for bypass was neglected trauma (violent or iatrogenic) in 12 cases, primary arteriopathy in nine patients, and vascular complications of thoracic outlet compression in six patients. A reversed saphenous vein graft was used in 22 cases, and polytetrafluoroethylene was used in the remaining 11 procedures. Proximal anastomoses were from the aortic arch (one), subclavian artery (five), axillary artery (11), carotid artery (seven), and brachial artery (nine). Distal reconstructions were to the subclavian (three), axillary (three), brachial (16), radial (four), ulnar (two), and interosseous (five) arteries. Complete pre- and postoperative Doppler pressure measurements were available in 19 cases and demonstrated a significant increase in forearm systemic pressure index, from 0.51 before bypass to 0.86 postoperatively (p less than 0.001). Finger systolic pressure measurement in 10 patients also showed a significant improvement after operation. Follow-up of 31 grafts from 6 to 72 months (mean, 35.5 months) revealed an overall patency rate of 73% at 2 years and 67% at 3 years. Similar to lower extremity revascularization, more proximal grafts fared better; the 2-year patency rate was 83% for grafts at or above the brachial artery but only 53% for bypass distal to the brachial bifurcation. Major amputation was not required in any case, even after graft occlusion.     

Imipenem/cilastatin, an alternative treatment of pseudomonas infection in cystic fibrosis

Imipenem, a new N-formimidoyl thienamycin was given together with cilastatin to 20 patients with cystic fibrosis and pulmonary infection due to Pseudomonas aeruginosa. The antibiotic was given in short-term infusions for 9-14 days (mean 11.5) in a dose of 45-60 mg/kg body weight/day. Good clinical results were obtained in all patients with significant improvement of clinical score, pulse rate, vital capacity and FEV1.0 (P less than 0.001). Blood PO2 increased and WBC decreased significantly. A slight increase in the minimum inhibitory concentration was noted during treatment but all strains examined were fully susceptible at follow-up one month later. The peak serum concentration was significantly increased in patients receiving the high dose of imipenem, but the sputum concentration was low in all patients and there was no difference in clinical or bacteriological outcome. The plasma and urinary clearance increased with body weight and was inversely correlated to clinical score. Imipenem/cilastatin appears a good alternative for the treatment of pulmonary infections caused by P. aeruginosa in cystic fibrosis.     

Pharmacokinetics of netilmicin in children with and without cystic fibrosis.

The pharmacokinetics of intravenous netilmicin was studied in cystic fibrosis (CF) and non-CF patients who were closely matched according to age. The serum concentrations showed a moderately higher variance within the CF group. The serum half-life in CF patients was 1.37 h compared with 2.29 h in the non-CF subjects (P less than 0.05). The apparent distribution coefficients were 0.306 and 0.356 liters/kg in the CF and non-CF groups, respectively. The mean body clearance was 6.6 liters/h per 1.73 m2 in the CF group compared with 5.3 liters/h per m2 in the non-CF controls, but the difference was not significant. The mean renal clearance in CF patients was 4.7 liters/h per 1.73 m2. From a pharmacokinetic point of view, the dosage of netilmicin required may be the same in CF as in non-CF patients.     

Therapeutic approach to chronic venous insufficiency and its complications: place of Daflon 500 mg

Early manifestations of chronic venous insufficiency (CVI) are edema, hyperpigmentation, and lipodermatosclerosis. Late complications are cutaneous ulceration and delayed healing. The specific hallmarks of this inflammation include CD68-positive infiltration into the dermal tissue, monocytes, and lymphocytes and enhanced endothelial permeability. This may lead to "fibrin cuff" formation. In addition, membrane adhesion molecules are present and cytokine expression is seen. In one experimental model of mesenteric venous hypertension, the inflammatory process was detected in its earliest stages. This was evident in the form of neutrophilic leukocyte adhesion to venular endothelium as well as migration of cells across the endothelium and basement membrane into the interstitial space. Simultaneously, parenchymal cell death was detected. This suggests that the mechanism that triggers the inflammatory reaction is venous hypertension. This may cause venous distension and a shift in fluid shear stress. Our observations suggest that patients with venous insufficiency demonstrate circulatory humoral stimulators for leukocyte activation. Otherwise, there is evidence that the inflammatory reaction is limited to the region of the venous ulceration or at least to the skin areas with severe microangiopathy. It may be that activated leukocytes traverse perivascular cuffs and release active transforming growth factor-beta1 (TGF-beta1) which has been found to be elevated exclusively in areas of clinically active CVI. Surgical intervention markedly decreases the number of dysfunctional vein segments and allows pharmacologic agents to protect normal structures from continuing damage. Daflon 500 mg, the purified micronized flavonoid fraction containing 90% diosmin and 10% hesperidin, acts favorably in venous ulcer treatment by inhibiting the synthesis of prostaglandins and free radicals. It decreases bradykinin-induced microvascular leakage and may act favorably to inhibit leukocyte activation, trapping, and migration. Clinically, edema is reduced, ulcer healing is accelerated, and leukocyte trapping diminished. The action of micronized purified flavonoid fraction is beginning to be better understood, and as further knowledge is gained, better pharmacologic control of CVI is a tantalizing promise.     

Distribution of Dysplasia in Ulcerative Colitis

Epithelial dysplasia was found in the large intestine of 8 of 15 patients with ulcerative colitis operated on between 1980 and 1982. In six of eight patients, dysplasia was found in the cecum and ascending colon, in one of eight in the descending or sigmoid colon, and in four of eight in the rectum. None of the five carcinomas in three patients were located in the sigmoid colon or rectum. The age of onset was much lower. 19 ± 7 years, and the duration of colitis longer, 15 ± 7 years, for the group with dysplasia compared with that without dysplasia, 37 ± 18 and 4 ± 3 years, respectively. Our study indicates that malignant transformation may frequently occur in the proximal colon and emphasizes the need for total colonoscopy with multiple biopsies in the evaluation of patients with long-standing ulcerative colitis.     

The role of noninvasive testing in the evaluation of chronic venous problems

Noninvasive instrumentation is now available to evaluate venous function in patients with a wide variety of chronic venous problems. The present analysis attempts to review the use of directional flow detection by Doppler ultrasound, venous refilling or maximal venous outflow by plethysmography, and the newly introduced venous imaging techniques (B-mode and duplex scanning) in evaluation of patients with varicose veins, the postphlebitic syndrome, sequelae after acute deep-vein thrombosis, and venous reconstructive surgery. Venous refilling time recorded by the photoplethysmograph is the simplest technique for assessment of venous dysfunction, and it can identify venous stasis or ulcer as a result of long saphenous vein insufficiency. Both the B-mode and the duplex scan allow direct examination of venous valve motion and determination of valve competency. The latter technique holds promise in the evaluation of venous valve reconstructive surgery and, more important, in accurate assessment of venous valve damage following acute deep-vein thrombosis.

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Resumen La instrumentación no invasiva se halla actualmente disponible para evaluar la función venosa en pacientes con una amplia variedad de problemas venosos crónicos. El presente estudio trata de revisar el uso de la detección de flujo direccional por Doppler de ultrasonido, la repleción venosa o el flujo venoso máximo por pletismografía, y de las nuevas técnicas de imagenología (modo B y escanografía duplex) en la valoración de pacientes con venas varicosas, el síndrome postflebítico, las secuelas de la trombosis venosa profunda, y la cirugía venosa reconstructiva. El tiempo de repleción venosa registrado por pletismografía es la técnica más simple para la valoración de la disfunción venosa, y es capaz de identificar estasis venosa o ulceración como resultado de insuficiencia de la vena safena mayor de larga duración. Tanto el modo B como la escanografía permiten el examen directo del movimiento valvular venoso y la determinación de la competencia valvular. Esta Última técnica es promisoria en cuanto a la evaluación de la cirugía reconstructiva de las válvulas venosas y, muy importante, en la determinación precisa de daño valvular después de una trombosis venosa profunda.

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Résumé Une instrumentation non invasive est maintenant disponible pour évaluer la fonction veineuse chez les malades qui présentent une large variété de problèmes veineux chroniques. L'article tente de passer en revue la détermination du flux veineux par le Doppler, le remplissage veineux ou l'écoulement veineux maximum par la pléthysmographie, les nouveaux procédés d' imagerie veineux (ultrasonographie en temps réel et double ultrasonographie) pour étudier les varices, le syndrome post-phlébitique, les séquelles de la thrombose aiguË veineuse profonde, et la chirurgie reconstructive veineuse. Le temps de remplissage veineux déterminé par la photo-pléthysmographie représente la technique la plus simple pour apprécier le fonctionnement veineux anormal et la méthode permettant d'identifier la stase veineuse ou l'ulcère résultant d'une insuffisance de la veine saphène longue. L'ultrasonographie en temps réel et la double ultrasonographie permettent l'exploration directe de la motilité de la valve veineuse et l'appréciation de la compétence valvulaire. La dernière méthode porte la promesse de pouvoir juger de la valeur de la chirurgie reconstructive valvulaire veineuse et, fait plus important, d'apprécier exactement l'altération valvulaire secondaire à la thrombose veineuse profonde.

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Supported in part by the Conrad Jobst Foundation, the Seabury Foundation, and the Northwestern Vascular Foundation.     

Multilocus enzyme electrophoresis of major O-antigen reference strains ofPseudomonas aeruginosa

Multilocus enzyme electrophoresis was used to characterize 27Pseudomonas aeruginosa serogroup reference strains used in the major O-antigen schemes according to whichPseudomonas aeruginosa has been typed. Sixteen enzyme loci were assayed, ten of which showed electrophoretic variation. Genetic diversity was expressed for each enzyme locus, and as the mean allelic diversity of loci. Ten electrophoretic types were identified among the strains. The genetic distance between pairs of electrophoretic types was expressed as the proportion of loci at which similar alleles occurred. More than 80 % similarity was observed between any pair of electrophoretic types, reflecting the homogeneity of multilocus genotypes within this species. Similarity between electrophoretic types was represented in the form of a dendrogram and by multi-dimensional scaling. Three distinct clusters of electrophoretic types were revealed; within each the serogroups appeared to be randomly distributed.