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The natural history of medically treated multivalvular endocarditis is associated with dismal short and long term survival. However, the impact of surgical intervention on these results is relatively unknown. The objective of this retrospective study was to report our long-term results in patients requiring multivalve surgery for multivalvular endocarditis.

Minimally-invasive surgery is increasingly being utilised in patients with isolated valve disease who do not require concomitant coronary bypass. Minimally-invasive valve surgery has been performed at the Brigham and Women's Hospital, Harvard Medical School since July 1996 and has now been used in over 273 mitral valve operations, primarily valve repairs. The incisions used have evolved; we used a right para-sternal approach at first and have now changed to a lower mini-sternotomy. The operative techniques employed through this incision are identical to those used in a complete sternotomy. Operative mortality in our mitral valve series is zero. There have been five re-operations. The length of hospital stay and amount of blood utilised are both less than with a complete sternotomy. Most importantly, the patients' return to normality after complete recovery was quicker by approximately 2 weeks versus the conventional sternotomy. Minimally-invasive mitral valve surgery is a technique that can be utilised reproducibly for all techniques of repair or replacement.

We developed techniques for 'inverted T' partial upper re-sternotomy for aortic valve replacement (AVR) or re-replacement (AVreR) after previous cardiac surgery. We previously reported on decreased blood loss, transfusion requirements and total operative duration when compared to conventional full re-sternotomy. This report updates our series, one of the few to document a substantial benefit from a 'minimally-invasive' approach, refines a number of technical aspects of this new approach and reports follow-up.

N-6 polyunsaturated fatty acids (N-6 PUFAs), major constituents of corn oil and natural ligands for peroxisome proliferator-activated receptors, increase the rate of growth of established tumors. It has been proposed that chemical peroxisome proliferators increase hepatocyte proliferation by mechanisms involving activation of nuclear factor-κB (NF-κB) and production of low levels of tumor necrosis factor α (TNFα) by Kupffer cells; however, how N-6 PUFAs are involved in increased cell proliferation in liver is not well understood. Here, the hypothesis that N-6 PUFAs increase production of mitogens by activation of Kupffer cell NF-κB was tested. A single dose of corn oil (2 ml/kg, i.g.), but not olive oil or medium-chain triglycerides (saturated fat), caused an ~3-fold increase in hepatocyte proliferation. Similarly, when activity of NF-κB in whole rat liver or isolated hepatocytes and Kupffer cells was measured at various time intervals for up to 36 h, only corn oil activated NF-κB. Corn oil increased NF-κB activity ~3-fold 1-2 h after treatment exclusively in the Kupffer cell fraction. In contrast, increases were small and only occurred after ~8 h in hepatocytes. The activation of NF-κB at 2 h and increases in cell proliferation at 24 h due to corn oil were prevented almost completely when rats were pretreated for 4 days with either dietary glycine (5% w/w), an agent that inactivates Kupffer cells, or the NADPH oxidase inhibitor, diphenyleneiodonium (s.c., 1 mg/kg/day). Furthermore, arachidonic acid (100 μM) activated superoxide production ~4-fold when added to isolated Kupffer cells in vitro. This phenomenon was not observed with oleic or linoleic acids. Interestingly, a single dose of corn oil increased TNFα mRNA nearly 2-fold 8 h after treatment. It is concluded that corn oil rapidly activates NF-κB in Kupffer cells via oxidant-dependent mechanisms. This triggers production of low levels of TNFα which is mitogenic in liver and promotes growth of hepatocytes.

N-6 polyunsaturated fatty acids (N-6 PUFAs), major constituents of corn oil and natural ligands for peroxisome proliferator-activated receptors, increase the rate of growth of established tumors. It has been proposed that chemical peroxisome proliferators increase hepatocyte proliferation by mechanisms involving activation of nuclear factor-kappaB (NF-kappaB) and production of low levels of tumor necrosis factor alpha (TNFalpha) by Kupffer cells; however, how N-6 PUFAs are involved in increased cell proliferation in liver is not well understood. Here, the hypothesis that N-6 PUFAs increase production of mitogens by activation of Kupffer cell NF-kappaB was tested. A single dose of corn oil (2 ml/kg, i.g.), but not olive oil or medium-chain triglycerides (saturated fat), caused an approximately 3-fold increase in hepatocyte proliferation. Similarly, when activity of NF-kappaB in whole rat liver or isolated hepatocytes and Kupffer cells was measured at various time intervals for up to 36 h, only corn oil activated NF-kappaB. Corn oil increased NF-kappaB activity approximately 3-fold 1-2 h after treatment exclusively in the Kupffer cell fraction. In contrast, increases were small and only occurred after approximately 8 h in hepatocytes. The activation of NF-kappaB at 2 h and increases in cell proliferation at 24 h due to corn oil were prevented almost completely when rats were pretreated for 4 days with either dietary glycine (5% w/w), an agent that inactivates Kupffer cells, or the NADPH oxidase inhibitor, diphenyleneiodonium (s.c., 1 mg/kg/day). Furthermore, arachidonic acid (100 microM) activated superoxide production approximately 4-fold when added to isolated Kupffer cells in vitro. This phenomenon was not observed with oleic or linoleic acids. Interestingly, a single dose of corn oil increased TNFalpha mRNA nearly 2-fold 8 h after treatment. It is concluded that corn oil rapidly activates NF-kappaB in Kupffer cells via oxidant-dependent mechanisms. This triggers production of low levels of TNFalpha which is mitogenic in liver and promotes growth of hepatocytes.

The expert system called Computerized Highway Noise Analyst (CHINA) was originally developed to address a nationwide lack of experience in the acoustic design of highway noise barriers. Since the development of CHINA, emphasis has moved from the need for tools on mainframe computers to the need for tools in the microcomputer environment. Implementation of the CHINA design tool for the personal computer began with the development of a series of routines that could be used to design a noise barrier effectively, test these routines independently of one another, and develop a control structure that would coordinate their activities. An interface was then developed that provided the user with configuration control, parameter control, and data and graphic interfaces. This paper describes both the development of individual modules of the system, as well as the integration of those modules into a single, easy‐to‐use system.

The expert system is a relatively new application of artificial intelligence technology that is beginning to emerge in the field of civil engineering. This new computer‐aided tool has the potential to significantly affect the way today's civil engineer assesses and solves complex problems. An expert system named CHINA (Computerized Highway Noise Analyst) has been developed that is capable of interacting with an existing FORTRAN model that aids an engineer in acoustically designing a highway noise barrier. CHINA executes the design model, interprets the results, and decides if those results are valid. If they are not, CHINA determines new input parameters and re‐executes the design model until a satisfactory design is obtained. Three actual highway noise abatement problems are examined in detail and the design solution from CHINA and a human expert are compared. The results of this comparison indicate that CHINA is capable of designing highway noise barriers that are at least equal, in terms of performance and cost, to those designed by a human expert. Thus, the concept of using expert systems as an expert advisor, or as a colleague to a human expert, is demonstrated to be feasible in this application.

Interleukin-5 (IL-5), which is produced by CD4(+) T helper 2 (Th2) cells, but not by Th1 cells, plays a key role in the development of eosinophilia in asthma. Despite increasing evidence that the outcome of many diseases is determined by the ratio of the two subsets of CD4(+) T helper cells, Th1 and Th2, the molecular basis for Th1- and Th2-specific gene expression remains to be elucidated. We previously established a critical role for the transcription factor GATA-3 in IL-5 promoter activation in EL-4 cells, which express both Th1- and Th2-type cytokines. Our studies reported here demonstrate that GATA-3 is critical for expression of the IL-5 gene in bona fide Th2 cells. Whereas mutations in the GATA-3 site abolished antigen- or cAMP-stimulated IL-5 promoter activation in Th2 cells, ectopic expression of GATA-3 in Th1 cells or in a non-lymphoid, non-IL-5-producing cell line activated the IL-5 promoter. During the differentiation of naive CD4(+) T cells isolated from T cell receptor transgenic mice, GATA-3 gene expression was up-regulated in developing Th2 cells, but was down-regulated in Th1 cells, and antigen- or cAMP-activated Th2 cells (but not Th1 cells) expressed the GATA-3 protein. Thus, GATA-3 may play an important role in the balance between Th1 and Th2 subsets in immune responses. Inhibition of GATA-3 activity has therapeutic potential in the treatment of asthma and other hypereosinophilic diseases.

Functional analysis of mutant class II major histocompatibility complex molecules has begun to identify regions important for antibody binding and for T-cell activation. By using in vitro mutagenesis directed at the beta 1 domain of the Ab beta gene we have constructed three structurally distinct mutant Ab beta genes. Each of these genes, as well as the wild-type Ab beta gene, was cotransfected together with the wild-type Ab alpha gene into the Ia-negative B-lymphoma cell line M12.C3. Transfection resulted in the successful synthesis and cell surface expression of three mutant class II antigens that showed serological and functional alterations as compared to the I-Ab antigens from the M12.C3 cell transfected with the wild-type gene. The variable patterns of both I-Ab-specific monoclonal antibody binding and activation of I-Ab-specific T-cell hybridomas show that the mutations result in the loss of structural epitopes required for both monoclonal antibody binding and for T-cell recognition. The data suggest that there are multiple sites on a single Ia molecule that are recognized by T helper cells and also that the tertiary conformation of the Ia molecule can be critical in the formation of such sites.

At the request of the Councils of the Society of Thoracic Surgeons (STS) and the American Association of Thoracic Surgery (AATS) the Ad Hoc Liaison Committee for Standardizing Definitions of Prosthetic Heart Valve Morbidity reviewed the "Guidelines" published in September 1988 [3, 7, 8]. The purpose of the review was to update and clarify definitions within the guidelines and to consider recommendations made by other [2, 11]. The variety of cardiac valvular procedures has expanded since 1988; therefore, in this document the term "operated valve" indicates prosthetic and bioprosthetic heart valves of all types, operated or repaired native valves and allograft and autograft valves. The term "operated valve" includes any cardiac valve altered by a surgeon during an operation. Much morbidity and mortality is a direct consequence of the interaction between the patient and operated valve(s), although patient variables (e.g., age, degree of coronary arterial disease, follow-up care, etc.) may be more responsible for outcomes than an operated valve. However, no set of guidelines can identify all possible patient factors that may affect morbidity and mortality. General agreement regarding the following definitions of terms and suggestions for reporting data do not preclude more detailed analyses or constructive recommendations and investigators are encouraged to identify relevant patient factors in addition to factors related to operated valves. Purpose The purpose of these guidelines is to facilitate the analysis and reporting of results of operations on diseased cardiac valves. The definitions and recommendations that follow are guidelines, not standards, and are designed to facilitate comparisons between the experiences of different surgeons who treat different cohorts of patients at different times with different techniques and materials.

According to Schrager, the first references to aberrant thyroids were by von Haller in 1779, Albers in 1839 and Gruber in 1845; the first accurate description was by Porta in 1849, and the first extirpation was by Stanley in 1850.Hinterstoisser in 1888 described 3 cases of lateral aberrant thyroid tissue, and von Eiselberg in 1901 collected 11 cases. In 1906 Schrager collected 15 cases from the literature of the preceding fifty years and added 2 of his own, and in 1908 McGlannan reported 3 cases. Wohl in 1917 added 4 cases. In 1923 Parcelier, Venot and Bonnin collected 23 cases from the literature and added 2 of their own. These authors noted that the disease becomes manifest most frequently between the ages of 20 and 40.Billings and Paul in 1925 made a résumé of 34 previously reported cases and added 1 of their own, bringing the total to

During the first sixteen years of my experience as an associate of Dr. Bloodgood, I took part in the diagnostic study and operation in 276 cases of lesions of the colon and of the rectum. In addition, I studied sections and roentgenograms in 125 cases of of similar lesions treated elsewhere, in which material was sent to the clinic for diagnosis. Table 1 summarizes these experiences.In 136 of the 276 personally observed cases, approximately 50 per cent, and in 72 of the 125 cases in which we were sent material, approximately 60 per cent, cancer was present. In the former group, in the great majority of instances the cancer had reached the stage in which one could make the diagnosis by digital palpation and by inspection through a proctoscope when the rectum was involved or by study of a roentgenogram taken after a barium sulfate enema when the lesion

Complete excision of the glands of the neck for malignant disease consists of excision of the submental lymphatic glands; unilateral excision of the submaxillary lymphatic and salivary glands and of the occipital, the deep cervical, the paratracheal, the prelaryngeal, the superior anterior cervical, and the infrahyoid lymphatic glands, and resection of the sternocleidomastoid and the omohyoid muscle, and of the internal jugular vein (fig. 1). Descriptions of the operation by Crile and others1 are in the literature. Each operator's technic naturally is a little different, and, as others have noted, many complete block dissections of the glands of the neck are such in name only; therefore, even at the risk of repetition, it seems well to describe mine.The position of the patient on the operating table is flat on the back with the neck extended. The incision in the skin extends from the mastoid process of the temporal

In the recent surgical literature there are seven articles to which I should like to call special attention.1 Six of these deal with preoperative irradiation in the treatment of carcinoma of the breast. The seventh is concerned chiefly with the statistical study of cancers of the breast treated by surgical measures alone and by surgical measures and postoperative irradiation. From one of these articles, namely, that of Adair and Stewart, I have taken the following data on eighty-one cases of operable carcinoma of the breast in which preoperative irradiation was followed by a radical Halstead operation.In each of these cases biopsy was performed preliminary to irradiation.In the Nova Scotia Medical Bulletin of June 1935 Bloodgood gave his conclusions in favor of irradiation preliminary to operation for carcinoma of the breast.Bloodgood and Stewart, in a brief paper in the Southern Medical Journal for July 1936, made further

Paget concluded from his observation of fifteen patients, each of whom presented a raw, finely granular nipple or an acute diffuse eczema of the nipple followed in one or two years by cancer of the breast, that chronic conditions of the skin of the nipple and areola are often succeeded by carcinoma of the mammary gland. He suggested and carried out excision of the involved area of the nipple and areola, but, as he himself acknowledged, too late.1 This conclusion of Paget that the primary lesion was on the nipple and areola and that the tumor of the breast was secondary was debated in the surgical literature from 1874 until 1924, a period of forty-eight years. And Kilgore,2 as late as 1921, after studying the material in the laboratory of surgical pathology of the Johns Hopkins Hospital, felt that while Paget's disease is usually primary in the nipple,

In an earlier article1 I published the data on 192 cases of primary and recurrent carcinoma of the female breast occurring during the period from Jan. 1, 1931 to Dec. 31, 1935. Patients observed during this time were selected for study because this period marked the beginning of my experience with preoperative irradiation for operable carcinoma of the breast. In table 1 (reproduced from my earlier article) the classification of patients according to method of treatment applied for the eradication of primary tumor is given. The cases of recurrent carcinoma are included but are separately considered.The analysis of these 192 cases and the study of the results to September 1936 seemed to indicate that the routine employment of preoperative irradiation might have value as an adjunct to the complete operation in the treatment of operable carcinoma of the female breast. In making microscopic studies I found no residual

The incidence and course of acute renal failure following cardiopulmonary bypass (CPB) was retrospectively analyzed. The incidence of oliguric acute renal failure was 1.5% and the mortality rate was 27%, a figure substantially lower than previously reported. Both peritoneal dialysis and hemodialysis were initiated early, with a mean of 3.6 days between the onset of acute renal failure and initiation of dialysis. Survivors had a mean duration of acute renal failure of 24 days. Deaths were caused by cardiac failure (one) and sepsis (two). Mortality rate from acute renal failure complicating CPB resembles that from acute renal failure related to other causes and may be lowered by early aggressive dialysis.