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Some patients who have transient ischemic attacks are denied operation because severe occlusive lesions in other extra-cranial arteries may be inappropriately interpreted as constituting an unacceptable surgical risk, or because the lesion is so distal as to make its removal hazardous. Failure of endarterectomy is usually due to incomplete removal of the lesion or to thrombosis upon the frayed intima. Such lesions require excellent visualization and meticulous surgical technique -- not always possible with a shunt. Among 130 consecutive carotid endarterectomies performed under general anesthesia, EEG changes consistent with cerebral ischemia appeared in only nine (7%). These patients required a shunt. In 11 patients normal EEG tracings were obtained during endarterectomy despite contralateral carotid occlusion. None of these patients had a neurological deficit. Continuous EEG monitoring is a reliable method of detecting changes in cerebral perfusion, permits a more meticulous endarterectomy in high-lying lesions without a shunt, and extends operability in high risk patients. Angiographical findings may be an unreliable predictor concerning risk of endarterectomy.

To study the effects of amitriptyline in treating postherpetic neuralgia, 24 patients were randomly assigned to either drug or placebo in a double-blind crossover study. We found good to excellent pain relief in 16 of 24 patients (p less than or equal to 0.001). We did not find an antidepressant effect in most patients (p greater than 0.05). The median dose of amitriptyline was 75 mg. The median blood level was 65 ng per milliliter, and of nortriptyline 30 ng per milliliter. Good responses were maintained in 12 of 22 patients. Amitriptyline is useful in treating postherpetic neuralgia and may not act as an antidepressant.

A history of myocardial infarction should not be a deterrent to the performance of an elective inguinal herniorrhaphy. This operation has been proved to be safe for this patient population and is attended by a low and quite acceptable complication rate. Thorough preoperative evaluation ensures optimal management in both the perioperative and postoperative period. In stark contrast with elective inguinal herniorrhaphies, emergency procedures are associated with an alarming morbidity and mortality, often the result of cardiovascular complications. In the postinfarction patient with an inguinal hernia, the dual goals of complete cardiac rehabilitation and improved quality of life can be facilitated in a safe and sure manner by elective inguinal herniorrhaphy under local anesthesia.