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The role of retroperitoneal lymph node dissection (RPLND) in testicular cancer is well established in both the primary and post-chemotherapy setting. The aim of this study was to report our 2 years oncological outcomes of robotic RPLND. A retrospective review was performed of all patients undergoing robotic RPLND by a single surgeon at Princess Margaret Cancer Centre. Demographic, perioperative, and oncologic data were analyzed using descriptive statistics. Between September 2014 and June 2020, 141 patients underwent an RPLND [33 (23.4%) were primary, 108 (76.6%) were post-chemotherapy]. 27 (19.1%) patients underwent a robotic bilateral template nerve-sparing RPLND. RPLND indication was primary (i.e. pre-chemotherapy) in 18 (66.7%), and post-chemotherapy in 9 (33.3%) patients. Stage at RPLND was 2A (n = 15, 55.6%), 2B (n = 9, 33.3%), 2C (n = 1, 3.7%) and 3 (n = 2, 7.4%). Median OR time (incision to closure) was 525 min and blood loss was 200 ml. Nerve sparing was performed in all but one case. Six (22.2%) adjuvant procedures were performed including two (7.4%) vascular repairs. Median length of stay was 2 days. Viable tumor was detected in 17 (63%) and teratoma in 9 (33.3%). Median follow-up was 31.3 months. No adjuvant chemotherapy was given. Three patients (11.1%) relapsed: 2 out-of-field and 1 with both in-field and out-of-field disease. Robotic RPLND can be performed safely. Long-term follow-up of series such as ours, enriched with patients with viable disease and/or teratoma, and not treated with adjuvant chemotherapy is required to ensure oncological outcomes are comparable to the open approach.

BackgroundMedication reconciliation (MedRec) can improve patient safety. In Canada, most provinces are implementing electronic health records (EHR). The Quebec Health Record (QHR) can theoretically be used for medication reconciliation. However, the quantity and the quality of information available in this EHR have not been studied. ObjectivesThe main objective was to compare the quantity and quality of the information collected between the inpatient best possible medication history (BPMH) and the QHR. MethodsThis is a descriptive prospective study conducted at CHU Sainte-Justine, a 500-bed tertiary mother-and-child university hospital center. All inpatients from May 19-26, 2015 were considered for inclusion. Every prescription line in the BPMH and QHR were compared. ResultsThe study included 344 patients and 1,039 prescription lines were analyzed. The medications' name and dosing were more often available in the QHR (95%) than in the BPMH (61%). Concordance between the medication names between QHR and BPMH was found in 48% of the prescription lines; this rate fell to 29% when also factoring daily dosage. ConclusionsThis study suggests that the QHR can provide high-quality information to support the MedRec hospital process. However, it should be used as a second source to optimize the BPMH obtained from a thorough interview with the patient and/or his or her family. More studies are required to confirm the most optimal way to integrate the QHR to the MedRec process in hospitals.

To review our experience of caspofungin in the treatment of persistent candidemia in the neonatal intensive care unit. This was a retrospective chart review on 13 infants in whom caspofungin was added to conventional antifungals (amphotericin B and/or fluconazole or flucytosine) for the treatment of refractory candidemia. A total of 12 infants were preterm (gestational age, 24 to 28 weeks) and one was term; the median birth weight was 800 g (range, 530 to 5600 g). Candidemia (Candida albicans in five, C. parapsilosis in six, C. albicans and C. parapsilosis in one and C. tropicalis in one) persisted despite 6 to 30 days of conventional antifungal therapy. After the addition of caspofungin, sterilization of blood cultures was achieved in 11 infants at the median time of 3 days (range, 1 to 21 days). Adverse events included thrombophlebitis (one patient), hypokalemia (two patients) and elevation of liver enzymes (four patients). Three infants had a second episode of candidemia and seven patients died. Caspofungin may be an efficacious addition for treatment of candidemia refractory to conventional antifungal therapy. This drug should be further investigated in neonates.

Research and development of the adenosine A 2A receptor selective antagonist KW6002 have focused on developing a novel nondopaminergic therapy for Parkinson’s disease (PD). Salient pharmacologic features of KW6002 were investigated in several animal models of PD. In rodent and primate models, KW6002 provides symptomatic relief from parkinsonian motor deficits without provoking dyskinesia or exacerbating existing dyskinesias. The major target neurons of the A 2A receptor antagonist were identified as GABAergic striatopallidal medium spiny neurons. A possible mechanism of A 2A receptor antagonist action in PD has been proposed based on the involvement of striatal and pallidal presynaptic A 2A receptors in the “dual” modulation of GABAergic synaptic transmission. Experiments with dopamine D 2 receptor knockout mice showed that A 2A receptors can function and anti-PD activities of A 2A antagonists can occur independent of the dopaminergic system. Clinical studies of KW6002 in patients with advanced PD with l-dopa–related motor complications yielded promising results with regard to motor symptom relief without motor side effects. The development of KW6002 represents the first time that a concept gleaned from A 2A biologic research has been applied successfully to “proof of concept” clinical studies. The selective A 2A antagonist should provide a novel nondopaminergic approach to PD therapy.

OBJECTIVE: To identify infants at risk of death and abnormal neurodevelopmental outcome following extracorporeal membrane oxygenation (ECMO) in the neonatal period. METHODS: The medical records of 82 neonates treated with ECMO were reviewed to evaluate risk of death. All survivors were followed by neurologic examinations and tested using the Bayley Scales of Infant Development or McCarthy Scale of Children’s Abilities, and risk for abnormal neurodevelopmental outcome was assessed. RESULTS: The overall survival was 91% (75 of 82). The mean gestational age and birth weight of nonsurvivors were lower than those of survivors (37 ± 1 weeks vs 40 ± 0 weeks; 2734 ± 230 vs 3325 ± 69 gm, p < 0.05). Infants who were lost to follow-up (16%) did not differ from those with follow-up in demographic variables or clinical indicators of illness severity. Thirty-five of 63 infants (56%) with follow-up had normal neurodevelopmental outcome. Risk of abnormal outcome was higher in infants requiring assisted ventilation for ≥15 days (relative risk [RR] 5.5; 95% confidence interval [CI] 2.0 to 14.8), supplemental oxygenation for ≥22 days (RR 3.1; 95% CI 1.3 to 7.6), and black race (RR 8.9; 95% CI 1.3 to 62.9). None of the neuroimaging studies accurately predicted the neurodevelopmental outcome of these infants. CONCLUSION: We conclude that ECMO in critically ill infants is associated with good survival. The need for prolonged respiratory support may help in identifying infants at risk for abnormal neurodevelopmental outcome.

Congenital hepatic arteriovenous malformations are rare anomalies, which typically present in infancy with congestive heart failure, anemia, and hepatomegaly. Morbidity and mortality is high if the condition is not recognized and treated promptly. Hepatic arteriovenous malformation associated with persistent pulmonary hypertension of the newborn has been reported in two cases in the literature. We report a neonate who was referred for management of persistent pulmonary hypertension and was subsequently diagnosed with a large hepatic arteriovenous malformation. He underwent coil embolization following which pulmonary hypertension resolved.

Objective. To evaluate the effect of antenatal phenobarbital (PB) therapy on neonatal intracranial hemorrhage (ICH) in preterm infants. Design. Prospective, randomized, controlled trial. Setting. Single institution study. Subjects and Interventions. Women in preterm labor ( Outcome Measures. Incidence of neonatal ICH in all infants, infants weighing less than 1250 g, and infants of multiple gestations. Results. The study population comprised 110 women, 60 in the control group and 50 in the PB group. Neonates in the control group (n = 74, including 10 pairs of twins and 2 sets of triplets) were comparable to those in the treatment group (n = 62, including 7 pairs of twins, 1 set of triplets, and 1 set of quadruplets) regarding birth weight, gestational age, and other clinical risk factors for ICH. There was a trend for the incidence of any grade of hemorrhage to be lower in the PB group (22% [14 of 62]) compared with the control group (35% [26 of 74]). Moderate and severe hemorrhages were significantly lower in the PB group (1.6% [1 of 62]) compared with the control group (9.4% [7 of 74]). Among infants weighing less than 1250 g, overall ICH was lower in the PB group (23% [6 of 261) compared with the control group (51% [18 of 35]). Among multiple-gestation infants, overall ICH was 4.7% (1 of 21) in the PB group, compared with 31% (8 of 26) in the control group. Conclusions. Antenatal PB therapy results in a significant decrease in moderate and severe ICH in infants born at less than 35 weeks' gestation. Antenatal PB therapy also resulted in a decrease in the incidence of all grades of ICH in infants weighing less than 1250 g and infants born of multiple gestations.

Gastrointestinal cytomegalovirus infection is a common opportunistic infection in immunocompromised patients. It is a rare cause of enterocolitis in immunocompetent hosts. We present a case of severe cytomegalovirus enterocolitis causing intractable diarrhea in a previously healthy infant. The child was successfully treated with intravenous ganciclovir.

Twenty-eight term neonates with severe perinatal asphyxia were referred to a tertiary neonatal intensive care unit (NICU). The morbidity of asphyxia included involvement of the pulmonary (n = 24 infants), central nervous system (n = 22), renal (n = 15), cardiac (n = 14), metabolic (n = 13) and hematologic (n = 10) systems. The majority of neonates had more than three organ systems involved. Twenty-four neonates survived the neonatal course and at NICU discharge all system effects other than the central nervous system had resolved. At 5 years (60 months), 14 children had a normal neurologic examination, 9 had spastic quadriplegia and one had hemiplegia. Nine children had a McCarthy General Cognitive Index (GCI) greater than or equal to 84, 3 had a GCI between 68 and 83 and 12 scored less than 67. Neonatal seizures, renal problems, microcephaly at 3 months, and post-neonatal seizures were associated with an abnormal neurologic outcome or a GCI less than 67. A neurologic examination during the first year of life may reveal whether children with birth asphyxia will be relatively normal at age 5 years or whether they will show considerable delay.

The incidence and site of electroencephalogram (EEG) abnormalities and the efficacy of post-ECMO EEG as a predictor of neurodevelopmental outcome was evaluated in survivors of neonatal extracorporeal membrane oxygenation (ECMO). All survivors of neonatal ECMO with an EEG performed prior to their discharge were included if they had at least 12 months of follow-up. The neurodevelopmental outcome was reported as normal, suspect, and abnormal on the basis of neurological examination and the scores on Bayley Scales of Infant Development or McCarthy Scale of Children's Abilities. EEG abnormalities were noted in 31 (70%) of 44 infants. The distribution of EEG abnormalities was not significantly different for right and left hemispheres. The incidence of abnormal neurodevelopmental outcome was similar in infants with a normal or an abnormal EEG (3 of 13 vs. 7 of 31; p = 0.8). EEG abnormalities had no correlation with neurodevelopmental outcome. We conclude that the high incidence of EEG abnormalities and their lack of correlation with neurodevelopmental outcome would suggest that these abnormalities do not represent permanent brain injury and a single EEG performed after decannulation from ECMO is not helpful in identifying infants at risk of subsequent abnormal neurodevelopmental outcome.

Osteogenesis imperfecta (OI) is an inherited connective tissue disorder, a group that includes Ehlers-Danlos syndrome, Marfan's syndrome and pseudoxanthoma elasticum. OI is a heterogeneous disease of collagen I biosynthesis characterized by variable clinical phenotypes, including skeletal and cardiovascular manifestations. A 65-year-old man with OI who had extensive prior successful cardiac valve surgeries is described. He survived for 18 years after his initial valve surgery, but died of multiorgan failure and sepsis after repair of a spontaneous type A aortic dissection. This is the fourth reported case of aortic dissection secondary to OI and illustrates the extensive cardiovascular pathology associated with OI. Aggressive management of arterial dissection risk factors, such as systemic arterial hypertension, is advocated for patients with OI.

Objective. To evaluate the effect of antenatal phenobarbital (PB) therapy on neurodevelopmental outcome at 36 months. Design. Prospective, randomized, controlled trial. Setting. Single-institution study. Subject and Interventions. Children born to women who participated in the study evaluating the effect of antenatal phenobarbital (PB) on neonatal intracranial hemorrhage were prospectively followed to 3 years of age. Outcome Measures. Physical growth, neurologic examinations, and developmental testing (McCarthy Scales of Children's Abilities). Comparisons between groups were made on all children and those born to multiple gestations. Results. Forty-one children born to women who received 10 mg/kg PB before delivery and 55 children in the control group were evaluated. Three children, all in the control group, had growth parameters (height, weight, and head circumference) below the fifth percentile. The McCarthy General Cognitive Index (standard, 100 ± 16) was 93 ± 20 in the PB group and 85 ± 18 in the control group. The subscores tended to be higher in the PB group than in the control group, with higher quantitative scores in the PB group (44 ± 11 vs 39 ± 8). Neurologic deficits were noted in 2 of 41 in the PB group and in 6 of 55 in the control group. Conclusions. Infants born to women who received antenatal PB therapy had similar neurodevelopmental outcomes as infants born to women who did not receive PB. No adverse effects of PB exposure were detected.

The objective of the investigation was to determine what effect intracranial pathology has on alterations of superior sagittal sinus blood flow, and to determine the role of color flow Doppler imaging of the superior sagittal sinus in the diagnosis of intracranial pathology in the neonate and infant. One hundred examinations were performed prospectively in 96 patients. The velocity was determined with an angle correction at 30-60 degrees and was obtained with and without gentle transducer compression. Superior sagittal sinus thrombosis was identified in two patients by the absence of flow. Multiple t-tests for independent measures showed no clinically significant differences between flow velocities with regard to intracranial hemorrhage, ventriculomegaly, extracorporeal membrane oxygenation therapy or prematurity. The authors conclude that color flow Doppler can accurately diagnose superior sagittal sinus thrombosis and may be used to screen high risk neonates such as those with thrombosis elsewhere or those treated with extracorporeal membrane oxygenation. No clinically significant associations were found between superior sagittal sinus flow velocity and any of the parameters evaluated in this study.

The mitral Ionescu-Shiley standard-profile prosthesis of a 53-year-old woman who had it placed 12 years previously is described. The observed cicatricial retraction of one of the bioprosthesis' cusps is unusual, and it contributed to the bioprosthetic dysfunction which necessitated this valve's replacement.

To determine the incidence and site of single photon emission computed tomography scan (SPECT) abnormalities in survivors of neonatal extracorporeal membrane oxygenation and to evaluate the efficacy of SPECT scan as a predictor of neurodevelopmental outcome in these infants.Tertiary care neonatal intensive care unit in Detroit, MI.Survivors of neonatal extracorporeal membrane oxygenation who had a SPECT scan of the brain performed after decannulation and before their discharge from the neonatal intensive care unit were included if they had at least 12 months of follow-up in our developmental assessment clinic.The neurological outcome was reported as normal, suspect, and abnormal on the basis of neurological examination and developmental milestones. The developmental outcome was assessed by Bayley mental development index or McCarthy general cognitive index scores.A total of 59 patients met study criteria. SPECT scan abnormalities were noted in 45 (76%) infants. Global hypoperfusion was the most frequent abnormality followed closely by bilateral focal perfusion defects. The distribution of perfusion abnormalities was not significantly different for right and left hemispheres. Among 14 infants with normal SPECT scans, 13 infants had normal neurological outcome and all had a normal developmental outcome. Of the 45 infants with an abnormal SPECT scan, 7 infants had an abnormal neurological outcomes and 4 infants had an abnormal developmental outcome. SPECT scan abnormalities had no significant correlation with neurodevelopmental outcome of these infants.Although a normal SPECT scan was more likely to predict a normal neurodevelopmental outcome, an abnormal SPECT scan did not predict an abnormal outcome in these infants.

Seven term neonates with encephalopathy resulting from asphyxia and/or intracranial hemorrhage underwent invasive monitoring of intracranial pressure through the epidural or intracerebral space. The average age (in hours) at insertion of the monitor was 27 h in the 3 neonates with asphyxia and 70 h in the 4 neonates with hemorrhage. Intracranial hypertension was noted in 6 neonates. The management of the hypertension included hyperventilation followed by mannitol for pressures that were sustained above 20 mmHg and pentobarbital for pressures above 30 mmHg. The duration of the hypertension varied in 5 neonates from 4 to 72 h, while in the remaining neonate, the pressure remained elevated until death at 70 h. All 4 survivors with intracranial hemorrhage have minimal neuromotor deficits on follow up and 2 survivors with asphyxia have cognitive deficits and are microcephalic. From this small series, it appears that in the management of term neonates with intracranial hemorrhage, monitoring of intracranial pressure should be considered.

From 1977 to 1987, 829 Ionescu-Shiley pericardial valves (Shiley, Inc., Irvine, Calif.) were implanted in 766 patients at the University of Ottawa Heart Institute. There were 476 patients who had aortic valve replacement, 234 who had mitral valve replacement, and 44 who had double valve replacement. The standard-profile design was used in 508 patients and the low-profile design in 321 patients. Follow-up was obtained for 97% of patients, with calculation of event-free probabilities. At 10 years the overall probability of freedom from structural failure was 48% +/- 7% after aortic valve replacement, 44% +/- 15% after mitral valve replacement, and 79% +/- 11% after double valve replacement. Although at 5 years the probability of failure was statistically lower with the low-profile design, this favorability was lost by 6 years. Freedom from structural failure was only 47% +/- 7% for the standard-profile valve at 10 years. Thus the probability of freedom from reoperation was only 46% +/- 7% after aortic valve replacement, 39% +/- 6% after mitral valve replacement, and 65% +/- 20% after double valve replacement at 10 years. Thromboembolism occurred in 69 patients, for a predicted freedom from this complication at 10 years of 79% +/- 3% after aortic, 73% +/- 7% after mitral, and 96% +/- 4% after double valve replacement. There were 31 cases of endocarditis. The 10-year predicted freedom from endocarditis, therefore, was 86% +/- 3% after aortic, 98% +/- 1% after mitral, and 97% +/- 1% after double valve replacement. A total of 221 operative and late deaths were recorded in this series. Prosthetic valve failure accounted for 27% of late deaths. The 10-year survival rates were estimated to be 56% +/- 5% (aortic valve replacement), 54% +/- 6% (mitral valve replacement), and 51% +/- 8% (double valve replacement). We concluded that the Ionescu-Shiley pericardial xenograft provides less than optimal clinical performance and its use has been discontinued.

The case of a 45-yr-old woman who had balloon valvuloplasty for rheumatic mitral stenosis is presented. An anterior mitral leaflet tear occurred as a complication of the procedure. Both partial healing of the anterior mitral leaflet and gradual dilatation of the left atrium occurred which allowed the damaged valve to remain in situ for several months. Some of the late changes which occur after such a complicated valvuloplasty are illustrated here, as this patient eventually required surgery and valve excision for definitive repair.

An unusual complication after tricuspid valve annuloplasty is described where a ring suture ligated right coronary artery and precipitated myocardial infarct and patient death. The need for caution to prevent this complication with such surgery is emphasized.

Severe akinesia can be observed in macaques following MPTP injections destroying dopaminergic nigrostriatal neurons. Akinesia also results from inhalation of toxic substances inducing bilateral lesions of the two pallidal nuclei and of the pars reticulata of the substantia nigra, and not of the pars compacta. Most of the recent studies of the anatomo-physiological substratum of akinesia used MPTP injections. Deoxyglucose studies have shown a clear increase in the neuronal activity of the medial nucleus of the pallidum and of its thalamic projection territory. Electrophysiological studies have shown a major modification of the spontaneous activity of medial pallidal neurons which is influenced in an excessive and non selective manner by sensorimotor inputs. Analysis of the relative three dimensional geometry of nervous arborizations have shown that the striato-pallido-nigral system is extremely convergent. Akinesia consecutive to nigrostriate lesions could be linked to an excessive and anarchic activation of this system. The contradiction which exists between akinesia with an abnormal activity of the medial pallidum and akinesia with bilateral pallidal lesions could only be apparent if akinesia was linked to the ineffective emission or to the interruption of messages to the thalamus.

The neurodevelopmental sequelae in 33 low birth weight neonates with moderate or severe hemorrhage and ventriculomegaly (VM group) and in 39 neonates with mild hemorrhage only (non-VM group) were evaluated prospectively. Both groups were comparable in birth weight, gestational age, and socioeconomic status. Ventriculoperitoneal shunts were inserted in 23 of the 33 VM group infants at a mean age of 26 days. Eighty-two shunt revisions were performed, for obstruction (71 revisions) or infection (11 revisions), in 18 of the 23 children. At a mean age of 50 months, 19 of 33 children in the VM group had sequelae; 14 children had moderate or severe neurologic deficits, and 5 children had mild sequelae. In the non-VM group, only 3 of 39 children had deficits, all of which were mild (p less than 0.05). In the VM group, 19 of 33 children had mental developmental delay in comparison with 8 of 39 in the non-VM group (p less than 0.05), and 17 of 33 children in the VM group had motor developmental delay in comparison with 5 of 39 in the non-VM group (p less than 0.01). Within the VM group, the number of children with neurodevelopmental sequelae did not differ significantly among the 23 children with shunts, in comparison with the 10 who did not require shunting. Among the children with shunts, a higher incidence of sequelae occurred when lack of ventricular decompression was noted immediately after shunt insertion (p less than 0.005) and when shunt infections occurred (p less than 0.01). The most important predictor of mental and motor outcome in the group with shunts was lack of ventricular decompression immediately after shunt insertion. We speculate that, in some infants, loss of brain tissue, cerebral atrophy, or both may occur before insertion of the ventriculoperitoneal shunt, even when the shunt is inserted early.

Seven neonates (four preterm and three term) with severe hypoxic-ischemic parenchymal brain changes are presented to illustrate the kinds of parenchymal lesions demonstrable on ultrasound, to show the similarity of parenchymal lesions in preterm and term infants, and to correlate the severe neurologic deficits with the parenchymal changes. The lesions demonstrated are periventricular leukomalacia, large-vessel infarction, isolated parenchymal hemorrhage, multiple cystic encephalomalacia, and parenchymal atrophy. Parenchymal changes should be sought in such infants during any stage of their disease.

Forty-six pregnant women less than 35 weeks of gestation were enrolled in a prospective randomized controlled study evaluating the effects of antenatal phenobarbital on neonatal intracerebral hemorrhage. The women were randomly assigned to control (n = 22) or treatment (n = 24) groups; the treatment group received 500 mg of phenobarbital intravenously. The time interval between the dose of phenobarbital and delivery was 5.5 +/- 4.8 hours (mean +/- SD). The infants in the control group (n = 23) and those in the phenobarbital-treated group (n = 25) were comparable regarding birth weight, gestational age, and other obstetric and neonatal risk factors associated with intracerebral hemorrhage. The incidence of intracerebral hemorrhage was 56.5% (13 of 23 infants) in the control group and 32% (eight of 25 infants) in the phenobarbital-treated group (p = 0.08). Moderate or severe hemorrhage was diagnosed in six of 13 control infants and in none of the phenobarbital-treated infants (p less than 0.01). The mortality rate was significantly lower in the phenobarbital-treated group (two of 25 infants) than in the control group (eight of 23 infants; p less than 0.05). Our study suggests that antenatal phenobarbital administration results in a decrease in mortality and in the severity of intracerebral hemorrhage in the preterm neonate.

SUMMARY:We have studied a large family of which seven members suffer from a progressive disease with onset in the first decade. The first symptoms were gait ataxia and clumsiness in all cases, followed by progressive development of severe distal amyotrophy reminiscent of Charcot-Marie-Tooth disease. In four patients a postural tremor which was relieved by pharmacological agents was also evident in the limbs or head.Cerebellar atrophy was confirmed on CT scan. Motor nerve conduction velocities were in the low normal range, while sensory nerve conduction was markedly decreased. All patients had impaired proprioception and vibration sense. The laboratory investigation revealed a normal CSF protein level and elevated serum bilirubin.The patients reported in this study apparently suffer from an original recessive form of spinal and olivocerebellar degeneration associated with a neuronal form of Charcot-Marie-Tooth disease.

Dopamine receptors in intracerebral motor and endocrine systems1,2 have been divided into two main types, D-1 and D-2, dependent on the presence or absence of adenylate cyclase linkage3. Here we have investigated a number of dopamine agonist and antagonist drugs in man that have different actions on D-1 and D-2 receptors in animals. Motor and endocrine effects in parkinsonian subjects seem to depend on drug interaction with D-2, but not D-1, receptors. These results may have important implications for the design of anti-parkinsonian and antipsychotic agents.

Extracorporeal membrane oxygenation (ECMO) has been performed on 45 neonates at the Children's Hospital of Michigan in a 39-month period. Ultrasound evaluation of these patients prior to and during ECMO therapy has demonstrated abnormalities in the central nervous system including intracranial hemorrhage (21), extra-axial fluid collections (5), and ventricular enlargement (2). Ultrasonic evaluation of the thoracic cavity in 12 infants revealed pleural fluid in 8. There were seven children with varying types of peritoneal fluid. Two children had visceral abnormalities — 1 with liver hemorrhage and 1 with hydronephrosis found prior to ECMO. Most of these findings could not have been diagnosed without ultrasound and may lead directly to alterations in clinical management. Ultrasound is an extension of physical examination which is important in hour-by-hour clinical care of patients on ECMO.

Sixty-two neonates diagnosed to have periventricular-intraventricular hemorrhage were classified by sonographic findings as follows: mild, confined to the subependymal region or accompanied by a small amount of blood in the normal-sized lateral ventricle (10); moderate, intermediate amount of blood in the enlarged lateral ventricle (26); and severe, hemorrhage filling the entire ventricle forming a cast (12) or intraventricular hemorrhage with an intracerebral extension (14). Twenty-six of 35 surviving neonates had posthemorrhagic hydrocephalus, and 11 infants required shunt insertion. The survival rate of neonates with periventricular-intraventricular hemorrhage and the incidence of posthemorrhagic hydrocephalus correlated with the severity of the hemorrhage (P less than 0.05). The highest mortality rate was seen in the group with ventricular casts. All surviving neonates with casts developed hydrocephalus. All surviving neonates with intracerebral hemorrhage developed porencephaly. The severity of the hemorrhage correlated with short-term neurologic outcome (P less than 0.05), the group most severely affected being the one with intracerebral extension of hemorrhage. The severity of the hemorrhage also correlated with abnormal ventricular size by sonography on follow-up (P less than 0.05). However, posthemorrhagic hydrocephalus and abnormal ventricular size on follow-up did not correlate with neurologic outcome in the moderate and severe hemorrhage groups.

Between December 1970 and October 1973, 74 patients underwent emergency myocardial revascularization for the relief of acute coronary insufficiency. Through our experience in this area, we have established three categories for which we perform emergency surgery. The first of these is cardiogenic shock complicating acute myocardial infarction for which 14 patients underwent emergency saphenous vein grafting. Seven of these patients expired during operation and one died three months after operation. The second category is acute unstable myocardial infarction for which 25 patients received surgery. There were no operative deaths in this group, but two patients died at six weeks and four months after operation. Thrity-five patients were classified as pre-infarctional angina, the third category for which we perform surgery on an emergency basis. There was one operative death and two late deaths at four and ten months in this group of patients. Our experience suggests that immediate coronary angiography and revascularization will improve survival in the three above-named categories.

Forty-two premature infants less than 24 hours of age, with normal admission echoencephalograms, were randomly assigned to control or phenobarbital treatment groups. Infants in the treated group received two loading doses of 10 mg/kg of phenobarbital 12 hours apart, followed by a maintenance dose of 2.5 mg/kg every 12 hours for 6 days. Serial echoencephalograms were obtained in both groups. The groups were comparable with regard to birth weight, gestational age, and potential risk factors for subependymal-intraventricular hemorrhage. Ten infants (48%) in each group developed hemorrhage. The hemorrhages in the phenobarbital-treated group were significantly less severe than those in the control group. The phenobarbital-treated infants who bled, however, were also significantly larger and more mature than control infants who bled. The results of this study indicate no effect of phenobarbital on the incidence of subependymal-intraventricular hemorrhage, but a possible beneficial effect on the severity of hemorrhage.

Of the first 600 patients to receive aortocoronary bypass grafts 383 had three diseased vessels, and of them 36 (9%) have died: 20 (5%) in hospital and 16 (4%) late. In 10 of those who died, ventricular function was normal, class I or class II and in the other 26 function was class III or class IV. For all ventricular classes except class IV, improvement in myocardial blood flow with operation was considerably lower than average in those who died. The leading cause of late death was congestive heart failure followed by myocardial infarction, and then by other cardiac complications. Of patients with good (normal, classes I or II) ventricular function, 3.5% died during a mean follow-up period of 27 months; and since, according to published reports, 1% of patients with triple-vessel disease without surgical intervention die each month, the data from this study suggest that survival in this group is improved by 23.5%. This study also shows that in patients with triple-vessel disease and good ventricular function, adequate coronary artery bypass operations (i.e., placement of three grafts or more) improves survival.

Hemorrhage related to systemic heparinization is the major complication of extracorporeal membrane oxygenation (ECMO). Intracranial hemorrhage (ICH) is the most devastating complication. ICH developed in 13 of our 25 ECMO patients (52%). Six died, six survived with normal neurologic function, and one is severely impaired. In nine of 13 patients (69%) ECMO was discontinued when serial cranial ultrasounds showed progressive ICH. Seizures developed in six infants while receiving ECMO, and ICH developed in all. There is a correlation between hypertension and ICH. A hypertension index (hours systolic BP greater than 90/hours receiving ECMO) was 0.1 +/- 0.12 for infants without ICH and 0.37 +/- 0.28 for infants with ICH (P less than .05). ICH developed in 79% of the patients with an index greater than 0.1. Twenty neck explorations were required in the first 20 patients for incisional bleeding (mean blood loss, 21.9 +/- 18.0 mL/kg/d). We now use fibrin glue following cannulation and have done only one neck exploration in the last five patients (mean blood loss, 2.8 +/- 2.2 mL/kg/d, P less than .05). Endobronchial bleeding has responded to phenylephrine lavage and increased positive end-expiratory pressure. We have controlled pleural space bleeding with topical thrombin. None of the hemorrhagic complications encountered correlate with the activated clotting time or the amount of heparin used. There is an increased risk of hemorrhage associated with platelet counts less than 100,000/microL for 75% of a day (P less than .05) so that aggressive platelet transfusion remains important in preventing hemorrhagic complications during ECMO.

1 Eight patients who failed or ceased to respond to levodopa, or who had developed the `on-off' phenomenon were treated additionally with nomifensine. 2 The dosage of nomifensine started at 50 mg, was increased to 150 mg daily, and other medication was continued unchanged. The duration of treatment was from 2-5 months. Assessments were carried out at 2-week intervals using a validated rating scale. 4 Loss of dopaminergic nigrostriatal neurones characterizes Parkinson's disease, and it is probably for this reason that indirect dopamine (DA) agonists, whose actions depend on intact presynaptic mechanisms, are less active. 3 Nomifensine was not shown to be of antiparkinsonian value in these patients but may be of value as an antidepressant in patients with Parkinson's disease.