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The mechanism of sudden cardiac death following acute fluoride intoxication has been thought to result from profound hypocalcemia produced by the precipitation of calcium fluoride salts. In studies of a canine model, the onset of lethal ventricular arrhythmias was temporally more associated with an elevation of serum potassium than with a drop in serum calcium. Fluoride-induced hyperkalemia could not be prevented with glucose, insulin, or bicarbonate. In the erythrocytes, a five-minute exposure to 10 mM NaF caused a 50% increase in extracellular potassium concentrations after 12 hours compared to control erythrocyte suspensions (P less than .001). The total potassium efflux after 12 hours of incubation was linearly related to the log of fluoride contact time (r, 0.886; P less than .001). The treatment of fluoride-induced hyperkalemia may depend on removal of fluoride and potassium.

Dissection of the young women without Marfan disease is related, in most instances, to pregnancy. The structural changes in the arterial wall that occur during pregnancy may predispose women to this complication of pregnancy. In this study, two young women, who had none of the characteristics of Marfan's syndrome, were operated upon for dissection of the ascending aorta. The first patient was in the 35th week of gestation and a cesarean section was performed prior to replacement of the ascending aorta. In the second patient, diagnosis of dissection and severe aortic regurgitation occurred in the postpartum period. Knowledge of this albeit relatively rare complication of pregnancy may assist the clinician in diagnosing and referring patients early for surgical treatment that, in most instances, may save the lives of both mother and fetus.

Hemopericardium developed following adequate (and not excessive) anticoagulation in a patient with acute transmural anterior myocardial infarction and an early pericardial friction rub. Drainage of a bloody effusion by pericardiocentesis did not prevent progression to constrictive pericarditis within one year. The clinical features of this case and of the only two other similar occurrences reported in the medical literature are described and lead to a discussion of therapeutic and preventive measures.

This study was undertaken to examine the value of rapid atrial pacing (RAP) combined with left-ventricular nuclear (LVN) angiography in the diagnosis of ischemic heart disease. It included 32 patients: 12 normal subjects and 20 with clinical coronary artery disease (CAD) and greater than 50% narrowing of a coronary artery (significant CAD). The ECG and an LVN angiogram (LVNA) were recorded at rest and during graded RAP. In the normal subjects, left-ventricular wall motion was normal at rest and during atrial pacing, but a wall motion abnormality (WMA) appeared in one subject. Left-ventricular ejection fraction (EF) did not change significantly. In the 20 patients with significant CAD, the diagnostic sensitivity of the ECG during RAP was 100% and 90% for the nuclear angiogram (presence or appearance of WMA at rest and during RAP). The mean EF in this group decreased from 0.38 to 0.31. WMA on the LVNA was present in 79% of patients with significant left-anterior descending, in 44% of those with right, and in 33% of those with circumflex coronary artery disease. WMA (at rest or on pacing) occurred in 17% of patients with 50 to 89% narrowing of an artery, in 50% with 90 to 99% narrowing and in 68% with total obstructions. The LVNA (rest and/or RAP) identified patients with significant single-vessel disease, but underestimated the extent of double-and triple-vessel disease. The LVNA at rest and during atrial pacing was an excellent method of evaluating significant coronary artery disease.

Based on findings in 2 fluoride-toxic patients, it was suspected that hyperkalemia played a clinically important role in the etiology of sudden death from fluoride poisoning. Using fluoridated human erythrocytes as an in vitro model, it was confirmed that fluoride produced a marked potassium efflux from intact cells. Further, neither glucose and insulin in pharmacologic doses, nor various buffers could halt the efflux by shifting the potassium intracellularly. If these results can be extrapolated to the clinical situation, removal of potassium and fluoride via exchange resins or dialysis remains the only reasonable approach to this life threatening problem. Aside from sudden hyperkalemia and hypocalcemia, no serologic marker for fluoride toxicity has been identified. A high degree of clinical suspicion is therefore essential to the diagnosis.

Biliary tract resistance was measured in 142 patients during cholecystectomy with the use of narcotic or nonnarcotic anesthesia techniques. If fentanyl citrate (narcotic) was used, there was no difference in the pressures measured in normal ducts between these cases and those patients receiving nonnarcotic anesthesia. When morphine sulfate was administered, the resistance exceeded normal values in five of seven patients with normal ducts.

A case of a 32-year-old woman in her 7th month of pregnancy presented with intractable pulmonary edema due to mitral restenosis is reported. Open-heart mitral commissurotomy was done as an emergency procedure. She continued pregnancy to term after the operation and delivered a healthy female baby. The literature related to "the closed" and "open" heart surgery during pregnancy has been reviewed.

Biliary tract resistance was measured in 142 patients at the time of cholecystectomy, using a simple technique in which contrast media is infused through the cystic duct at a fixed flow rate. A sharp demarcation exists between the resistance of patients with normal and abnormal common bile ducts. A resistance of less than 2.5 units was found in only one patient with a common duct abnormality, and the test was improperly performed in that case. Two patients with normal common ducts had resistance values of greater than 2.5 units, for a false-positive rate of 1.63%. Overall, the technique gave accurate results in 97.9% of the cases studied.

Idiopathic prolapse of the mitral valve is a common disorder, but many cases are clinically subtle. Thoracic skeletal abnormalities, reported recently to accompany the syndrome, may serve as an easily identifiable clinical indicator. The prevalence of these abnormalities was defined in 24 patients with proved prolapse of the mitral valve. The valvular syndrome was defined clinically, by echocardiography and, in seven cases, by left ventricular angiography. The skeletal deformities were defined clinically and radiographically. Pectus excavatum was present in 62 percent of the patients, "straight back" in 17 percent and severe scoliosis in 8 percent. Eighteen of the 24 patients (75 percent) had a definite thoracic skeletal deformity. The association of idiopathic prolapse of the mitral valve with these skeletal deformities may represent a forme fruste of Marfan's syndrome. Patients with "straight back" and pectus excavatum should be examined clinically and perhaps by echocardiography to exclude idiopathic prolapse of the mitral valve; when murmurs are present, a diagnosis of "pseudoheart disease" should not be made before mitral valve prolapse has been excluded.

Two patients, who suffered from pericardial tamponade in the course of prophylactic anticoagulant treatment, are reported. The mitral valve had been replaced by a prosthesis in both cases. The diagnosis was suspected clinically and radiologically and proven by pericardiocentesis. One of the patients was treated by a percutaneously inserted small polyethylene tube for continous drainage and the other by thoracotomy and partial pericardiectomy. Both patients recovered and are at present asymptomatic. Th mechanism of bleeding patients receiving anticoagulant therapy is briefly discussed.

The number of elderly patients living in institutions is increasing. Many of them are unable to maintain an adequate nutritional status because of: 1) neurologic deficits that preclude normal swallowing; 2) obstruction of the upper gastrointestinal tract; or 3) a systemic disease that has produced profound anorexia. This report presents the data on 106 permanent-feeding gastrostomies, performed with low morbidity and low mortality. Use of a gastrointestinal anastomotic stapling device greatly facilitated the operation. The permanent gastrostomy offers an effective means of providing adequate nutrition for elderly patients who otherwise cannot maintain the necessary nutritional status.

We describe a microcomputer-based, stand-alone, on-line scheduling data entry and retrieval clinical data base system, specially tailored for a nuclear medicine department. It includes provision for free format clinical diagnostics text answers to each radioisotope scan. Such a system is currently installed at the Department of Medical Biophysics and Nuclear Medicine at the Hadassah University Hospital, and handles all the patient tests performed in this department. We feel that the design of an independent microprocessor-based system customized for one's department needs has indeed improved the quality of the clinical services, both in ensuring that the patient records are kept up-to-date and complete, and in providing, through fast interactive retrieval transactions, immediate answers for a given patient status.

A 35-year-old woman was seen because of a two-year history of exertional dyspnea. She had a high-pitched systolic and diastolic murmur and evidence of left ventricular hypertrophy. Increased hemoglobin oxygen saturation was noted as the level of the pulmonary trunk, and indocyanine green dye curves were characteristic of a left-to-right shunt. Aortic root angiography revealed that the right coronary artery arose from the pulmonary trunk and that blood flow was reversed. The incidence, clinical manifestations, and therapy of this rare syndrome are reviewed.

Parents and patients in the Rhode Island Cystic Fibrosis Center were interviewed to determine the extent of compliance with various aspects of the therapeutic regimen. Current patterns of compliance were compared with retrospective clinic records of reported compliance up to 8 years prior to the time of study. Actual clinic attendance and reported compliance with medications were high. Patients reported significantly lower compliance with diet and chest physiotherapy. Most patients reported less compliance with chest physiotherapy at the time of study than 3 to 8 years earlier, regardless of the severity of their lung disease. Patients frequently reported self-medication with non-prescribed vitamins, antibiotics, or other drugs. Patients' perceptions of the severity of their disease and the possible adverse consequences of discontinuing therapy probably contribute to both good medication compliance and self-medication.

Echocardiography during active pulmonary embolism can reveal the embolic mass in transit through the chambers of the right side of the heart. The pattern produced is that of multiple masses of varying sizes, shapes, and densities moving from the right atrium to the right ventricle. It was not present on repeated echocardiogram performed several weeks later, after anticoagulation treatment. Proper recognition of this pattern can lead to prompt medical treatment with anticoagulants, which, in this case, led to a quite satisfactory clinical outcome.

Forty-two patients were treated for combat injuries of the chest, caused by shrapnel fragments, bullet wounds, blunt trauma and blast injury. Twenty-three required only intercostal tube drainage, while 19 underwent thoracotomy. There were two deaths, both unrelated to the thoracic injury. Our indications for emergency thoracotomy were hemorrhage of 1,000 ml with the initial insertion of the chest tube or 500 ml of fresh bleeding during the first 2 hr after insertion of the chest tube, massive air leak, extensive chest wall injury, the location of metal fragments in the mediastinum, evidence of cardiac tamponade or significant mediastinal shift. The positive results obtained in this series of cases were due to the effective first aid treatment on the battlefield and in field hospitals, and to an aggressive policy of operative intervention where indicated, together with intensive postoperative care.

Rupture of the left ventricle following mitral valve replacement occurred in 2 women among 520 patients (0.4%) during a 17-year-period at the Beilinson Medical Centre. In one patient, a delayed, type II rupture, followed by immediate exanguination, resulted from a 31 mm cloth-covered Starr-Edwards prosthesis inserted in a normal sized left ventricle. In the second patient, an intra-operative type I rupture occurred as a result of an over-zealous resection of a heavily calcified valve and annulus. Repeated attempts at surgical repair were unsuccessful. A review of 46 previously reported cases revealed several other factors that might be responsible for this complication which carries a 40-100% mortality rte, depending on whether it is diagnosed intra-operatively or in the immediate postoperative period. These factors and the variety of surgical approaches used for the repair of this grave complication are discussed.

Rest and exercise thallium 201 myocardial scintigraphy and multiple gated radionuclide angiography were correlated with the results of clinical status, exercise electrocardiography, coronary arteriography, and contrast left ventriculography in a series of 12 prospectively studied consecutive patients before and after aortocoronary bypass operation. Patients were divided into two groups based on a comparison between preoperative and postoperative 201T1 scintigrams. Group 1 (6 patients) demonstrated improved or normal postoperative perfusion scintigrams and excellent correlation between the site of a patent graft and the improvement in myocardial perfusion on the postoperative exercise scintigrams. Regional wall motion remained normal in 3 patients and improved in 3. In Group 2 (6 patients) the postoperative 201T1 scintigrams were unchanged or worse. Each patient demonstrated graft occlusion, graft stenosis, distal disease, or a perioperative myocardial infarction. No improvement in regional wall motion occurred in 4 of these 6 patients. Neither the symptomatic response to aortocoronary bypass operation nor the response to exercise testing successfully predicted graft patency.