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Conventional arteriography is the investigation of choice in patients with critical ischaemia to select the site for the distal anastomosis of a femorodistal bypass. Several arteriographic scoring systems have been devised in an attempt to quantify the run-off. More recently Pulse Generated Run-off and intraoperative peripheral resistance measurements have been proposed as better predictors of early graft patency. Eighty-eight consecutive femorodistal bypass grafts were studied using Pulse Generated Run-off (PGR), conventional and intra-arterial digital subtraction arteriography (DSA) and peripheral resistance measurement. Three widely used arteriographic scoring systems were used to grade the arteriographic run-off. There were significant correlations between the scoring systems and the measured peripheral resistance, although PGR correlated better with peripheral resistance than arteriography (rs = -0.59, P less than 0.001). Intra-arterial DSA improved the correlation between the arteriogram scoring systems and the measured peripheral resistance in the distal popliteal artery, but not in single calf vessels. In contrast, PGR correlated much better with peripheral resistance in single calf vessels (rs = -0.82, P less than 0.001). We recommend that selection for femorodistal reconstruction be based on a combination of intra-arterial DSA and PGR. PGR will identify patent distal calf vessels not seen on arteriography and determine their continuity with the pedal arch, two features which are essential prerequisites for successful femorodistal bypass.

Aganglionic rectal tissue from patients with Hirschsprung's disease contains four forms of acetylcholinesterase; the major component has a sedimentation coefficient in the region of 10.0S. Results from gel filtration confirm these findings and, when used in conjunction with the sedimentation data, allow the determination of the molecular mass of these forms. The four species of acetylcholinesterase include: monomer, G1, 74 kDa dimer, G2, 131 kDa; tetramer G4, 275 kDa and an asymmetric form, A12, 811 kDa. Evidence is provided which shows that the major form, G4 interacts with the detergent Triton X-100. Selective measurement of G4-AChE using a suitable assay may provide the basis for improving the existing means of diagnosis of Hirschsprung's disease.

The chlD gene in Escherichia coli is required for the incorporation and utilization of molybdenum when the cells are grown with low concentrations of molybdate. We constructed chlD-lac operon fusions and measured expression of the fusion, Mo cofactor, and nitrate reductase activities under a variety of growth conditions. The chlD-lac fusion was highly expressed when cells were grown with less than 10 nm molybdate. Increasing concentrations of molybdate caused loss of activity, with less than 5% of the activity remaining at 500 nM molybdate; when tungstate replaced molybdate, it had an identical affect on chlD expression. Expression of chlD-lac was increased in cells grown with nitrate. Strains with chlD-lac plus an additional mutation in a chl or nar gene were constructed to test whether the regulation of chlD-lac required the concerted action of gene products involved with Mo cofactor or nitrate reductase synthesis. Mutations in narL prevented the increase in activity in response to nitrate; mutations in chlB, narC, or narI resulted in partial constitutive expression of the chlD-lac fusion: the fusion was regulated by molybdate, but it no longer required the presence of nitrate for maximal activity. Mutations in chlA, chlE, or chlG which affect Mo cofactor metabolism, did not affect the expression of chlD-lac.

A non-invasive method of determining calf vessel patency before femorodistal bypass has been developed. This pulse-generated runoff (PGR) system generates blood flow in patent calf arteries by means of a pulsatile cuff even if the existing Doppler signal is inaudible. PGR was compared with pre-operative arteriography in 95 ischaemic limbs and both were compared with the peripheral resistance measured at operation in 62 limbs. There was a highly significant correlation between the PGR and arteriogram scores (rs = 0.74, P less than 0.001) but PGR tended to detect more patent vessels than arteriography. The peripheral resistance correlated better with PGR than arteriography (rs = -0.71 and -0.54 respectively, P less than 0.001). PGR is a simple, non-invasive method of determining calf and foot vessel patency pre-operatively.

The long saphenous vein is frequently used as a graft in both coronary artery and femoro-distal bypass surgery. The histological changes which are seen after implantation into the arterial system have been well documented in the past, but little attention has been focused on the histological appearances of the donor long saphenous vein prior to grafting. In this study, samples of the long saphenous vein in excess of that required for bypass have been examined. In none of the veins did the histological appearances conform to the described normal. All showed evidence of intimal fibrosis which contained elastic tissue and enmeshed smooth muscle cells. The longitudinal and circular muscle layers showed evidence of muscle cell hypertrophy with increase in intervening connective tissue. Elsewhere, similar histological changes have been attributed to 'arterialization'. This study shows that many of the changes are present prior to grafting and may be important in graft failure.

The results of 85 in situ vein femoro-distal bypass grafts using a modified technique where the vein was completely mobilised but left "non-reversed" have been reviewed with particular regard to risk factors and complications. The distal anastomosis was to the infrageniculate popliteal artery in 55% and to the tibioperoneal trunk or a single calf vessel in the rest. Arteriographic run-off was by a single vessel in 42%. The primary failure rate at 1 month was 20% and the secondary failure rate 9%; the majority of early failures being due to missed technical errors despite the use of a pulse volume recorder. The cumulative secondary patency rate at 1 and 2 years was 77% and 72%; limb salvage 85% and 77%; and patient survival 89% and 83% respectively. The only significant risk factors were the level of the distal anastomosis and the run-off (P = 0.002 and 0.03 respectively). Complete mobilisation of the vein allows a tension free proximal anastomosis to the common femoral artery and avoids the risk of arteriovenous fistulae. A high vein utilisation rate of 93% was achieved by using a small 2.5 mm Hall valvulotome. Although there was a trend towards lower patency rates in veins with a minimum diameter less than 4 mm the results are still superior to PTFE. Compared to reversed vein the in situ technique has a better utilisation rate and the long-term patency rates are at least as good if not better. Improved methods of haemodynamic assessment during reconstruction to reduce technical errors may be the key to better early patency rates.

We report a series of six severe pelvic injuries associated with traumatic abduction of the leg. All sustained a severe fracture of the pelvis associated with a deep perineal wound extending into the anus. Laparotomy was usually required to control haemorrhage and packing was only effective once the pelvis had been stabilized by external fixation. A sigmoid loop colostomy was required in all five initial survivors because of sphincter disruption, but three out of four long-term survivors are now fully continent. If mortality is to be reduced, blood loss must be rapidly controlled and sepsis prevented.

Between January 1980 and September 1988, 34 octogenarians underwent aortic aneurysm repair. There were 26 men and eight women with a median age of 83 years (range 80-88 years). Twenty underwent 'emergency' repair after presenting with pain and/or collapse: 11 with a retroperitoneal rupture, three with an intraperitoneal rupture and six with an expanding aneurysm. The mortality rate for this group was 35 per cent. During the same period 14 patients had an elective repair and there were no deaths within 30 days. The mean hospital stay for the elective group was 14.2 days compared with 17.0 days for survivors in the emergency group. There was no significant difference in terms of risk factors between those who developed postoperative complications and those who did not. These mortality rates compare favourably with our overall mortality results for elective (4.6 per cent) and emergency (31 per cent) surgery. Those patients over 80 years of age with infrarenal abdominal aortic aneurysms should not be refused surgery on the basis of age alone; each patient should be judged individually.

Patients who presented within 5 days of an inversion injury to the ankle joint, were clinically selected for early radiological investigation and diagnosis of rupture of the lateral ligament of the ankle. Stress tenography was performed in 142 cases, and normal ranges for talar tilt and anterior draws were established in 216 normal ankles. In addition 38 cadaveric ankles were examined by peroneal tenography. No normal connection between the tendon sheath and the ankle joint was demonstrated. Sixty-five patients had positive peroneal tenograms; nine of these were positive only after manipulation. No complications occurred. Surgery was performed on 20 patients and demonstrated that common peroneal tenography was 95% accurate in diagnosing rupture of the calcaneo-fibular ligament. Of the 19 patients with proven calcaneo-fibular ligament rupture, six had a positive anterior draw sign, and nine had talar tilt. In this series both the talar tilt and anterior draw signs were found to be inaccurate. Common peroneal tenography is recommended as the method of choice for demonstrating acute rupture of the calcaneo-fibular component of the lateral ligament.

The diagnoses and age at presentation of 1665 infants with symptomatic heart disease, who were admitted to the Brompton Hospital, London, during the period 1973-82 were reviewed. The frequency of certain conditions had changed during the period of the study. Complete transposition of the great arteries and critical aortic stenosis had become less common, whereas the frequency of right ventricular outflow tract obstruction, and of critical pulmonary stenosis in particular, had increased. Several conditions, including coarctation of the aorta, hearts with univentricular-atrioventricular connexion, and double outlet ventricle, formed a higher proportion of cases in the present series than in the New England Regional Infant Cardiac Program study, whereas the proportion of cases of atrial septal defect, hypoplastic left heart syndrome, and pulmonary atresia with intact septum was smaller. Most of the cyanotic infants presented during the first 14 days of life at the time of ductal closure. As expected this was also true of other duct dependent circulatory disorders such as aortic coarctation and interrupted aortic arch. Acyanotic infants with potentially large left to right shunts tended to present during the second month of life, when the pulmonary vascular resistance fell. This study emphasises that most symptomatic infants with heart disease present during the first two months of life. As a consequence the provision of expert neonatal and infant medical services is an integral part of any paediatric cardiac service.

Oedema of the leg, particularly the calf, is a well-recognised complication following lower limb reconstructive vascular surgery, but its effect on the limb is unknown. In this study, anterior compartment pressures and calf circumference were measured in both the operated and non-operated limbs following femoropopliteal bypass in 15 patients. All the patients developed lower limb swelling, which was significantly greater than the non-operated limb, P less than 0.05 paired t test (day 2-5). There was a significant difference in the mean anterior compartment pressures between the operated and non-operated limbs on the third and fourth postoperative days for the overall and below knee group, P less than 0.05 (paired t test). However, none of the patients developed signs, symptoms or pressures indicative of a compartment syndrome. These results suggest that the oedema following reconstructive vascular surgery is subcutaneous rather than compartmental in origin and that compartment pressure measurements should only be undertaken if a fasciotomy is being contemplated.

A prospective study was undertaken of 75 patients complaining of epistaxis who presented to an Accident and Emergency Department. The patients were placed into four groups according to their presenting features, and various forms of appropriate management applied. It was found that in the group that had ceased bleeding on presentation, whether or not a bleeding point was visible, there was no benefit obtained by treatment. If the nose was still bleeding on presentation, and the bleeding point was visible, successful management could be obtained by cauterising the bleeding point. This is a treatment that could be carried out by either the General Practitioner or the Accident Department. If the nose was actively bleeding, and the bleeding point could not be seen, then even initially successful treatment by the Accident Department was usually found to be ineffective within forty-eight hours. It is suggested that this group should be referred to an ENT unit on presentation.

To assess the effectiveness of the surgical correction of vesico-ureteric reflux, current renal function was determined in 56 children with scarred kidneys who had undergone ureteric reimplantation between 1978 and 1983. The children were aged between 2 and 15 years, had no coexisting urological disease and a glomerular filtration rate (GFR) of less than 90 ml/min/1.73 m2. In the 32 patients who had bilateral reimplantation of ureters draining bilaterally scarred kidneys the improvement in GFR following surgery was highly significant (P less than 0.001), with improvement occurring in 75%. The greatest improvement was in patients where the GFR was less than 50 ml/min/1.73 m2 (29%). Individual kidney GFR was estimated in 42 kidneys and 81% improved after surgery. This improvement was highly significant (P less than 0.001).

Classic teaching implies that arterial walls are a resistance to tumour invasion. We report a case of tumour cell infiltration of an obturator artery aneurysm following an abdomino-perineal excision of rectum.

The effect of surgical operation upon monocyte numbers and function was studied in patients with both benign and malignant disease. In patients with benign disease a significant increase in the phagocytosis of 99Tc latex-labelled particles by monocytes was observed at 24 h postoperatively (P less than 0.01 compared with preoperatively) and also a significant increase in monocyte numbers (P less than 0.001 compared with preoperatively). In patients undergoing surgery for malignant disease no significant increase in phagocytic activity of monocytes was found postoperatively. A significant decrease in monocyte numbers was shown to follow surgery in this group (P less than 0.001). The implications of these findings are discussed.

Clinical and pathological evidence of overheating was sought in a consecutive series of infants dying in Newcastle and Gateshead. In 8 of 33 cases of cot death investigated pathologically histological changes in the small intestine of the kind described in association with heatstroke were seen. Such changes were not seen in any of 12 deaths from chronic or congenital conditions, and in only 1 of 8 acute explained deaths--in a baby who died with necrotising enterocolitis. 15 of 34 cot-death babies investigated clinically were judged to have been excessively clothed or covered at the time of death. 7 babies were unusually hot when found dead, and 4 others had been noticed to be hot shortly before death. 10 more babies had evidence of a terminal infection without observed fever. The possibility that overheating contributes to some cot deaths has important implications for health education.

Type V hyperlipoproteinaemia complicated a pregnancy in a 38 year old Samoan multigravida with previous noninsulin dependent diabetes. The hypertriglyceridaemia was associated with severe insulin resistance, nonacidotic ketosis and poor control of the diabetes. Continuous subcutaneous insulin infusion resulted in excellent diabetic control and plasma triglyceride levels fell to normal without specific dietary fat restriction. The pregnancy resulted in the live birth of a normal healthy infant at 38 weeks' gestation.

Three cases of xylene poisoning occurred after prolonged inhalation of paint fumes. Analysis showed that xylene comprised more than 90% of the solvent in the paint, the total solvent comprising 34% of the paint by weight. One patient was dead on admission, while the other two recovered after at least 15 hours' loss of consciousness. Both patients had transient liver cell damage, and one temporary impairment of renal function.