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The mixed lymphocyte response (MLR) of the guinea pig was assessed using skin allografts placed in the tympanic cavity, in comparison to the MLR obtained with allografts sutured on the backs of these animals. The MLR obtained from middle ear stimulation was transient. It was not altered by previous systemic immunization, nor did it alter the subsequent MLR obtained when the allografts were implanted on the backs of the guinea pigs. Immunoperoxidase and hematoxylin/eosin stainings of the tympanic allografts were also attempted to make a pathological correlation. Our findings are compatible with other observations of mucosal immune systems.

Nosocomial parotitis is an uncommon postoperative complication, usually affecting elderly, debilitated, dehydrated patients. The preponderance of gram-positive pathogens has been emphasized. The authors present two cases of gram-negative parotitis and review the literature on this condition. Because the organisms producing nosocomial infection in patients receiving intensive care are commonly gram-negative bacilli, treatment should be based on the findings of Gram's staining of the pus obtained from Stensen's duct, altered when necessary by the final culture results.

Since 1978, the operation chosen for patients with variceal hemorrhage has been based on preoperative hemodynamic and clinical factors. One hundred sixteen consecutive patients were managed with the following operations: distal splenorenal shunt (75 patients), nonselective shunts (33 patients), and nonshunting operation (8 patients). Emergency surgery was required in 19 percent of patients. The selection criteria used resulted in the majority of high risk patients receiving nonselective shunts. This selective operative approach resulted in an overall operative mortality of 12 percent, a median survival of 3 years, and postoperative encephalopathy, ascites, and recurrent variceal hemorrhage in 20, 23, and 11 percent of patients, respectively. Operative mortality for the total group was closely related to Child's class. Whereas encephalopathy was most frequent after nonselective shunts, ascites was more common after the distal splenorenal shunt. Recurrent hemorrhage rarely occurred after a shunting procedure, but was a frequent complication of nonshunting operations. Neither the type of procedure selected nor the cause of liver disease influenced long-term survival.

In September 1982, a prospective randomized trial comparing shunt surgery and endoscopic sclerotherapy for the elective management of variceal hemorrhage in patients with cirrhosis was initiated. Twenty-seven patients have received shunts (distal splenorenal = 23, nonselective = 4) and 30 patients have had chronic sclerotherapy. Eighty-six per cent of patients had alcoholic cirrhosis and 33% were Child's class C. After a mean follow-up of 25 months, 19% of shunt and 57% of sclerotherapy patients have had rebleeding (p = 0.003). Kaplan-Meier survival analysis reveals similar 2-year survival rates for shunt (65%) and sclerotherapy (61%) groups. Only two of 10 sclerotherapy failures have been salvaged by surgery. Posttherapy quantitative hepatic function, frequency of encephalopathy, and cumulative medical costs were similar for both groups. Hepatic portal perfusion and portal pressure at 1 year were better maintained by sclerotherapy than by distal splenorenal shunt. In conclusion, endoscopic sclerotherapy and shunt surgery provide similar results with respect to survival, hepatic function, frequency of encephalopathy, and costs. Sclerotherapy is an acceptable, but not superior, alternative to shunt surgery for treatment of variceal hemorrhage.

DT, a 63-year-old white male with insulin-dependent diabetes mellitus and severe peripheral vascular disease, was admitted with a five-day history of vague abdominal pain and diarrhea. On the day of admission he vomited three times, was noted to have a bloody stool, and came to the emergency room. DT denied hematemesis, fever, or chills. He had bilateral leg amputations and had sustained three myocardial infarctions, the last one 15 months before this admission. He had never experienced symptoms of abdominal angina. Of significance was his history of congestive heart failure, mitral regurgitation, and atrial fibrillation. His medications on admission included digoxin 0.25mg per day, furosemide 40mg per day, and NPH insulin 15 units per day. On admission to the hospital his oral temperature was 38 degrees C, pulse was 90/min, respiratory rate was 24/min, and blood pressure was 134/80mmHg. Abdominal examination revealed a distended abdomen with hypoactive bowel sounds and mild tenderness. Chest x ray revealed cardiomegaly. The electrocardiogram demonstrated atrial fibrillation. A plain film of the abdomen was positive for gallstones and edema of the bowel wall (thumb-printing). Laboratory results included blood urea nitrogen 48mg%, creatinine 1.2mg%, hemoglobin 18g/dl, and hematocrit 52.9%. White blood cell count was 11,900 cells/cc with 33% polymorphonuclear leukocytes, 47% bands, 8% lymphocytes, 11% monocytes, and 1% atypical lymphocytes. The prime considerations for differential diagnosis were mesenteric ischemia and infectious gastroenteritis. While it was appreciated that mesenteric ischemia, if present, might warrant surgical intervention, the risk of anesthesia itself in this patient was felt by his attending physicians to exceed 30%. Furthermore, the clinical findings were only "suggestive" of mesenteric eschemia. They were certainly not "diagnostic." In view of this dilemma, a consultation with the Division of Clinical Decision Making was requested.

Eighty-five subjects were tested for the presence of circulating candidal antigen (CAg) and anti-candidal antibody (CAb) using both an enzyme immunoassay (ELISA) and counterimmunoelectrophoresis (CIE). The 72 studied controls included laboratory volunteers; hospitalized patients without evidence of infection; febrile hospitalized patients without evidence of candidiasis; and patients with superficial candidiasis and candiduria. The control subjects were compared with 13 patients with proven disseminated candidal infection (disease prevalence = 15%). The ELISA CAb test was of greater individual sensitivity (92%) in separating patients with systemic candidiasis from all controls combined than the ELISA CAg, CIE CAg, or CIE CAb test (61%, 15%, 69%, respectively). The CIE CAg test, though specific (100%), was insensitive. Sensitivity, specificity, and predictive values were generally enhanced by employing combinations of tests. Sera from patients with disseminated candidiasis were much more likely to yield a positive result by two or more serologic tests than were control sera (p = less than 0.0004). The sensitivity of combinations ranged from 15% to 92%. The specificity of combinations ranged from 21% to 100%. The predictive value positive of combinations test ranged from 40% to 100%. Predictive value negative of combinations ranged from 69% to 98%. Patients with a variety of superficial and deep candidal infections apparently have detectable circulating CAb and/or CAg. The ELISA CAb test was superior to the other tests in identifying patients with disseminated candidiasis. Combinations of serologic tests may be superior to individual tests in the diagnosis or exclusion of serious disease due to Candida albicans.

Plasma diamine oxidase (DAO) activity may reflect intestinal involvement in Crohn's disease. The purpose of this study was to develop a simple heparin stimulation test for assessing postheparin plasma diamine oxidase activity in Crohn's disease. Ten volunteers and five patients with Crohn's disease received 1000 units and 3000 units of heparin intravenously and plasma samples were obtained at timed intervals. Plasma DAO activity increased significantly, compared with basal values, 30 minutes after 3000 units of heparin in both volunteers (26.2 +/- 5.0 vs. 4.5 +/- 0.5 units/ml) and patients with Crohn's disease (14.6 +/- 2.0 vs. 4.0 +/- 1.1 units/ml, P less than .05) and was significantly greater in the volunteers. There was no significant increase in DAO activity after 1000 units of heparin. Plasma DAO activity increased significantly within 15 minutes after 3000 units of heparin and remained at this high level at 60 minutes. Postheparin DAO activity correlated with the integrated area under the DAO activity curve. Plasma DAO activity correlated with the Crohn's Disease Activity Index in the patients with Crohn's disease. Plasma DAO activity, 30 minutes after the intravenous administration of 3000 units of heparin, should reflect intestinal involvement in Crohn's disease.

Patients with cirrhosis who had undergone the distal splenorenal shunt were grouped based on preoperative to early postoperative changes in hepatic portal perfusion and corrected sinusoidal pressure. Early and late postoperative morbidity and mortality rates were determined for each hemodynamic group. Morbidity was least when both hepatic portal perfusion and sinusoidal pressure were maintained near preoperative levels (Group 1). Survival for this group was significantly better than for patients who lost portal flow to the liver during the early postoperative interval (Group 4). Patients with absent hepatic portal perfusion had the worst survival and greatest morbidity. Intermediate results were achieved for the two groups of patients that had postoperative preservation of portal perfusion but significant preoperative to postoperative alterations in sinusoidal pressure. Although survival curves for these two groups were not significantly different from Group 1, morbidity was greater, especially for patients with an increase in sinusoidal pressure (Group 2).

In this project, we studied the cell-mediated response of guinea pig's middle ear. The specific objective was to characterize rejection of skin grafts on the back (allo- and iso-grafts) after primary stimulation (iso- or allo-) in the ear or on the back. The method used was the mixed lymphocyte response with and without phytohemagglutinin (PHA). Preliminary results showed that the middle ear is able to mount a normal immune response, both locally and systemically. Such basic studies will help us to understand the otologic immune response as a whole and may shed some light on the immune phenomena observed in middle ear transplantations.