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We used 99 human umbilical vein (HUV) grafts for femoropopliteal or tibioperoneal artery reconstruction in 94 patients. Results were calculated according to the life-table method for several categories possibly influencing graft patency. For above-knee v below-knee distal anastomosis, there was no difference in patency or limb-salvage rates at 30 months. Comparison of good and poor runoff situations disclosed similar 30-month graft patency rates, but significantly better limb-salvage rates among patients with good runoff. Primary revascularization fared significantly better than secondary procedures in terms of patency and limb salvage. We found no significant differences between HUV and polytef (polytetrafluoroethylene) for above-knee anastomoses or good runoff situations. However, patency and limb salvage were better for HUV use in below-knee anastomosis and poor runoff situations. The HUV may offer advantages in long-term patency and limb salvage in selected patients.

A multiclinic, collaborative study has been designed to assess the natural progression and efficacy of treatment of Duchenne muscular dystrophy. This article describes the protocol for the evaluation technique and the method used to establish within (intraobserver) and between (interobserver) reliability of the protocol evaluation procedures. Standardized patient evaluations were used, and consistency of evaluation was monitored by a computer. The reliability of the measures was analyzed 1) within observers by comparing the results of each of the first three tests done by each evaluator for all patients and 2) between observers by comparing, at multicenter group meetings, the results of each of the four evaluators' tests of the same patient. We have demonstrated reliability for an evaluation method that will provide an objective foundation on which to claim a drug or therapeutic procedure does or does not have an effect in treating Duchenne muscular dystrophy.

Effects of 24 to 48 h serum Ig concentration on growth and survival of 1000 Holstein heifer calves were evaluated. Average serum Ig for all calves was 25.71 (SD = 19.06) mg/ml with a range of .05 to 108.27. Serum Ig concentrations were below 12 mg/ml in 28% of the heifers. Both season and age of dam contributed significantly to the variation in 24 to 48 h concentrations of serum Ig. Concentration of serum Ig at 24 to 48 h was a significant source of variation affecting average daily gain through the first 180 d of life. Seasonal factors also were significant in influencing rate of gain from birth to 180 d. Age of dam was a significant source of variation in calf weight gains but only for the first 35 d. Mortality was 6.78% for heifers with less than 12 mg/ml serum Ig at 24 to 48 h as compared with 3.33% mortality for calves with greater than 12 mg/ml concentration.

This article investigates the relationship of skeletal facial pattern and soft-tissue nasal form. The case sample comprises 123 white female subjects, aged 11.0 to 20.6 years, with no histories of pathology, trauma, surgical intervention, or orthodontic treatment. Measurements were made from cephalometric radiographs, posteroanterior radiographs, and the physioprint photographs. Skeletal classifications were based on the relationship of the maxilla to the mandible; the three classifications were straight profile, retrusive chin profile, and prognathic profile. Pearson product--moment correlation coefficients were used to test intercorrelations of all quantitative variables (including age) with each other. Correlations were highly significant for age, the three profile measurements, and two of the frontal measurements. Hence, noses and skeletal structures showed, as expected, increases with age. Also, profile measurements were highly significantly correlated; larger noses were larger in all profile dimensions. A stepwise discriminant analysis was used to study nonquantitative categories of nasal shape (straight, convex, and concave). This analysis indicated that more than 86% of patients in the sample of 123 demonstrated a correlation of nasal shapes with specific skeletal groupings. Patients with straight profiles tended to have straight noses; convex profiles accompanied convex nasal shapes; and concave profiles were found with concave nasal shapes. The clinical significance of this research is to emphasize the importance of total facial harmony (especially nasal shape) during orthodontic diagnosis and treatment planning.

The success of lower limb bypass surgery depends, in the major part, on the availability of autologous saphenous vein as the most satisfactory arterial substitute known to date. Although various prosthetic conduits, used in the absence of saphenous vein, have shown promising success on short term follow-up, more long-term comparative data are required for adequate assessment. This study analyses, by life table method, the results of 134 infra-inguinal bypass grafts using polytetrafluoroethylene (PTFE) over a 6 year period. The results reconfirm the superior long-term patency of vein bypasses compared with such prosthetic grafts. Analysis suggests that, while PTFE may give acceptable results in the immediate and short-term follow-up period, 6 year patencies approach 20-30 per cent.

Of 115 cases of renal trauma 75 injuries were blunt and 40 were penetrating. Primary exploration was done in20 per cent of the patients with blunt injuries and in 100 per cent of those with penetrating injuries. A reparative procedure was done in 60 per cent of the patients operated on for blunt trauma and in 73 per cent of those operated upon for penetrating trauma. Only 3 per cent of the patients with blunt injury and 28 per cent of those with penetrating injury required a nephrectomy. We have concluded that renal injuries should be classified by type and extent rather than by etiology, that the extent of injury should be determined and not surmised, and that the management of renal trauma is a function of the extent of injury and the over-all status of the patient. In addition, the non-operative management of an inadequately defined renal injury cannot be considered conservative management.

A patient with primary solid carcinoid of the testis is described and 8 previous cases are reviewed. Ultrastructural study of our case disclosed pleomorphic granules, typical of the insular type carcinoid of the intestine of midgut derivation. Primary solid testicular carcinoid appears to behave as a benign neoplasms. None of these patients had evidence of metastases or the carcinoid syndrome for periods ranging from 20 months to 25 years.

Results of aortofemoral reconstruction of 181 consecutive patients with multilevel occlusive disease were reviewed and correlated with possible predictors of outcome. Overall, 74% of patients attained satisfactory relief of ischemic symptoms with proximal operation alone. Forty-six patients (26%) had an unsatisfactory result, 31 (17%) of whom underwent distal bypass grafts. Of 42 variables studied, 12 achieved statistical significance as predictors of outcome, and multivariate analysis identified five factors an independent indicators. Factors documenting hemodynamically significant inflow disease were associated most strongly with a good result. Several noninvasive laboratory variables were found helpful, particularly in assessing the hemodynamic compensation of distal disease. While no single variable reliably indicated the definite need for distal grafting, careful consideration of important factors together with the clinical situation will aid the surgeon in selection of the small group of patients best treated by synchronous aortofemoral and femoropopliteal grafts.

The use of transcutaneous oxygen tension (TCpO2) measurements to objectively and noninvasively diagnose peripheral arterial occlusive disease (PAOD) and to aid in the planning of vascular surgery was investigated. Thirty-two normal subjects and 100 patients with PAOD were studied. TCpO2 values decreased with age; when normalized by measurements on the chest, they did not. Absolute and normalized values of TCpO2 were equally effective in identifying the presence of PAOD and accurately characterized different degrees of severity (claudication vs. rest pain vs. impending gangrene; p less than 0.001). This was true even in diabetic patients, in whom tests based on hemodynamic function were less reliable. Healing of amputations was observed when TCpO2 greater than or equal to 38 mm Hg either preoperatively or after reconstruction; failure to heal in the absence of infection was associated with TCpO2 less than or equal to 38 mm Hg. The need for revascularization was associated with TCpO2 less than 30 mm Hg. A similar distribution of TCpO2 values was associated with success vs. failure of ulcer healing. TCpO2 is a useful complement to standard hemodynamic tests in the diagnosis and management of PAOD and, in addition, provides some distinct advantages.

Previous studies of reliability of goniometric measurements have produced varied findings suggesting the need to document further the reliability of measuring range of motion in different patient groups. The purpose of this study was to determine the intratester and intertester reliability of goniometric measurements of seven common upper and lower extremity joint limitations in children with Duchenne muscular dystrophy. Five physical therapists participated in the study. The procedure and order of measurements were standardized. Results showed that intratester reliability for all measurements was high (ICC = .81 to .94), but intertester reliability showed a wide variation (ICC = .25 to .91). The results of this study indicate the need to use the same examiner for long-term follow-up and for assessing results of specific treatment interventions.

The angiographic evaluation of 38 patients younger than 40 years of age with lower-extremity arterial disease is reviewed. Although atherosclerosis was the most common diagnosis, other etiologies included thromboembolism, popliteal artery entrapment, Buerger's disease, collagen vascular disease, and arteritis. The two features of the angiographic workup that proved most helpful in establishing an accurate diagnosis were biplane aortography and runoff exams designed to demonstrate possible popliteal artery entrapment.

To evaluate the determinants of the plasma norepinephrine (NE) response to orthostatic stress, NE kinetics were measured during steady-state infusion of [3H]NE of high-specific activity for two consecutive 90-minute periods; the first was supine, and the second was during 60 degrees head-up tilt. In 6 normal subjects, plasma NE increased from 242 to 570 pg/ml, and NE clearance decreased from 1.43 to 1.00 l/min X M2. In 6 patients with congestive heart failure, there was no significant change in plasma NE during orthostatic stress. This has been interpreted previously to indicate that there was little activation of the baroreflex arc. In fact, NE clearance decreased from 1.08 to 0.79 l/min X M2; however, there was a decrease in NE spillover from 4.04 to 2.88 nmol/min X M2. A reduction of organ blood flow with tilt could be responsible for the reduced NE clearance by both groups, but the mechanism for the reduction in NE spillover with tilt in congestive heart failure is unclear.

While proximal bypass graft flows are known to increase by the sequential technique, the possibility of a "steal phenomenon" caused by the intermediate anastomosis has been raised. We compared graft and distal flow rates using simple reversed vein versus sequential bypass grafts in a canine model. A blind segment was created by occluding the common iliac artery above and the superficial femoral artery below a profunda femoris artery equivalent, which served as runoff from the blind segment. Reversed saphenous vein harvested from the contralateral thigh in seven anesthetized dogs was used to perform a simple common iliac artery to superficial femoral artery bypass. Graft and distal superficial femoral artery flow were measured with a calibrated flow probe of appropriate diameter (3-5 mm). A sequential side-to-side vein graft to arterial blind segment anastomosis was then added and flow measurements repeated after equilibration. Mean graft flow increased by 20 cc/min with the sequential technique (p = 0.05), while distal flow actually decreased by 1 cc/min (NS). Although no "steal phenomenon" was demonstrated, distal flow was not significantly improved by the sequential technique. We conclude that no convincing case based on presumed hemodynamic superiority can be made for performing sequential bypass in preference to standard reversed vein bypass. The increased potential for technical error introduced by the additional anastomosis and the lack of any demonstrable augmentation in distal flow suggest inherent limitations of the technique, and caution against its widespread use.

Cells recovered from normal or mastitic bovine milk were examined by flow cytometry. All milk samples contained particulate material that was heterogeneous in size and that produced a right-angle light-scatter signal equal to or greater than that produced by human or bovine neutrophils. Although this material labeled with Hoechst 33342, it produced fluorescence intensities below that of intact bovine cells, suggesting that it consisted of cell fragments. Mastitic milk additionally contained other populations of cells that were poorly resolved from the normal particulate material by size (electronic volume sensor) and right-angle light scatter. In order to improve this resolution, the milk cells were incubated with carboxydimethylfluorescein diacetate (CMFDA) to label intact cells. When milk samples labeled with CMFDA were examined by dual-parameter analysis using green fluorescence and right-angle light scatter, five or more populations of cells could be identified in mastitic milk. These populations included intact and degenerate neutrophils, lymphocytes, including both small and activated cells, monocytes, and large activated macrophages containing many vacuoles and phagocytosed particles. Using this procedure, all the animals in the University of Nevada-Reno Holstein dairy herd were tested once a month for 6 months. In addition, individual animals with mastitis were examined one or more times each day during the course of the inflammatory process. In the routine screening, the flow cytometric examination detected mastitis before overt symptoms developed. In cows identified to have mastitis, the flow cytometric examination provided prognostic information regarding the success of treatments.

General and vascular surgeons are consulted occasionally to evaluate young adults with ischemia of the lower extremity. Between 1975 and 1985, 51 adults under 40 years of age who had arterial occlusive disease of the lower limb were managed. Although premature atherosclerosis was the most common problem (50%), claudication or limb-threatening ischemia also resulted from other sources (thromboembolism, popliteal artery entrapment, Buerger's disease, collagen vascular disease, and Takayasu's arteritis). Identifying the exact cause was sometimes difficult. The authors were impressed with the number of young adults who had delay in diagnosis and treatment (30 patients, 59%) before referral for a surgical opinion. In this paper, the attempt has been made to uncover the reasons for delayed diagnosis and to suggest a systematic approach that should lead to early recognition of lower extremity ischemia in this age group.

Iatrogenic vascular injuries occurring at our institution were reviewed and several special problems not previously well described were found. These include carotid and femoral pseudoaneurysms, occult hemorrhage and knotting of the angiographic catheter. These problems are exemplified in four patient reports to illustrate how appropriate planning of operative approach and adherence to vascular surgical principles can optimize results.

Seventy-one cases of iatrogenic arterial injury requiring repair at our institution from 1972 through 1984 were retrospectively analyzed. Cardiac catheterization accounted for most of the injuries (62%). Ten injuries (14%) resulted from angiography or percutaneous transluminal angioplasty; four injuries (5.6%) occurred after invasive monitoring devices were inserted. Six injuries (8.45%) stemmed from complications of intra-aortic balloon pump insertion, whereas the remainder occurred during various surgical procedures. Most injuries were in the femoral (42.3%) and brachial (38.1%) locations. Thrombectomy (23.9%) and resection with end-to-end anastomosis (35.2%) were the repairs most commonly performed. Morbidity and mortality were low; only one case resulted in limb loss, and neither of the two deaths resulted from the vascular repair itself. On the basis of our experience, we can make certain recommendations with regard to specific injuries. First, the conservative approach to brachial artery thrombosis occurring after catheterization is early exploration and repair. Second, although most injuries can be managed simply with thrombectomy and primary repair, iliofemoral injuries are more likely to require complex reconstructive techniques. Third, large-bore catheter injuries to the carotid artery require immediate exploration and repair to prevent thrombosis, pseudoaneurysm, and cerebral embolism. Fourth, symptoms of nerve compression after transaxillary arteriography require prompt exploration. Our results indicate that, depending on the site of injury, individualized techniques of varying complexity are required for repair. In general, serious sequelae can be minimized by early recognition, prompt operation, and adherence to sound vascular surgical principles.

An 18-year-old male presented with left foot ischemia secondary to emboli from a pseudoaneurysm of the left popliteal artery. His past history was significant only for two arthroscopies of his left knee. After evaluation, the patient was successfully treated with obliteration of the aneurysm and a reverse saphenous vein bypass graft.

Secondary aortocolonic fistula is an uncommon complication of prosthetic aortic grafts; apparently there have been only two previously described long-term survivors. We describe a long-term survivor with this complication in which preoperative computed tomographic scanning and percutaneous abscess drainage allowed early diagnosis and intervention and contributed to optimal treatment and survival. Adherence to time-honored principles of abscess drainage and graft removal, followed by extra-anatomic bypass when indicated, are essential to successful treatment.

In this prospective study, we have documented the limited usefulness of thrombolytic therapy in the management of all patients with arterial occlusion of the lower extremities. We have also emphasized the significant rate of recurrent thrombosis unless an underlying obstructive lesion is corrected surgically after clot dissolution. Because thrombolytic drugs can lyse clots of a duration of several weeks, we recommend consideration of fibrinolytic therapy for subacute graft occlusions and segmental arterial thromboses. In such instances, thrombolysis is likely to reveal a focal underlying lesion that is correctable by a limited anastomotic revision or balloon angioplasty. Without fibrinolytic therapy, these older occlusions generally require more extensive bypass grafting or graft replacement. In contrast, we are less enthusiastic about thrombolytic therapy for distal small vessel thrombosis or embolism because complete clot lysis was achieved in only one of five patients. The primary problems with regional arterial low dosage thrombolytic infusions are bleeding at the angiographic catheter entry site and distal thromboemboli of the lysing clot. These difficulties may discourage wide acceptance of fibrinolytic therapy. However, they can be minimized by careful technique. Although its usefulness is limited and complications are common, catheter directed arterial low dosage thrombolytic therapy can be an important initial step in the diagnosis and treatment of selected arterial occlusion of the lower extremities.

Dairy Herd Improvement data from a large, commercial dairy farm were used to evaluate the relationships of first lactation milk and fat yield and age at first calving on passively acquired immunity in Holstein heifers. Total serum Ig concentration was measured 24 to 48 h postpartum (mean = 25.5 mg/ml, SD = 19.2) on calves allowed to suckle their dams freely through 24 h postpartum. No additional colostrum was supplied and no attempt was made to ensure adequate colostrum intake. Calves were raised in Tucson, AZ until 6 mo of age, then transferred to Idaho to complete the growing phase and to be bred. Heifers were returned to Tucson during their 7th or 8th mo of gestation. Serum Ig concentration, measured shortly after birth, was an important source of variation for mature equivalent milk (b = 8.5 kg/Ig unit) and mature equivalent fat (b = .24 kg/Ig unit) production in the first lactation but did not affect age at first calving. It is impossible to ascertain from these data whether Ig concentration at birth was directly or indirectly related to production; regardless, supplying an adequate amount and concentration of colostrum at the appropriate time to dairy heifers may enhance their future productivity.

We examined 188 failed femoropopliteal grafts during a 16-year period to evaluate the clinical consequences of graft failure and success of secondary revascularization procedures. In limbs with grafts placed for claudication, conditions of 9% with failed grafts remained improved despite graft occlusion, 67% returned to preoperative status, and 24% showed worsened ischemia. One third of claudicants with failed grafts underwent secondary procedures. Ultimately, only 7% of failed grafts in claudicants resulted in amputation, and overall risk of limb loss in patients undergoing operation for claudication alone was low (2%). After failure of grafts performed for limb-salvage indications, 21% of limbs were still improved, and 79% reverted to limb-threatened status, more than half of the limbs undergoing subsequent reoperation. Overall, secondary attempts at reconstruction appeared justified. Although the five-year patency rate of such grafts was only 31%, limb salvage was achieved in 52%, with relatively low morbidity and mortality.

Computed tomographic scanning of the abdomen in 50 patients evaluated for suspected intraabdominal abscess resulted in an overall accuracy of 92 percent. It proved the most accurate diagnostic tool in determining the presence of intraabdominal abscess. Computed tomography of the abdomen is a useful diagnostic adjunct to clinical judgment and may assist in localizing intraabdominal abscesses and planning early surgical intervention.

The proximal articular set angle (PASA) is used in the evaluation of hallux abducto valgus, as well as a criterial parameter for the selection or rejection of various hallux abducto valgus corrective procedures. The authors casually observed variability in the measurement of PASA in clinical situations, stimulating the development of the presented study to determine if, in fact, the measurement of PASA varies excessively from one physician to another. The results clearly indicate that the interevaluator measurement of PASA is excessive (p less than 0.001 in seven of eight x-ray series and p less than 0.01 in one of eight x-ray series). The authors discuss the clinical implications of the findings. Furthermore, the shortcomings of the study are discussed, specifically the inability to conclude about intraevaluator variability.

Seven carotid body tumors in six patients were successfully managed using a multimodality approach that included the vascular surgeon, head and neck surgeon and angiographer. Five tumors were managed with preoperative subselective embolization of tumor vessels. Two required vascular reconstruction. The mean operative blood loss was 332 milliliters. All of the patients survived, and the only morbidity was one instance of transient vocal cord paresis. Surgical resection remains the treatment of choice for carotid body tumors. After angiographic embolization, a combined surgical approach by both the vascular surgeon and the head and neck surgeon reduces the associated morbidity and blood loss during resection.

Between 1979 and 1987 we documented the natural history of Duchenne muscular dystrophy in 170 patients, aged from 3 to 23 years, by making serial measurements in over 5000 individual evaluations. This database makes it possible to design and conduct therapeutic trials using natural history controls. Such trials do not replace the need for randomized placebo-controlled trials of promising agents but they do require fewer patients, are cost-effective, and permit the use of high-risk therapy where toxicity monitoring may be important. Natural history-controlled trials, therefore, may serve as a screening method for new therapeutic agents. Drugs showing a significant benefit can then be evaluated in a randomized controlled trial.

We studied a group of 23 manic patients to ascertain the prognostic significance of mixed affective features. Eight patients (34.8%) presented with a mixed manic state. This mixed state correlated with a longer hospitalization and significantly worse disposition outcome. In the light of previous conceptual models the authors speculate about the meaning of DSM-III defined mixed bipolar disorder.

Seventeen patients with clinical chronic obstructive pulmonary disease (COPD) who required aortic reconstruction underwent preoperative pulmonary function testing that categorized them as extremely high risk for pulmonary complications. Ten patients (Group 1) received perioperative steroids and seven patients (Group 2) received no perioperative adjunctive steroids. The mean forced expiratory volume (FEV 1) was 45% of the predicted value in Group 1 patients and 47% in Group 2 patients. The forced expiratory flow (25% to 75%) was severely restricted in both groups: 0.47 liters per second in Group 1 (16% +/- 6% predicted value) and 0.53 liters per second (20% +/- 7% predicted value) in Group 2 patients. Using a regimen consisting of preoperative pulmonary physiotherapy, optimization of theophylline levels, and early postoperative extubation with initiation of postoperative physiotherapy resulted in survival in all cases. There did not appear to be a clear advantage to the use of adjunctive perioperative steroids. The overall incidence of pulmonary complications was 22%. Four patients died during the follow-up interval. The remaining 13 patients were alive at a mean follow-up interval of 35 months. Using a number of adjunctive techniques, successful aortic reconstruction can be accomplished in many patients with severe COPD, and the majority will survive for extended periods after operation despite their impaired pulmonary function.

A 16 year review of femoropopliteal bypass grafts identified five factors with significant influence on long term patency. Most important was the nature of the graft itself, with vein grafts having superior long term performance as compared to a variety of prosthetic grafts. Arteriographic runoff, indications for operation, site of the distal anastomosis and prior femoropopliteal operation had a major influence on long term patency of prosthetic grafts but rather minimal effects on the patency of autogenous vein grafts. The influence of several variables proved cumulative, leading to a favorable subset of patients in whom prosthetic grafts may approach long term performance of vein grafts. Differences in such key variables is a major contribution to the widely differing patency rates of previous studies and must be carefully controlled in any future prospective studies.