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This study investigated the synovial fluid concentrations of glycosaminoglycan (GAG), keratan sulphate (KS) epitope 5D4 and chondroitin sulphate (CS) sulphation patterns in healthy volunteers and patients with osteoarthritis (OA) and rheumatoid arthritis (RA). Synovial fluids were collected from knee joints of healthy volunteers (n = 24), and patients with OA (n = 28) and RA (n = 29). Concentrations of GAG and the keratan sulphate epitope 5D4 were measured in 15 of the healthy volunteers, and all of the OA and RA synovial fluids. Total GAG was measured using a dye-binding method and 5D4 by an ELISA. The unsaturated CS disaccharides delta C4 and delta C6 were measured by capillary electrophoresis in all synovial fluids. The concentrations of GAG, 5D4 and delta C6 in the normal synovial fluid were higher but that of delta C4 lower than those of the disease groups. The delta C6:delta C4 ratios correlated with age (r = -0.437, P < 0.001) and the mean value was lower in females than males (2.92 compared with 5.22, P < 0.001). After allowing for age and sex, the delta C6:delta C4 ratio in the control group was significantly elevated (P < 0.001) compared to both OA and RA. The ratio was also related to proteoglycan markers (r = 0.383 for 5D4 and r = 0.357 for GAG). The finding that 5D4 and delta C6:delta C4 ratios are higher in synovial fluid from healthy volunteers compared to OA and RA suggests that they may be markers of the susceptibility of articular cartilage to early damage in arthritis.

Diagnosing diaphragmatic disruption requires a high level of suspicion. Diaphragmatic disruption must be considered in all cases of severe thoracoabdominal trauma. Initial chest x-rays can provide much useful information. Pathognomonic signs of diaphragmatic disruption on chest x-ray are stomach gas bubble in the chest, contrast material in the chest after its introduction into the upper gastrointestinal tract, and a nasogastric tube positioned above the diaphragm. In some cases a diaphragmatic disruption may not be diagnosed until exploratory laparotomy is done for associated injuries. One must carefully inspect both hemidiaphragms at the time of surgery, especially in injuries associated with penetrating trauma. Repair of the disruption should be undertaken at the time of diagnosis. The repair should be approached through a midline abdominal incision. A chest incision should be considered in cases of right-sided diaphragmatic disruption, or to assist with the delivery of contents back into the abdomen. Non-absorbable suture is recommended for all repairs of diaphragmatic disruption.

A 34-year-old white woman had external drainage of a pancreatic pseudocyst. During sinography, contrast medium filled perigastric varices, causing septic shock. From this experience, we believe that although sinograms are helpful, they should be preceded by prophylactic administration of antibiotics and that contrast material should be sterile. The drainage catheter should be removed as soon as possible.

THE MANAGEMENT of chronic venous insufficiency of the lower extremity, particularly the postphlebitic type, has been the subject of considerable discussion for several years and has in many instances proved to be a perplexing problem to the physician. The various forms of simple or extensive surgical procedures and of local conservative therapy which have been advocated are evidence of the fact that no one type of therapy is adequate in all cases. A rational approach to the treatment of chronic venous insufficiency must include adequate knowledge of the status of the deep, communicating, and superficial venous systems, with reference to the patency of the venous channels and the competence of the valves. Past history and clinical examination may at times fail to provide an accurate evaluation of the venous return from the lower extremities. We have found ascending phlebography performed with the patient in the erect position to be of