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Background: Octylcyanoacrylate (OCA) is a tissue adhesive used to close wounds and to treat minor abrasions. Objective: To explore the use of OCA in patients with superficial, partial-thickness burns. Methods: A prospective, noncomparative, pilot study was conducted in an emergency department (ED) and burn center. Consecutive patients with early (,6 hours), small (,5% total body surface area [TBSA]), superficial, partial-thickness burns were enrolled. Burns were cleaned and any nonadherent necrotic epidermis was removed. Tense blisters were aseptically aspirated. Burns were then covered with a liquid OCA that was applied with a sponge brush. Pain of cleansing and OCA application was recorded, and physicians assessed ease of application. Burns were evaluated every one to two days until complete epithelialization for the presence of infection and exudation, and the OCA was reapplied as necessary. Main outcomes measured were the need for additional topical therapy, pain and ease of application, patient comfort, and satisfaction. Results: Ten patients were enrolled. Mean patient age (6 standard deviation [SD]) was 23 (616) years, four were female, and nine were white. Burns were located on the hands (5), forearms (3), ankle (1), and back (1). Etiologies included contact (4), flame (4), and scald (2) burns. Mean (6SD) burn size was 71 (672) cm 2 . Blisters were present on admission in all patients and remained intact in five. Application of OCA was very easy in all patients; it immediately relieved pain in four patients and had no effect in three patients, while three patients complained of a brief increase in pain on OCA application. Exudation was present in four of ten patients within one to two days, all of whom had ruptured blisters at initial presentation. OCA was reapplied in two of these patients, and two patients were changed to silver sulfadiazine due to excessive exudation. The OCA was removed in one patient due to accumulation of exudate. There was no infection, and all burns were epithelialized within five to ten days. Conclusions: The results of this pilot study suggest that OCA may be useful for some, but not all, small, superficial, partial-thickness burns. Further studies may help clarify the indications and contraindications to proper usage of OCA in small, superficial burns. Key words: octylcyanoacrylate; tissue adhesives; burns; wounds. ACADEMIC EMERGENCY MEDICINE 2005; 12:900‐904.

Congenital constriction band syndrome is a rare entity with a wide spectrum of associated congenital anomalies. Review of the pathogenesis and an unusual case of constriction band syndrome in a newborn are presented. Surgical excision of the deformity and the band was performed within the first week of life. There were no vascular or neural structures within the excised tissue, and there were no other associated anomalies other than dextrocardia and an equinovarus deformity of the foot. The wound was closed primarily without the need for Z-plasties. This alternative method of treatment can be considered in such unusual locations of constriction band syndromes.

The purpose of this study was to initiate a hospital-based case review of all laparoscopic cholecystectomies performed on Medicare and Medicaid patients in New York State in 1991 where there were one or more complications. Another purpose was to facilitate efforts by hospitals to monitor the performance of laparoscopic cholecystectomy through an educational process of data-sharing. There were 2,940 Medicare and 1,108 Medicaid cholecystectomies in New York State in 1991. Of these, 351 (11.9%) Medicare and 107 (9.7%) Medicaid patients were reported as having complications. The complication rate for Medicare patients was slightly lower than that observed (15.8%) in an epidemiologic study of Medicare patients in New York State who underwent laparoscopic cholecystectomy during the period January 1, 1990-June 30, 1991. Both of these observed rates for Medicare patients are higher than the mean 6.0% complication rate reported for open cholecystectomy in the literature. These increased rates may in part be due to age related risk factors present among Medicare patients. The absence of age related risk factors may also largely account for the lower laparoscopic cholecystectomy complication rate (9.7%) observed among Medicaid patients. The complication rate of 9.7% for Medicaid patients is similar to rates reported in other recent studies. The 11.9% complication rate for Medicare patients is higher than that reported in other recent studies. However, careful patient selection, the absence of age related risk factors, and greater surgical experience may account for the lower complication rates reported in some published series. Overall, the coding of complications was found to be accurate. The coding of laparoscopic cholecystectomy was found to be slightly flawed.(ABSTRACT TRUNCATED AT 250 WORDS)

External counterpulsation is a noninvasive method of applying external pressures to vascular beds of the lower extremities synchronous with the cardiac cycle. Numerous animal experiments and a number of clinical trials have been conducted over the years in patients with various forms of cardiac disease to evaluate the effectiveness of external counterpulsation. The external counterpulsation machines (known as ECP and EECP machines) are currently widely available for use in the treatment of angina by applying positive pressure to the lower extremities during cardiac diastole to increase coronary flow. External counterpulsation has also been shown to be capable of perfusing the ischemic myocardium following an AMI and of assisting the failing left ventricle in patients with CHF. In these applications, positive pressure is applied externally to the lower extremities during cardiac diastole and negative pressure during cardiac systole so as to increase coronary flow and reduce the work of the heart. This paper provides a review of the developments in the area of external counterpulsation and the related devices. The paper also reviews the experimental evidence that provides the scientific basis for the design of a device now under development and called external left ventricular assist device (XLVAD) that should provide effective support of the left ventricle of a patient in congestive heart failure or following an AMI. The evolutionary development of the external counterpulsation devices into the XLVAD is presented in detail. The clinical and mechanical advantages as well as the shortcomings of each device are described.

Eighteen patients with chronic angina despite surgical and medical therapy were treated with an improved system of enhanced external counterpulsation (EECP) (1 hour daily for a total of 36 hours). Patients underwent a baseline treadmill thallium-201 stress test. After EECP treatment, a thallium stress test was repeated for the same exercise duration. One week after treatment, patients also underwent a maximal stress test. All patients improved in anginal symptoms and generally decreased antianginal medications, with 16 obtaining complete relief from angina. Pre- and post-thallium stress testing performed for the same duration showed complete resolution of ischemic defects in 12 patients (67%), reduction in the area of ischemia in 2 (11%), and no change in 4 (22%). Thus, a decrease in myocardial ischemia was observed in 14 patients (78%; p less than 0.01). The exercise duration of maximal stress testing after EECP significantly improved from 8.14 +/- 0.71 to 9.72 +/- 0.77 minutes (p less than 0.005), although the double product did not change significantly. Analysis of these 2 tests in the subgroup of 14 patients with improvement in thallium studies showed significant increases in both exercise duration (8.58 +/- 0.66 to 10.44 +/- 0.59 minutes; p less than 0.001) and double product (21,827 +/- 2,044 to 24,842 +/- 1,707 mm Hg.beats/min; p less than 0.01). The improvement in reperfusion defects and increase in exercise duration are reflections of improved perfusion to ischemic regions of the myocardium. EECP uses additional thigh balloons and sequenced balloon inflation, effecting a significant increase in diastolic augmentation over previously available methods.(ABSTRACT TRUNCATED AT 250 WORDS)

BACKGROUND B-type natriuretic peptide (BNP) released from cardiac myocytes plays an important role in cardiac homeostasis through cyclic guanosine monophosphate (cGMP) activation. BNP also reduces cardiac remodeling and fibrosis. The antifibrotic effects of BNP are mediated in part by blocking the effects of transforming growth factor beta, a profibrotic cytokine that plays a significant role in cutaneous wound healing. It is unclear if BNP plays any role in cutaneous wound healing. OBJECTIVES To investigate if BNP levels would be elevated in thermally injured human skin and if human-derived fibroblasts would respond to BNP exposure by increasing levels of cGMP. METHODS This was an in vitro analysis of human skin. Skin samples and cells were collected from patients with and without thermal injury. The authors stained three skin samples from normal skin (taken at the time of elective cosmetic surgery) with antibodies to BNP and compared these with three tissue samples obtained from burned human skin taken during tangential excision of deep burns. Normal human-derived fibroblasts and keratinocytes were exposed in triplicate to BNP in vitro, and cGMP accumulation was evaluated. Levels of cGMP were quantified and compared with analysis of variance. RESULTS BNP was present in all specimens of thermally injured skin (especially around collagen, epithelial cells, and endothelial cells) but not in any uninjured skin samples (p = 0.05, single-tailed Fisher's exact test). In vitro grown fibroblasts showed significant increases of cGMP levels with increasing levels of BNP exposure (mean [+/-SD]: 0.6 [+/-0.3], 1.2 [+/-0.2], 4.6 [+/-0.1], and 5.0 [+/-0.9] pmol/mL with BNP concentrations of 0, 10, 500, and 1,000 nmol/L, respectively; p < 0.001). The effect of BNP on keratinocytes was minimal and below the level of quantification. CONCLUSIONS These findings demonstrate proof of principle that human fibroblasts are responsive to the effects of BNP in vitro and that BNP is present in injured skin, suggesting that BNP may play a role in cutaneous wound healing.

Enhanced external counterpulsation (EECP) is an effective noninvasive treatment for chronic stable angina. Despite intensive risk factor modification, a patient required two surgical coronary revascularizations and seven multivessel angioplasties over a 26‐monfh period, demonstrating recurrent unstable angina and persistent thallium perfusion defects despite revascularization. Post EECP, angina was relieved, thallium defects were resolved, and the patient has remained asymptomatic for 36 months.

The effect of treatment with enhanced external counterpulsation (EECP) on exercise hemodynamics and myocardial stress perfusion in 27 patients with chronic stable angina was studied. A majority (22/27 or 81%) of patients improved their exercise tolerance after EECP treatment, and a similar percentage (21/27 or 78%) of patients improved their radionuclide stress perfusion images. Post-EECP maximal exercise heart rate and blood pressure, while demonstrating a linear relation with exercise duration, did not increase significantly despite the increased exercise duration. This suggests that the increase in exercise duration after treatment with EECP is due to both improved myocardial perfusion and altered exercise hemodynamics. EECP therapy thus appears to exert a "training' effect, decreasing peripheral vascular resistance and the heart rate response to exercise. Coronary disease patients may improve their exercise tolerance after EECP because of both improved myocardial perfusion and a decrease in cardiac work load.

A multifaceted approach that involves early debridement and control of infection is critical to successful and rapid burn wound healing. This pilot study was conducted in 15 adult patients with burns to assess the usefulness of early enzymatic debridement with a combination of collagenase ointment and polymyxin B sulfate/bacitracin spray versus silver sulfadiazine cream in partial-thickness burns. Combination treatment with collagenase and polymyxin B sulfate/bacitracin resulted in significantly shorter time to achieve a clean wound bed than silver sulfadiazine (median 6 vs 12 days; p = 0.0012) and significantly more rapid wound healing than silver sulfadiazine (median 10 vs 15 days; p = 0.0007). These results are encouraging and justify implementation of a larger, multicenter, comparative study.

Both the short-term and now long-term (over a 3-year period) clinical benefits of EECP appear to be maintained in almost all patients treated for chronic disabling angina. That most patients maintained their 3-year benefits suggests that long-term improvement in myocardial perfusion can occur. Future angiographic studies are planned to evaluate collateral function in these patients.

• To ascertain if service specialization and procedure standardization would improve the complication rate of inguinal herniorrhaphy, the results of all inguinal herniorrhaphies performed during a 3-year period by board-certified general surgeons who also performed a variety of other procedures common to the field of general surgery, assisted by general surgical residents (group B, 390 patients), were compared in the same institution with the results of inguinal herniorrhaphy when performed during 3 years under protocol by a Hernia Service directed by a senior faculty member assisted by junior surgical residents (group C, 442 patients). Group B patients had essentially no follow-up until they reappeared for care at the Hernia Service, whereas patients in group C achieved an 82% 7-year follow-up. The infection and recurrence rates of group C patients (0.45% and 0.9%, respectively) were significantly better than those of group B patients (5.9% and 4.6%, respectively). These results suggest that in our institution, the concentration of patients with hernias in a hernia service, manned by a specialized surgeon, produced better short-and long-term results than those obtained by general surgeons not dedicated to the field of hernia repair. Further studies will be necessary to confirm these findings. ( Arch Surg. 1991;126:628-630)

The clinical need for central venous cannulation has been well established. The usual route for catheter placement is by either the subclavian or internal jugular vein. No randomized, prospective evaluation has been yet conducted to determine which of these approaches, if either, is better with respect to reliability, placement, and frequency of nonseptic complications. One hundred consecutive patients requiring elective central venous cannulation were randomized to either the subclavian or internal jugular route. Successful venipuncture and catheter passage were significantly more common with the subclavian route, and in the absence of special clinical situations, it appears to be the route of choice.

Elective abdominal herniorrhaphy carries morbidity and mortality rates of 26 percent and 1.5 percent, respectively, in patients over 65 years of age. These figures climb to 55 percent and 15 percent during emergent surgery. Our purpose was to investigate if standardization of treatment could improve such results. Our program stressed centralization of care in a hernia clinic; early operation of patients at risk of incarceration; optimization of underlying systemic disorders by consultative services; operation under local anesthesia; preoperative, operative, and postoperative protocol; and continuity of care by senior personnel. Over a 4 year period, we have performed 241 abdominal herniorrhaphies in patients over 65 years of age (median age 71.5 years old) who exhibited an 84 percent incidence of significant preoperative systemic disorders. Since the inception of our program, our rate of emergent operation has decreased significantly from 7 percent to 2 percent (chi-square ≤ 0.05). Our rate of systemic complications after elective operation was 1.2 percent and 0 after emergent operation. These data are statistically better than those reported in the literature (chi-square ≤ 0.05). These results suggest that the creation of a hernia clinic significantly improves the care of herniated patients.

Fifteen patients with superficial low-grade bladder tumors were treated with combined thiotepa and mitomycin C instillation as definitive therapy. The amount of both thiotepa and mitomycin C used in each instillation in the presenting protocol was one half the conventional dose of either used alone. Patients with multiple bladder tumors, bladder tumors inaccessible to endoscopic resection, or lesions too extensive to completely resect, or with medial contraindications for endoscopic resection procedures, were included in these studies. No serious adverse effect was revealed in these 15 patients. Ten of the 15 patients (66.7%) had a complete response and 4 (26.7%) had a partial response. One patient (6.6%) did not respond to this regimen. This protocol seems to provide a therapeutic modality that is more effective than conventional single-drug therapy, less toxic than thiotepa used alone, and less expensive than mitomycin C used alone.

Calmodulin, a cytoplasmic calcium binding protein, is present in concentrations two- to four-fold higher in malignant cells compared to normal cells. In an effort to learn the significance of these elevated levels, we examined the effect of calmodulin blockage on the growth of normal and malignant keratinocytes in vitro. The level of calmodulin in SCC12.B2, a line of keratinocytes derived from an epidermal squamous cell carcinoma (SCC), was about 3.5 times greater than in normal, human newborn foreskin keratinocytes. When exposed to trifluoperazine (TFP), an inhibitor of calmodulin, cell growth was reduced primarily in the cultures of normal keratinocytes. This growth inhibition resulted from two changes in the replicating population of cells, namely an increase in cell cycle length and an increase in rate of cell cycle withdrawal. Cell cycle withdrawal is the irreversible arrest of the cell cycle and is an early event in keratinocyte terminal differentiation. There was no measurable effect on the cell cycle time or withdrawal rate in SCC12.B2. The increased resistance to growth arrest in SCC cells may be a consequence of the elevated level of calmodulin in these cells.

This article traces the development of external counterpulsation from its beginnings to the present. Initially, counterpulsation was carried out by cannulating the femoral artery. The hemodynamic goals were to reduce the afterload of the left ventricle, and to raise or augment the diastolic pressure. This gave rise to the term "counterpulsation." The intra-aortic balloon is capable of producing these salutary effects because of its proximity to the outlet of the left ventricle. The same hemodynamic effects can be obtained by external counterpulsation. However, one must produce a negative pressure during cardiac systole, and ensure that this is applied to the lower extremities. The only clinical study in which this was done was in the treatment of patients in cardiogenic shock by Soroff and colleagues. The results of the clinical studies reviewed are all suggestive of benefits derived from external counterpulsation in a variety of clinical settings. These studies suggest the following avenues for improvement in the equipment used to carry out external counterpulsation: 1. Inclusion of the vascular bed of the buttocks to be subjected to the external pressures, as advocated by Zheng. 2. Inclusion of a negative pressure blanket, as advocated by Soroff. 3. Further investigation of graded-sequential external counterpulsation, using the buttocks and negative pressure. 4. Application of external counterpulsation earlier in cardiogenic shock and for at least 4 hours in acute myocardial infarction. Our evaluation is that this method has not been studied in a way that demonstrates its full potential. We feel that it is on the threshold of being shown to be useful in all of the clinical settings reviewed, and we hope that the necessary equipment will be created to allow investigators to establish its proper place in our therapeutic armamentarium.

In a comparative study on a general surgical service, intravenous clindamycin phosphate or methicillin was used to treat a variety of soft tissue infections due to gram-positive organisms, chiefly staphylococci. The infections were rated according to severity, responsible organisms, and site of the infection. Excellent or good clinical and bacteriologic responses were obtained with both clindamycin and methicillin as adjuncts to basic surgical therapy in these soft tissue infections. The adverse effects of each drug were detailed, and were comparable. Clindamycin phosphate is a satisfactory substitute for methicillin in soft tissue infections secondary to gram-positive organisms.

Temporary circulatory assist devices now appear to hold more promise of clinical application than permanent, implanted artificial hearts. Two contrasting approaches to temporary assist are described: the bypass and the counterpulsation pump. The latter has developed into a completely external system through which coronary filling is enhanced and blood delivered to the systemic circulation during diastole.

1. (1) The life cycle of adults with calcific aortic stenosis is discussed. The ominous significance of left ventricular failure, even as manifested by dyspnea on exertion, is emphasized. 2. (2) A transaortic technique for the correction of this condition is presented. The substantial advantages of using a special Ivalon operating tunnel are reviewed. 3. (3) In the first 100 cases there have been 12 late deaths and 16 operative deaths. The operative mortality has been reduced to 5 in the last 60 consecutive patients. 4. (4) Eighty-six per cent of the surviving patients followed from 6 to 36 months are improved. 5. (5) The gratifying salvage from this fatal disease encourages further use of this method of surgical relief.

The indications, technics, and results in discontinuing assisted ventilation in patients who had continuous assisted ventilation longer than seventy-two hours are presented. Significant differences between preassist and postassist values for PO 2 , tidal volume, and respiratory rates were observed. The significance of adequate ventilation, oxygenation, the work of breathing, and other physiologic requirements are stressed.

Clinical and laboratory observations are reported in a 21-year-old man in excellent health prior to injuiy in whom acute adrenocortical insufficiency developed after a severe burn. He responded well to hormonal therapy, which was not required after skin coverage had been completed. Although the concentration of plasma hydrocortisone and the urinary excretion of 17-hydroxycorticoids were within normal limits, there was persistent failure to respond to exogenous ACTH, together with other evidences of adrenocortical abnormalities. This refractoriness to exogenous ACTH could not be attributed to the presence of adrenocortical remnants functioning maximally under the stimulus of high levels of circulating ACTH, since the plasma level of ACTH was not elevated. Certain speculations concerning the possible nature of this lack of response to ACTH are presented.

DURING the past decade there has been increasing interest in methods of assisting the circulation of patients in circulatory failure. This review traces the development of synchronous types of circulatory assist and, in the last section, reports the progress to date in cardiac pacing by bigeminal electrical stimulation. Approaches to assisting the circulation fall into three major categories. In the first, the work of the heart is lessened by reduction of the amount of blood that the ventricle must eject (that is, the preload); this is referred to as shunt or flow assist because part of the circulation is diverted . . .

Twenty-five patients with massive upper gastrointestinal hemorrhage have been treated by control of the intragastric pH at 7.0 with antacids. In twenty-three of the twenty-five patients, bleeding stopped. The two treatment failures included one patient in whom the pH could not be raised above 4.5 despite massive instillations of antacid; the other failure occurred in a patient who had had thrombolytic therapy and extensive small bowel resection for gangrene.

Thrombosis of the superior vena cava and other major central veins is an unusual and infrequent complication of total parenteral nutrition. When it does occur, it may be life threatening and prompt therapy is indicated. A case of superior vena cava thrombosis secondary to an indwelling Broviac catheter for long-term parenteral nutrition is presented, which was successfully treated with Streptokinase with reestablishment of flow through the catheter and veins. (Journal of Parenteral and Enteral Nutrition9:55-57, 1985)

• Thirty-nine studies of closed postoperative peritoneal lavage were reviewed, including four prospective, randomized studies, eight nonrandomized comparative studies, and 27 noncomparative studies. Mortality rates and abscess rates were determined for various subsets of patients. Despite the large number of studies performed, the therapeutic value of this procedure remains unknown. It is unlikely that further noncomparative or nonrandomized studies will yield useful information. There remains a need for a large-scale, prospective, randomized study to evaluate closed postoperative peritoneal lavage. Smaller prospective, randomized studies can contribute meaningfully if data on the specific causes of peritonitis, severity of disease, and patient age and chronic health status are provided in the form of widely used and well-validated stratification systems. ( Arch Surg 1987;122:1005-1010)

During the past 10 years significant advances have been made in the treatment of burns. Modern concepts of therapy are based on a more thorough understanding of the physiological derangements that occur after burning. APPRAISAL OF THE BURNED PATIENT The magnitude of injury is based upon two principal factors, extent of injury and depth of burn. The extent of burn is usually expressed as the percentage of the total body surface area. For many years, Berkow's table was used as a guide for estimating the percentage of body surface burned. A modification of this table by Tennison and Pulaski into the "rule of nines" has been employed recently (see figure).1 For children, the extent of burn should be increased for the head and trunk and decreased for the extremities. Burns are usually divided into three categories based on depth: first degree, second degree, and third degree. A first degree burn

Two BASIC approaches to the development of an "artificial heart" have been introduced by several groups of investigators: total replacement of the diseased heart by pumps contained within the vacated pericardial space1-8and intrathoracic bypass pumps which divert the flow of blood past the diseased ventricle or ventricles, thus reducing the flow work9,10(Fig 1). The inlet of such a pump is anastomosed to the left atrium and the outlet is anastomosed to the aorta. Inlet (mitral) and outlet (aortic) prosthetic valves must be provided to assume the function of mitral and aortic valves respectively. A third basic approach is presented in this study (Fig 2). The prosthetic ventricle serves to reduce the pressure against which the disease ventricle must eject its stroke volume to the extent that the diseased ventricle is performing the function of an auxiliary left atrium. The pressure work of the physiologic ventricle is

There is mounting experimental evidence which indicates that the arterial pulse plays a significant physiologic role. Studies comparing pulsatile and nonpulsatile flow have indicated that pulsatile flow affects the capillary circulation, the maintenance and regulation of vascular tone and blood pressure, cellular metabolism, and the function of such organs as the kidney.1The specific role played by the pulse in the regulation of blood pressure has been well documented and indicates that it exercises its control by means of its effect on the stretch receptors within the arterial wall. Experiments have shown that arterial pressure does not act directly on the baroceptors of the aortic arch and carotid sinus, but indirectly by stretching the wall of the arteries where these receptors are located.2-4The state of contraction and thus resistance to stretch of the arterial wall where the baroceptors are located are the primary factors affecting these receptors.

Summary 1. The metabolic effects of human growth hormone were studied in six patients who sustained moderate to severe burns averaging 30% of the body surface area. 2. Two normal controls were also studied. 3. The patients and the controls were placed on a constant intake of 9.0 gm of nitrogen/m2 of body surface and 1500 cal/m2 and complete balance studies of nitrogen, potassium, sodium and chloride were carried out for 16 days. 4. When growth hormone was given, increased storage of nitrogen, potassium, sodium and chloride and weight gain occurred, but with marked variability from patient to patient and even in the same patient at various times post-burn. 5. The administration of growth hormone was associated with an increase in oxygen utilization which, however, did not show a quantitative relationship with the degree of nitrogen storage. 6. Fat mobilization was indicated by a sustained increase in serum nonesterified fatty acid levels with growth hormone administration. 7. The most striking nitrogen retention occurred in the early anabolic phase and not during the height of the catabolic phase.

Twenty patients in cardiogenic shock following myocardial infarction were treated with external counterpulsation. Eleven patients died during or soon after treatment. One patient survived for three days and another for three weeks; both died in the hospital of complications apparently unrelated to counterpulsation. Seven patients were discharged from the hospital and remained well. The patients who responded to external counterpulsation did so within the first few hours. There seemed to be no benefit in applying counterpulsation for more than six hours. Sequential analysis of mortality statistics indicated that the 45% survival rate (which included the two short-term survivors) was a significant improvement (P (JAMA229:1441-1450, 1974)

A REVIEW of the physiologic disturbances encountered in nonpulsatile perfusion suggests a far greater importance to pulsatile blood flow than has heretofore been accorded. Although there is some evidence that blood flow through organs may be affected by nonpulsatile perfusion, it is now generally accepted that it is not. However, considerable evidence is available favoring the view that nonpulsatile perfusion may impair organ function in a number of ways. 1 That kidney function might be affected by the arterial pulse is suggested by several studies. Hamel 2 and Hooker, 3 studying the isolated kidney, found that a reduction in pulse pressure resulted in a drop in urine output. Gasell, 4 studying the intact kidney, confirmed this. Judson and Rausch 5 demonstrated a direct correlation between pulse pressure and urine output in humans undergoing aortic surgery. Senning et al 6 showed that nonpulsatile perfusion resulted in a depression in renal function

THE RENEWED interest in the physiologic effects of pulsatile and nonpulsatile flow has been, in large measure, stimulated by the desire to support the circulation for prolonged periods with extracorporeal devices. The excellent studies of Mandelbaum and associates,1,2Wesolowski,3Ogata and associates,4Nakayama et al,5and Dalton et al6have all used extracorporeal devices to provide either pulsatile or nonpulsatile flow. While these studies have been illuminating and have generally pointed to a significant increase in pressure and resistance in response to a nonpulsatile flow, the use of extracorporeal devices as the source of the flow has made the application of these findings to the intact organism open to serious question. This group has adopted a different approach. We have introduced an experimental model for studying the chronic effects of depulsation in which the aortic flow is exteriorized through a subcutaneous graft anastomosed in-series to

STUDIES at the US Army Surgical Research Unit dating from 1954,1established septicemia as a major cause of death following burns. The relationship between colonization of the burn wound by gram-positive organisms and death resulting from septicemia was clearly indicated by repeated positive blood cultures associated with a gradually deteriorating clinical course which often ended in death. However, with the emergence of gram-negative organisms as the major cause of death in burns, the relationship between the wound and the clinical course of the patient was not clear until the classic studies of Order,2Rittenbury,3Teplitz,4,5and associates established the burn wound as the source of the gram-negative organisms responsible for the patient's death. Their work demonstrated that the bacterial invasion of the burn wound occurs at a predictable rate and that the prognosis is related to the bacterial colony counts obtained from the wound. The control