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This study determined the incidence of cardiac diagnoses demonstrably related to chest pain in young patients and determined whether those with exertional chest pain were more likely to have a cardiac diagnosis. It evaluated the course of patients with chest pain after pediatric cardiology evaluation regarding interventions, outcomes, and additional test burden. This was a retrospective study of 203 patients with an office pediatric cardiology assessment of chest pain from January 2000 through December 2004. Fifteen patients (7.4%) had cardiac diagnoses, 5 (2.5%) had cardiac diagnoses demonstrably related to their chest pain complaints (arrhythmias, mitral valve prolapse), and none had ischemia. Exertional chest pain, in this study, did not increase the risk of having a cardiac diagnosis. Following evaluation, 80% of patients did not return for complaints of chest pain. Ten percent had 2 or more additional visits to any medical site for chest pain but no additional cardiac diagnoses were found.

Background Pancreaticoduodenectomy (PD) is a complex surgical procedure with a historically high morbidity rate. The goal of this study was to determine if the implementation of a 12-measure perioperative surgical care bundle (SCB) was successful in reducing infectious and other complications in patients undergoing PD compared with a routine preoperative preparation group (RPP). Methods In this retrospective cohort study utilizing the HPB surgery database at the Thomas Jefferson University, we analyzed clinical data from 233 consecutive PDs from October 2005 to May 2008 on patients who underwent RPP, and compared them with 233 consecutive PDs from May 2008 to May 2010 following the implementation of the SCB. The SCB was the product of multidisciplinary discussion and extensive literature review. Results The RPP group and the SCB group had similar demographic characteristics. The overall rate of postoperative morbidity was similar between groups (42.1% versus 37.8%). However, wound infections were significantly lower in the SCB group (15.0% versus 7.7%, P = 0.01).The rates of other common complications, as well as postoperative hospital length of stay, readmissions, and 30-d postoperative mortality were similar between groups. Conclusions The implementation of a SCB was followed by a significant decline in wound infection in patients undergoing PD.

A retrospective study was performed to evaluate the association between arterial invasion and survival in patients with stage I non-small cell lung cancer.One hundred patients were identified who had undergone complete anatomic resection as definitive treatment for stage I non-small cell lung cancer. The tumors were reviewed for the presence or absence of arterial invasion. Five-year survival data were obtained for all patients.The 100 patients had an overall 5-year survival of 61%. There were 64 stage IA patients with a 62% 5-year survival and 36 stage IB patients with a 58% 5-year survival. The 39 patients identified with arterial invasion had a 38% 5-year survival compared with a 73% 5-year survival in the 61 patients without arterial invasion (p0.001), with an unadjusted hazard ratio of 3.5 (p0.001). Multivariate analysis by stage IA versus IB and by size greater or less than 2 cm demonstrated hazard ratios of 3.5 and 4.0, respectively (p0.001). This difference was independent of demographic characteristics, tumor type, or grade. Subgroup analysis revealed a hazard ratio of 5.8 in patients with stage IA non-small cell lung cancer (p0.001) and 19.8 in patients with tumorsor = 2 cm (p = 0.006).Arterial invasion is present in a substantial percentage of patients with stage I non-small cell lung cancer and is adversely associated with survival.

Intraoperative rapid parathyroid hormone (iPTH) assay is changing parathyroid surgery. One surgeon's experience at a tertiary care hospital was followed as minimally invasive parathyroidectomy (MIP) was adopted.In this prospective case study, patients underwent technitium 99m sestamibi scanning, iPTH monitoring, and MIP. A sestamibi-directed incision was made, and iPTH was measured preincision, preexcision of abnormal gland(s), and at 5- and 10-minute intervals. MIP was complete after gland(s) was excised and iPTH fell to less than 50% of preoperative levels. Routine discharge was on the day of surgery with daily calcium and calcitriol to minimize outpatient hypocalcemia. Secondary and tertiary hyperparathyroidism patients were excluded.From December 1999 to June 2002, 101 patients underwent MIP. Patients were 27% men and 73% women, with two reoperations. Preoperation laboratory results averaged serum calcium 11.08 (normal 8.5 to 10.5 mg/dL) and parathyroid hormone (PTH) 169 pg/mL (normal 10 to 55 pg/mL). Average iPTH values at operative intervals were 152, 151, 68, and 50 pg/mL, respectively. Operation demonstrated 12% of patients had four-gland hyperplasia, 3% had double adenomas, 2% had parathyroid carcinomas, and 83% had single adenomas. Discharge on the day of surgery occurred in 83% of single-adenoma patients. Postoperative laboratory results averaged calcium 9.4 mg/dL (p0.001 versus preoperation) and PTH 48 pg/mL (p0.001). Fifteen patients (16%) had elevated PTH after operation, but without elevated calcium levels. One patient had persistant hyperparathyroidism.MIP with iPTH monitoring is a safe and effective means of treating hyperparathyroidism. This approach allows for limited dissection and early discharge for the majority of patients.

John Young Templeton III was born in 1917 in Portsmouth, Virginia, and graduated from Jefferson Medical College in 1941. He completed his residency training under Dr. John H. Gibbon, Jr., and was the first resident who worked on Gibbon's heart–lung machine. After his training, he remained at Jefferson as an American Cancer Society fellow and Damon Runyon fellow and went on to become the fourth Samuel D. Gross Professor and Chair of the Department of Surgery in 1967. Dr. Templeton was the recipient of numerous grants and published over 80 papers in the field of cardiothoracic surgery. As a teacher and mentor, he was a beloved figure who placed great faith in his residents. He participated in over 60 professional societies, serving as president to many such as the Philadelphia Academy of Surgery and the Pennsylvania Association of Thoracic Surgery. He was also recognized through his many awards, in particular the John Y. Templeton III lectureship established in 1980 at Jefferson of whom Denton Cooley was the first lecturer. Dr. Templeton retired from practice in 1987. He is forever remembered as an important model of a modern surgeon evident in numerous academic achievements, the admiration and affection of his trainees, and the lives of patients that he had touched.

Background: The role of imaging studies before parathyroidectomy has been extensively debated and recent advances in unilateral parathyroidectomy intensify this controversy. The purpose of this study was to review the parathyroidectomy experience of a single surgeon, looking at the role of sestamibi scans and a standard postoperative care regimen. Study Design: Retrospective review of office and hospital charts was completed on 90 patients with primary hyperparathyroidism who underwent parathyroidectomy from 1991 to 1998. Patient workup and outcomes were noted, as were results of preoperative imaging. True-positive scans visualized an abnormality ipsilateral to the adenoma found at operation. Statistics were performed using nonparametric testing and Student's t -test. Results: There were 21 male and 69 female patients, with an average age of 54 years (range 29 to 81). There were zero mortalities, three morbidities (3.3%), and three patients who had persistent hypercalcemia, yielding a 96.7% success rate. Sixty-seven patients underwent preoperative sestamibi scanning, with a sensitivity of 74% and positive predictive value of 89%. Operative time in imaged patients averaged 103 ± 49.9 minutes versus 121.5 ± 85.9 minutes for patients without sestamibi scans. Operating time differences were not statistically significant and a preoperative sestamibi scan did not affect the success of parathyroidectomy. Discharge on postoperative day 1 was accomplished in 80% of patients and 13% were discharged the next day. There was no morbidity from hypocalcemia. Conclusions: A preoperative sestamibi scan does not improve efficacy or decrease operating time for primary hyperparathyroidism when bilateral neck exploration is performed. A postoperative care protocol including oral calcium and vitamin D supplementation allows the majority of patients to be discharged on postoperative day 1 with excellent results.

Study objectives Bronchioloalveolar carcinoma is a primary lung neoplasm of variable histopathologic, radiologic, and clinical expression. There are three cell types described in bronchioloalveolar carcinoma: Clara cells, mucin-producing cells, and alveolar type II epithelial cells. It is unclear whether these three tumor cell types are associated with a specific radiologic presentation and clinical course. In this study, we investigated whether tumor cell type, identified by transmission electron microscopy, correlated with a specific radiologic pattern, and whether tumor cell type or radiologic presentation correlated with the patient's clinical course and outcome. Design Transmission electron microscopy was used to restudy tissue blocks from the original surgical histopathologic specimens in 54 patients with primary bronchioloalveolar carcinoma diagnosed over a 10-year period (1980 to 1990). The pretreatment radiographs were reviewed in each case, and the first chest radiograph obtained at the time of the discovery of the tumor in each patient was compared with the results of the ultrastructural study. The medical records of each patient were examined to obtain pertinent radiologic, clinical, and patient outcome information. Measurement and results There were 32 Clara cell tumors, 10 mucin-producing cell tumors, and 1 alveolar type II epithelial cell tumor in this series. Eleven additional tumors had mixtures of two or more cell types. No statistically significant relationship was detected between tumor cell type and radiologic presentation or patient mortality pattern. There was increased mortality among patients who presented radiologically with segmental, lobar, multifocal, or diffuse disease compared with those patients exhibiting a solitary pulmonary nodule at presentation. Conclusion Radiologic presentation, rather than tumor cell type, provides prognostic information that aids in predicting patient outcome.

John Young Templeton III was born in 1917 in Portsmouth, Virginia, and graduated from Jefferson Medical College in 1941. He completed his residency training under Dr. John H. Gibbon, Jr., and was the first resident who worked on Gibbon's heart-lung machine. After his training, he remained at Jefferson as an American Cancer Society fellow and Damon Runyon fellow and went on to become the fourth Samuel D. Gross Professor and Chair of the Department of Surgery in 1967. Dr. Templeton was the recipient of numerous grants and published over 80 papers in the field of cardiothoracic surgery. As a teacher and mentor, he was a beloved figure who placed great faith in his residents. He participated in over 60 professional societies, serving as president to many such as the Philadelphia Academy of Surgery and the Pennsylvania Association of Thoracic Surgery. He was also recognized through his many awards, in particular the John Y. Templeton III lectureship established in 1980 at Jefferson of whom Denton Cooley was the first lecturer. Dr. Templeton retired from practice in 1987. He is forever remembered as an important model of a modern surgeon evident in numerous academic achievements, the admiration and affection of his trainees, and the lives of patients that he had touched.

Large-for-delivery date babies, considered characteristic of diabetic pregnancy, are believed to result from fetal hyperinsulinemia. Paradoxically, infant birth weights tend to be low-for-delivery date in mothers with more severe diabetes. We tested the hypothesis that hypoxemia in such fetuses leads to sympathoadrenal stimulation and inhibition of insulin secretion; and, thus, produces a net reduction in the growth-promoting effects. Fetal sheep were prepared with chronic peripheral and adrenal cannulas. Fetal blood gases, lactate, norepinephrine, and epinephrine secretion rates; and plasma norepinephrine, glucose, and immunoreactive insulin concentrations were determined at 30-min intervals during a 2-h baseline period and a 4-h period of hyperglycemia divided into 2-h segments of hypoxemia (with and without alpha-blockade) and hyperoxia. Hypoxemia-hyperoxia sequences were varied randomly. Well-oxygenated fetuses responded to a threefold increase in glucose with a sixfold increase in plasma immunoreactive insulin. With hypoxemia, norepinephrine and epinephrine secretion were elevated and the insulin response was blocked. With hypoxemia and phentolamine blockade, the insulin response was enhanced with a 10-fold increase above baseline. In severe maternal diabetes with vascular disease or with poor control and very high glucose levels, the fetus is likely to be relatively hypoxemic. Our experiments suggest that in this situation, the fetal insulin response to hyperglycemia will be attenuated; this effect is mediated, at least partly, through sympathoadrenal stimulation.

Rounded atelectasis is a benign entity that is often misinterpreted as a pulmonary neoplasm. The roentgenologic appearance of a mass is due to an infolding of atelectatic tissue intermingled with pleura, blood vessels, and bronchi. Rounded atelectasis is usually asymptomatic and is commonly associated with chronic pleural disease or pleural effusions. The distinctive radiologic features include a rounded, pleural-based opacity associated with adjacent pleural thickening and volume loss of the affected lobe. The pathognomonic sign is the "comet tail" that results from the crowding of vessels and bronchi as they enter the atelectatic region. Many authors consider this constellation of findings diagnostic. Rounded atelectasis usually remains stable over time; however, slow growth, as well as diminution in size, has been described. A retrospective analysis revealed 7 cases of rounded atelectasis at our institution over a 9-year period. Three were operated on to exclude malignancy, one was confirmed at operation performed for other reasons, and 3 were followed up expectantly. We conclude that recognition of this entity and its radiologic features can be diagnostic and render further workup, including thoracotomy, unnecessary.

Background The incidence of carcinoma of the distal esophagus and GE junction is rapidly increasing. A large single-center experience was reviewed to determine the impact of lymph node positivity and ratio on survival. Methods All patients undergoing esophagogastrectomy at Thomas Jefferson University Hospital between January 1994 and December 2004 were reviewed. Univariate and multivariate analyses were performed using log-rank and Cox proportional hazard models, and survival curves were estimated using the Kaplan-Meier method. Results Of 173 patients with invasive cancer, 123 (71%) underwent preoperative chemoradiation therapy. The largest number of patients (45%) had adenocarcinoma of the GE junction; 29% of patients had esophageal adenocarcinoma while 14% had squamous cell cancer of the esophagus. Perioperative mortality was 5.7%. Median overall survival of the entire group was 22 months and 5-year overall survival was 27%. The most significant prognostic factor for overall survival was the presence of positive LN ( P = 0.01). Additionally, patients with zero involved LN had a 5-year survival of 34%, while patients with 1 to 3 positive LN and >3 positive LN had 5-year survival of 27% and 9%, respectively ( P = 0.01). Finally, an increasing ratio of positive to examined LN was linearly associated with a worsening 5-year survival, ( P = 0.153). Conclusions Increasing number of positive LN in patients with esophageal cancer and increasing ratio of metastatic to examined LN portend a poor prognosis. These factors should play an important role in determining which patients receive adjuvant therapy.

It is generally believed that minimally invasive surgery (MIS) results in less postoperative pain, fewer complications, and shorter recovery periods compared with open procedures. Yet despite these benefits, the level of reimbursement assigned to the surgeon by United States health-care payers is often lower than that for open procedures. Furthermore, the cost of performing a MIS may be higher vs an open procedure because specialized equipment, increased surgical time, or both may be required. In this report, we examine the issue by comparing reimbursements for MIS with open procedures, summarizing the medical literature on MIS vs open surgical procedures, and offering recommendations for payers who establish reimbursement policies. The review is focused on six MIS procedures where outcomes data exist: laparoscopic cholecystectomy (lap chole), laparoscopic colectomy (LC), laparoscopic fundoplication (LF), laparoscopic hysterectomy (LH), laparoscopic ventral hernia repair (LVHR), and laparoscopic appendectomy (LA). Outcomes summarized were length of hospital stay (LOS), operating room time, operating room costs, complications, and return to work or normal activities. The level of scientific evidence was assigned to each study using predetermined criteria. A total of 112 articles were reviewed: 14 for lap chole, 26 for LC, 7 for LF, 19 for LH, 9 for LVHR, and 37 for LA. The data demonstrate that these procedures result in reduced hospital stay, reduced hospital costs, and faster return to work or normal activities. Yet, the operating room time and costs are frequently higher for MIS. These findings suggest that as both the outcomes value and level of operating room resources are greater, MIS warrants reimbursement that meets or exceeds that of open procedures.

A human cancer vaccine composed of autologous tumor cells modified with the hapten dinitrofluorobenzene (DNP) induces cell-mediated immunity to the tumor cells and the development of inflammatory responses within metastatic sites. In this study we determined whether DNP vaccine could induce regression of established metastases. Ninety-seven patients (83 evaluable) with surgically incurable metastatic melanoma were treated with DNP vaccine preceded by low-dose cyclophosphamide. Tumor regression was assessed by standard criteria. The development of cell-mediated immunity to melanoma-associated antigens was measured by delayed-type hypersensitivity (DTH) testing before and after DNP vaccine treatment. Survival analysis was performed by the Kaplan-Meier method. There were 11 antitumor responses: 2 complete, 4 partial and 5 mixed. Both complete responses and 2 of the 4 partial responses occurred in patients with lung metastases. Response durations were as follows: partial responses—5, 6, 8 and 47+ months; and complete responses—12 and 29 months. Tumor regression required at least 4 months to become evident and in 2 cases maximum regression was not observed until 1 year after beginning treatment. Patients who exhibited tumor regression survived longer than those who did not (median survival times: responders, 21.4 months; non-responders, 8.7 months; p = 0.010). DTH to DNP-modified and unmodified autologous melanoma cells was induced in 87% and 42% of patients, respectively. The DTH response to unmodified cells was significantly associated with prolonged survival. Autologous DNP-modified melanoma vaccine can induce clinically meaningful regression of metastases and small lung metastases appear to be unusually sensitive. The development of DTH to unmodified, autologous tumor cells may be an important indicator of the vaccine's efficacy. © 2001 Wiley-Liss, Inc.

Video-assisted thoracic surgery is an important component of modern thoracic surgery, providing a safe, less invasive alternative to open thoracotomy in the evaluation of pleural, mediastinal, and parenchymal pathology. Advancements in endoscopic techniques and video-optics have permitted greater visualization of the thoracic cavity and allowed limited pulmonary resections with significantly reduced postoperative morbidity. Thoracoscopy is indicated for diagnosis of intrathoracic pathology when usual methods of diagnosis, including fine-needle aspiration and transbronchial biopsy, are inconclusive. The diagnostic accuracy of video-assisted thoracic surgery approaches 100%. Increasingly, the indications for thoracoscopy include therapeutic resections of pulmonary nodules in cases of limited lung metastases and bronchogenic carcinoma when pulmonary function is poor. Successful diagnostic and therapeutic resection by thoracoscopy requires intraoperative localization of the lesion within the collapsed lung. The indications and methods of thoracoscopic surgery and preoperative localization are discussed.

A 58-year-old man patient with a history of hyperparathyroidism with recurrent renal stones was evaluated by ultrasonography of the neck and Tc-99m methoxy isobutyl isonitrile (MIBI) scintigraphy. Both imaging modalities correctly visualized a parathyroid adenoma. Increased Tc-99m MIBI uptake was noted in the sternum, clavicle, and shoulders. These findings are the result of hyperactive bone turnover rate occurring secondary to the hyperparathyroidism

Fifty-seven patients with myasthenia gravis have had thymectomies over a 27 year period. Of the 50 patients surviving operation, 42 have shown definite improvement, with 18 having complete remissions to this time. Thirty-four out of 37 patients without thymomas have shown sustained improvement since operation. Almost all of the patients with improvement had follicular hyperplasia of the thymus gland. At least 85 per cent of properly selected patients with myasthenia gravis should obtain improvement following thymectomy, with minimal operative morbidity and mortality.

Fetal and maternal heart rates were studied in unrestrained, pregnant harbor seals during the last third of gestation. Heart rates were recorded while the mothers were resting on land or performing trained simulated dives of up to 2.25 min. Data from resting mothers showed the development of a bimodal or two-speed fetal heart rate pattern during late gestation. The mean faster and slower fetal heart rates at term were 125 ± 3.7 and 79 ± 3.1 (mean + SEM) respectively. The amount of fetal bradycardia observed increased steadily towards term, and fetal heart rate changes were not correlated with changes in maternal heart rate or maternal respiration. The bimodal fetal heart rate was also seen during the simulated dives, and no decrease in either the faster or slower heart rate was found. Heart rates from resting, unrestrained harbor seal pups were also studied. The pups displayed a bimodal heart rate similar to the fetuses' with the slower rate occurring during breath-holds. The bradycardia in the pups was equivalent to the slower fetal heart rate. These findings suggest that the regulatory mechanism that determines the apneic bradycardia in young harbor seals during non-stressful conditions develops in the last quarter of gestation.

To evaluate complications and mortality following cardiac catheterization (CC) in patients under one year of age, we prospectively examined 312 CC on 273 patients from the centers in the New England Regional Infant Cardiac Program during a one-year period. Among CC performed on patients less than four months old, the incidence of complications requiring treatment was 12%; for patients 4-12 months, it was 1.5% (p less than 0.02). By pre-CC risk assessment, 13% of CC were high risk, 21% medium risk, and 66% low risk. The incidence of major complications was much greater among the High Risk (30%) compared with Medium Risk (14%) (p less than 0.05) and with Low Risk (4%) (p less than 0.001). The overall mortality rates 24 h, 48 h, and one week after CC were 3.8%, 8.3%, and 13.5%, including patients with inoperable lesions and those having cardiac surgery, while deaths directly attributable to a CC complication were 0, 0.3%, and 0.3%, respectively. We can predict, prior to CC, the high-risk cases where major complications and death are likeliest to occur. The incidence of death from CC-related complications is extremely low in patients under one year of age, compared with death from the underlying lesion or following cardiac surgery.

A new method for quantifying adrenal secretory function in chronically catheterized fetal lambs was developed. This preparation included insertion of a catheter distally into the fetal left renal vein and placement of a remotely operated, hydraulically controlled choker around the renal vein at its junction with the vena cava. With the choker open, adrenal venous blood flowed into the renal vein and then into the vena cava. With the choker closed, adrenal blood flowed into the catheter so that timed samples of adrenal venous effluent could be obtained. With this technique, left adrenal secretory rates of norepinephrine and epinephrine were determined across a spectrum of oxygen concentrations in five near-term fetal lambs. There was a rapid rise in norepinephrine secretion after induction of hypoxemia. Maximum secretory rates occurred at about 5 min, concomitantly with the lowest attained fetal arterial partial pressure of oxygen (PO2s). There was an inverse exponential relation between these catecholamine secretion rates and fetal arterial PO2 (P less than 0.001). Norepinephrine secretion appeared to increase in response to lesser degrees of hypoxemia than did epinephrine, although a longer time delay between stimulation and epinephrine response may have been a factor. Overall, norepinephrine secretion was greater than that of epinephrine. The ratios of norepinephrine to epinephrine in individual adrenal samples varied considerably and in some instances were less than one. These ratios did not correlate significantly with the degree of hypoxemia. During 25 min of a relatively steady state of hypoxemia, norepinephrine secretion declined markedly after about 5 min, although it remained above control levels throughout. Epinephrine secretion rose more gradually but then was relatively stable during the remaining period of hypoxemia.

Circulatory responses to hypoxemia and acidemia were studied in 10 fetal lambs in utero with gestational ages of 122 to 142 days. Vinyl catheters were placed in fetal and maternal vessels, and the fetuses were studied 2 to 5 days postoperatively. Fetal heart rate, arterial pressure,Po 2 ,Pco 2 , and pH were measured during a control period and while the standing ewe breathed 6 per cent oxygen and 3 per cent carbon dioxide through a plastic bag over its head. Fetal cardiac output and distribution and absolute organ blood flows were calculated from injections of 15μ nuclide-labeled microspheres, during the control and hypoxemic states. One group of 5 fetuses only became hypoxemic (meanPo 2 12 and mean pH 7.36), but the other 5 fetuses also developed acidemia (meanPo 2 12 and mean pH 7.28). Fetal arterialPco 2 values were normal throughout. During hypoxemia, fetal arterial pressure increased, and fetal heart rate decreased. Although cardiac output fell in all but one fetus, the decrease was significant only in the acidemic group. Blood flow to the fetal body decreased in all, but the change was significantly greater in the acidemic group. Umbilical blood flow was maintained in all fetuses during hypoxemia. The per cent distribution of cardiac output to the placenta rose from 41 to 48 per cent and from 41 to 57 per cent in the hypoxemic and acidemic groups, respectively. Blood flow to the brain, heart, and adrenals increased two- to three-fold in all fetuses during hypoxemia while pulmonary, renal, splenic, gut, and carcass flows decreased. The changes were of greater magnitude in fetuses with combined hypoxemia and acidemia. These studies quantitate the fetal circulatory changes that occur in unanesthetized fetal lambs in utero during maternal hypoxemia.

The effect of heart rate changes on cardiovascular function during hypoxemia was studied in lamb fetuses. In chronic preparations, we determined fetal heart rate, descending aortic blood flow (by electromagnetic flowmeter), Po 2 , Pco 2 , and pH and calculated fetal cardiac output (CO) and organ blood flows (with the use of 15 μ nuclide-labeled microshperes). Observations were made during control and hypoxemic states either alone or in the presence of parasympathetic blockade by atropine. Fetuses exposed to moderate hypoxemia (ewe breathing 10% oxygen) developed a significant bradycardia which was prevented by atropine pretreatment; no significant change in CO occurred in either case. Fetuses exposed to severe hypoxemia (8% oxygen) developed bradycardia and a significant decrease in CO; atropine pretreatment prevented the bradycardia but failed to prevent the decrease in CO. Atropine administered to the already severely hypoxemic fetus increased the heart rate but did not restore the depressed CO. The redistribution of blood flow from low-priority (e.g., viscera) to high-priority (e.g., myocardium) tissues correlated with the degree of hypoxemia. Myocardial blood flow was greater during hypoxemia when bradycardia was prevented by atropine than during hypoxemia alone; otherwise, blood flow distribution in response to hypoxemia was unaffected by atropine blockade.

This work was undertaken to investigate the fetal adrenal corticoid secretory response to hypoxic stress in late gestation. Experiments were performed in two groups of fetal sheep of different gestational ages, group I, 129-132 (mean, 130) days and group II, 135-139 (mean, 136) days. Fetuses were prepared with chronic adrenal cannulas as well as peripheral arterial and venous catheters. With the fetus at rest and after 7, 9, 11 and, in some instances, 30 and 60 min of hypoxia (maternal FIO2 10%), precisely timed (2 min) samples of adrenal effluent were collected for determination of cortisol (F) and corticosterone (B) secretion rates. Peripheral samples were obtained intermittently for blood gas and lactate determinations. Resting corticoid secretory rates were highly variable, suggesting an episodic secretory pattern. Corticoid secretory responses to hypoxemia were significantly elevated at 7-11 min, peaked at 30 min, and remained stable at 60 min. Specifically, in group I, F secretion increased from a baseline value of 37 +/- 19 ng/min to a peak hypoxemic response of 376 +/- 80 ng/min; B secretion increased from 6 +/- 4 to 170 +/- 32 ng/min. In group II, F secretion increased from 99 +/- 20 to 653 +/- 107 ng/min; B secretion increased from 12 +/- 5 to 200 +/- 28 ng/min. When related to adrenal gland weight, there was no difference between F secretory responses in groups I and II, whereas relative B secretory responses were lower in group II than in group I at 9 and 11 min of hypoxemia. We conclude that the 129-139 day sheep fetal adrenal cortex is highly sensitive to hypoxic stress with the effect presumably mediated by elevated levels of endogenous ACTH. The B stress response decreases as gestational age advances from the 129-132 day range to 135-139 days.

During the period from July 1983 through October 1984, a group of 38 patients with elevated serum calcium, parathormone (PTH) and/or clinical suspicion of hyperparathyroidism were studied by TI-201 Tc-99m dual tracer parathyroid imaging (DTPI). Seventeen of 18 parathyroid lesions were identified correctly. There was one false-negative, and the size of the adenoma missed by DTPI was less than 1.0 cm in diameter (1.0 x 0.5 x 0.2). There was one true-negative case. The other fifteen with negative scans are being followed clinically. Because of the small population studied, statistical analysis was not ascertained. However, this simple, noninvasive procedure has become a very useful diagnostic tool for the detection and localization of parathyroid lesions causing hyperparathyroidism, and the DTPI should be used in conjunction with ultrasonography and CT scanning in the preoperative evaluation in primary and secondary hyperparathyroidism.

Congenital bronchoesophageal fistulas usually present in infants and may occur with or without esophageal atresia. Twenty cases of congenital bronchoesophageal fistula in adults have been reported in the English literature. Another case of this rare developmental anomaly is presented here. The radiographic, endoscopic, surgical, and pathologic findings are discussed with a review of the literature.

A multiinstitutional study of 39 esophageal injuries treated between 1982 and 1988 and a comprehensive review of the literature revealed an unacceptably high mortality rate of more than 20%. Results of the current study indicated that prompt diagnosis and aggressive surgical management of esophageal injuries could improve the outcome and lower the associated mortality. The clinical experience and literature review allowed us to elaborate caveats and principles that, if adhered to, should improve the outcome in esophageal injuries.

Thirty-seven patients with fractures of the thoracic or lumbar spine underwent anterior corpectomy (partial or complete) and vertebral body replacement for either destructive lesions from tumor or infection (13 patients) or trauma (24 patients). The vertebral bodies were replaced using either rib (12 patients) or tricortical iliac crest (25 patients) autografts. The Dunn device was utilized in conjunction with the autografts in 19 patients. Posterior stabilization was used in five patients; three prior to anterior stabilization and two after anterior stabilization. Within 2 weeks of the operative procedure, all patients began walking or sitting. Of the 37 patients, 21 with incomplete neurologic deficits improved, and 10 of those went onto complete recovery. Of the 27 patients who have been followed for a minimum of 1 year, 25 have obtained solid fusions, one developed a pseudarthrosis that required regrafting, and one had a delayed union prior to death from metastatic disease. There were two deaths in the immediate postoperative period and three deaths in the first six postoperative wounds due to metastatic disease. The purpose of this study is to present a consecutive series of patients who have undergone corpectomy and vertebral body replacement as well as to define the adequacy of stabilization.

A case of thoracic chordoma successfully treated with surgical excision is reported and described. Thoracic chordomata presenting as posterior superior mediastinal tumors occur infrequently and may be highly malignant lesions. Early radical surgery through thoracotomy provide the best hope of cure, and radiation offers only temporary regression of tumor.

Presentation of the various techniques used for the construction of arteriovenous fistulas, circumstances that led to the choice of the various techniques, and the complications encountered after construction.

EFFECTS OF PARASYMPATHETIC BLOCKADE ON THE CARDIOVASCULAR RESPONSE TO HYPOXEMIA IN UNANESTHETIZED FETAL LAMBS

NERICP is a voluntary association of all New England hospitals offering cardiac care for infants and dedicated to improving care for these babies. NERICP began in 1968 and has emphasized professional education, improved casefinding, transportation, nursing, and social service and monitoring of patient experience. There has been increased new case discovery, decreased unrecognized deaths in state vital statistics and earlier admission. Because the data are consecutive, epidemiologic studies are possible, hospital experience can be monitored and studies of determinants of survival are possible. Self evaluation by individual hospitals has resulted in gradual restructuring of case delivery in the region. From an original 11 hospitals offering definitive care for infants, 5 now offer full diagnostic and surgical service, 3 offer full diagnostic and limited surgical service, 2 offer only non invasive diagnostic evaluation and 1 has discontinued all pediatric cardiology, Multivariate analysis indicates that, before and during these transitions, variation in survival among infants arriving at NERICP hospitals (except for one full service hospital with poor results) are not statistically significant. Successful management by limited service hospitals is accomplished through informed surgical referral. These changes in care delivery are believed to be an individual hospital response to reliable regional information about the available patient pool and the problems of management identified by NERICP.

Erythrokinetic studies on two anephric and asplenic patients are described. The patients were nephrectomized in preparation for renal homotransplantation and maintained on hemodialysis for six and eight months. Results of these studies indicate that despite absence of kidneys and spleen, and intrinsic base line erythropoietic activity remains, with a relatively constant and persistent reticulocyte production and radioiron turnover. Autonomy of this erythropoietic activity was apparent by lack of responsiveness to induced anemia and polycythemia. In the second patient a reticulocytosis and increased iron turnover occurred five months postnephrectomy. This was accompanied by significant plasma titers of erythropoietin-like substance. A renin-like enzyme was also found in the plasma of both patients. These observations suggest the existence of an autonomous base line erythropoietic activity of bone marrow and a possible functional relationship between inappropriate secretion of extrarenal "erythropoietin" and extrarenal "renin."

For the first day or so after a major operation, the patient's cough may be ineffective in clearing the trachea and bronchi of secretions, with resultant pneumonitis and atelectasis. Retained tracheobronchial secretions are often seen after upper abdominal operations,1such as gastrectomy and cholecystectomy, and the condition may be aggravated by the use of an indwelling nasogastric tube.2Atelectasis is probably the most frequent post-operative complication of thoracic operations.3 A high humidity in the inspired air or in oxygen and the control of pain are probably the most important factors in promoting an effective cough. Despite these measures, post-operative patients are frequently unable to clear the tracheobronchial tree of secretions. When this occurs, nasotracheal aspiration4is undoubtedly the most effective method of removing the retained secretions. Moreover, it frequently stimulates an effective cough. It is readily available at the bedside and may be repeated frequently without the need

Excerpt Segments of ileum or jejunum were isolated from the remaining bowel and one or both ends exteriorized in 19 chronically uremic patients. The etiology of their uremia varied widely, and all ...

Establishment of a colostomy is frequently part of the operative procedure for a variety of surgical problems. A well-constructed colostomy can usually be managed with little inconvenience to the patient. However, occasional complications occur, one of the more common of which is a peristomal hernia. A rare complication directly attributable to a peristomal hernia has prompted this report. Report of Case A 70-year-old white woman was admitted to the Jefferson Medical Hospital on March 31, 1963, with the chief complaint of intermittent vomiting of three days' duration. The patient had undergone an abdominal-perineal resection for carcinoma of the rectum in 1952. Within a year following this operation, a peristomal hernia was noted. This produced no symptoms until approximately one year prior to the present admission. On occasion she noted an increase in the size of the hernia and this was associated with vomiting of clear, watery material. This would lead

THREE recent reviews1,2,3have stressed the unilaterality of benign mesenchymomas of the kidney (hamartomatous angiomyolipoma) except in those patients with tuberous sclerosis. The sudden onset of shock is reported by Price and Mostofi3in two of 30 patients and is even more of a rarity in the sporadic cases reported in the English language literature.1-31The following report demonstrates both that this lesion can be bilateral and that severe spontaneous retroperitoneal hemorrhage can rapidly develop. Report of a Case A 42-year-old white woman (JMCH 217456) with no evidence of tuberous sclerosis was in good health until June 22, 1962, when severe right flank, abdominal and back pain developed and she was admitted to Delaware County Memorial Hospital. Despite no obvious external blood loss hypovolemic shock developed necessitating blood replacement. Abdominal x-ray film showed absence of the right psoas shadow, and an intravenous pyelogram revealed no calyceal deformity