Complex venation patterns in the leaves of selaginella: megaphyll-like leaves in lycophytes.

Venation patterns of the leaves of two lycophytes, Selagiella adunca and Selaginella schaffneri, do not fit the definition of microphylls as having a single, unbranched vein. Although S. adunca has a simple pattern, S. schaffneri has a complexity matching that of many megaphylls, with numerous branching veins. The veins of S. schaffneri undergo an average of 13 branchings (range, 8 to 21), and reticulation between veins is frequent. The discovery of this radical departure from the familiar microphylls of lycophytes indicates that complex venation patterns in leaves do not necessarily arise from fusion of whole branches. The microphyll may not be as structurally stable as formerly believed.

Lipid-based parenteral nutrition and the immunosuppression of protein malnutrition.

Protein malnutrition has been directly related to impaired immunocompetence. An experimental protocol was designed to determine the efficacy of a lipid-based system of total parenteral nutrition (TPN) in restoring immunocompetence in nutritionally depleted subjects. Thirty rats sensitized to PPD were made anergic by the oral administration of a protein-free diet. Nutritional repletion was instituted with either a complete oral diet or lipid-based TPN. The two groups of animals did not differ significantly in the time required to regain positive skin test reactivity or in the weight gained during the repletion period. The lipid-based system of TPN was comparable to the complete oral diet in reversing the anergy of protein malnutrition.

Objective measurement of limb perfusion by dermal fluorometry. A criterion for healing of below-knee amputation.

Quantitative fluorometry has been recommended as an accurate adjunct to clinical judgment in the preoperative assessment of lower-extremity amputation level. In this prospective study of 56 patients who had below-knee amputation, clinical judgment was used as the sole criterion for site selection. Quantitative fluorometry was compared with clinical judgment in a prospective, blinded study. All patients were studied before amputation with administration of intravenous fluorescein. Fifteen minutes after injection, objective measurement of dye fluorescence was performed at multiple sites with a quantitative fluorometer, and a dye fluorescence index was derived. All limbs undergoing amputation were ischemic, manifested by rest pain, nonhealing ulcers, or gangrene. Five patients (8.7%) failed to heal at the below-knee level. The mean dye fluorescence index for the group that healed was 81 +/- 51 (range, 13 to 259) and for the group that failed to heal, 110 +/- 49 (range, 70 to 195). Objective measurement of fluorescein perfusion did not correlate with amputation healing at the below-knee level in our patient population.

Percutaneous angiographic embolization for hepatic arterial hemorrhage.

Eight cases of hepatic arterial bleeding are reported. Bleeding in five instances was consequent to trauma and was either persistent postoperative (three cases) or delayed with hemobilia (two cases). Bleeding in the other three cases was from rupture of a subcapsular hematoma of the liver, with spontaneous hepatic rupture of pregnancy (two cases) and metastatic melanoma (one case). Angiography demonstrated pseudoaneurysm in six cases, a hepatic artery to portal venous fistula in one case, and a subcapsular hematoma in the final case. Percutaneous angiographic embolization controlled bleeding in seven cases and was not feasible in one case with tortuosity of the celiac axis. Complications included hepatobiliary necrosis in one patient and subphrenic abscess in two patients. Percutaneous angiographic embolization can selectively occlude a branch of the hepatic artery and is effective in the control of hepatic arterial bleeding from a variety of causes.

The role of arterial reconstruction in penetrating carotid injuries.

The outcome of 80 patients with 85 penetrating injuries to the extracranial carotid artery (CA) were analyzed after three types of treatment: (1) 54 patients, 17 with a neurologic deficit, who underwent arterial reconstruction; (2) 18 patients, eight with a neurologic deficit, who had CA ligation or non-operative management of a CA occlusion; and (3) eight patients, two with a deficit, who had minimal nonocclusive injuries managed nonoperatively. Outcome was analyzed using a Carotid Neurologic Score (CNS). The CNS is a quantitative measure of neurologic outcome and survival and ranges from -1 to +3. The higher the CNS, the more favorable the outcome. The conditions of nine patients in group 1 neurologically improved after treatment, 41 were the same, and four were worse. Forty-four patients were neurologically intact and three died. The mean (+/- SD) CNS was 1.9 +/- 0.8. In group 2, one patient's condition improved, 13 stayed the same, and four deteriorated. Ten patients were intact and two died. The mean CNS was 1.3 +/- 1.13. In group 3, two patients' conditions improved and six stayed the same. All eight patients were intact; there were no deaths. The mean CNS was 2.3 +/- 0.35. There was a significantly higher CNS for groups 1 and 3 compared with group 2. The CNSs of groups 1 and 3 were not significantly different. Arterial reconstruction provides the best outcome for all penetrating CA injuries except nonocclusive limited intimal injuries that require only observation.

Angioscopy for intraoperative management of thromboembolectomy.

Our experience with angioscopy suggests that direct visualization of the arterial lumen during thromboembolectomy procedures would provide a more reliable method of assessing luminal morphologic characteristics than angiography alone. We inspected 32 grafts (seven aortobifemoral, 18 infrainguinal bypass, and seven dialysis access fistula grafts) in 32 patients. Thirty-one patients had thrombotic events and one patient had an acute embolus. Angioscopy following standard catheter thrombectomy revealed significant amounts of retained thrombus or neointima in all thrombectomies. Angioscopic information from 18 patients with an infrainguinal bypass graft led to graft revision in six cases and placement of a new graft in 10 cases. One graft limb was replaced in seven aortobifemoral grafts, and multiple repeated thrombectomies were employed to extract debris in the remaining six cases. Repeated graft thrombectomy was also beneficial in dialysis access fistulas. Angioscopy allowed us to omit the completion angiogram and led to an improved technical result. We conclude that angioscopy is useful during thromboembolectomy procedures.

Vascular complications of the intra-aortic balloon pump.

The lower extremity complications of 100 consecutive patients who required the placement of an intra-aortic balloon pump (IABP) during a 3-year period were studied. Indications for the IABP included hypotension during cardiac catheterization (33%) or coronary angioplasty (13%), hemodynamic instability after open heart surgery (35%), unstable angina (5%), and cardiac arrest (14%). The incidence of IABP morbidity was 29%. Complications included ischemia (25%), bleeding (2%), lymph fistula (1%), and femoral neuropathy (1%). Twenty patients required 1 or more surgical interventions for lower extremity vascular complications. The majority of patients who underwent operation (70%) had significant pre-existing arterial occlusive disease. Local femoral artery reconstruction or repair was performed in 18 patients. Two patients had adjunctive bypasses. Continued IABP support was required in four patients after treatment of complications. One patient (1%) had an above-knee amputation. Limb ischemia was treated nonoperatively by removal of the IABP in five patients. Color-flow duplex scans were useful in distinguishing hematomas from pseudoaneurysms as well as for assessing femoral artery flow. We conclude that: (1) limb ischemia remains the primary complication of the IABP; (2) pre-insertion documentation of the severity of existing peripheral arterial disease by noninvasive studies may aid in the management of subsequent acute limb ischemia; (3) femoral artery thrombectomy or endarterectomy is usually sufficient for revascularization; and (4) noninvasive color flow studies are an important diagnostic tool in the nonoperative management of limb complications.

ICU care after infra-inguinal arterial surgery: an analysis of indications and outcomes.

The authors analyzed 632 consecutive, nontrauma Surgical Intensive Care Unit (SICU) admissions after infra-inguinal arterial surgery over a 3-year period (4/89-3/92) for the need for postoperative SICU care. Group I consisted of 122 patients (58 males, 64 females) with at least one absolute indication for SICU care, including mechanical ventilation, pulmonary artery, catheter monitoring, or intravenous infusion of vasoactive or antiarrythmic drugs. Group II comprised 510 patients (275 males, 235 females) without an absolute indication for SICU care. Data collected included age, first day ICU severity of illness scores (Simplified Acute Physiology Score [SAPS] and Quantitative Therapeutic Intervention Scoring System [QTISS]), preoperative length of stay (LOS), SICU LOS, hospital LOS, and mortality. Ten patients (8.2%) in Group I and ten patients (2.0%) in Group II died in the SICU (P = 0.0004). There was no significant difference in the age of Group I and Group II patients, but Group I patients had a significantly longer preoperative LOS (6.1 +/- 0.7 vs 3.2 +/- 0.3 days, P < 0.0005). In Group II patients there were significant correlations between patient age and postoperative death, as well as between preoperative LOS and SICU LOS > 1 day. Patient age > or = 80 years and preoperative LOS > 3 days are significant preoperative correlates of the need for SICU care following infra-inguinal arterial surgery in patients who do not have an absolute indication for such care.

When is ICU care warranted after carotid endarterectomy? A three-year retrospective analysis.

The purpose was to determine the valid indications for Surgical Intensive Care Unit (SICU) admission after carotid endarterectomy (CEA). The indications for admission to the SICU after CEA were studied over a 3-year period (4/89-3/92). Absolute indications for ICU admission (AIA) included mechanical ventilation, a pulmonary artery catheter, and intravenous vasoactive or antiarrhythmic drug infusion. Patients were grouped according to presence of an AIA (Group A), absence of an AIA and a one day SICU length of stay (Group B), or absence of an AIA and a SICU length of stay > 1 day (Group C). A total of 305 patients were admitted to the SICU during the study. There were 55 patients in Group A. Of the 250 patients without an AIA, 239 were in Group B and 11 comprised Group C. Group A patients had a significantly higher severity of illness compared with Groups B and C (P < 0.05). Group B patients demonstrated no need for SICU care. Group C patients received ongoing SICU care due to postoperative neurological changes, arrhythmias, angina, incisional bleeding, vocal cord paresis, and unavailability of a ward room. None of these conditions was life-threatening, and only vocal cord paresis would have required SICU admission. Two patients in Group A died; no patients died in Group B or C. Only patients with an AIA, perioperative neurological changes, or early hemodynamic instability require SICU admission after CEA. An observation period in the recovery room allows for selection of nearly all patients who will eventually require SICU care.

Outcomes from abdominal aortic aneurysm resection: does surgical intensive care unit length of stay make a difference?

Recent studies indicate that surgical intensive care unit (SICU) length of stay (LOS) may be shortened without significantly compromising patient care. We tested the validity of that claim in patients following abdominal aortic aneurysm (AAA) resection, a group that traditionally mandated SICU care, to determine whether recent changes in care have affected outcomes. Severity of illness, utilization of SICU-specific resources, lengths of stay, and outcomes were measured in 295 consecutive AAA patients admitted to the SICU postoperatively over a 6-year period (1988-1994). Patient age ranged from 32 to 97 years (mean, 73.1 +/- 0.5) with 82 per cent males and 18 per cent females. There were 266 elective AAAs and 29 ruptured AAAs. Overall mortality was 5.8 per cent, including a 3.4 per cent mortality in elective AAA patients and 27.6 per cent mortality in the ruptured group. Patients with ruptured AAAs were 4.5 years older than were elective AAA patients, had higher severity of illness scores, and had longer SICU and hospital LOS. In the elective group, SICU LOS declined from 3.3 +/- 0.4 to 1.7 +/- 0.3 days over the study period, without a concomitant change in admission severity of illness, hospital LOS, or mortality. Severity of illness at the time of transfer from the SICU to floor care rose over 21 per cent during the study period. Over a 6-year period, SICU LOS was reduced by nearly 50 per cent in patients receiving elective AAA resections without affecting outcome, as measured by hospital LOS or mortality. Decreasing the SICU LOS was effected by transferring patients to floor care with a higher severity of illness. This change saved approximately $175,000 per year in SICU costs.

The influence of diabetes mellitus on the risk of abdominal aortic surgery.

Risk factors and postoperative complications of 153 diabetics (DM) who underwent an abdominal aortic operation for occlusive disease or an intact aneurysm from 1964 through June, 1988 were compared with 970 nondiabetics (nonDM) who underwent similar operations during the same time period. Heart disease, hypertension, cerebrovascular disease, and renal insufficiency were more prevalent in diabetics. Postoperatively, DM had a statistically significant increase in the incidence of myocardial infarction (DM 5.2%, nonDM 2.1%, P = .0434) and wound infection (DM 2.6%, nonDM 0.6%, P = .0359). The incidence of renal failure (DM 1.3%, nonDM 1.0%), stroke (DM 2.0%, nonDM 0.6%), and death (DM 3.9%, nonDM 2.9%) was higher in diabetics, but the differences were not statistically significant (P = NS). Operative mortality was greater for patients operated on for aneurysm (DM 5.3%, nonDM 3.2%) than for patients operated for occlusive disease (DM 3.3% versus nonDM 2.7%). Diabetics treated with insulin or oral agents had a higher complication rate than diabetics treated with diet alone or nondiabetics (insulin 13.0%, oral 13.4%, diet 4.2%, nonDM 8.6%). This study finds that diabetic patients can undergo an abdominal aortic operation with operative mortality comparable to that of nondiabetics. Diabetics have more postoperative complications than nondiabetics, but only myocardial infarction and wound infection are of statistical significance. Diabetics treated with insulin or oral agents have more complications than do diabetics treated by diet alone or nondiabetics.

[The present situation of antibacterial resistance (author's transl)]. / Die gegenwärtige Resistenzsituation.

The various types of bacterial resistance (natural species resistance, chromosomal and plasmidic resistance) and their mechanisms are described. Thereafter, a survey on the resistance is given using investigations from different sources. The distribution of resistant strains dependent on the geographical location and the situation of the patients (ambulatory--hospitalized) is described, and the development of resistant strains in dependance of time is analyzed. Finally, the phenomena of resistance against aminoglycoside and beta-lactam antibiotics are explained in more detail.

[Special problems in the chemotherapy of bacterial infections in otolaryngology (author's transl)]. / Spezielle Probleme der Chemotherapie bakterieller Infektionen in der HNO-Heilkunde.

The different occurrences of pathogens in acute and chronic otitis media, sinusitis, tonsillitis and infections of the respiratory tract are described, with consideration given to the development of gram-negative flora. Therapeutic plans are presented with regard to each of the possible organism patterns. Specific emphasis is given to the aminoglycoside antibiotics which can affect the auditory and vestibular systems.

[Control of malaria--chemotherapy and immunoprophylaxis. 1. Chemotherapy]. / Malariabekämpfung--Chemotherapie und Immunprophylaxe. 1. Mitteilung: Chemotherapie.

A survey on the advances of the fight against malaria is given, and the present world-wide situation of this disease is described including the important role World Health Organization (WHO) is playing in this fight. The chapter on chemotherapy deals with recent progress in this field with special regard to mefloquine and quinghaosu, but other newer compounds are also discussed. The prospects of vaccination against malaria in general are considered, and the results of in vitro and in vivo experiments using antigens from sporozoites, asexual blood stages and gametocytes are reported. Humoral and cellular immunity and their part in the immune response of the infected host are evaluated as well as the progress in the continuous cultivation of the malaria parasites. Finally, the perspectives of the fight against malaria in the years to come are discussed.

Host-parasite interactions with peritoneal macrophages of mice and rats in vitro and in vivo.

This paper deals with the intracellular multiplication of mycobacteria in peritoneal macrophages from mice and rats immunized with tubercle bacilli or pretreated with Triton WR 1339. If unstimulated macrophages were used, almost unrestricted multiplication of mycobacteria was observed in macrophages from both vaccinated and pretreated hosts after infection of the cells in vitro. Only when the infection of the cells was perfored in the peritoneal cavity of vaccinated hosts did the macrophages display a high degree of inhibition. This striking difference in the behavior of macrophages infected in vitro and in vivo is explained by the local inflammation caused by the intraperitoneal infection, which leads to an influx of T-cell mediators. When macrophages from hosts pretreated with Triton WR 1339 were used, inhibition of the multiplication of mycobacteria within cells infected in vitro or in vivo was very slight, though this compound displayed a marked protective effect in the host. Addition of streptomycin to the culture medium caused a strong inhibition of intracellular mycobacteria even in small concentrations; there was no difference between normal and "immune" macrophages. When rats were infected with virulent tubercle bacilli, they were initially fully susceptible to the infection but showed rapid onset of a strong immune response.

[Helminthic infections of the tropics: parasitology and therapy (author's transl)]. / Parasitologie und Therapie tropischer Wurminfektionen.

The significance of tropical heminthiases for the populations of tropical countries is discussed and a survey on the incidence of these parasitic infections is given. The difference between infection and disease is explained, and the properties of an ideal drug for combatting the different diseases are described. After a short comment on the goals of the primary and secondary screening procedures the authors refer to WHO's Special Programme for Research and Training in Tropical Diseases. As to the different forms of filariasis, the most important problem is onchocerciasis due to the high rate of blindness. The existing drugs (suramin DEC) are evaluated, however, there is a need for a safe, macrofilaricidal drug. The chemotherapy of filariasis caused by W. bancrofti and B. malayi and the drugs used is also discussed. Thereafter, a survey on the chemotherapy of schistosomiasis and the drugs at hand and in development is given with special reference to praziquantel. Chemotherapy of opistorchiasis and clonorchiasis is still unsatisfactory. The problems arising from this situation are mentioned. Up to now, we have a similar situation in hydatid disease, caused by Echinococcus species. The therapy of choice is operation, however, in animal experiments it could be demonstrated that benzimidazole derivatives inhibit the growth of cysts what indicates the possibility of chemotherapy in man also. Finally, a survey is given on anthelminthic drugs for the therapy of different forms of intestinal helminthiasis with special regard to ancylostomiasis.