Correlation of Radiographic Mental Foramen Position and Occulusion in Three Different Indian Populations.

BACKGROUND: The knowledge of the position of the mental foramen (MF) is important for administering local anaesthesia for diagnostic, surgical or operative procedures. AIMS: To determine the shape, position, symmetry of MF and its continuity with the inferior dental canal (IDC) on a digital panoramic view and to find its correlation with Angle's molar relations in three Indian subpopulations. The study also determines the correlation of inter-foramen distance in both genders of three Indian subpopulations. SUBJECTS AND METHODS: One hundred and twenty digital panoramic radiographs were evaluated from three Indian subpopulations (Punjab, Rajasthan and Northeast [NE]). The assessment of occlusion was based on Angle's molar relationships. The data obtained were statistically analysed. RESULTS: The commonest position of the MF in the Rajasthan and NE populations was position 4 bilaterally, while in the Punjab population, it was position 3 on the right and position 4 on the left side. The majority of the MF was round in shape followed by oval. The mean distance between two MF was highest among the Punjab male population and least among the NE female population. The most frequent pattern of MF continuity with IDC was diffuse in Rajasthan population, separated in NE and continuous in Punjab. Correlation between Angle's molar relation with MF position was significant for Classes I and II but not for Class III. Correlation of inter-foramen distance between genders was highly significant in the NE and Punjab populations. CONCLUSION: The commonest MF position was aligned with the 1st premolar and between the 1st and 2nd premolar.

Trainee as trainer in paediatric laparoscopic appendicectomy.

BACKGROUND: Intraoperative teaching is an essential surgical skill, but there is little literature regarding trainees acting as trainers; we characterised these cases in paediatric laparoscopic appendicectomy. METHODS: This is a retrospective review of casenotes over two years (2015-2017) in a single tertiary paediatric surgical centre in the UK. Operating were: paediatric surgery Core Trainees (CT) (postgraduate year (PGY)3-4), Junior Registrars (JR) (PGY5-6) and Senior Registrars (SR) (PGY7+); collectively described as trainees. RESULTS: A total of 53 (20.7%) of 256 appendicectomies were trainee as trainer (TT) cases; 22 cases (41.5%) were performed by a CT supervised by a Registrar, and 31 (58.4%) by a JR supervised by a SR. Among the cases, 17 (32.1%) were complex, 47 (88.7%) were in working hours (8am-5pm), and 50 (94.3%) took place Monday to Friday. Median (interquartile range) duration of surgery was 65 (52-77) minutes. In the first year, 60 (47%) appendicectomies were performed by JRs. JR 1 was TT in three cases (8.8%) and JR 2 in five cases (19.2%); in all cases, the learner was a CT. Overall, there were 26 (10.6%) negative appendicectomies, 8 (3%) conversions, 19 (7%) readmissions within 30 days of discharge and 3 (1.1%) required reoperation; there was no statistically significant difference in complications between TT and non-TT cases. CONCLUSION: Laparoscopic appendicectomy is an excellent model for trainees to act as trainer; case selection included simple cases during daylight hours. Our outcomes are comparable with published literature, suggesting that this teaching method is safe for patients.

Systematic analysis of the interactions driving small molecule-RNA recognition.

RNA molecules are becoming an important target class in drug discovery. However, the principles for designing RNA-binding small molecules are yet to be fully uncovered. In this study, we examined the Protein Data Bank (PDB) to highlight privileged interactions underlying small molecule-RNA recognition. By comparing this analysis with previously determined small molecule-protein interactions, we find that RNA recognition is driven mostly by stacking and hydrogen bonding interactions, while protein recognition is instead driven by hydrophobic effects. Furthermore, we analyze patterns of interactions to highlight potential strategies to tune RNA recognition, such as stacking and cation-π interactions that favor purine and guanine recognition, and note an unexpected paucity of backbone interactions, even for cationic ligands. Collectively, this work provides further understanding of RNA-small molecule interactions that may inform the design of small molecules targeting RNA.

Changing clinical practice. Prospective study of the impact of continuing medical education and quality assurance programs on use of prophylaxis for venous thromboembolism.

OBJECTIVE: To determine the effect of continuing medical education (CME) with and without a quality assurance component (CME+QA) on physician practices in the prevention of venous thromboembolism. METHODS: A communitywide study was performed in 15 short-stay hospitals in central Massachusetts. The study population included 3158 patients in acute-care hospitals with multiple risk factors for venous thromboembolism. Study hospitals were randomly assigned to one of two educational strategies or to a control group that received no intervention. RESULTS: The proportion of patients at high risk for venous thromboembolism who received effective methods of prophylaxis increased significantly from 29% in 1986 to 52% in 1989 (P < .001). This increase was seen in all study groups: control hospitals, 40% to 51% (P < .001); CME hospitals, 21% to 49% (P < .0001); and CME+QA hospitals, 27% to 55% (P < .0001). The increase in prophylaxis use from 1986 to 1989 was significantly greater among patients cared for in hospitals whose physicians participated in a formal CME program (an increase of 28%) than in control hospitals (an increase of 11%) (P < .001). There was no significant difference in the use of prophylaxis in hospitals whose physicians received CME+QA interventions compared with hospitals whose physicians received CME interventions alone (identical increases of 28%). CONCLUSION: A formal CME program significantly increased the frequency with which physicians prescribed prophylaxis for venous thromboembolism. We believe the key factor in our CME interventions that motivated clinicians to change their practices was the provision of hospital-specific data demonstrating a compelling need for improvement. Despite the substantial investment by hospitals in QA, traditional QA intervention appeared to provide no additional benefit. Even after extensive CME/QA interventions, prophylaxis for venous thromboembolism remained underutilized, suggesting the need to develop new approaches to changing clinical practice.

A population-based perspective of the hospital incidence and case-fatality rates of deep vein thrombosis and pulmonary embolism. The Worcester DVT Study.

A community-wide study was conducted in 16 short-stay hospitals in metropolitan Worcester, Mass, to examine the incidence and case-fatality rates of deep vein thrombosis and pulmonary embolism in patients hospitalized between July 1, 1985, and December 31, 1986. The average annual incidence of deep vein thrombosis alone was 48 per 100,000, while the incidence of pulmonary embolism with or without deep vein thrombosis was 23 per 100,000. The incidence rates of deep vein thrombosis and pulmonary embolism increased exponentially with age. The in-hospital case-fatality rate of venous thromboembolism was 12%. Among patients discharged from the hospital, the long-term case-fatality rates were 19%, 25%, and 30% at 1, 2, and 3 years after hospital discharge. Extrapolation of the data from this population-based study suggests that there are approximately 170,000 new cases of clinically recognized venous thromboembolism in patients treated in short-stay hospitals in the United States each year, and 99,000 hospitalizations for recurrent disease. Because of the silent nature of this disease and the low rate of autopsy in the United States, the total incidence, prevalence, and mortality rates of venous thromboembolism remain elusive.

Tumor necrosis factor-alpha decreases thyrotropin-induced 5'-deiodinase activity in FRTL-5 thyroid cells.

Tumor necrosis factor-alpha (TNF-alpha) exerts various effects on many cell types. Acute administration of TNF-alpha to rats decrease hepatic 5'-deiodinase activity (5'D-I) and TNF-alpha has been implicated in the pathogenesis of the low triiodothyronine syndrome in non-thyroidal illness in humans. The thyroid, liver and kidney are rich in 5'D-I. Unlike hepatic and renal 5'D-I, thyroid 5'D-I is regulated by thyrotropin. We have investigated the effects of TNF-alpha on 5'D-I in FRTL-5 cells, a cultured rat thyroid follicular cell line. Tumor necrosis factor-alpha did not significantly affect basal 5'D-I but thyrotropin markedly increased 5'D-I (p < 0.001). This TSH-induced increase in 5'D-I was attenuated by TNF-alpha in a dose-dependent manner (p < 0.001). Enzyme kinetic analysis demonstrated that thyrotropin increased 5'D-I by increasing Vmax (p < 0.01) without significantly affecting Km. Likewise, TNF-alpha decreased the thyrotropin-induced 5'D-I by decreasing Vmax (p < 0.05) but not Km. The effect of TNF-alpha on thyrotropin-induced 5'D-I in FRTL-5 cells is probably mediated through post-thyrotropin-induced generation of cyclic adenosine monophosphate (cAMP) because TNF-alpha inhibited both dibutyryl cAMP (p < 0.001) and forskolin (p < 0.001)-induced increases in 5'D-I without affecting cAMP generation stimulated by thyrotropin. In conclusion, we have demonstrated that TNF-alpha inhibits thyrotropin-induced 5'D-I activity in FRTL-5 cells by pathways distal to the generation of cAMP and that TNF-alpha may play a role in the modulation of the production of triiodothyronine by the thyroid gland. (ABSTRACT TRUNCATED AT 250 WORDS)

The role of cell cycle regulatory proteins, cyclin D1, cyclin E, and p27 in thyroid carcinogenesis.

The cell cycle is controlled in part by cyclin-dependent kinases (CDKs), which are activated by forming complexes with cyclins. CDKs phosphorylate certain substrates to facilitate the proliferating cells through the cell cycle. CDK inhibitors (CDKIs) such as p27 inhibit cyclin-CDK complexes and function as a negative cell cycle regulator. The overexpression of the positive regulators (cyclins) or the underexpression of the negative regulators including p27 has been seen in a variety of neoplasms, but their role and interaction in thyroid carcinogenesis is yet to be established. We studied the expression of cyclins D1 and E, and the CDKI, p27 by immunohistochemistry in 116 cases, including 59 cases of follicular variant of papillary carcinoma (FVPC) and 57 cases of follicular adenoma (FA). The positive staining was divided into four grades: 1+ if less than 10%, 2+ if 11% to 25%, 3+ if 26% to 50%, and 4+ if greater than 50% of the nuclei of tumor cells stained positively. Cyclin D1 expression was seen in 37 (63%) FVPC and 34 (60%) FA. Cyclin E-positive cells were seen in 51 (86%) FVPC and 47 (82%) FA. No significant differences in the grade of cyclins D1 (P = .261) and E (P = .284) staining was seen between FVPC and FA. Of the 59 FVPC, 53 (89%) showed p27-positive cells; of these, 33 were 1+, nine were 2+, seven were 3+ and only four were 4+ positive. Conversely, all 57 FA were p27 positive, 53 were 4+, and four were 3+ positive. This difference in the grade of p27 staining between FVPC and FA was statistically significant (P < .001). This study shows a significant underexpression of p27 in FVPC compared with FA, suggesting that a decrease in p27 expression plays a more important role than overexpression of cyclins D1 and E alone in thyroid carcinogenesis and that p27 immunostaining may be helpful in the diagnosis of FVPC.

CD57 (Leu-7) expression is helpful in diagnosis of the follicular variant of papillary thyroid carcinoma.

CD57 (HNK-1) is a oligosaccharide antigen that is expressed by cells of several lineages. It is present on multipotential neuroepithelial cells during embryogenesis, and tumours of epithelial, neuroectodermal and nerve sheath origin also express CD57. Its role in the diagnosis of thyroid tumours is controversial. We have studied CD57 expression by immunohistochemistry to determine its utility in the classification of thyroid follicular lesions. Study material included 114 normal thyroid sections, 77 benign thyroid lesions (29 colloid nodules, 22 follicular adenomas, 20 cases of Hashimoto's thyroiditis and 6 of Grave's disease) and 83 thyroid carcinomas, including 31 follicular variants of papillary carcinoma. We observed CD57 positivity in 95% of thyroid carcinomas, 27% of follicular adenomas and 10% of colloid nodules. It was not expressed in the normal thyroid. CD57 expression in thyroid carcinomas was significantly different from that in normal and benign thyroid lesions (P < 0.0001). The follicular variant of papillary thyroid carcinoma also showed significantly higher CD57 expression than colloid nodules (P < 0.0009) or follicular adenomas (P < 0.0009). No significant difference was seen between colloid nodules and follicular adenomas. We conclude that CD57 immunohistochemistry is valuable in the classification of thyroid follicular lesions into benign and malignant groups and is also helpful in the diagnosis of the follicular variant of papillary thyroid carcinoma.

Effect of tumor necrosis factor on growth and function in FRTL5 cells.

Tumor necrosis factor (TNF) is a cytokine produced by inflammatory macrophages and monocytes. FRTL5 cells are a continuous line of functional, nontransformed rat thyroid cells that depend on thyroid-stimulating hormone (TSH) for sustained growth. The following experiments characterize the effects of TNF on growth and differentiated functions in FRTL5 cells. Cells were incubated with different concentrations of TNF (1 to 100 ng/ml), alone or with TSH. FRTL5 cell proliferation was assessed by 3H-thymidine incorporation assays. Differentiated functions were studied by measuring radioactive iodine uptake (RAI) and triiodothyronine (T3) production. TNF inhibited FRTL5 cell growth both in basal conditions and after cells had been exposed to TSH. TNF caused small inhibition of both basal RAI uptake and T3 release but greatly decreased TSH-stimulated RAI uptake and T3 secretion. In summary, TNF appears to affect both growth and differentiated functions in the FRTL5 cell line. Although it is difficult to extrapolate these in vitro results to the human disease state, we postulate that TNF production in septic states may contribute to the pathogenesis of the low T3 syndrome; moreover, locally produced TNF may modulate thyroid function in autoimmune thyroid diseases.

Surgery still has a role in Graves' hyperthyroidism.

BACKGROUND: A recent survey of American thyroidologists defining their management of a 43-year-old woman with hyperthyroid Graves' disease and a thyroid weighing 40 to 50 grams revealed that 69% recommended iodine 131 therapy, 30% prolonged antithyroid drug therapy, and only 1% operation. If the patient was younger or had a larger thyroid, 4% to 7% of the respondents recommended operation. METHODS: In our clinic we often recommend operation for young adult patients with large goiters who have had recurrent hyperthyroidism after antithyroid drug (ATD) therapy, have allergic reactions to ATD, are not compliant, are ATD failures, or refuse 131I therapy. Thus operation for Graves' disease is recommended more frequently in our clinic than this survey indicates. From 1980 to 1992, 81 patients with Graves' disease (15 men and 66 women; mean age, 30 years) underwent a subtotal thyroidectomy. Patients had been pretreated with antithyroid drugs and saturated solution of potassium iodide, and thyroid conditions were normal at the time of operation. All patients underwent subtotal thyroidectomy by one surgeon and 3 to 5 grams of thyroid were left on each side. RESULTS: There was no permanent recurrent nerve damage or hypoparathyroidism. Hyperthyroidism recurred in one patient (1.2%). Hypothyroidism developed in 59% of our patients, 77% within 1 year after operation, which was easily managed with replacement doses of levothyroxine. Ophthalmopathy had not developed or progressed in any patient, as has recently been suggested to occur after 131I therapy of Graves' disease. CONCLUSIONS: Because our patients are almost always hospitalized for no more than 24 to 36 hours, have had no complications except for hypothyroidism, have had their disease abruptly terminated, did not have ophthalmopathy, required far fewer physician visits and laboratory tests compared with patients treated with ATD or 131I, surgery remains a reasonable approach to the management of Graves' disease.

Suspected deep vein thrombosis. Management by impedance plethysmography.

Controversy exists as to whether patients suspected of having deep vein thrombosis (DVT) can be studied safely without venography, with its attendant expense, inconvenience, and potential risk. We used impedance plethysmography (IPG) in 1,464 consecutive patients suspected of having DVT, with 96% of these patients with normal IPGs, there were no fatal pulmonary emboli (PE). The incidence of nonfatal PE was 1%. In 284 outpatients suspected of having DVT, but discharged without treatment because of normal IPGs, only one patient returned with subsequent symptoms of DVT (0.4%). Noninvasive testing with IPG is a safe and highly cost-effective alternative to venography for routine management of patients suspected of DVT.

Expression of eukaryotic translation initiation factors 4E and 2alpha correlates with the progression of thyroid carcinoma.

Cell growth and proliferation depend on protein synthesis that is regulated, in part, by two eukaryotic translation initiation factors, eIF-4E and eIF-2alpha. These factors are transiently increased as normal cells respond to growth factors and are constitutively elevated in transformed cells. In cultured cells, eIF-4E facilitates cell cycle progression by increasing the expression of cell cycle promoting proteins including cyclin D1. Our previous study revealed elevated cyclin D1 expression in histologically more aggressive thyroid carcinomas as compared to conventional papillary carcinoma. We hypothesized that the increased cyclin D1 expression might correlate with increased eIF-4E expression. We, therefore studied the expression of eIF-4E by immunohistochemistry in 25 cases of conventional papillary carcinoma (CPC) and 28 cases of aggressive thyroid carcinomas (ATC), the latter included 11 tall cell/columnar cell variant of papillary carcinoma, 5 insular carcinomas, and 12 anaplastic carcinomas. We also analyzed the expression of eIF-2a in the same samples as this factor is usually regulated similarly to eIF-4E in cell culture models. Of the 25 CPC, 13 were eIF-4E positive (11 weakly and 2 strongly), and 19 were eIF-2a positive (14 weakly and 5 strongly). Conversely, of the 28 ATC, 25 were eIF-4E positive (4 weakly and 21 strongly), and 23 were eIF-2alpha positive (4 weakly and 19 strongly). There was a significantly increased expression of both eIF-4E (p < 0.001) and eIF-2alpha (p < 0.001) in ATC compared to CPC, suggesting that these translation initiation factors may play a role in the progression of thyroid cancer.

Surgical management of the patient with papillary cancer.

Papillary cancer is the most common thyroid cancer occurring in all age groups and is usually an indolent tumor, and patients have an excellent prognosis. The majority of patients with papillary cancer do well. It is for the small number of patients who do poorly that it is critical to carry out the appropriate initial operation. The recognized primary treatment of papillary cancer is surgical excision, and the controversy regarding lobectomy versus total thyroidectomy continues. We favor total thyroidectomy because it eradicates multicentric disease, facilitates postoperative radioactive iodine ablation, and allows thyroglobulin levels to be used as a tumor marker for follow-up. Total thyroidectomy should be done by an experienced surgeon to decrease morbidity. Otherwise a total lobectomy on the side of the nodule with subtotal removal on the opposite side is preferred to avoid serious postoperative complications.

Frequency and Distribution of DNA fragmentation in Hashimoto's thyroiditis and development of papillary thyroid carcinoma.

Downregulation of apoptosis and high expression of bcl-2 play an important role in the development of follicular lymphoma. However, little is known about apoptosis in thyroid disease, particularly with respect to the development of papillary carcinoma from Hashimoto's thyroiditis. To study the early stages of cell death in various types of thyroid disease, surgical specimens from 31 patients including Hashimoto's thyroiditis (HT,n=7), papillary carcinoma (PC,n=12), Hashimoto's thyroiditis with papillary carcinoma (HTPC,n=5), and Graves' disease (GD,n=7) were examined by anin situ nucleotidyl transferase assay (ISNTA), which detects DNA fragmentation. Control normal thyroid tissue (NT,n=7) was obtained from surgically resected papillary thyroid carcinomas sampled away from the primary tumor. An immunohistochemical (IHC) method was used to detect bcl-2 expression. Positive ISNTA nuclei in thyroid follicular cells or tumor cells per section were counted in all parenchymal areas, excluding areas of lymphocyte aggregates. The intensity of bcl-2 staining was graded on a scale of 1+ to 3+. The number of ISNTA-positive thyroid follicular cells was a significantly higher in HT compared to GD. In addition, there was significantly lower number of ISNTA positive non-neoplastic thyroid follicular cells in HTPC compared to HT alone. Strong expression of bcl-2 was found in all cases of GD and NT, but much less bcl-2 staining was seen in HT. There was moderate expression of bcl-2 in HTPC and PC. These findings suggest that (1) DNA fragmentation of the thyroid follicular cells plays an important role in the thyroid injury in HT but not in GD, (2) expression of bcl-2 may overcome the apoptosis in GD but not in HT, and (3) downregulation of DNA fragmentation of the follicular cells in Hashimoto's thyroiditis associated with papillary carcinoma may suggest an important mechanism for tumor pathogenesis.

beta-Catenin expression in thyroid follicular lesions: potential role in nuclear envelope changes in papillary carcinomas.

The morphologic distinction of benign and malignant thyroid follicular lesions can sometimes be challenging, therefore an immunohistochemical marker to aid in this distinction would be useful. beta-Catenin is one such potential marker. It is part of a membrane-bound cell growth-signaling complex that plays a role in cell adhesion, as well as in promotion of growth through activation of the Wnt signaling pathway. Oncogenic signaling occurs when beta-catenin is released, accumulates in the cytoplasm, translocates into the nucleus, and promotes transcription of genes including bcl-1 (cyclin D1) and c-myc that induce cell proliferation. Paraffin blocks from 133 thyroidectomy specimens were stained with monoclonal antibodies reactive with beta-catenin and cyclin D1. These included 53 cases of papillary thyroid carcinoma (PTC), 46 cases of follicular variant of papillary carcinoma (FVPC), 10 cases of follicular carcinoma (FC), and 24 cases of follicular adenoma (FA). Tissue from six normal thyroid specimens served as a control. The malignant lesions (PTC, FC, and FVPC) expressed strong cytoplasmic/nuclear staining and minimal residual membranous staining in 87%, 80%, and 71% of cases, respectively. In contrast, all normal thyroid tissue and 79% of FAs showed strong membranous reactivity with very minimal cytoplasmic staining. Interestingly, in 83% of PTC cases and 20% FVPCs, the intranuclear inclusions were distinctly beta-catenin positive. Cyclin D1 over expression correlated with cytoplasmic relocalization of beta-catenin in almost all cases, and no evidence of cyclin D1 gene amplification was observed. beta-Catenin can be of a diagnostic utility for thyroid lesions, because it highlights intranuclear inclusions in PTC, and shifts from a membranous localization to a cytoplasmic localization in malignant lesions. We speculate that the localization of beta-catenin in intranuclear inclusions may reflect a cytoskeletal remodeling activity of beta-catenin that is functionally significant for the PTC pathway.

Follicular variant of papillary thyroid carcinoma: a comparative study of histopathologic features and cytology results in 141 patients.

OBJECTIVE: To characterize the histopathologic features of follicular variant of papillary thyroid carcinoma (FVPC) and its cytology results on fine-needle aspiration (FNA) biopsy and compare them with those of papillary thyroid carcinoma (PC). METHODS: We searched the University of Massachusetts Medical Center pathology database for all surgical specimens associated with a diagnosis of FVPC or PC between January 1992 and February 1998 and reviewed the related pathology reports. In addition, the associated preoperative FNA results were analyzed. RESULTS: On initial assessment, FVPC was associated with a significantly lower incidence of cervical lymph node metastatic involvement in comparison with PC (5.6% versus 35.7%; P<0.001). Even though the mean size of FVPC was larger than that of PC (2.57 cm versus 1.75 cm; P<0.05), FVPC showed a lower incidence of thyroid capsule invasion (5.6% versus 11.4%), infiltrative resection margins (2.8% versus 20.0%; P = 0.01), local soft tissue invasion (7.0% versus 25.7%; P<0.005), and multicentricity (25.4% versus 47.1%; P<0.01). Lymphocytic thyroiditis was a common feature of both FVPC (36.6%) and PC (35.7%). FNA biopsy revealed the presence of malignant cells in 9.8% of patients with FVPC in comparison with 67.5% of patients with PC. Most cytology specimens of FVPC (58.8%) were interpreted as suspicious for a malignant lesion or as a follicular neoplasm. CONCLUSION: FVPC is associated with a significantly lower incidence of cervical lymph node metastatic lesions and invasive histologic features than is PC. Long-term prospective clinical studies are needed to determine whether these findings translate into a more benign natural history for this variant of PC. Results of FNA biopsy in FVPC are more commonly interpreted as suspicious rather than malignant; this factor has major implications for preoperative planning.

Colostomy for anorectal anomalies: high incidence of complications.

PURPOSE: The aim of this study was to characterize the type and incidence of complications related to colostomy formation in newborn infants with anorectal anomalies. METHODS: The authors reviewed a 5-year (1994 to 1999) experience of a single institution in the management of neonates with high and intermediate anorectal anomalies who required colostomy at birth. Patients with colostomy still in place have been excluded from the study to maximize the chances of detecting colostomy-related complications. RESULTS: There were 80 neonates with anorectal malformations, of whom, 49 (31 boys and 18 girls) were included in the study. The site of colostomy was sigmoid colon (n = 32), transverse colon (n = 7), and descending colon (n = 10). Thirty-nine colostomies were loop, and the remaining 7 were divided. The median birth weight was 2.96 kg (range, 1.46 to 3.88). The age at colostomy formation was 2 days (range, 1 to 210). Mechanical complications related to colostomy formation were observed in 16 infants (32%) with 3 infants having more than 1 mechanical complication. These included prolapse in 8 (50%), intestinal obstruction (adhesions, intussusception, and volvulus) in 7 (44%), and skin dehiscence in 3 (19%). One neonate had necrotizing enterocolitis (NEC) after colostomy formation. Urinary tract infection was observed after colostomy in 14 infants (29%). The incidence of urinary tract infection was not higher in infants who had loop colostomy (11 of 39, 28%) compared with infants who had divided colostomy (3 of 10, 30%). There were no differences in the incidence of colostomy-related complications and urinary tract infection between male and female infants. There were no deaths in this series. CONCLUSIONS: Formation of colostomy for anorectal anomalies should not be considered a minor procedure. In our experience the incidence of complications after colostomy formation is high. The incidence of urinary tract infections does not seem to be affected by the type of colostomy performed.

Noninvasive detection of axillary and subclavian venous thrombosis by impedance plethysmography.

Venous occlusion impedance plethysmography (IPG) is an objective noninvasive test which is widely employed for the detection of deep venous thrombosis (DVT) in the lower extremities. The IPG technique is easily adapted to the evaluation of upper extremity venous thrombosis, as demonstrated in 46 patients with symptoms of axillary and subclavian venous thrombosis (88 limbs) and 26 normal volunteers (52 limbs). Venograms were obtained in 18 patients (22 limbs) and correlated in all cases with the previous IPG interpretation. The test procedure and interpretation criteria for the noninvasive detection of upper extremity deep venous thrombosis are similar to those previously developed for the lower extremities, but with more emphasis on comparison with the contralateral limb. Vascular laboratories performing IPG for lower extremity DVT should be able to employ this test for the detection of upper extremity venous thrombosis as well.

A simplified method for evaluating peripheral arterial occlusive disease in a clinical vascular laboratory.

A relatively simple, inexpensive, and accurate procedure for the vascular laboratory evaluation of patients with suspected peripheral arterial occlusive disease is described. This method was evaluated in a series of 110 limbs in 58 patients seen in the Vascular Laboratory at the Worcester City Hospital. All patients were evaluated clinically and angiographically as well, to provide additional standards for evaluation. The method described was 100% accurate in predicting the presence or absence of significant occlusive disease, and over 90% accurate in defining the location of the major occlusive process. The method utilizes a combination of two well-established measurements--ankle systolic pressure and ankle pulse wave amplitude--as a screening method for determining the presence or absence of significant occlusive disease. Only patients with abnormal findings are tested further, resulting in a considerable savings in time and expense in the clinical vascular laboratory. The method may also prove valuable for following patients with known vascular disease for evidence of progression and for evaluating the effectiveness of various reconstructive procedures. Other methods and instruments may be adapted utilizing the same general principles.