First Report of Target Spot Caused by Corynespora cassiicola on Cotton in Georgia.

In 2005, crop consultants in southwestern Georgia reported an unusual occurrence of leaf spot in cotton (Gossypium hirsutum L.). Initial symptoms first developed as brick red dots that led to the formation of irregular to circular lesions with tan-to-light brown centers. Lesions further enlarged and often demonstrated a targetlike appearance formed from concentric rings within the spot. Observations included estimates of premature defoliation up to 70%, abundant characteristic spots on the leaves and bracts, and losses of several hundred kg of lint/ha. When symptomatic leaves were submitted to the University of Georgia Tifton Plant Disease Clinic in Tifton, GA, for identification in 2008, the causal agent was tentatively diagnosed as Corynespora cassiicola (Berk. & M.A. Curtis) C.T. Wei on the basis of similar symptoms and signs previously reported on cotton (3). In September 2011, symptomatic leaves were obtained from diseased cotton within a field (var. DP 1048B2RF) near Attapulgus, GA. Symptomatic tissue from diseased leaves was surface disinfested in 0.5% sodium hypochlorite for 1 min and plated on potato dextrose agar (PDA). Ten isolates were incubated at 21.1°C for 2 weeks with a 12/12 h light/dark cycle using fluorescent light located approximately 70 cm above the cultures. After 1 week, two isolates were transferred to quarter strength PDA for enhanced sporulation and were grown under the same conditions. Conidiophores from the isolated fungus were simple, erect, intermittently branching and septate, and gave rise to single, subhyaline conidia. Conidia had 4 to 17 pseudosepta and were 50 to 197 µm long and 7 to 16 µm wide, straight to curved, and obclavate to cylindrical. Pathogenicity tests were conducted by spraying 10 cotton seedlings (DP 555BR and DP 1048B2RF, two to four true leaf stage) until runoff with a blended suspension from a 2-week-old pure culture of the fungus diluted with 100 mL of sterile water. Five plants were sprayed with sterile water as noninoculated controls. Cotton seedlings were then incubated in a moist chamber at 21.1°C for 48 h. Within 1 week, all inoculated plants showed symptoms similar to those of diseased field plants. Symptoms were not observed on noninoculated control plants. The fungus was reisolated five times from symptomatic leaves and grown in pure culture. Conidia and conidiophores were identical to the morphology of the original isolates, and were similar to descriptions of C. cassiicola (2). To confirm the identity of the pathogen, DNA was extracted from a week-old culture and amplified with specific primers for loci "ga4" and "rDNA ITS" (1). DNA sequences obtained with the Applied Biosystems 3730xl 96-capillary DNA Analyzer showed 99% identity to C. cassiicola from BLAST analysis in GenBank. The resulting sequence was deposited into GenBank (Accession No. JQ717069). To our knowledge, this is the first report of this pathogen in Georgia. Given the increasing prevalence of this disease in southwestern Georgia, its confirmation is a significant step toward management recommendations for growers. Because foliar diseases caused by C. cassiicola are commonly referred to as "target spot" in other crops (e.g., soybeans), it is proposed that Corynespora leaf spot of cotton be known as "target spot of cotton." References: (1) L. J. Dixon et al. Phytopathology 99:1015, 2009. (2) M. B. Ellis and P. Holliday. CMI Description of Pathogenic Fungi and Bacteria, 303, 1971. (3) J. P. Jones. Phytopathology 51:305, 1961.

Comparative survival after permanent ventricular and dual chamber pacing for patients with chronic high degree atrioventricular block with and without preexistent congestive heart failure.

To determine whether survival after permanent ventricular demand (VVI) pacing differs from survival after permanent dual chamber (DVI or DDD) pacing in patients with chronic high degree atrioventricular (AV) block (Mobitz type II or trifascicular block), 132 patients who received a VVI pacemaker (Group 1) and 48 patients who received a DVI or DDD pacemaker (Group 2) were followed up for 1 to 5 years. There was no significant difference in sex distribution, mean age or incidence of coronary heart disease, hypertension, valvular heart disease, diabetes mellitus, stroke or renal failure between Groups 1 and 2. Overall, the predicted cumulative survival rate at 1, 3 and 5 years was 89, 76 and 73%, respectively, for Group 1 and 95, 82 and 70%, respectively, for Group 2. In patients with preexistent congestive heart failure, the predicted cumulative survival rate at 1, 3 and 5 years was 85, 66 and 47%, respectively, for Group 1 (n = 53) and 94, 81 and 69%, respectively, for Group 2 (n = 20). The 5 year predicted cumulative survival rate was significantly lower in Group 1 patients with preexistent congestive heart failure than in Group 2 patients with the same condition (p less than 0.02). There was no significant difference in 5 year cumulative survival rate between Groups 1 and 2 for patients without preexistent congestive heart failure. The results suggest that permanent dual chamber pacing enhances survival to a greater extent than does permanent ventricular demand pacing in patients with high degree AV block and preexistent congestive heart failure.

Organ preservation solutions in heart transplantation--patterns of usage and related survival.

Despite experimental advantages for certain heart preservation solutions (HPS), their clinical popularity and related survival are uncertain. We surveyed all active UNOS heart transplant centers to determine their HPS. HPS survival benefits were tested using the UNOS heart transplant registry. Centers used from 1 to 3 types of 167 solutions. Of these formulations, 55.1% were commonly cited solutions. The other (custom) mixtures differed from those usually reported. All solutions were classified as intracellular (I, [Na++] < 70 mEq/L) or extracellular (E, [Na++] > or = 70 mEq/L). Significant variations in solution usage were observed among major regions of U.S. transplant activity (Northeast [NE], Southeast [SE], and West [W], P < 0.001). For example, 62.5% of University of Wisconsin (UW) and 49.3% of "Other" usage occurred in the NE; 75% of Roe and 100% of Collins usage occurred in the SE; and 100% of Krebs and 46% of Stanford usage occurred in the W. Logistic regression analyses of 9401 patients who underwent transplantation from 10/87 to 12/92 showed a reduction in the adjusted one month mortality odds ratio for grafts preserved with I rather than E solutions (0.85, P < 0.05). Compared with the most commonly used solution, Plegisol (20.1% of cases), the following adjusted odds ratios for one-month mortality were observed: UW, 1.09 (ns); Stanford, 0.80 (P < 0.10); Roe, 0.36 (P < 0.001); Collins, 0.82 (ns); Krebs, 0.14 (P < 0.01). Using the same one month comparison with Plegisol, 16.8% of grafts that received Custom-I solutions also fared better (0.75, P < 0.05) than the 21.4% that had Custom-E mixtures (0.91, ns). HPS usage varies greatly and there are regional preferences. There may be early survival benefits for certain intracellular HPS--however, further study is warranted to explore such relationships.

Percutaneous balloon aortic valvuloplasty: results in 23 patients.

Percutaneous balloon aortic valvuloplasty (BAV) was performed in 23 consecutive patients with valvular aortic stenosis with no associated cardiac defects. The patients were 2 to 17 years old and were referred from 12 hospitals in 4 states. The balloon was positioned across the aortic valve and inflated to pressures of 80, 100, then 120 psi. Each inflation lasted 5 to 10 seconds. The arterial and venous catheters were connected together outside the groin to avoid excessive increase in left ventricular pressure during total aortic valve occlusion with the inflated balloon. Peak systolic aortic valve pressure gradient and cardiac output were measured before and 15 minutes after BAV. There was no significant change in cardiac output, but all patients had a lessened gradient. The gradient before BAV was 113 +/- 48 mm Hg, decreasing to 32 +/- 15 mm Hg after BAV (p less than 0.01). The left ventricular peak systolic pressure decreased from 221 +/- 54 to 149 +/- 21 mm Hg (p less than 0.01). No aortic regurgitation was noted in 13 patients and very mild aortic regurgitation was noted in 10 patients after BAV. The balloons were 10 to 20 mm in diameter, chosen at least 1 mm smaller than the diameter of the aortic valve anulus. Pressures of 100 to 120 psi were required to achieve full inflation of the balloons. Six patients had repeat cardiac catheterization studies 3 to 9 months after BAV. In none was there a significant change in peak systolic aortic valve pressure gradient or cardiac output compared with the study immediately after valvuloplasty.

Transluminal balloon dilatation for discrete subaortic stenosis.

Ten children, 10 weeks to 18 years old, with discrete subaortic stenosis (DSS) underwent transluminal balloon dilatation of the subaortic obstruction. The DSS was visualized by 2-dimensional echocardiography and cineangiography. Six patients had a thin discrete "membrane" immediately below the aortic valve (group I) and 4 patients had a thicker fibromuscular ring about 1 cm below the aortic valve (group II). In group I, the mean gradient decreased from 82 +/- 49 mm Hg (range 35 to 164) to 22 +/- 15 mm Hg (range 5 to 40); in group II, it decreased from 155 +/- 18 mm Hg (range 132 to 177) to 85 +/- 44 mm Hg (range 60 to 150). Three patients had follow-up cardiac catheterization 1 year later. Their mean gradient soon after the procedure was 37 +/- 23 mm Hg. On follow-up, it was still 37 +/- 19 mm Hg, indicating persistence of relief of the obstruction. Because of the high residual gradient in group II, 3 patients had surgical relief of the obstruction. The degree of aortic regurgitation present before the dilatation in all 10 patients did not change after the procedure. The mechanism of relief of the obstruction was by tearing of the subaortic membrane. Our data suggest that relief of subaortic obstruction is more favorable in the thin, membranous DSS.

Lidocaine-induced reduction in size of experimental myocardial infarction.

In anesthetized open chest dogs, the effects of therapeutic doses of lidocaine on myocardial cell respiration, creatine kinase depletion, left ventricular stroke work and cardiac necrosis were assessed. The dogs were subjected to 40 minutes of occlusion of the left anterior descending coronary artery, followed by 5 hours of reperfusion. Group I (12 dogs) had infusion of saline solution; group II (8 dogs) had infusion of 0.2 mg/kg per min of lidocaine (serum level 16.8 +/- 1.4 microgram/ml); group III (5 dogs) had infusion of 0.04 mg/kg per min or lidocaine (serum level 3.6 micrograms/ml). Ischemic regional myocardial blood flow (measured by 9 micrometer spheres of strontium-85) was 6.34 +/- 1.62 ml/100 mg per min in group I, 1.48 +/- 0.59 in group II (p < 0.05) and 1.32 +/- 0.50 in group III (p < 0.05). Oxygen consumed during conversion of adenosine diphosphate to adenosine triphosphate in mitochondria from control and lidocaine-treated ischemic tissue was depressed (p < 0.05) and correlated (r = 0.63) with creatine kinase depletion. Left ventricular stroke work was not significantly different among the three groups. Infarct size (in percent of left ventricular weight) was 12.6 +/- 2.0 for group I, 4.8 +/- 1.2 for group II (p < 0.01) and 4.8 +/- 2.5 for group III (p < 0.05). The data suggest that the reduction of myocardial infarct size by lidocaine was not dependent on enhanced myocardial blood flow and was independent of left ventricular stroke work.

Adverse effects of permanent cardiac internal defibrillator patches on external defibrillation.

At the time of left ventricular aneurysm resection, antiarrhythmic operations or other open-heart operative procedures in patients with ventricular dysrhythmia, permanent internal defibrillator patches may be inserted. Insertion of the energy source may be delayed due to its unavailability or to a desire for postoperative electrophysiologic study before its insertion. To assess the effects of permanent internal defibrillator patches on external defibrillation, 7 anesthetized calves were studied. Fibrillation-defibrillation studies were performed before and after insertion of permanent internal defibrillator patches (model L67, 27 cm2, Intec Systems), one on each ventricle. The values of percent successful defibrillation obtained before insertion of the patches, although much lower than values that would be expected in humans, are consistent with the results of an extensive earlier study involving this calf model. Similar values obtained after insertion of the patches are appreciably lower than the values obtained before implantation of the patches, and appreciably lower than the results predicted by the earlier study. A significant decrease in the percent of successful defibrillations (p less than 0.001) was observed for a shock intensity of approximately 400 J. Permanent internal cardiac defibrillator patches on the right and left ventricles reduce the probability of achieving successful defibrillation externally with unidirectional shocks. The wisdom of implanting permanent large internal cardiac defibrillator patches without the energy source is questioned.

Protective effect of lidocaine during regional myocardial ischemia: an altered pathophysiologic response assessed by NADH fluorescence.

Studies were undertaken to determine the effects of lidocaine on ischemic myocardium, which was induced by coronary artery constriction in open-chested dogs. A real-time epicardial fluorescent technique to detect in vivo-reduced nicotinamide adenine dinucleotide (NADH) during 60 seconds of ischemia was used. Blood flow of ischemic myocardium was measured by using radioactive microspheres of 9 +/- 1 micrometers (mean +/- SE) and was compared with that of normal myocardium, shown by injection of alpha-zurine blue dye. Lidocaine effectively reduced peak NADH fluorescence by 18.6%, from 93.9 +/- 7.2 to 76.4 +/-4.1 mV (p less than 0.005). Lidocaine delayed the onset of fluorescence (2.2 +/- 0.2 versus 1.3 +/- 0.1 s p less than 0.002) and facilitated the recovery from ischemia (38.4 +/- 2.9 versus 54.8 +/- 2.9 s p less than 0.001). Increase in NADH concentration during ischemia correlated (r=0.76, p less than 0.006) with ischemic fluorescence. These findings were independent of altered hemodynamics or change in myocardial blood flow. Results indicate that lidocaine provides myocardial cellular protection during transient ischemia; there is an altered NADH fluorescent response to coronary artery occlusion.

Operative balloon pulmonary valvuloplasty.

Closed operative pulmonary valvulotomy for relief of critical pulmonary valve stenosis can be performed effectively by intraoperative use of a balloon catheter without inflow occlusion or hemodynamic instability and with minimal blood loss. Follow-up evaluation indicates adequate growth of the valve.

Assessment of percutaneous balloon pulmonary and aortic valvuloplasty.

Percutaneous balloon pulmonary or aortic valvuloplasty was performed in 66 consecutive patients with no deaths. The transvalvular pressure gradient was reduced from 85 +/- 35 to 30 +/- 15 mm Hg (p less than 0.01) in 39 patients with congenital pulmonary valve stenosis and from 108 +/- 46 to 32 +/- 16 mm Hg (p less than 0.01) in 27 patients with congenital aortic valve stenosis. Subsequent mild aortic regurgitation occurred in seven patients and moderate regurgitation occurred in one patient. Operative evaluation of seven patients with pulmonary valve stenosis who had additional cardiac anomalies revealed the mechanisms of valve opening to be commissural splitting, cusp tear, or avulsion of the cusp from the anulus. Operative evaluation of two patients with residual high aortic valve gradients revealed minor degrees of commissural splitting. Although further evaluation is required to determine the long-term effects, early evaluation indicates that percutaneous balloon valvuloplasty may be useful in the definitive treatment of isolated pulmonary valve stenosis in some patients and of palliative value in others. The procedure is considered palliative in patients with aortic valve stenosis.

Experience with the Sarns centrifugal pump in postcardiotomy ventricular failure.

The reported clinical use of the Sarns centrifugal pump (Sarns, Inc./3M, Ann Arbor, Mich.) as a cardiac assist device for postcardiotomy ventricular failure is limited. During a 25-month period ending November 1988, we used 40 Sarns centrifugal pumps as univentricular or biventricular cardiac assist devices in 27 patients who could not be weaned from cardiopulmonary bypass despite maximal pharmacologic and intraaortic balloon support. Eighteen men and nine women with a mean age of 60.4 years (28 to 83) required assistance. Left ventricular assist alone was used in 12 patients, right ventricular assist in 2, and biventricular assist in 13. The duration of assist ranged from 2 to 434 hours (median 45). Centrifugal assist was successful in weaning 100% of the patients. Ten of 27 patients (37%) improved hemodynamically, allowing removal of the device(s), and 5 of 27 (18.5%) survived hospitalization. Survival of patients requiring left ventricular assist only was 33.3% (4/12). Complications were common and included renal failure, hemorrhage, coagulopathy, ventricular arrhythmias, sepsis, cerebrovascular accident, and wound infection. During 3560 centrifugal pump hours, no pump thrombosis was observed. The Sarns centrifugal pump is an effective assist device when used to salvage patients who otherwise cannot be weaned from cardiopulmonary bypass. Statistical analysis of preoperative patient characteristics, operative risk factors, and postoperative complications failed to predict which patients would be weaned from cardiac assist or which would survive.

Beneficial effects of multidose coronary artery washout during elective cardiac arrest and cardiopulmonary bypass: biochemical and hemodynamic evaluation.

Coronary artery washout with buffered saline (pH 7.4) during 60 and 120 minutes of elective cardiac arrest was studied in dogs during moderate hypothermic cardiopulmonary bypass. Compared with results in a group undergoing simple ischemic arrest, significantly greater myocardial adenosine triphosphate concentrations were present at 90 and 120 minutes of cardiac arrest in the coronary artery washout group. After 60 minutes of aortic cross-clamping and 60 minutes of reperfusion, left ventricular function was significantly superior in the coronary artery washout group. Coronary artery washout during the period of aortic cross-clamping preserves dynamic myocardial performance during reperfusion and is an important principle of myocardial protection during elective cardiac arrest.

Experience with four surgical techniques to repair traumatic aortic pseudoaneurysm.

We report our experience with 27 (22 male and 5 female) patients who were from 16 to 82 years of age (median 29 years) who underwent surgical repair for traumatic pseudoaneurysm of the thoracic aorta. The cause of injury in all cases was blunt trauma. Repair was accomplished with partial bypass by means of a roller pump with systemic heparinization in 6 (23%), Gott shunt in 7 (27%), clamp-and-sew technique in 6 (23%), and centrifugal pump without systemic heparinization in 8 (30%). Significant postoperative complications occurred in 12 patients. Paraplegia occurred in 1 patient (clamp and sew), anterior spinal cord syndrome in 1 (clamp and sew), renal failure in 1 (Gott shunt), temporary vocal cord paralysis in 2 (Gott shunt, centrifugal pump), permanent vocal cord paralysis in 1 (roller pump), and coagulopathy in 2 (centrifugal pump, Gott shunt). Hospital mortality occurred in 5 of 27 (19%), (1 clamp and sew, 1 Gott shunt, 1 centrifugal pump, 2 roller pump). Follow-up of survivors (1 week to 20 years, median 2.1 years) revealed no further problems from either aortic graft or primary repair. Although patient numbers are small, evaluation of each of the four surgical techniques leads us to favor repair with shunting with a centrifugal pump without heparin. The potential advantage of left atrial-left femoral artery shunt with centrifugal pump support was evident in operative field exposure, afterload reduction, avoidance of clamp injury, and maintenance of stable distal aortic perfusion without heparin.

Impact of unstable angina on operative mortality with coronary revascularization at varying time intervals after myocardial infarction.

We have performed a retrospective study of patients undergoing coronary artery bypass grafting for postinfarction angina in an effort to determine the influence of recency of myocardial infarction and unstable angina on operative mortality. Time from myocardial infarction to bypass was arbitrarily divided into five intervals. Nine hundred ninety-three patients having isolated coronary bypass for postinfarction angina were analyzed, and a significant trend of increased operative mortality with recency of myocardial infarction was found (p less than 0.001). When patients were operated on during the time interval zero to 24 hours after infarction, the operative mortality rate was 18.6%. In the interval from 1 day to 1 week after infarction, the operative mortality rate was 7.4%; 1 week to 3 weeks, 5.9%; and 3 weeks to 3 months, 2.7%. In patients operated on more than 3 months after infarction, the operative mortality rate was 3.9%. The operative mortality rate in 360 patients with postinfarction stable angina was 0.83% compared with 7.3% in 633 patients with postinfarction unstable angina (p less than 0.001). Of 18 risk factors tested, 12 were found by univariate analysis to be independent predictors of operative mortality, including recency of myocardial infarction and unstable angina. Stepwise logistic regression analysis of independent predictive variables revealed that unstable angina, previous surgical revascularization, preoperative hypotension, nonelective surgery, preoperative cardiac arrest, and female sex were the strongest predictors of mortality; recency of myocardial infarction was not a factor. When acute surgical reperfusion is not the primary treatment strategy for patients with myocardial infarction, operative mortality with coronary bypass is increased with the recency of myocardial infarction. The reason for this increase in operative mortality is a patient selection process in which those with persistent or intermittent myocardial ischemia, as reflected in the clinical syndrome of unstable angina, are selected for operation. Unstable angina is a major determinant of operative mortality after myocardial infarction. In patients with stable angina, operative mortality is not increased by the recency of myocardial infarction.

The effect of muscle-sparing versus standard posterolateral thoracotomy on pulmonary function, muscle strength, and postoperative pain.

Increased interest in alternative approaches to thoracotomy has developed because of the considerable morbidity associated with the standard posterolateral technique. We conducted a prospective, randomized, blinded study of 50 consecutive patients to compare postoperative pain, pulmonary function, shoulder strength, and range of shoulder motion between the standard posterolateral and the muscle sparing thoracotomy techniques. Pulmonary function (forced expiratory volume in 1 second and forced vital capacity), shoulder strength, and range of motion were measured preoperatively and at 1 week and 1 month postoperatively. Pain was quantitated by postoperative narcotic requirements, the visual analogue scale, and the McGill pain questionnaire. Morbidity, mortality, and hospital stay were compared between the standard posterolateral and muscle-sparing techniques. There were no differences in postoperative pulmonary function, shoulder range of motion, extent of lung resection, surgical approach time, mortality, or hospital stay. There was significantly less postoperative pain in the muscle-sparing group. The narcotic requirement was less in the first 24 hours (p = 0.0169), and visual analogue scale scores were significantly lower (p less than 0.05) throughout the first postoperative week. Shoulder girdle strength was decreased at 1 week in the standard incision group whereas the strength was preserved with the muscle-sparing approach. Muscle strength had returned to preoperative levels by 1 month in both groups. Morbidity was identical in the two groups with the exception of postoperative seromas. The prevalence of seroma was 23% in the muscle-sparing group and 0% in the standard incision group (p = 0.0125). We have demonstrated that the muscle-sparing incision may be a reasonable alternative to the standard posterolateral approach.

Load-Insensitive Measurements from an Isolated Perfused Biventricular Working Rat Heart.

To determine whether a rat heart model can provide load-insensitive measurements of cardiac function, a recently developed biventricular perfused preparation was tested. Using 29 Sprague-Dawley rat hearts perfused with modified Krebs-Henseleit buffer, ventricles functioned simultaneously with adjustable independent preload (venous reservoirs) and afterload (compliance chambers). Ultrasonic crystal pairs provided continuous left (LV) and right ventricular (RV) short-axis dimensions. LV and RV pressure-length loops (loop area = work) were generated from paired intraventricular pressure and short-axis dimensions. Load-insensitive measurements were obtained from the slopes (elastance) and x-intercepts (L(0)) of regression lines generated from the end-systolic coordinates of these pressure-length loops over ranges of RV and LV preloads. Measurements were made after 15 min of stable function and after 20 min of warm (37 degrees C) ischemia. During perturbations in LV afterload, there were linear changes in dP/dt, but loop work remained relatively unchanged. RV dP/dt and work varied little with physiologic ranges of afterload. Increased RV afterload had little effect on LV function. Ischemia affected LV function more than RV function using these measurements. Elastance, however, increased after ischemia with diastolic 'creep' (increased L(0)) for both ventricles. Load-insensitive and other sophisticated hemodynamic measurements are possible with this new preparation. Copyright 1997 S. Karger AG, Basel

Heparin-induced thrombocytopenia in patients who undergo open heart surgery.

To determine whether heparin-dependent antiplatelet antibodies (HAAb) have an effect on morbidity and/or mortality rates, we reviewed the cases of 3438 patients who underwent open heart surgery from 1981 to 1989. Forty-six patients (1.3%) had HAAb. The patients were divided into two groups: those patients who were known to have HAAb before surgery (group I) and those patients who were diagnosed with HAAb after surgery (group II). Group I patients (n = 5) were pretreated with platelet-inhibiting drugs before reexposure to heparin during cardiopulmonary bypass and were maintained with strict abstinence from heparin afterward. Their lowest observed platelet counts ranged from 42,000/mm3 to 89,000/mm3 (median, 63,00/mm3). Thromboembolic complications did not occur, and all patients survived. Group II patients (n = 41) who were diagnosed to have HAAb after surgery had not been pretreated with platelet-inhibiting drugs before surgery. Lowest platelet counts ranged from 11,000/mm3 to 128,000/mm3 (median, 42,000/mm3). Bleeding complications occurred in 21 patients (51%), and thromboembolic complications occurred in 13 patients (32%). Hospital mortality in group II patients was 37%. Late recognition of HAAb was associated with an increase in morbidity and mortality rates. Thromboembolic complications of HAAb, which had been diagnosed before surgery, were eliminated, and bleeding was reduced by pretreatment with platelet-inhibiting drugs and strict abstinence from heparin after surgery.

Subclavian-axillary artery aneurysms.

The records of all patients with aneurysm of the subclavian-axillary artery who were seen between January, 1960, and January, 1980, were reviewed. There were 31 patients (21 male and 10 female) with a mean age of 47 years. The aneurysm (mean size, 3.0 cm) was located on the right in 20 patients and on the left in 10; one patient had bilateral aneurysms. Mural thrombus was present in 25 patients. Eight patients were asymptomatic and 23 presented with upper extremity pain. Thromboembolism occurred in five patients, one presenting with impending loss of tissue. Two patients had the aneurysm rupture and one of them died. A pulsating mass was palpable in 20 patients, including the eight who were asymptomatic. Vocal cord paralysis occurred in two patients. The cause of the aneurysm was atherosclerosis in 12 patients, trauma in 10, poststenotic dilation secondary in thoracic outlet obstruction in 6, mycotic aneurysm in 2, and Ehlers-Danlos syndrome in one patient. Seven patients had nine aneurysms in other areas. Surgical treatment consisted of thoracic outlet decompression in 4 patients, graft interposition in 11, tangential aneurysmorrhaphy in 8, ligation in 4, and exploratory surgery only in one. One forearm amputation was subsequently performed. Three patients did not undergo surgery. Average length of follow-up was 9.2 years. Except for the patient who underwent amputation, all treated patients had adequate circulation in the extremities. No aneurysm recurred and no complication of the repair developed. We conclude that aneurysms of the subclavian-axillary artery, although rare, are both life- and limb-threatening. Resection and arterial reconstruction are recommended.

Cancer of the parathyroid glands.

Hyperfunctioning parathyroid carcinoma is a relatively rare endocrine tumor, accounting for approximately 1% of all cases of primary hyperparathyroidism. The diagnosis is suspected when the tumor is large, parathyroid hormone (iPTH) levels are high, and a palpable tumor is present in the neck. Patients who have recurrence of hyperparathyroidism several months after surgical treatment should be suspected of having a recurrent or persistent parathyroid carcinoma. At operation, a large invasive tumor is usually found. The fibrous, inflammatory-like reaction is the most characteristic indication of malignancy. Even in tumors with minimal invasiveness, the possibility of a carcinoma should be considered if the tumor has mitotic activity and a monotonous instead of a pleomorphic cellular population. If the surgeon can recognize the possibility of parathyroid malignancy and adequately treat the patient during the initial operation, more gratifying results should be obtained.

Clinical evaluation of a sutureless cardiac pacing lead: chronic threshold changes and lead durability.

Chronic threshold changes and durability of the Medtronic 6917 sutureless cardiac pacing lead were evaluated in 100 consecutive patients. A bipolar pacing system was established in each patient. Lead failure occurred in 4 patients; all failures resulted from exit block or loss of adequate contact between electrode and myocardium. Electrode fracture or loss of lead insulation was not observed. Fifty patients had replacement of the pulse generator 27.4 +/- 1.8 months after implantation. Long-term stimulation threshold voltage was about 2.5 times greater and current was about 3.5 times greater than values obtained at initial implantation, yet they continued to permit safe and effective cardiac pacing.