Multiple digital glomus tumors.

In 28 patients with glomus tumors of the digits, 21 were relieved of symptoms by excision of a solitary tumor. Seven other patients had multiple tumors, four of which were the cause of recurrent symptoms. Three patients had multiple tumors--five in one patient, four in another, and two in a third, which had been found at the time of the first operation. A 25% incidence of multiple tumors and a 15% incidence of recurrent symptoms indicates that a careful search should be made for additional tumors.     

Cecal volvulus associated with incomplete situs inversus and splenic dysgenesis

An unusual case of cecal volvulus in a patient with partial situs inversus viscerum is presented. The associated conditions of liver symmetry and splenic dysgenesis were also present. The patient claimed to be a conjoined twin at birth. The association of twinning and situs inversus is discussed as are some of the lesser appreciated physical findings associated with the phenomenon. Treatment of the cecal volvulus in this case required consideration of a number of operative alternatives.     

Cardiovascular and Respiratory Manifestations of Pulmonary Sequestration in Childhood

Intralobar pulmonary sequestration was diagnosed in 14 patients, 12 of whom were under 10 years of age, including 2 infants aged 2 weeks. Half of the patients had respiratory problems when first seen. “Classic” purulent bronchiectatic disease was present in only 2; 5 had mild pneumonitis, asthma, or bronchitis. A second group had cardiovascular problems. Two children had severe congenital heart disease, and 4 had significant arteriovenous shunts in the sequestration, including an infant with cardiac failure. All the shunts were characterized by a continuous murmur in the back or axilla on the affected side. Early operation can prevent more severe respiratory problems and obviate the hemodynamic sequelae of the A-V fistula. Segmental resection of the sequestration was performed in 2 children, which suggests that lobectomy may not always be necessary.     

Use of continuous positive airway pressure breathing in the improved management of neonatal emergencies

A ventilatory system consisting of spontaneous breathing with continuous positive airway pressure has dramatically decreased mortality in newborn infants with hyaline membrane disease.¹ In the past 2 yr, we have applied this new technique in the management of noncardiac thoracic and abdominal emergencies in more than 25 small infants, most of whom were newborn. The purpose of this paper is to describe the use of continuous positive airway pressure breathing (CPAPB) in this group of babies with life-threatening conditions, which included intestinal atresia, meconium peritonitis, fecal peritonitis, gastroschisis, omphalocele, tracheoesophageal fistula, and diaphragmatic hernia (Table 1). As an adjunctive measure in the management of respiratory insufficiency associated with these conditions, we believe this new system has contributed importantly to the survival of these infants.A common denominator in this group of varied newborn emergencies was pulmonary dysfunction which was usually manifested by peripheral arterial unsaturation associated with right to left pulmonary shunting. The pulmonary abnormality was often a concomitant complication of severe metabolic acidosis, sometimes in the presence of gram-negative septicemia. Since these congenital anomalies all required urgent operative procedures, the above physiologic derangements were further distorted by anesthesia and the surgical trauma. In the past, pulmonary insufficiency, combined with severe sepsis and metabolic acidosis, was frequently lethal; but the postoperative courses in this group of infants have demonstrated improved respiratory function with the use of CPAPB. Selected cases have been chosen from this series to illistrate this experience.     

Pulmonary and ductal hemodynamics in studies of simulated diaphragmatic hernia of fetal and newborn lambs

Congenital Posterolateral Diaphragmatic Hernia is associated with ipsilateral pulmonary hypoplasia and blood flow to the affected lung remains diminished into late childhood.¹ Although this unilateral pulmonary hypoplasia is physiologically significant, it is probably not primarily responsible for the high mortality of congenital diaphragmatic hernia. The major immediate threat to a baby's life is the tension effect of the herniated abdominal viscera, but even after successful reduction of these organs, a greater than 50% mortality occurs. The mortality and morbidity is often due to continuing and progressive hypoxemia and metabolic acidosis. Several authors^2–4 have reported pulmonary hypertension, patent ductus arteriosus and variable right-to-left shunting in babies with diaphragmatic hernias. Right-to-left shunting via a patent ductus may contribute significantly to increasing hypoxemia and acidosis in addition to the efect of pulmonary hypoplasia.To test this hypothesis, we have developed a simplified fetal model to simulate diaphragmatic hernia and permit studies of pulmonary and ductal hemodynamics. The fetal lamb was chosen for studies of the pathophysiology of diaphragmatic hernia because pulmonary development in fetal lambs occurs late in gestation and because many studies have been made of normal pulmonary function in newborn lambs.^5–8 This cumulative data is available for comparison with laboratory models of pulmornary abnormalities. These studies were therefore designed to test our belief that right-to-left shunting via the patent ductus arteriosus (PDA) is due to persistent fetal circulation and associated with altered blood flow to the hypoplastic lung.     

Studies of the pathophysiology of gastroschisis in fetal sheep

An experimental model of gastroschisis has been developed in fetal lambs which grossly and microscopically resembles this anomaly in human infants. Histologic studies of the exposed eviscerated intestine demonstrate interstitial edema without cellular infiltration which appear to result from contact with amniotic fluid. The specific damage to the myenteric ganglion cells and a progressive disappearance of ATPase in the muscle of exposed bowel strongly suggest an alteration in neural conduction and a decrease in contractile potential. Preliminary enzyme studies show concomitant abnormalities in intracellular enzymes within the mucosa of the exposed bowel.     

Heparin-induced thromboembolism: a case report.

A case of heparin-induced thrombosis of the brachial artery with thrombocytopenia is described. With discontinuation of the heparin, the circulating platelet volumes returned to normal. The role of pre-existing arterial disease and sepsis in patients exhibiting this phenomenon is unresolved.     

Harvey H-200 Disposable Blood Oxygenator: Experience in 300 Patients

During the last few years attempts have been made to design improved disposable oxygenators. One such unit, the Harvey H-200 disposable blood oxygenator, has been evaluated clinically at The Johns Hopkins Hospital during recent months. The unit was used to perfuse 300 patients undergoing open-heart operations. The average Po₂ on bypass was 309 mm. Hg, and the Pco₂ averaged 33 mm. Hg. Acid-base balance remained within normal limits. The hemolysis rate was low, averaging 69.2 mg. per 100 ml. during an average perfusion lasting 1 hour 33 minutes. We have found the H-200 oxygenator to be a dependable unit which is useful in a wide range of operative procedures.     

Use of continuous positive airway pressure in the improved postoperative management of neonatal respiratory emergencies

In newborns with hyaline membrane disease, spontaneous breathing with continuous positive airway pressure (Gregory technique) has dramatically decreased the mortality. We have applied this technique in the postoperative management of cardiac and noncardiac thoracic emergencies in more than 13 low-weight infants (2 to 6 kg.) from 12 hours to 6 months old. This type of ventilatory support raises the intraalveolar pressure throughout the respiratory cycle and appears to prevent lobular and segmental atelectasis. The physiological effect is to increase Pa_o2 by decreasing intrapulmonary shunting and improving the ventilation-perfusion abnormalities, possibly by changing the relationship of interstitial fluid to the respiratory membrane. This technique allowed us to eliminate the hazardous use of mechanical ventilators in these tiny infants.     

Algorithm for nasal reconstruction.

The aesthetic qualities of nasal reconstruction are reviewed and an algorithm that provides a basic plan of approach is presented. The nose is divided into the proximal two thirds and the distal third, in terms of the skin requirements for reconstruction. Lining and support are considered individually in each area.     

Aneurysm of the sinus of Valsalva resulting from bacterial endocarditis

This report describes a patient in whom an aneurysm of the sinus of Valsalva secondary to bacterial endocarditis was successfully repaired. The literature pertaining to this rare condition is reviewed, and a simple and secure method of repair is illustrated.     

Aspiration pneumonia. Prevention of aspiration in patients with tracheostomies

Previous work has documented the incidence of aspiration in patients with tracheostomies to be very high. This has been suggested as a reason for the frequent pulmonary complications seen in patients with tracheostomies. In this study, two modified tracheostomy tube cuffs were evaluated as to their ability to act as a mechanical barrier and prevent aspiration. Forty spontaneously breathing patients with tracheostomies were studied. Utilizing an Evans blue dye test for aspiration, 13 (87%) of the 15 patients with standard tracheostomy tubes aspirated. Aspiration in the two study groups in which modified tracheal cuffs were used was decreased to 17% (2/12) and 15% (2/13). It is suggested that by proper tracheostomy cuff design, the high incidence of aspiration in patients with tracheostomies can be decreased.     

The effect of cardiopulmonary bypass perfusion pressure on myocardial gas tensions in the presence of coronary stenosis.

Mass spectrometry was utilized to determine myocardial gas tensions in dogs subjected to cardiopulmonary bypass. Myocardial ischemia occurred in animals with normal coronary arteries when cardiopulmonary bypass perfusion pressure fell 40 to 60 mm Hg below the mean aortic pressure measured prior to bypass. Myocardial ischemia did not occur, or could be eliminated when present, if cardiopulmonary bypass perfusion pressure was maintained near prebypass mean aortic pressure. In animals with constricted circumflex coronary arteries, the adverse effect of low perfusion pressure on myocardial metabolism during cardiopulmonary bypass was found to be more severe in areas of myocardium supplied by the stenotic coronary artery. It is concluded that maintenance of cardiopulmonary bypass perfusion pressure near the level of preoperative mean aortic pressure will help prevent myocardial ischemia during operation; particularly in patients with coronary artery disease.