Biomedical subjects
Publications and source records attributed to A R Graham.
Shwachman's syndrome is an uncommon disorder; its principal manifestations are pancreatic and hematopoietic insufficiency. We report here a case of Shwachman's syndrome with autopsy findings of cardiomegaly (anticipated from clinical observations) and unexpected testicular fibrosis, both examined by electron microscopy.
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Endometrial carcinoma of the prostatic utricle is a rare pupillary prostatic tumor arising in the region of the prostatic urethra and verumontanum. Since the first description by Melicow and Pachter in 1967, 8 additional cases have been reported. This case is the tenth reported, and the first in which metastases to bone have been proved by biopsy. Transurethral resection of the tumor with postoperative radiation therapy to the prostatic region and metastases has resulted in clinical improvement. The importance of accurate diagnosis of this neoplasm is emphasized to avoid unnecessary delay in the appropriate choice of therapeutic modalities.
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Thoracoabdominal aortic reconstruction distal to the left subclavian artery was carried out on 19 patients between 1974 and 1990. Screening procedures to detect cardiac, respiratory or renal impairment were undertaken in all patients. Reconstruction was in the upper third of the descending aorta in 6 patients, middle third in 6 patients, and lower third in 7 patients. The Crawford inclusion technique was used in all cases. There were six deaths, four of which were from the high reconstruction group, and one each from the middle and lower group. Paraparesis occurred in 4 patients, 2 of whom survived with some impairment. Temporary renal failure was seen in 2 patients, liver failure in 2, respiratory failure in 2, sepsis in 1, myocardial infarction in 1, and severe coagulopathy in 3. The perioperative mortality rate was 32% for the group as a whole and 15% for reconstructions which started at the middle or lower thoracic level. We conclude that the mortality rate for the middle and lower reconstructions is acceptable but that alternative techniques for the high aneurysms should be sought.
In a two year period eight patients have presented with acute aortic occlusion and a poor outcome in seven. Initial failure to diagnose aortic occlusion, with a mean delay from presentation to diagnosis of 24 hours, was mainly responsible. All patients had varying degrees of paralysis on presentation which misled clinicians although other findings of acute ischaemia (pain, absent pulses, colour change and anaesthesia) were always present. Two patients were initially referred to a neurologist, another to a neurosurgeon, and the fourth to an orthopaedic surgeon. Even after diagnosis had been established, the need for urgent revascularization was not always recognized, the mean time from diagnosis to revascularization being 13 hours. Unnecessary aortography contributed to this delay in four patients. In two patients operative treatment was not undertaken while six were treated operatively by: aortic bifurcation graft (3), aortic thromboendarterectomy and femoropopliteal bypass (1), open aortic embolectomy (1) and bilateral femoral embolectomy (1). The causes of aortic occlusion were thrombosis of an atherosclerotic aorta (5), thrombosis of an aneurysm (2) and embolism (1). In the latter patient, the heparin induced thrombocytopenia syndrome (HITS) was primarily responsible. The outcomes in the eight patients were death (5), paraplegia (1), amputation (1), and uncomplicated recovery (1). The single patient who made an uncomplicated recovery had the shortest delay from presentation to revascularization of only 2 1/4 hours. Acute aortic occlusion rivals aortic rupture as a vascular emergency and demands immediate operative intervention.
Dilatation of the dysplastic internal carotid artery has been controlled by intraoperative radiography including angiography. The method minimizes the risk of damaging the artery at the base of the skull while allowing immediate visualisation of the results. In one case persisting stenosis after passage of a metal dilator was treated by balloon dilatation with the formation of a localised aneurysm.
Between May, 1969, and December, 1985, 680 carotid endarterectomies were carried out in the Surgical Professorial Unit in St. Vincent's Hospital, Sydney. Recurrence requiring re-operation was detected in nine arteries in seven patients. Continued smoking after the initial operation may have contributed to the restenoses. The origin of the internal carotid artery was the most common site of recurrence, irrespective of whether restenosis was caused by myointimal fibroplasia or recurrent atheroma.
Endomyocardial biopsy is currently the best method to monitor cardiac allograft rejection. The histologic criteria of infiltration by mononuclear cells with pyroninophilic cytoplasm and acute myocyte necrosis indicate immunologic activation and require an increase of immunosuppressive therapy. Of particular concern is the persistence of necrotic fibers on biopsies for some time after ischemic episodes associated with the transplant procedure and after acute rejection episodes. Because the presence of acute myocyte necrosis plays a key role in the clinical decision on immunotherapy, we evaluated the resolution pattern of acute necrotic fibers under standard immunosuppression treatment. Myocardial infarction of the posterior papillary muscle was surgically induced in two groups of dogs that were killed (three from each group) at 4, 7, 14, and 21 days after surgery. The first group consisted of 12 control animals, and the second group was composed of 12 dogs, immunosuppressed with cyclosporine, methylprednisolone, and prednisone. The histologic sections demonstrated a persistence of myocyte necrosis for 14 days after infarction in the treated group but for only 7 days in the untreated control group. This slow resolution pattern needs more emphasis in clinical practice. Criteria other than myocyte necrosis should be used to differentiate ongoing from resolving rejection after the first rejection episode. Preservation injury may persist for 2 weeks after transplantation and be misinterpreted as acute rejection.