H. Brownell Wheeler

Experimental Whole-organ Transplantation of the Liver and of the Spleen°

THE RAPIDLY growing experience in experimental homotransplantation is largely based on observations of the skin, kidney, blood and bone marrow. These studies have been the pioneer ones for reasons that are clear historically: skin for its availability; kidney for its significance as a paired organ with a simple vascular pedicle, the biochemical product of which can easily be measured; blood for its circulatory support; and bone marrow for its use as a replacement tissue after hematopoietic destruction either in cancer

Applicability and interpretation of electrocardiographic stress testing in patients with peripheral vascular disease

Abstract Electrocardiographically monitored arterial stress testing was performed before surgery in 130 patients with peripheral vascular disease. When limitations of claudication or pain at rest precluded treadmill exercise, arm ergometry was employed. The electrocardiographically monitored arterial stress test proved a cost-effective, easily applicable means of screening for coronary artery disease in this group of patients. Unlike statistical analyses of historical risk factors, the electrocardiographically monitored arterial stress test evaluates the current functional state of the myocardium. We believe that preoperative electrocardiographic exercise testing should be employed more widely and should be considered in any patient facing major surgery in whom coronary artery disease is suspected on the basis of past history or known risk factors. In patients who have an ischemic response to exercise, particularly at less than 75 percent of the maximum predicted heart rate, coronary angiography and possibly coronary revascularization should be considered before elective major surgery is performed.

Diagnosis of deep venous thrombosis by measurement of electrical impedance.

Abstract Electrical impedance can be measured in the leg by a simple noninvasive technic, somewhat analogous to electrocardiography. Normal tracings show a marked fall in impedance with deep inspiration, due to increased local venous blood volume. In the presence of deep venous thrombosis, these respiratory changes are damped or obliterated. Based on use in fifty-one patients, measurement of electrical impedance has proved to be a safe and useful screening procedure for the diagnosis of deep venous thrombosis, correlating almost uniformly with venography or objective verification at surgery (thirty-four of thirty-five cases).

A prospective study of the incidence of deep venous thrombosis in hospitalized children

PURPOSEnIt is commonly believed that the incidence of deep venous thrombosis (DVT) in hospitalized children is less than in adults. However, it is possible that the disease is significantly underdiagnosed in children because the index of suspicion of pediatric practitioners is low, a substantial number of patients may have no symptoms, and DVT screening is not routinely performed. We therefore undertook a prospective study to define the incidence of DVT in hospitalized children with no symptoms.nnnMETHODSnPatients included in the study were those younger than 18 years of age who were hospitalized for more than 72 hours and were identified to have two or more risk factors for the development of DVT and had at least one screening duplex scan. Risk factors for the development of DVT considered were a history of DVT or pulmonary embolism, recent operation, immobilization, trauma, stroke or acute neurologic deficit, the presence of cancer, sepsis, greater than 150% ideal body weight, a hypercoagulable state, and the presence of a femoral venous catheter.nnnRESULTSnOver the 9-month period ending December 1994, 1997 patients 17 years of age and younger were admitted to the hospital, and 59 patients including 19 girls and 40 boys were enrolled in the study. The one patient with DVT was a 17-year-old boy hospitalized after a motor vehicle accident with blunt head trauma and a neurologic deficit who underwent multiple orthopedic and neurosurgical procedures.nnnCONCLUSIONSnThe development of acute DVT in children is unusual. As a result, DVT prophylaxis and screening is unnecessary in young children with only two risk factors for the development of the disease. Young age appears to be an important protective risk factor for the prevention of DVT.

Assessment of operative risk with electrocardiographic exercise testing in patients with peripheral vascular disease

Doppler ankle blood pressures were performed inere obtained in 100 consecutive patients with peripheral arterial insufficiency after treadmill exercise. A twelve lead electrocardiogram was monitored during and after exercise. Despite a restricted ability to exercise because of peripheral vascular insufficiency, forty-six patients had ventricular dysrhythmia or ischemia, or both, usually without associated symptoms. Electrocardiographic monitoring during treadmill exercise proved a useful predictor of postoperative complications. Thirty-two vascular operations were performed in patients with no electrocardiographic evidence of ischemia. No patient had a postoperative myocardial infarction or died. Sixteen vascular procedures were performed in patients with ischemic responses on exercise electrocardiography. Six patients had postoperative myocardial infarctions, two of which were fatal. Electrocardiographic monitoring during treadmill exercise for peripheral vascular insufficiency in recommended (1) to assess the severity of coronary artery disease and the likehood of postoperative complications, and (2) as a precautionary measure to identify potentially dangerous dysrhthmias or ischemia during exercise before the development of clinical symptoms.

Prophylaxis against venous thromboembolism in surgical patients

Venous thromboembolic disease is a common, potentially life-threatening, but preventable complication of surgery. Venographic studies have shown a high incidence of deep vein thrombosis in patients who do not receive prophylaxis. The long-term sequelae of deep vein thrombosis in these patients can be disabling, but the exact prevalence of post-thrombotic complications has not been well documented. Fatal pulmonary embolism has been reported in 0.5% to 1% of patients after major abdominal surgery and in 2% to 6% after total hip replacement. Several methods of prophylaxis against venous thromboembolism have demonstrated efficacy, but a surprising number of patients still do not receive prophylaxis. A medical record review in 16 hospitals recently disclosed that only 32% of high-risk patients received prophylaxis, with a range from 9% in a community hospital to 56% in a major teaching hospital. The possible reasons for this comparatively low rate of utilization are discussed. Current issues and future trends in the prophylaxis of venous thromboembolism are briefly summarized.

Surgical Treatment of Subclavian-Artery Occlusions

CEREBROVASCULAR insufficiency due to subclavian-artery occlusion is more frequent, more simply diagnosed and more easily treated than generally recognized. Only recently has attention been focused on this condition, chiefly since the description of the subclavian steal syndrome in 1961. Physicians who treat patients with cerebrovascular disease should become familiar with this diagnosis, since in selected cases, dramatic relief of symptoms can be obtained from arterial reconstructive surgery. The current article reviews a five-year personal experience with the management of 22 patients with occlusions of the subclavian artery. Nine patients were not deemed sufficiently symptomatic to warrant surgery and have been .xa0.xa0.

Healing and Heroism

The centennial anniversary of this distinguished lecture series provides an opportunity to survey our profession from a long perspective, one that encompasses decades and perhaps even centuries. I would like to speak briefly about the physicians in the Shattuck family and then reflect at greater length on Sir William Osler, who was the fourth Shattuck Lecturer. I will consider what made Osler a hero to the public as well as to the medical profession, and why for a hundred years he has been regarded as the preeminent role model for a physician. A centennial anniversary is also a time to .xa0.xa0.

RECONSTRUCTIVE OPERATIONS FOR AORTOILIAC OBLITERATIVE DISEASE. RESULTS AND REFLECTIONS FROM AN ELEVEN-YEAR EXPERIENCE.

THE purpose of this report is to analyze the experience with reconstructive operations for obliterative disease of the distal aorta and iliac arteries at the Peter Bent Brigham and West Roxbury Veterans Administration hospitals between October, 1952, and October, 1963. The results in the 52 patients operated upon between 1952 and 1958 have previously been reported.1 In the years 1958 to 1963, 62 additional patients have been operated upon. The total experience comprises 114 operations. The present communication will deal with the 1952–58 group only to the extent of examining the five-year to eleven-year follow-up results of the 40 patients .xa0.xa0.

TRANSPLANTATION OF TISSUE SLICES IN MICE

Laboratory investigations utilizing inbred strains of mice have contributed much to current knowledge of transplantation biology. Use of these experimental animals allows control of the genetic factors which underlie transplantation phenomena. The scope of work possible with inbred mice has been limited, however, by the types of transplantation possible in such small animals. Whole organ grafts are not feasible because of the difficulty in carrying out vascular anastomoses. Grafts of intact normal tissue have not been widely employed, with the notable exception of the skin graft, presumably because of the severe ischemic damage which occurs with most techniques of tissue grafting. Except for skin grafting, transplantation in mice has usually been accomplished by the injection of dissociated cell suspensions. The current article describes a technique of transplantation which allows good histologic survival of morphologically intact tissue slices. As contrasted with the injection of dissociated cell suspensions, transplantation of tissue slices allows the grafted cells to function in their usual anatomic relationships within the parent tissue. I t also allows the graft to be recovered for pathologic examination, secondary transplantation or other special investigations. Because of these advantages, study of morphologically intact tissue grafts might be expected to provide information which cannot be obtained through study of grafts of dissociated cells. Other workers have previously grafted intact lymphoid tissues (spleen, lymph node, thymus) to various sites in mice. Two reports of grafting of lymphoid tissue beneath the renal capsule in mice have appeared,13 and this site has also been employed for the study of placental tissue. In other small animals, various workers have reported on grafts of lymphoid tissues placed in subcutaneous, intra~eritoneal, .~ intramuscular, and intramarrow recipient sites. Many of these approaches proved disappointing in our laboratory with respect to the degree of necrosis and the inability to preserve relatively normal tissue architecture. However, gratifying survival was obtained with kidney slice grafts when these grafts were placed on the cut surface of the kidney. These results suggested that the renal cortex, an extremely vascular tissue, might prove to be a favorable site for transplantation of grafts derived from other tissues as well. After