John C. Jones

Pleural Empyema in Children

n the late 1950’s a tremendous increase in the incidence of staphylococcal pneumonia and empyema occurred throughout many of the I pediatric centers in the country. This increase was thought to have been caused by the emergence of antibiotic-resistant strains of bacteria [3]. Several papers appeared in the literature reflecting this changing pattern [4, 6, 71, and some strict rules for surgical management were advised in order to decrease mortality in this disease [6]. Formerly, this mortality ranged from a high of 100% in some series [l] to about 25% in other centers [5, 61. The generally accepted surgical routine was to insert a chest tube in all children who exhibited pleural fluid containing gram-positive cocci. This was followed frequently by conversion to open drainage with or without rib resection, and finally decortication if there was no definite improvement in two or three weeks and a captive lung was assumed to be present. Strict adherence to these principles brought the mortality down to around 10 or 12% [6]. Since about 1962, pleural empyema in children, particularly that due to staphylococci, has become less virulent, probably entirely as the result of newer antibiotic agents. Now certain transgressions can be taken from the older rules of management in order to shorten the hospital stay and decrease the discomfort of these children. It is the purpose of this paper to review the experience with all children diagnosed as having primary pneumonia and secondary empyema over the past 20 years at the Children’s Hospital of Los Angeles, in order to compare present-day management with that practiced 10 years ago.

Cardiopulmonary arrest: Evaluation of an active resuscitation program☆

Abstract Cardiopulmonary resuscitation efforts in response to an emergency call are analyzed as to effectiveness in 302 patients. Over a seven year period there had been a marked improvement in the success rate of resuscitation. The reasons for this are the recognition of the patients most likely to suffer cardiac arrest and the monitoring of these patients closely in special units where nurses trained in resuscitation are constantly in attendance.

Pathology of bronchogenic carcinoma in long‐term survivors

The pathologic features of 94 cases of bronchogenic carcinoma in patients who survived for 5 years or longer after resection are reviewed. The incidence of squamous cell carcinoma is 56% and parallels that for the entire group of 358 resected cases. There were no survivors with oat cell carcinoma but bronchiolo‐alveolar cell carcinomas were found frequently and more than half of the tumors were located peripherally or in an intermediate zone. One of the long‐term survivors had a characteristic giant cell carcinoma which had metastasized to regional lymph nodes and appears to represent the first such case recorded in the literature. Metastasis to lymph nodes was recorded in 28% of the cases. All slides were examined on six occasions, leading to considerable discrepancy in the classifications. Problems arose especially in the definition of adenocarcinomas versus bronchiolo‐alveolar cell carcinomas but also in the classification of squamous cell and undifferen bated carcinomas.

The Selection and Medical Management of Patients with Mitral Stenosis Treated by Mitral Commissurotomy

The selection of patients for mitral commissurotomy must be made after considering all manifestations of the rheumatic state. A conservative approach is urged and no patients should be operated upon without evidences of increasing pulmonary hypertension and right heart strain. The preparation of the patient, the management of the arrhythmias during surgery and the postoperative care are the full responsibilities of the physician. A team composed of physiologists, cardiologists and surgeons must work together.

Palliative Procedure for Treatment of Transposition of the Great Vessels

1. Extreme efforts at palliation seem indicated in the very young infant with transposition of the great vessels and no accompanying defects of note since good candidates for later total correction may thereby be preserved.[see table in the PDF file]2. A palliative procedure is presented wherein an atrial septal defect is created, and the blood flow from the inferior vena cava is diverted through the defect.3. Presented are nine patients less than two months of age and with arterial oxygen saturations less than 35% who underwent the described procedure.4. There were two early and two late deaths. The survivors are all doing well clinically and have required no further procedure.

The Surgical Repair of Endocardial Cushion Defects

he incidence of endocardial cushion defects in a surgical series is not high. In our series of more than 1,300 open-heart operations T for congenital cardiac defects, this anomaly has been encountered 39 times. The surgical repair of these defects is attended by a significant mortality rate-26% of 256 cases as reported by the Committee on Cardiovascular Surgery of the American College of Chest Physicians [Z]. The problems of persisting mitral valvular incompetence [ 1, 10, 171 and surgical heart block [Z, 6-81 continue to be a challenge to the cardiac surgeon, as does the quest for completely satisfactory operative techniques to repair the more severe forms of endocardial cushion defects. This report analyzes our experience with the 39 cases of endocardial cushion ,defects that we have operated upon.

Surgical Correction of Tetralogy of Fallot with Previous Systemic to Pulmonary Artery Shunts

Fifty-four patients with previous Blalock (32) and Potts (22) systemic artery-pulmonary artery shunts and subsequent total correction for tetralogy of Fallot are reported. A separate posterolateral approach was employed to obliterate the Potts shunt. There were seven operative deaths and two late deaths. Infundibular stenosis with a normal pulmonary valve gave the best results. In comparison with our concomitant series without a shunt, the presence of a Blalock or Potts anastomosis did not affect the over-all result. Postoperative bleeding was a major complication, requiring reoperation in seven. An excellent result with probable cure was obtained in 30, and there was good improvement in ten of the 54 patients.