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Pathomechanism, pathogenesis, and results of treatment in cervical spondylotic myelopathy caused by dynamic canal stenosis. In this study, the pathomechanism and pathogenesis of dynamic canal stenosis caused by cervical instability in patients with cervical spondylotic myelopathy and the validity of the concept of instability are clarified by analyzing the results of treatment in 53 cases. In cases of cervical spondylotic myelopathy caused by dynamic canal stenosis, the authors found that the posterior slide of the vertebral body occurs as a result of degeneration in the cervical spine due to aging changes, and that the dynamic sagittal diameter of the spinal canal decreases with an increase of the degree of posterior slide. This is followed by gradual aggravation of the clinical symptoms. Continuous cervical traction was found to be the first choice of treatment. Surgical treatment is indicated in cases in which the traction was ineffective, or even when it was effective, in cases in which the Japanese Orthopaedic Association (JOA) score remained low or when there was a tendency toward rapid aggravation of symptoms. It was demonstrated that the shorter the duration of the myelopathy, the better the results of treatment obtained. A limit of the dynamic sagittal diameter of the spinal canal of 12 mm was considered as valid.

Occult vascular malformations of the optic chiasm: magnetic resonance imaging diagnosis and surgical laser resection. Angiographically occult vascular malformations of the optic nerve and chiasm are extremely rare. Before the advent of magnetic resonance imaging (MRI), it was difficult to diagnose these lesions preoperatively. We report MRI scan findings of optic chiasm cavernous angiomas in two patients with chiasmal syndrome. MRI was useful in localizing the vascular malformation and delineating its characteristics, especially chronic hemorrhage. One patient underwent biopsy of the lesion. The other patient underwent complete microsurgical resection of the malformation with the carbon dioxide laser with preservation of vision. Occult vascular malformations of the optic nerve and chiasm may be a more common cause of visual deterioration than previously recognized. The MRI scan is the imaging modality of choice for diagnosing and following these lesions. In certain patients, these vascular malformations may be amenable to complete surgical removal with stabilization or improvement of visual function.

A huge intracranial xanthogranuloma in the middle cranial fossa: case report. Xanthogranulomas of the dura presenting with clinical symptoms are rare. We report here a case of a huge dural xanthogranuloma in the middle cranial fossa, which caused hemiparesis through marked displacement and stenosis of the middle cerebral artery. Although such tumors usually arise in association with histiocytosis X or familial hyperlipoproteinemia, the present case was not associated with these diseases.

Anterior lesser curve seromyotomy and posterior truncal vagotomy versus truncal vagotomy and pyloroplasty in the treatment of chronic duodenal ulcer. In a prospective randomized controlled clinical trial, anterior lesser curve seromyotomy with posterior truncal vagotomy (AMPT, n = 77) has been compared with truncal vagotomy and pyloroplasty (TVP, n = 69) in 146 patients with chronic duodenal ulcer with a mean duration of symptoms of 7 years. The mean follow-up time was 4.5 years with a range of 2-7 years. One elderly patient died from a myocardial infarction in the TVP group. Acid secretory inhibition in response to insulin and pentagastrin stimuli was equal in both groups, indicating a similar degree of vagal denervation. Recurrent ulcers were more common after AMPT (five) than TVP (two) (P = 0.29, n.s.). Dumping and diarrhoea were significantly commoner (P less than 0.001) after TVP, with 31 instances as opposed to eight with AMPT. The mean operating time was increased by 6 min when AMPT was performed rather than TVP. The results of this study have shown that AMPT is associated with a lower incidence of dumping and diarrhoea and achieves better overall Visick grading. However, continued monitoring is required to assess the long-term incidence of recurrent ulceration after this procedure.

Protamine-heparin-induced pulmonary hypertension in pigs: effects of treatment with a thromboxane receptor antagonist on hemodynamics and coagulation. Adverse hemodynamic reactions after protamine neutralization of heparin are an infrequent but important clinical problem. Pre-treatment of swine with a thromboxane A2 receptor antagonist has been reported to prevent the pulmonary hypertensive response occasionally seen after protamine reversal of heparin anticoagulation. In the current study, a control group of pigs (n = 9) received intravenous heparin (300 IU/kg), followed after 10 min by a neutralizing dose of protamine (3 mg/kg). A treatment group of pigs (n = 11) was treated identically, except that the thromboxane A2 receptor antagonist L-670596 (2 mg/kg) was infused intravenously 2 min after the protamine infusion. Hemodynamic and coagulation profiles were monitored during these procedures. Pulmonary hypertension developed and reached a peak within 2 min of protamine administration, often at the same time that L-670596 was administered in the treatment group. There was no statistical difference between control and treatment groups' peak pulmonary arterial pressure and peak pulmonary vascular resistance. However, the interval for return of mean pulmonary artery pressure from peak to baseline values was 11.6 +/- 3.1 versus 5.5 +/- 1.9 min (mean +/- SD) for control and treatment groups, respectively (P less than 0.01). Thromboxane B2 plasma concentrations increased in both groups and were correlated with the pulmonary hypertensive response (r = 0.86, P less than 0.01). Platelet aggregation to collagen was inhibited by the thromboxane A2 receptor antagonist (P less than 0.05). Bleeding time was prolonged beyond normal range in 50% of L-670596-treated pigs. All other coagulation tests in both groups returned to baseline after reversal of heparin with protamine and were unaffected by L-670596.

Multimodality cisplatin treatment in nonresectable alpha-fetoprotein-positive hepatoma. Twenty-eight patients with alpha-fetoprotein-positive (AFP+) nonresectable hepatoma have been enrolled in a new multimodality Phase I, II program. Induction therapy consisted of 50 mg/m2 intravenous cisplatin followed by 2100 cGy irradiation to the tumor volume in seven fractions over 10 days. Hepatic arterial infusion of 50 mg/m2 cisplatin (IA-CDDP) was then administered at monthly intervals. Twenty-one patients have completed induction and at least two cycles of IA-CDDP. Twelve-month cumulative survival was 52% for all 28 patients and 69% for the 21 patients completing induction and IA-CDDP. Median survival has not yet been reached. Response rate (complete and partial) was 36% overall and 48% among the 21 patients who completed treatment. The improved survival of the present series of patients as well as the minimal hematologic toxicity suggests possible further integration of new modalities for therapy.

Comparison of four pulse oximeters: effects of venous occlusion and cold-induced peripheral vasoconstriction. The ability of four pulse oximeters (the Ohmeda 3700, Nellcor N100 and N200 and the Datex Oscar) to detect hypoxaemia was determined in the presence of venous obstruction and cold-induced peripheral vasoconstriction. Significant increases in detection time for hypoxaemia were found in both cases. There were no significant differences in detection time between the instruments, although the Ohmeda 3700 displayed smaller values of SaO2 under certain conditions. Peripheral vasoconstriction was induced using three differing methods which gave differing results, thus emphasizing the importance of methodology in assessments of pulse oximetry.

B-mode imaging and histomorphometric evaluation of carotid atherosclerosis. The quantitative and qualitative evaluation of atherosclerotic lesions by the ultrasonography has presented several problems, above all, the determination of accuracy and reproducibility of this methodology in humans. The present study aims to evaluated the results of B-mode imaging of extracranial carotid arteries in patients selected for surgery as compared with histologic results of the observations of the samples obtained by endarterectomy. Shrinkage effects of the histologic samples were taken into consideration. Several bidimensional images of atherosclerotic lesions, as obtained by ultrasound at different incident angles, were used to establish their maximum thickness. The maximum degree of the vessel stenosis calculated by ultrasound showed a high correlation (Y = 0.47X + 42.4, se = 0.11, r = 0.5, p less than 0.001) compared with the one obtained by histology. The imaging methodology provided however, a mean overestimation of the stenosis of about 7%. Relationships among the amount of calcium (p less than 0.03); necrotic core p less than 0.056); and echogenic types, ie, soft, mixed, and hard; have been suggested by a statistical trend. The results suggested that of the vascular lumen due to advanced atherosclerotic lesions. Qualitative interpretation of atherosclerosis by B-mode imaging, ie, morphologic characteristics, seem, at present, to be of value, but more investigations in depth are needed.

Histopathologic spectrum of clinically atypical melanocytic nevi. II. Studies of nonfamilial melanoma [published erratum appears in Arch Dermatol 1990 Dec;126(12):1616] We studied the clinically most atypical pigmented lesion removed from each of 142 patients with newly diagnosed sporadic melanoma. The specimens were categorized as to the type of nevus, ie, junctional or compound, presence of congenital features, and degree of nuclear atypicality--presence of nuclear enlargement, nuclear pleomorphism, hyperchromatism, and prominent nucleoli--of intraepidermal nevomelanocytes. The frequency of nuclear abnormality was graded as 1 (rare cells), 2 (10% to 50% of cells), or 3 (greater than 50% of cells) for each nuclear parameter. Among all lesions, 42 (29.6%) were junctional nevi, 74 (52.1%) were compound nevi, and 14 (9.9%) were dermal nevi. Eighteen percent of the total were either dysplastic nevi (23 cases) or malignant melanoma in situ (three cases). Fourteen nevi (9.9%) had congenital features. There were 12 junctional and 39 compound nevi and one dermal nevus that exhibited nuclear abnormality, but only four junctional nevi compared with 19 compound nevi had sufficient atypia for a designation of dysplastic nevus. Only two nevi with congenital features demonstrated any nuclear abnormality, and these were clearly nondysplastic. Thus, among nevi surgically removed as the clinically most atypical lesion in this study, compound nevi were much more likely to demonstrate nuclear atypia (and dysplasia) than were other nevi, ie, junctional or dermal nevi, or nevi with congenital features.

Mycobacterium paratuberculosis and Crohn's disease. The possible aetiological role of Mycobacterium paratuberculosis in Crohn's disease was investigated. The immunological response was studied using an enzyme-linked immunosorbent assay (ELISA), Western blotting, and immunocytochemistry. The antibody response to two protoplasmic antigen preparations of M paratuberculosis in the sera of patients with inflammatory bowel disease was measured by ELISA. IgG and IgM antibodies to these antigens were measured in serum samples from 52 patients with Crohn's disease, 15 patients with ulcerative colitis, and 41 control patients without inflammatory bowel disease. Although there was wide variation in the concentrations of antibody detected, patients with Crohn's disease had concentrations that were not significantly different from those of the other two groups. In addition, mycobacterial antigens were separated by sodium dodecyl sulphate polyacrylamide gel electrophoresis and the immune response to each antigen was then examined separately and assayed for IgG and IgM in 10 patients from each of the three groups. An indirect peroxidase test was also used to detect M paratuberculosis in sections of tissue from 18 patients with Crohn's disease and 10 with ulcerative colitis. The results were negative in all cases. This study does not support a role for M paratuberculosis in Crohn's disease.

Mechanical factors in large artery disease and antihypertensive drugs. Hypertension may induce early alterations in large arteries by 2 mechanical stresses: one related to intravascular pressure, the other to blood flow dynamics. Distending pressure force acts in a circumferential direction, inducing decreased arterial distensibility. Arterial distensibility can be evaluated in humans by measurement of arterial compliance and pulse-wave velocity. It is well established that in chronic hypertension age and elevated pressure act together to increase arterial rigidity. Blood flow dynamics induce frictional forces in the endothelial surfaces of arteries. These forces, expressed by shear stress, are proportional to the viscosity of the blood and to the velocity gradient at the arterial wall. Measurement of blood viscosity and evaluation of velocity profile in the brachial arteries of hypertensive subjects have shown a reduction in wall shear rate and stress despite the elevation in blood viscosity. Several studies have shown that drug therapy that successfully reduces blood pressure does not necessarily improve arterial compliance. In contrast, few data are available on the effects of antihypertensive medication on arterial wall shear in humans. Arterial compliance and wall shear stress are 2 main therapeutic targets of potential importance in the physiopharmacologic approach to the effects of hypertension on atherogenesis.

Inflammatory abdominal aortic aneurysm: an indication for the retroperitoneal approach. In three recent cases, one of which is described in this report, we have found the retroperitoneal approach to have the following significant and distinct advantages over the transabdominal repair of inflammatory abdominal aortic aneurysms: (1) The posterolateral aspect of the aorta characteristically is not significantly involved by the inflammatory process, whereas the anterior aspect is. (2) The duodenum does not need to be dissected away from the aorta and, in fact, is not seen. (3) The left renal vein moves up off the neck of the aneurysm with forward mobilization of the kidney, facilitating proximal control. Now that the computerized tomography scan has become the preferred preoperative imaging technique for abdominal aortic aneurysms, the diagnosis of inflammatory abdominal aortic aneurysm can routinely be made before elective operation allowing the retroperitoneal approach to be selected.

Giant breast hematoma requiring blood transfusion: an unusual complication after an echocardiographic study during thrombolytic therapy. We report on a patient in whom significant bleeding occurred during thrombolytic therapy. The bleeding occurred after an echocardiographic study, and it resulted in blood transfusion.

Effect of weight reduction in moderately overweight patients on recorded ambulatory blood pressure and free cytosolic platelet calcium. Although platelet cytosolic calcium has been shown to decrease during pharmacological treatment of hypertension, there is no evidence that cytosolic calcium also falls during a nonpharmacological reduction in blood pressure. To provide such evidence, we examined prospectively the relation between platelet cytosolic calcium and ambulatory blood pressure during weight reduction in moderately overweight (body mass index [BMI] greater than 25), mildly hypertensive individuals. The experimental group (responders: BMI reduction greater than 5%) consisted of 19 patients who lost 8.5 +/- 2.9 kg (mean +/- SD, p less than 0.05) during a 10-week hypocaloric diet, whereas the control group (nonresponders: BMI reduction less than 5%) consisted of 12 patients who showed no relevant change in body weight (-2.0 +/- 1.3 kg) during the same period of time. The moderate weight loss of the responders decreased blood pressure by 14/5 mm Hg (p less than 0.05), as measured by ambulatory monitoring, which renders a placebo effect unlikely. This nonpharmacological reduction in blood pressure was accompanied by a proportional 11% decrease (p less than 0.05) in platelet cytosolic calcium and also by significant (p less than 0.05) decreases in plasma catecholamines and serum cholesterol. These findings establish the concept of a nonpharmacological reduction in free cytosolic platelet calcium in humans and add further evidence suggesting a link between intracellular calcium homeostasis and blood pressure regulation.

Usefulness of epidurally evoked cortical potential monitoring during cervicomedullary glioma surgery. This report describes a patient with an intramedullary ependymoma at the region of the cervicomedullary junction in whom there was an abolition of somatosensory evoked potentials following median nerve stimulation. During intraoperative monitoring of cortical potentials elicited by epidural cervical cord stimulation, the tumor was removed. Posterior epidural stimulation appeared to depolarize more ascending fibers than did stimulation of a single peripheral nerve. We recommend that, in cases of operations in this vital area, epidurally evoked cortical potentials be monitored intraoperatively.

Changes in high-energy phosphate metabolism and cell morphology in four models of acute experimental pancreatitis. Previous studies using the isolated ex vivo perfused canine pancreatitis preparation showed that during a 4-hour perfusion pancreatitis (edema, weight gain, hyperamylasemia) can be induced by four different stimuli. The stimuli include the intra-arterial infusion of oleic acid (FFA), a 2-hour period of ischemia before perfusion (ISCH), partial obstruction of the pancreatic duct with secretin stimulation (POSS), and the intra-arterial infusion of cerulein at supramaximal doses (CER). In the present study, changes in high-energy phosphate metabolism, as determined by nuclear magnetic resonance spectroscopy, and changes in cellular structure, determined by light and electron microscopy, were documented for all four models of acute pancreatitis. The control preparations remained stable for the 4-hour perfusion period, with no decrease in adenosine triphosphate (ATP) levels. In the FFA preparations, ATP decreased to 36% of baseline levels during the 4-hour perfusion (p less than 0.001). In the ISCH preparations, ATP decreased to undetectable levels during the 2-hour period of ischemia, but recovered rapidly and remained at baseline levels during the perfusion. ATP levels remained stable in the remaining two models of pancreatitis (POSS, CER). Microscopy demonstrated that the initial injury was located chiefly in the capillaries (swollen endothelium, intravascular thrombi) in the FFA and ISCH preparations. In the POSS and CER preparations, capillary changes were minimal and the injury was located chiefly in the acinar cells (swollen endoplasmic reticulum, zymogen granule depletion, vacuolization). The POSS preparations also showed striking dilation of centroacinar lumens reflecting duct obstruction. In additional studies it was shown that the ATP decline in the FFA preparations could be significantly reduced by pretreatment with free radical scavengers. The morphologic changes could be reduced by free radical scavengers in the FFA and ISCH preparations. Any amelioration of morphologic injury in the POSS preparations was obscured by dilatation of centroacinar lumens in both treated and untreated groups. The morphologic changes in the CER preparations were reduced by treatment with a cholecystokinin inhibitor.

Congenital angiotropic lymphoma (intravascular lymphomatosis) of the T-cell type. The autopsy of a stillborn infant showed an extensive intravascular proliferation of atypical cells throughout the body. There was no infiltration by these cells of the parenchyma of the bone marrow, lymph nodes, or thymus. By histochemistry, these cells were negative for naphthol-ASD-chloroacetate esterase, a marker of granulocytes. By immunohistochemistry, they were reactive with MT-1 and anti-Leu-22, but unreactive with MB-1, L26, anti-Leu-M1, Tu-9, and antihemoglobin antibodies. A few cells reacted with antileukocyte common antigen and UCHL-1. Based on these findings, the lesion was diagnosed as angiotropic lymphoma (intravascular lymphomatosis) of the T-cell type, which occurred congenitally. Most angiotropic lymphomas in the literature are of the B-cell type, and no leukemia virus type I antibody was negative in the mother.

Motor units in incomplete spinal cord injury: electrical activity, contractile properties and the effects of biofeedback. The electrical and contractile properties of hand muscles in a selected population of quadriplegic subjects were studied intensively before and after EMG biofeedback. Spontaneously active motor units and units that could only be slowly and weakly activated were observed in these subjects, in addition to units that were voluntarily activated normally. This suggests a considerable overlap of surviving motor neurons to a single muscle that are below, near or above the level of a lesion. Despite the common occurrence of polyphasic potentials and other signs of neuromuscular reinnervation, the average twitch tension of single motor units in hand muscles of quadriplegic subjects was not significantly different from that in control subjects. Nor did it increase after biofeedback training that typically increased the peak surface EMG by a factor of 2-5 times. The percentage of spontaneously active units was also constant. The surface EMG may be increased during biofeedback by using higher firing rates in motor units that can already be activated, rather than by recruiting previously unavailable motor units.

Mallory-Weiss syndrome after cardiopulmonary resuscitation. We report hematemesis from Mallory-Weiss tears after successful cardiopulmonary resuscitation (CPR). A computer search of the English language literature disclosed only 3 similar cases, and we review them. This complication of CPR may occur more frequently than recognized and should be prevented by careful technique.

Renal artery stent placement with use of the Wallstent endoprosthesis. The Wallstent endoprosthesis was placed in 12 renal arteries of 11 patients; a total of 15 stents were placed. Indications for placement were restenosis after dilation and insufficient result after dilation. In two patients, malpositioning of the stent required placement of a second stent. Complications included a case of massive cholesterol embolization and a case of unexplained transient hematuria, proteinuria, and deterioration of renal function. At repeat angiography of seven renal arteries after stent placement, one was occluded and required thrombolysis and dilation. Another showed restenosis due to shortening of the stent and required redilation and, later, placement of another stent. This stent became occluded after 1 month. In this patient and in three other cases, angiography disclosed tissue buildup in the stent but without significant stenosis after this short-term follow-up. After a clinical follow-up of 6.7 months +/- 3.4 in 10 patients treated for hypertension, three were cured, four were improved, and three were unchanged when blood pressure levels before stent placement were compared with those obtained after stent placement.

Obstructive sleep apnea presenting with nocturnal angina, heart failure, and near-miss sudden death. An obese woman with a one-year history of episodic nocturnal chest pain was admitted because of shock and pulmonary edema. A clinical diagnosis of acute myocardial infarction and cardiogenic shock was made. She was ventilated and successfully resuscitated. Subsequent investigations showed no evidence of cardiac dysfunction or coronary disease, but sleep study confirmed the diagnosis of obstructive sleep apnea syndrome (OSAS). We suggest that the nocturnal angina and heart failure in this patient might have resulted from extreme hypoxemia produced by OSAS. This case raised the possibility that the high cardiovascular mortality rate reported in OSAS might not necessarily relate to underlying coronary artery disease. Further investigations are required to delineate the true incidence of coronary disease in patients with OSAS.

The cancer experience in the Framingham Heart Study cohort. The almost 40-year records of The Framingham Heart Study (FHS) cohort were reviewed to establish the cancer experience of this noninstitutionalized group of white subjects. Diagnoses were confirmed from pathology and laboratory reports and clinical notes. Age-specific incidence rates were compared with Connecticut Surveillance, Epidemiology, and End Results (SEER) data. Among the 5209 subjects, 1201 malignancies were confirmed. Median age at diagnosis was 69 for men and 65 for women. Lung, prostate, skin, and colon accounted for more than half of men's cancers; breast, colon, and skin made up half of the women's. FHS and Connecticut SEER rates matched closely, with the same primary tumor sites appearing commonly in both groups. Thus, the FHS cohort should provide a fair database for analysis of risk factors in cancer incidence, as it has done in cardiovascular diseases.

Myelopathic neurosarcoidosis: diagnostic value of enhanced MRI. Neurosarcoidosis is an underdiagnosed variant of the systemic disease. We report a case of myelopathic neurosarcoidosis, noting the contribution made by MRI in establishing the diagnosis, and we discuss the possibility that the disease is differentially responsive to various steroid formulations.

Spinal cord stimulation: a contemporary series Forty-three patients with chronic pain disorders of different causes were selected for spinal cord stimulation. All underwent implantation of a ribbon electrode through a small laminotomy, under general anesthesia. Thirteen patients (30%) failed to obtain significant pain relief during a period of trial stimulation, and their electrodes were removed. The remainder underwent a definitive implant and were followed for a mean of 13 months (range, 3-33 months). Nineteen of them (63%) continued to experience pain relief. A detailed analysis of this series, as well as a literature review, is presented.

Manual stretch: effect on finger movement control and force control in stroke subjects with spastic extrinsic finger flexor muscles. This study evaluated the effects of manual stretch of extrinsic finger flexor muscles on finger extension movement control and force control in 16 spastic hemiparetic subjects. These subjects were randomly divided into a control group and an experimental group. A group of able-bodied subjects also participated. A joint-movement tracking test (JMTT) quantified control of active finger extension movement at the metacarpophalangeal joint of the index finger within the available range of active movement, and a force tracking test (FTT) quantified control of isometric finger extension force at the same joint within the subject's available force range. Electromyographic activity was monitored in the extensor digitorum and flexor digitorum superficialis muscles during both tracking tests. Manual stretch was applied to the extrinsic finger flexor muscles of the experimental group between the pretest and posttest tracking tests. The JMTT performances of both control (p less than .025) and experimental (p less than .05) groups were significantly subnormal on the pretest as were FTT performances of controls (p less than .01) and study subjects (p less than .03). The JMTT improvement on posttest was significantly greater (p less than .05) in subjects than in controls. However, the change in FTT performance was not significantly different between the two groups. Manual stretch treatment, properly applied to extrinsic finger flexor muscles, is an effective method of temporarily improving the control of finger extension movement in spastic hemiparetic subjects.

Emergent aneurysm surgery without cerebral angiography for the comatose patient Neurologically based clinical grading scales offer excellent prognostic information for the patient suffering diffuse subarachnoid hemorrhage (SAH). These grading scales are less applicable to patients with life-threatening intraparenchymal hematomas after aneurysmal rupture. During the last 3 years, four patients in a comatose state with brain stem compression syndromes documented by computed tomographic scans have undergone emergent operation in our neurosurgical service. Each patient was so critically ill that we believed it unwise to delay craniotomy for diagnostic angiography. The average delay from the onset of coma to skin incision was 3.02 hours (range, 1.67-6.5 hours), and the average delay from arrival in our unit until skin incision was 1.8 hours (range, 0.75-2.5 hours). The condition of two arousable patients deteriorated while they were in the emergency room, presumably from new bleeding. Each patient underwent craniotomy for hematoma evacuation, definitive aneurysm clipping, and lobectomy for decompression. Temporary clipping was employed in one patient, and intraoperative rupture occurred in two others. Three patients survived but retain significant disability. Emergent craniotomy with empiric exploration of appropriate subarachnoid cisterns after hematoma decompression may be life-saving in some cases. The delay imposed for diagnostic angiography may be avoided in attempts to save vital minutes of severe brain stem compression.

Long-term follow-up of medical versus surgical therapy for hypertrophic cardiomyopathy: a retrospective study In a retrospective analysis 139 patients with hypertrophic cardiomyopathy were followed up for 8.9 years (range 1 to 28 years). Patients were divided into two groups: Group 1 consisted of 60 patients with medical therapy and Group 2 of 79 patients with surgical therapy (septal myectomy). Groups 1 and 2 were subdivided according to the medical treatment. Group 1a received propranolol, 160 mg/day (n = 20); Group 1b verapamil, 360 mg/day (n = 18); and Group 1c, no therapy (n = 22). Group 2a received verapamil, 120 to 360 mg/day, after septal myectomy (n = 17) and Group 2b had no medical therapy after surgery (n = 62). In Group 1, 19 patients died (annual mortality rate 3.6%) and in Group 2, 17 patients died (mortality rate 2.4%, p = NS). Of the patients who died, approximately one half to two thirds in both Groups 1 and 2 died suddenly and the other one half to one third died because of congestive heart failure. The 10 year cumulative survival rate was 67% in Group 1, significantly smaller than that in Group 2 (84%, p less than 0.05). In the subgroups, the 10 year survival rate was 67% in Group 1a, 80% in 1b (p less than 0.05 versus 1a) and 65% in 1c (p less than 0.05 versus 1b). The 10 year survival rate was 100% in Group 2a (p less than 0.05 versus 1a, 1b, 1c) and 78% in Group 2b (p less than 0.05 versus 2a). It is concluded that cumulative survival rate is significantly better in surgically than in medically treated patients.

The determinants and prognostic significance of serum uric acid in elderly patients of the European Working Party on High Blood Pressure in the Elderly trial. Determinants and risks associated with serum uric acid were investigated in 822 elderly hypertensive patients treated with hydrochlorothiazide and triamterene or placebo. Pretreatment serum uric acid levels were significantly higher in men than in women and had positive correlation with serum creatinine. After adjustment for serum creatinine, positive correlations of serum uric acid with body weight and fasting blood glucose in women and with serum cholesterol in men were significant. During follow-up, serum uric acid increased significantly in the treated patients, but remained unchanged in the placebo group. Total, cardiovascular, and noncardiovascular mortality were unrelated to initial serum uric acid levels. One placebo patient and seven treated patients developed gout. Of those seven, most were male patients and had significantly higher serum levels of uric acid and creatinine than the other patients. Gender and renal function were the major determinants of serum uric acid in elderly hypertensive patients.