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Single-molecule counting techniques enable a precise determination of the intracellular abundance and stoichiometry of proteins and macromolecular complexes. These details are often challenging to quantitatively assess yet are essential for our understanding of cellular function. Consider G-protein-coupled receptors-an expansive class of transmembrane signaling proteins that participate in many vital physiological functions making them a popular target for drug development. While early evidence for the role of oligomerization in receptor signaling came from ensemble biochemical and biophysical assays, innovations in single-molecule measurements are now driving a paradigm shift in our understanding of its relevance. Here, we review recent developments in single-molecule counting with a focus on photobleaching step counting and the emerging technique of quantitative single-molecule localization microscopy-with a particular emphasis on the potential for these techniques to advance our understanding of the role of oligomerization in G-protein-coupled receptor signaling.

Approximately 20–30 % of patients who undergo Roux-en-Y gastric bypass (RYGB) will not meet the goals of weight loss surgery. Revisional surgery is associated with higher morbidity compared to initial operative management, and results in terms of weight loss have been inconsistent. Endoscopic plication has been seen as a less invasive option, with encouraging initial results. The objective was to analyze the outcomes after Restorative Obesity Surgery, Endolumenal (ROSE) procedure. We retrospectively analyzed patients who underwent ROSE between 5/2008 and 11/2013. All patients had failure of weight loss or regain weight after RYGB. Demographics, operative data, and follow-up were recorded. Twenty-seven patients underwent ROSE. One patient was excluded due to lack of follow-up. Twenty-five (96 %) patients were female. Mean time since initial RYGB was 11.9 ± 4.3 years. Mean initial weight and BMI were 236 ± 47 lb and 40.6 ± 8.1 kg/m2, respectively. Mean OR time was 77 ± 30 min. Preoperative average pouch length and stoma diameter were 6.8 ± 2.3 and 2.1 ± 0.7 cm, respectively. On average, 4 ± 1.6 stitches were placed. Final pouch length and stoma diameter were 3.4 ± 1.6 (50 % reduction) and 0.86 ± 0.4 cm (61 % reduction). A total of 12 (46 %) and seven (28 %) patients underwent EGD at 3 and 12 months postoperatively. The mean pouch length and stoma diameter were 5 ± 1.9 (26.5 % reduction) and 1.2 ± 0.7 cm (42.9 % reduction) at 3 months and 6.14 ± 1.6 (10 % reduction) and 2.2 ± 1.2 cm (4.7 % increase) at 12 months, respectively. The %EWL was 8.9, 9.3, 8, 6.7, −10.7, −13.5, −5.8, −4.5 at 3, 6, 12, 24, 36, 48, 60, and 72 months, respectively. Although endoscopic plication achieved the intended reduction in the pouch and stoma diameter at 3 months, these tend toward the preoperative diameter at 12 months. This anatomical failure and the lack of follow-up may explain why most patients failed to achieve sustainable weight loss.

It has been published that patients who underwent gastric bypass surgery have impaired alcohol metabolism, predisposing them to higher rates of intoxication and DUI arrests. Yet the impact of laparoscopic sleeve gastrectomy (LSG) on alcohol metabolism and in particular the long-term effects are still unclear. We hypothesized that LSG does not alter alcohol metabolism. A prospective cohort study of patients undergoing LSG was evaluated. Blood alcohol concentration (BAC) was extrapolated using a Breathalyzer®. Alcohol metabolism was evaluated by determining BAC every 5 min after a single dose of alcohol (5 oz. glass of 14 % v/v Malbec wine), until BAC was equal to zero. Subjects were queried about alcohol intoxication symptoms. All parameters were obtained and analyzed preoperatively and at 3 and 12 months postoperatively. Our study consisted of 10 patients (9 female) with a mean age of 46.6 ± 2.2 years and BMI of 43.5 ± 2.2 kg/m2. The mean percentage excess weight loss was 39.5 ± 3.3 at 3 months and 55.6 ± 4.4 at 12 months. Peak BAC at 20 min was not different at 3 months (0.068 ± 0.007, p = 0.77) or at 12 months (0.047 ± 0.008, p = 0.19) when compared to the preoperative assessment (0.059 ± 0.014). In addition, the time to BAC equal to zero was not significantly different between baseline and the follow-up values (preoperative: 70 ± 9 min, 3 months: 95 ± 18 min, and 12 months: 57 ± 8 min, (p > 0.05). Symptoms of intoxication were not significantly different in patients before and after surgery. Our study suggests that LSG does not alter alcohol metabolism. Patients who undergo LSG do not have higher levels of intoxication following alcohol consumption and are therefore not prone to higher rates of DUI charges than the general public, in contrast to that previously reported following in patients who undergo gastric bypass surgery.

Today laparoscopy is necessary in the diagnostic and therapeutic management of abdominal masses also in neonatal period. We report the case of a 28 days old girl admitted in our department with a prenatal diagnosis of abdominal mass. The ultrasound and CT scan revealed a 4 cm cyst in the right superior abdominal region. Instead the MRI revealed the mass localized in the right iliac region. A diagnostic laparoscopy with an open transumbilical approach was performed, that revealed an intra-abdominal 5 cm cystic formation with a thin vascular bundle. A minimal laparotomy was performed and the cyst removed. The histological examination indicated a self amputated ovarian cyst. Laparoscopy is proved to be a significant contribution in the diagnosis of abdominal masses because it allows a correct diagnosis and to plan the best management.

Object To retrospectively review the value of laparoscopy in the management of impalpable testis. Materials and methods In 1993–2006, 182 laparoscopies for impalpable testis were performed for a total of 194 testicular units. Five laparoscopic findings were considered: testicular ectopia, intra-abdominal testis, and cord structures that are blind ending, completely absent (agenesis) or entering the internal inguinal ring. Results In 62 cases an intra-abdominal testis was found; 18 were classified as high and managed by a laparoscopic Fowler–Stephens procedure. Cord structures entering the inguinal ring were observed in 77 patients and 45 underwent an inguinal exploration: a testis was found in 12 cases and in 33 a remnant was excised. In 35 cases, intra-abdominal blind ending vas and vessels were observed and eight showed testicular agenesis. No major surgical complications were recorded. Follow up ranged from 1 to 3 years. Conclusions Our study confirms the value of laparoscopy in the management of non-palpable testis, providing a definitive diagnosis by the direct view of spermatic bundle and testis. Ninety-three patients were managed by laparoscopy only, and in 44 it was essential for the subsequent surgical approach. When the internal inguinal ring is patent and/or normal spermatic vessels are present an inguinal exploration is mandatory.

& Aims: We describe our experience with botulinum- A toxin (BTX-A) in children presenting idiopathic overactive bladder (OAB) refractory to anticholinergic drugs. Material and Methods: 21 patients, aged 8 – 12 years, were treated over a 3-year period. BTX-A was administered at a dosage of 12.5 UI / kg body weight, without exceeding 200 UI, at 20 detrusor sites. To ensure a stable solution, each 100 UI of botulinum toxin was diluted with 5 cc saline solution just prior to performing the cystoscopy. Results: No patient presented with severe systemic complications or urinary retention after injection therapy; 6 patients presented with slight hematuria for 2 – 3 days. The clinical results were as follows. At 6 months, 8 / 21 patients (38 % ) showed full response, 12 / 21 (57 % ) had a partial response after a 2 nd injection, and 1 / 21 (4.7 % ) showed no response after a 2 nd injection. At 12 months, 16 patients (76 % ) had a full response, 4 (19 % ) showed a partial response after a 3 rd injection, and 1 patient (4.7 % ) still had no response. At 18 months, 18 patients (85 % ) showed a full response, 2 patients (9.5 % ) had a partial response, 1 patient (4.7 % ) had no response. At the end of this study, 8 / 21 patients (38 % ) were symptomfree, after only one botulinum detrusor injection, 13 / 21 patients (61.9 % ) received a second botulinum injection because of recurrence of urinary incontinence 6 – 7 months after the initial treatment, and 4 / 21 patients (19 % ) received a third injection 12 – 14 months after the initial treatment, of whom 2 had a full response and 2 had a partial response. Patient no. 20 refused any further botulinum treatment after the 2 nd unsuccessful injection series. Conclusion: Intravesical BTX-A injection appears to be safe and useful in children presenting with idiopathic overactive drug-resistant bladder.

Aim: In this article, we report our experience with diverticulectomies of symptomatic congenital bladder diverticula in children, which was performed by utilizing pneumovesicoscopy. Materials and Methods: Six boys, 4–8 years of age (mean, 5.6) underwent pneumovesicoscopic diverticulectomy at our institution from June 2007 to June 2008. There were 4 right-single diverticula and 2 double-left diverticula. Under cystoscopic control, after the cystopexy to the abdominal wall, a midline 5-mm trocar for a 0-degree telescope and two lateral 3-mm reusable trocars through the anterolateral wall of the bladder in the midclavicular line were introduced, insufflating the bladder with carbondioxide to 10–12mmHg pressure. The diverticulum=a were inverted into the bladder and the mucosa around the neck was circumcized by using scissors and a monopolar hook. The defect was sutured with interrupted sutures and the bladder was drained with a Foley catheter, which was introduced at the site of the 5-mm port, and a urethral catheter. Results: Mean operative time was 110 minutes. No major peri- or postoperative complications were recorded, except that the displacement of one of the lateral trocars that resulted in gas leakage in 1 case. The trocar was replaced and the procedure was completed. An ultrasound and a voiding cystourethrogram, performed from 3 to 6 months after the operation, showed the disappearance of the diverticulum=a. Conclusions: In our experience, pneumovesicoscopic diverticulectomy is an easy, safe procedure and can be considered a valid alternative to the open or laparoscopic procedures. It also provides no postoperative discomfort and a good cosmetic result.

Aim of the study: Gastrointestinal stromal tumors (GISTs) may now be considered to encompass mesenchymal tumors that express Kit protein (CD117) or have activating mutations of receptor tyrosine kinase genes (PDGFRA). The purpose of this study is to define clinicopathologic characteristics of gastric GISTs in children. Materials and Methods: We conducted a review of the literature from 1962 and enrolled 85 patients (younger than 16 years of age) with gastric GISTs, including two cases treated in our pediatric surgery unit. All the patients’ clinical data and followup information were reviewed, including age, gender, tumour size and localization, presence of Kit mutation and outcome. Case 1: A 16-year-old girl with a history of weakness and pallor. A computer tomography scan confirmed 4 gastric lesions. The lesion in the fundus was excised and an inferior-middle gastric resection was perfomed. At 3 years follow-up the patient presents a progression of liver metastasis. Case 2: A 13-year-old boy was referred to our pediatric surgery unit because of an ulcerated neoformation of 3-cm-sized located in the gastric antrum. The patient underwent laparotomy gastric wedge resection. At the follow-up of 9 years the patient was disease free. Results: Our results are based on our systematic review of 85 cases. The multifocal disease was identified in 21 children (25%). 10 patients are died, all patients presented liver metastases but only 1 had multiple nodules.

Laparoscopic and endoluminal surgical techniques have evolved and allowed improvements in the methods for treating benign and malignant gastrointestinal diseases. To date, only case reports have been reported on the application of a laparo-endoscopic approach for resecting gastric submucosal tumors (SMT). In this study, we aimed to evaluate the efficacy, safety, and oncologic outcomes of a laparo-endoscopic transgastric approach to resect tumors that would traditionally require either a laparoscopic or open surgical approach. Herein, we present the largest single institution series utilizing this technique for the resection of gastric SMT in North America.We performed a retrospective review of a prospectively collected patient database. Patients who presented for evaluation of gastric SMT were offered this surgical procedure and informed consents were obtained for participation in the study.Fourteen patients were included in this study between August/2010 and January/2013. Eight (8) patients (57.1 %) were female and the median age was 56 years (range 29-78). Of the 14 cases, 8 patients (57.1 %) underwent laparo-endoscopic resection of SMTs with transgastric extraction, 5 patients (35.7 %) had conversions to traditional laparoscopic surgery, and 1 patient (7.2 %) was abandoned intraoperatively. The median operative time for this cohort was 80 min (range 35-167). Ten patients (71.4 %) had GISTs, 3 (21.4 %) had leiomyomas, and 1 (7.1 %) had schwannoma. There were no intraoperative complications. Two patients had postoperative staple line bleeding that required repeat endoscopy. The median hospital stay was 1 day (range 1-6) and there were no postoperative mortalities. At 12-month follow-up visit, only one GIST patient (10 %) had tumor recurrence.Our experience suggests that this surgical approach is safe and efficient in the resection of gastric SMT with transgastric extraction. This study found no intraoperative complications and optimal oncologic outcomes during the follow-up period. Minimally invasive surgical approaches are emerging as a valid and potentially better approach for resecting malignancies; however, continued investigation is underway to further validate this data.

We report on studies aimed at employing the atomic force microscope (AFM) to measure the viscosity of aqueous solutions. At ambient temperature, the AFM cantilever undergoes thermal fluctuations that are highly sensitive to the local environment. Here, we present measurements of the cantilever’s resonant frequency in aqueous solutions of glycerol, sucrose, ethanol, sodium chloride, polyethylene glycol, and bovine plasma albumin. The measurements revealed that variations in the resonant frequency of the cantilever in the different solutions are largely dependent on the viscosity of the medium. An application of this technique is to monitor the progression of a chemical reaction where a change in viscosity is expected to occur. An example is demonstrated through monitoring of the hydrolysis of double stranded deoxyribonucleic acid by DNase I.

Aim.To retrospective review the laparoscopic management of Meckel Diverticulum (MD) in two Italian Pediatric Surgery Centers. METHODS: Between January 2002 and December 2012, 19 trans-umbilical laparoscopic-assisted (TULA) procedures were performed for suspected MD. The children were hospitalized for gastrointestinal bleeding and/or recurrent abdominal pain. Median age at diagnosis was 5.4 years (range 6 mo-15 years). The study included 15 boys and 4 girls. All patients underwent clinical examination, routine laboratory tests, abdominal ultrasound and technetium-99m pertechnetate scan, and patients with bleeding underwent gastrointestinal endoscopy. The abdominal exploration was performed with a 10 mm operative laparoscope. Pneumoperitoneum was established based on the body weight. Systematic overview of the peritoneal cavity allowed the ileum to be grasped with an atraumatic instrument. The complete exploration and surgical treatment of MD were performed extracorporeally, after intestinal exteriorization through the umbilicus. All patients' demographics, main clinical features, diagnostic investigations, operative time, histopathology reports, conversion rate, hospital stay and complications were registered and analyzed. RESULTS: MD was identified in 17 patients, while 1 had an ileal duplication and 1 a jejunal hemangioma. Fifteen patients had painless intestinal bleeding, while 4 had recurrent abdominal pain and exhibited cyst like structures in an ultrasound study. Eleven patients had a positive technetium-99m pertechnetate scan. In the patients with bleeding, gastrointestinal endoscopy did not name the source of hemorrhage. All patients were subjected to a TULA surgical procedure. An intestinal resection/anastomosis was performed in 14 patients, while 4 had a wedge resection of the diverticulum and 1 underwent stapling diverticulectomy. All surgical procedures were performed without conversion to open laparotomy. Mean operative time was 75 min (range 40-115 min). No major surgical complications were recorded. The median hospital stay was 5-7 d (range 4-13 d). All patients are asymptomatic at a median follow up of 4, 5 years (range 10 mo-10 years). CONCLUSION: Trans-umbilical laparoscopic-assisted Meckel's diverticulectomy is safe and effective in the treatment of MD, with excellent results. KEYWORDS: Gastrointestinal bleeding; Ileal duplication; Jejunal hemangioma; Laparoscopy; Meckel’s diverticulum; Minimal invasive surgery; One trocar surgery

In this paper it is presented the development of a telecommunications platform application to drive remotely a homing device, it is implemented an ‘any time-any where’ solution, where any user can access to a graphical interface located in an Internet Network domain where it is possible monitoring the mobile robot's route. The mobile vehicle design and building is presented according to the integration of a hardware/software application based on ZigBee wireless technology, Global Position System (GPS) and a digital compass. Also the interface allows to drive it easily and watch the mobile robot movement in real time. Finally the results are presented with the data taken in practice.

This paper presents an innovative acquisition, analysis and processing software for many GPS data bit streams provided from an electronic receiver, it is able to extract a great variety of information remotely and make possible monitoring it from Internet using IP. Some other technologies are needed on this application such a web server and ZigBee antennas in order to test the platform performance in a homing robot. The graphical interface design presented describes what data are acquired. Finally the results confirm the GPS location according the dispersion index in real time.

Protein structure prediction is one of the most important problems in bioinformatics and structural biology. This work proposes a novel and suitable methodology to model protein structure prediction with atomic-level detail by using a parallel multi-objective ab initio approach. In the proposed model, i) A trigonometric representation is used to compute backbone and side-chain torsion angles of protein atoms; ii) The Chemistry at HARvard Macromolecular Mechanics (CHARMm) function optimizes and evaluates the structures of the protein conformations; iii) The evolution of protein conformations is directed by optimization of protein energy contributions using the multi-objective genetic algorithm NSGA-II; and iv) The computation process is sped up and its effectiveness improved through the implementation of an island model of the evolutionary algorithm. The proposed model was validated on a set of benchmark proteins obtaining very promising results.

In the past 20 years a variety of indices have been suggested for measuring the severity of trauma, however none of them meets the requirement of being a simple and objective instrument that can be utilized efficiently by lay persons and providers of health services without previous experience in triaging. A new system has been proposed which meets this requirement and which has been validated with 197 injured persons at the emergency ward of the Valle University Hospital in Call, Colombia. The instrument showed a high level of concordance with the conventional triaging method and classifies victims into four categories: critical with recovery unlikely, critical but recoverable, moderately serious, and ambulatory. There is discussion on the reliability of this instrument and it is recommended that it be validated with victims from larger disasters. Regardless, it has the advantage of being specific and free of the subjectivity that characterizes other indices.

Il criptorchidismo e la mancata presenza di uno o di entrambi i testicoli nello scroto; l’incidenza e dell’ 1% a 1 anno di eta, del 3% nei nati a termine e del 33% nei prematuri. L’eziopatogenesi sembra essere multifattoriale per la possibile azione di diversi meccanismi: genetici, ormonali e meccanici. Circa il 20% dei pazienti criptorchidi ha un testicolo non palpabile; questo e tale perche agenesico, scomparso in utero (vanishing testis) o localizzato in addome a una distanza variabile dall’anello inguinale interno. La laparoscopia e la procedura piu efficace nella diagnostica del testicolo non palpabile e nella pianificazione chirurgica del testicolo intraddominale.

AIM: We report our experience with pneumovesicoscopic cross-trigonal ureteral reimplantation to correct primary vesicoureteral reflux (VUR) in children. MATERIAL AND METHODS: 14 children (10 girls, 4 boys, aged 4 to 12 years) with persistent VUR≥grade III (5 bilateral, 19 refluxing ureters) underwent pneumovesicoscopic Cohen's cross-trigonal reimplantation. Under cystoscopic control, a first midline 5-mm trocar was introduced for a 0°\30° telescope at the dome of the bladder, and 2 left and right 3- or 5-mm trocars were inserted through the anterolateral wall. The ureter was freed by creating a sharp plane between the detrusor muscle and the ureteral wall. If necessary, the ureter was tailored outside the bladder. Submucosal tunnel(s) were prepared with the help of scissors and graspers. The detrusor at the site of the ureter mobilization was repaired and ureteroneocystomy was performed using 4-5 interrupted absorbable sutures. A 12-Ch Foley catheter was introduced at the site of the dome port. The urethral and suprapubic catheters were removed 2-3 days after the procedure and the patients were discharged on day 3. RESULTS: One boy developed mild suprapubic emphysema postoperatively. Mean operating time was 136 min (range 80-230 min). No patient required conversion to the open technique. Renal US, VCUG, and MAG3 radionuclide scans were obtained in all patients between 3-6 months postoperatively, and provided evidence of reflux resolution in 13 out of 14 patients. CONCLUSION: Our experience seems to confirm that pneumovesicoscopic cross-trigonal ureteral reimplantation can be performed safely and effectively.

Syringocele is a cystic dilation of the excretory bulbourethral Cowper gland duct, and is a rather uncommon finding in pediatric age. It is frequently asymptomatic but sometimes may cause voiding symptoms and urinary tract infection (UTI). This case report describes an unusual manifestation of syringocele presenting with hydrocele. The case concerns a 2-year-old boy who was referred to our Clinic with a diagnosis of hydrocele. The patient underwent hydrocelectomy through a bilateral inguinal incision, but no clear communication with the patent peritoneal vaginal ducts could be demonstrated. The histology evidenced an epidermoid cyst. One year later the scrotal mass relapsed. Sonography, voiding cistography (VCG), computed tomography (CT) scan and magnetic resonance imaging (MRI) were performed. VCG, CT scan and MRI demonstrated the communication between the urethra and the scrotal mass. A surgical excision of the syringocele with endoscopic resection of the collar were performed. Syringocele is a rare entity in pediatrics. To this authors' knowledge there are no reports in the literature describing cases presenting with scrotal mass.

To explore the effect that Atropine, a competitive antagonist for the muscarinic acetylcholine receptor (mAChR), has on the response to LPS.Eight-week-old, male, B6 mice.Mice were treated with Atropine prior to, or after LPS challenge.Survival was monitored and analyzed via Kaplan-Meier analysis using the log-rank test. The effects of atropine on the inflammatory response (TNF-alpha, IL-6 and IL-10) were monitored at various time intervals following LPS injection in mice that were treated and not treated with atropine.Atropine administration prior to LPS induction of the inflammatory response resulted in reduced TNF-alpha and elevated IL-10 plasma levels without affecting the production of IL-6. This reduction in TNF-alpha levels was independent of the increase in IL-10 production. Atropine pretreatment improved the rate of survival from endotoxic shock in mice. The improved survival of mice after endotoxic shock could still be observed when atropine was administered several hours after LPS injection.The administration of atropine after injury may have a beneficial clinical effect.

An efficient method to analyze the electromagnetic field inside rectangular anechoic and semianechoic chambers from 30 to 100 MHz is shown. A modal expansion is employed to develop the homogeneous and the inhomogeneous field. This is combined with circuital techniques to compute the effect of the layers of ferrite and dielectrics in the walls of the chamber. Several numerical results of the Free Space Transmission Loss (FSTL) of an anechoic chamber and the Normalized Site Attenuation (NSA) of a semianechoic chamber are provided.

The paper shows how to model times series by using random iterated neural networks with place-dependent probabilities. The model assumes that the time series comes from a dynamical system which has a compact global attractor and a physical probability measure supported on the attractor. Also, an evolutionary algorithm is used to train a random iterated neural network that models a financial time series.

Background: The purpose of this study was to determine whether the incidence of recovery and patterns of antibiotic susceptibility of pathogenic bacteria vary between intensive care units (ICUs) in a single teaching hospital. Methods: Culture and susceptibility results were collected prospectively for a 3-month period (April through June 1999) in each of the surgical, trauma, and medical ICUs. The number of unique isolates and susceptibility patterns were determined. Susceptibility of isolates among ICUs was compared with X 2 . Results: Statistically significant differences between ICUs in susceptibility to various antibiotics were found for Staphylococcus aureus, Enterococcus sp, Acinetobacter sp, Enterobacter sp, Klebsiella sp, and Pseudomonas sp. Notably, vancomycin-resistant Enterococcus was not seen in the medical ICU, whereas it was seen in both the surgical and trauma ICUs. Klebsiella spp resistant to ceftazidime were seen only in the trauma ICU. The aminoglycosides and quinolones had attenuated activity against Pseudomonas sp in the surgical ICU, whereas they remained highly effective in the trauma ICU. Cefazolin had no activity against the Enterobacter sp in either of the surgical ICUs, but was highly effective in the medical ICU. Conclusion: Although the microbiologic results of this study should not be extrapolated to other institutions, the principle is of value. There is variability between ICUs in a single large teaching hospital in susceptibility of bacterial pathogens to various antibiotics. This may have implications in the design of empiric antibiotic strategies and the planning of the hospital formulary. Hospital wide or composite ICU antibiograms are inadequate for planning empiric therapy in the ICU.

Three patients with severe chronic lung disease had left ventricular failure develop with marked impairment of cardiac function. Ejection fractions by radioactive blood pool ventriculography were 0.17, 0.24, and 0.20. Right ventricular endomyocardial biopsy specimens showed interstitial hemorrhage and foci of interstitial polymorphonuclear leukocytes, strongly suggestive of catecholamine myocarditis. These patients had used beta-adrenergic agonist inhalants and methylxanthines. One of them clearly abused the inhalant and had elevated levels of urinary catecholamines. Progressive deterioration of pulmonary and cardiac function occurred in two patients, with death within three months of the initial myocardial biopsy. Concomitant use of beta-adrenergic agonists and methylxanthines may cause myocarditis with left ventricular failure in susceptible patients.

Three patients with severe chronic lung disease had left ventricular failure develop with marked impairment of cardiac function. Ejection fractions by radioactive blood pool ventriculography were 0.17, 0.24, and 0.20. Right ventricular endomyocardial biopsy specimens showed interstitial hemorrhage and foci of interstitial polymorphonuclear leukocytes, strongly suggestive of catecholamine myocarditis. These patients had used beta-adrenergic agonist inhalants and methylxanthines. One of them clearly abused the inhalant and had elevated levels of urinary catecholamines. Progressive deterioration of pulmonary and cardiac function occurred in two patients, with death within three months of the initial myocardial biopsy. Concomitant use of beta-adrenergic agonists and methylxanthines may cause myocarditis with left ventricular failure in susceptible patients.

The mortality rate of shock complicating myocardial infarction is extremely high (80-100%) despite intensive medical management. Five patients with acute myocardial infarction and cardiogenic shock received an emergency aorto-coronary bypass graft, from three hours to five days after the onset of infarction and three to nine hours after the onset of shock. Selective coronary angiography was performed in all cases prior to operation. Four of the five patients survived and were discharged from hospital. Two cases with A-V dissociation and complete heart block reverted to normal sinus rhythm after the operation. This limited experience indicates that emergency aortocoronary bypass graft surgery can reduce mortality significantly in properly selected cases of cardiogenic shock.