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The use of ultrasonography to diagnose cholelithiasis has recently been recommended to supplement standard reinforced oral cholecystography or as an alternative to reinforced oral studies when a single dose fails to visualize the gallbladder. As yet the use of ultrasonography in the primary diagnosis of cholelithiasis is not generally accepted. To assess the specificity and sensitivity of this mode of diagnosis, fifty patients were reviewed retrospectively. The findings of ultrasonography are compared with standard oral cholecystography and with the pathologic findings. The results of this analysis suggest that diagnosis of cholelithiasis by ultrasonography has a high level of accuracy. Use of this mode of evaluating the gallbladder is suggested as a primary diagnostic test for jaundiced or pregnant patients.

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Exsanguinating retroperitoneal hemorrhage secondary to pelvic fractures is a frequent cause of death in the injured pedestrian. Attempts at lowering the mortality from these injuries have led to a variety of suggested treatment modalities, including observation, arterial ligation, or direct suturing of the bleeding sites. Arteriographic embolization is perhaps the newest modality but requires implementation of a rapid and efficient triage and treatment plan. Each of the suggested modalities and the formulation of such a treatment plan are discussed and a case report showing the feasibility of immediate arteriographic embolization as the preferred mode of management is presented.

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Use of the Fogarty balloon catheter for hemostasis in vascular trauma and difficult vascular dissections requires constant balloon inflation. A syringe holder to maintain balloon inflation without requiring constant attention of an assistant has been designed. Other applications of the syringe holder are discussed, including use with endotracheal tubes, gastrointestinal tubes, and for Fogarty balloon occlusion of pulmonary segments.

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Liposarcomas are common soft tissue tumors of the mediastinum and the retroperitoneum. Although they are rarely found in the greater omentum, when they occur in that area they can become enormous and be mistaken for pancreatic pseudocysts or ascitic distension. Recently, successful resection of a 10--kg liposarcoma of the omentum was performed at our institution. A description of the clinical presentation, preoperative assessment, and characteristics of this tumor are reported and the literature is surveyed. The use of adjuvant chemotherapy for these tumors is also discussed.

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The Bristow operation with its modifications has become a popular therapeutic modality for recurrent subluxation of the humerus. A patient was recently treated for a false aneurysm of the axillary artery six months after such a procedure. The artery had been lacerated by the dislodged fixation screw. The clinical presentation, intraoperative management and postoperative course were described, and a suggestion for removing the orthopedic screw eight weeks after a Bristow procedure was offered.

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A neonate with idiopathic brachial artery occlusion was recently treated at the San Bernardino County Medical Center. At birth, the right upper extremity was cold, pulseless and cyanotic. Arteriography demonstrated brachial artery occlusion, following which thrombectomy and postoperative heparinization resulted in a viable limb. This represents an unusual case of neonatal arterial occlusion with diagnostic preoperative arteriography and successful Fogarty thrombectomy. Possible etiological factors, treatment alternatives, and long term prognosis are discussed in this report.

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Cavitary pulmonary disease secondary to coccidioidomycosis occurs in endemic areas of the southwestern United States. Significant hemoptysis requiring pulmonary resection may develop in patients with cavitary lesions. In rare instances hemoptysis may be due to the development of a fungus ball within the cavity, and such mycetomas may contain spherule and mycelial forms of Coccidioides immitis. A patient with a documented coccidioidal cavity who had hemoptysis is described in this report. Chest radiograph revealed a fungus ball within a left lower lobe cavity. The patient underwent left lower lobectomy and recovered without complications. Examination of the resected left lower lobe disclosed a cavity containing a fungus ball comprised of mycelial and spherule forms of Coccidioides immitis. A review of the literature found three reports of biphasic growth of this condition within a coccidioidomycosis cavity and two additional cases of radiographically diagnosed coccidioidal mycetoma. Discussion of the potentially contagious nature, the medical and surgical management, and the prognosis of coccidioidal mycetoma form the basis of this report.

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The sporadic occurrence of several dermoid cysts of the head and neck in children led us to investigate the relative incidence in a series of 594 epidermal cysts in which 33 such lesions were found. We review the classification of dermoid cysts according to their embryogenesis and location to help avert diagnostic or therapeutic pitfalls. This study emphasizes the importance of adequate general anesthesia and excision of these interesting lesions.

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The growing number of reports of benign hepatic tumors occurring in young women who have been receiving oral contraceptive steroids has led us to review the 33 patients reported in the literature and to cite two additional case reports. By presenting two reports, one describing focal nodular hyperplasia and the other multiple hepatic cell adenomas, we hope to emphasize the pathological differentiation between these two lesions in order to calrify further reporting. Twelve of the 35 patients had massive intraperitoneal bleeding; two other patients had less severe hemoperitoneum. Five deaths have been reported. Although the frequency of use of these agents has become such that a direct relationship between them and benign hepatic tumors is not proved, the clinician should bear the association in mind when presented with women taking oral contraceptives who have abdominal pain. The review is made in the hope of stimulation further case reporting and microscopical and ultrastructural analysis. We trust that three will clarify the possible role of contraceptive steroids as predisposing or etiologic agents.

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