A 28 year old man had an acute myocardial infarction and was found to have coronary artery aneurysms. These may have been caused by a previous episode of Kawasaki's disease, an entity that should be considered in adults presenting with proximal discrete coronary artery aneurysms.

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Between 1970 and 1981, 12% of patients undergoing mitral valve surgery were found to have chordal rupture. Spontaneous or primary rupture accounted for 74.6% of patients (primary group); in the remainder (secondary group) chordal rupture complicated chronic rheumatic valvular disease (8.9%), bacterial endocarditis on both normal (8.5%) and rheumatic valves (4.7%), ischaemic heart disease (2.3%), acute rheumatic fever (0.5%), and osteogenesis imperfecta (0.5%). Isolated posterior rupture was seen most frequently (54%), with anterior rupture in 36% and rupture of both mitral cusps in 10% of patients. A short symptomatic history of acute mitral regurgitation was rare, occurring in only 4% of patients in either the primary or secondary groups, suggesting that mitral regurgitation due to ruptured chordae is a progressive disease. In contrast to previous reports the clinical presentation did not help to differentiate the aetiology of the chordal rupture.

During the period 1970-81, 183 patients underwent mitral valve surgery for chordal rupture. Of these, 82 (45%) patients were treated by mitral valve repair and 101 (55%) by mitral valve replacement. Mean age at surgery was 57 years. The early mortality was nine of 183 (4.9%) patients, of whom five had undergone replacement and four repair. During the follow up period (mean 3.6 years, range 0.8-12.2 years) a further 27 patients died; 23 of these had undergone mitral valve replacement and four mitral valve repair. Cerebrovascular events accounted for 35% of the deaths after mitral valve replacement and none of those after mitral valve repair. In 11 patients repair was technically unsatisfactory, and mitral valve replacement was undertaken at the same operation; a further five patients required late replacement (mean 1.4 years) for pronounced mitral regurgitation. Actuarial curves predict a six year survival of 68 +/- 5.7% (mean +/- SD) for all patients after mitral valve replacement compared with 88 +/- 6.9% (mean +/- SD) after repair (p less than 0.01). Actuarial survival curves favour mitral valve repair as the procedure choice for chordal rupture, and in isolated posterior cusp repair breakdown of the repair is a rare occurrence.

A 46 year old woman developed membranous nephropathy following the use of a mercury-containing skin lightening cream. This association has not been reported in the literature for over a decade and apparently never from this country. It is important that clinicians are aware of this usually eminently treatable cause of the nephrotic syndrome as it is likely to be missed unless specifically enquired for.

A survey of lumbar punctures performed in adults in a district general hospital over a two year period was carried out. As well as being used for conventional, specific indications, lumbar puncture was often employed as a screening investigation in undiagnosed neurological illness. Although this was not inappropriate in patients with meningeal symptoms and signs, or patients with disordered consciousness, lumbar puncture was also used in patients with focal neurological signs. Although the dangers of lumbar puncture in these latter patients, and the fact that it is unlikely to yield information unobtainable by other investigations have been stated by many authorities, almost 20% of patients fell into this group. This suggests that these points require further emphasis.