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Two women developed coumadin-induced skin necrosis. A 16-year-old woman sustained necrosis on the leg after a single dose of the drug, and a 59-year-old woman developed gangrene of most of her left breast.

Nine patients with morbid obesity were evaluated for the presence of Helicobacter pylon (Hp) before gastric reduction, and all were negative. Fifteen patients, Including those nine, were evaluated for the presence of Hp in antral and 'channel' region biopsies by culture and urease test after gastric reduction. Hp-negative patients totaled 73.3% by both tests, although chronic superficial gastritis type 'B' was found In eight out of 13 (61.5%), and six out of seven (85.7%) gastritis patients were positive for Holicobacter-like organisms in the hematoxylin- and eosin-stained biopsies. Our data suggest that in stomachs of morbid obesity patients before as well as after gastric reduction procedures, the incidence of Hp is very low, and the reasons for this observation are yet unknown.

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The rapid increase in the use of maintenance hemodialysis (MHD) for the treatment of end stage chronic renal failure in the last decade has given impetus to the development of methods for easy access to large blood vessels to make this form of treatment feasible over prolonged periods. The Scribner arteriovenous external shunt (1) was the first successful attempt. With good surgical technic and meticulous care afterwards, the external shunt may have a long life, often over a year (2, 3) . However, the usual cannula life is much shorter, ranging between 3 and 5 months only, infection and clotting being the frequent complications encountered (4, 5). Thus this method was soon found to be associated with considerable morbidity. The description of the internal arteriovenous fistula (AVF) in 1966 by Brescia and Cimino (6) was a big step forward in this field. They created a side to side anastomosis between the radial artery and a nearby vein, thus obtaining an arterialized vein which can be punctured with large needles with ease. Within a short time, this technic became the method of choice in most dialysis centers, because it is easier to manage and is better accepted by both patients and medical staff. It is relatively free of complications and its survival is much longer than that of the external shunt (8-12).However, we have found that in our hands the side to side anastomosis is not always easily performed and failure rates are relatively high. These difficulties have also been described by Salomon et al (11). Furthermore, in the obese female or in patients who have previously had operations on the blood vessels of their forearms, it is frequently impossible to find a vein near the available artery. In this paper we describe methods of modification of the original anastomoses : An end-vein side-artery anastomosis and a transplantation of a vein graft in the forearm, in an attempt to overcome these two problems and to establish a suitable AVF in the difficult extremities. MATERIAL Twenty-one patients with end stage renal disease (creatinine clearances 2-6 ml/min), had various types of internal arteriovenous anastomoses constructed for chronic hemodialysis. There were 14 male patients (ages 21-53 years) and 7 female patients (16-40 years old). The avarage age for all patients was 39 years.Four patients died during the period of the study-three from their disease, and one following renal transplantation. One patient is alive after transplanta-

A case of early postoperative inferior mesenteric arteriovenous fistula is described in a sixty-three-year-old man who underwent an anterior resection of the rectum for carcinoma.Six weeks after surgery, he developed increasingly severe rectal bleeding. A single incident of copious bleeding caused him to go into shock and require resuscitation. A selective angiography revealed an arteriovenous fistula of the inferior mesenteric artery, which was managed by embolization of the artery by three spring steel coils.These rare postoperative arteriovenous fistulae are probably caused by the incorporation of an artery and vein in a single stitch or ligature and usually present many years after surgery.