Pastoral care: finding a niche in ethical decision making

The last three articles within this section of Cambridge Quarterly have focused on organizations or disciplines outside the mainstream of bioethics that are making inroads within the field. This issue's article may be viewed as a departure, but it is not-my thesis is that despite the active presence of the clergy in the ethics field, individuals involved in pastoral care are often thought by health professionals, as well as by a sizeable number of pastors themselves, to not be within the mainstream of ethical decision-making for patients.

New voices ask to be heard in bioethics

The shape, function, and dynamic of the field of bioethics is in constant flux, and nowhere is this more apparent than at gatherings of those immersed in th discipline. This section presents coverage and commentary on conferences and settings where voices out-side the mainstream of biomedical ethics can be heard.

Etoposide in combination with cytarabine, doxorubicin, and 6-thioguanine for treatment of acute nonlymphoblastic leukemia in a protocol adjusted for age

Etoposide combined with cytarabine, doxorubicin, and 6-thioguanine was used to treat 34 patients with acute nonlymphoblastic leukemia (ANLL) in an age-adjusted protocol, with patients greater than 50 years old receiving fewer days of therapy. Complete remissions (CR) occurred in 85% of all patients (29 of 34 patients). Patients less than or equal to 50 years of age achieved a 94% CR rate (17 of 18 patients) compared to a 75% CR rate (12 of 16 patients) in older patients. Duration of remission was less for those greater than 50 years of age. The remission rate for primary ANLL was 86% (19 of 22 patients) and for secondary or relapsed ANLL was 83% (ten of 12 patients). Thus, this is effective therapy for primary and secondary or relapsed ANLL. When the days of therapy are reduced for older patients' age, the remissions are fewer and less durable.

Intimal proliferation of smooth muscle cells as an explanation for recurrent coronary artery stenosis after percutaneous transluminal coronary angioplasty

The pathologic changes in the coronary arteries of three patients who died 5, 17 and 62 days, respectively, after percutaneous transluminal coronary angioplasty were studied. Changes in the vessel wall seen early after angioplasty included focal denudation of the endothelium, splits in the intima extending to and along the inner aspect of the media, focal intimal necrosis and adventitial hemorrhage. Extensive medial dissections were seen in the coronary arteries of the two patients who died 5 and 17 days after coronary angioplasty. Fibrin was deposited on the surface of the intima, within intimal cracks and in areas of intimal and medial necrosis. Focal proliferation of smooth muscle cells was prominent on neointimal surfaces of the coronary artery from the patient who died 17 days after angioplasty. The previously dilated coronary segment from the patient who died 62 days after angioplasty was stenosed by an extensive recent proliferation of smooth muscle cells that were distributed over the entire circumference of the intimal surface as well as within gaps in the old atherosclerotic plaques. This type of intimal proliferation would appear to be responsible for the recurrent coronary artery stenosis that develops in some patients after coronary angioplasty.

Combined cardiac catheterization and carotid cineangiography: an analysis of complications

Two hundred fifty-three patients underwent cardiac catheterization with selective cineangiography of the carotid arteries. Diagnostic angiograms of both the right and left carotid arteries were obtained in 240 patients (95%). Of these, 217 patients (90%) were studied without complication, 18 (8%) had minor complications, and five (2%) had major complications. Four of the five major complications occurred in patients with bilateral carotid atherosclerosis obliterans. Variations of catheterization technique used in an effort to reduce risk are discussed.

Nosocomial infections: a glimpse into the '80s

The 1970s saw many changes in the way physicians dealt with infections. For example, greater emphasis was placed on specific risk environments rather than on the hospital's general physical environment and significant progress was made in controlling diseases such as post-transfusion hepatitis. Many challenges remain for the '80s, however, such as development of a data base to determine what infection control practices are the most cost-effective and development of a model for describing and measuring infection risk.

Late survival following use of intraaortic balloon pump in revascularization operations

The early and late results of intraaortic balloon pump (IABP) support in 197 patients with pure myocardial revascularization were analyzed. Group I, 61 patients, had IABP support initiated preoperatively; Group II, 99 patients, had IABP support in the operating room because of inability to be weaned from bypass; and Group III, 37 patients, had support instituted for persistent low cardiac output state in the postoperative period. The early results showed that 73% were discharged from the hospital and that delayed use of the IABP was associated with a high mortality and high rate of perioperative myocardial infarction. When the results between men and women were compared, no statistical difference was noted. After a mean follow-up of 18 months, there were 9 late deaths. Three were due to noncardiac causes. The two-year cardiac actuarial survival for the hospital survivors was 96% and all three groups had uniformly good symptomatic relief. After hospital discharge, the late results of patients who required use of the IABP in conjunction with pure myocardial revascularization were the same as for patients who did not require IABP support.

M-mode echocardiography in anteroseptal myocardial infarction. Lack of sensitivity

Eighteen patients with documented anteroseptal myocardial infarction (ASMI) were investigated with both cardiac catheterization and M-mode echocardiography. All had greater than 75% occlusion of the left anterior descending artery (LAD), proximal to the first septal perforator in 12, and distal to it in 6; 17 of 18 had abnormal septal motion by angiography. In contrast, echocardiography revealed abnormal septal motion in only 5 of 18; two others had diminished septal wall thickness in relation to posterior ventricular wall. The presence of these echocardiographic signs was not dependent either on relation of stenosis to septal perforators or on presence of septal collaterals. Although abnormal septal motion by M-mode echocardiography may indicate ASMI, normal motion does not exclude it nor does it help localize stenosis of the LAD.