Saphenous vein graft patency 1 year after coronary artery bypass surgery and effects of antiplatelet therapy. Results of a Veterans Administration Cooperative Study

To determine whether antiplatelet therapies improve saphenous vein graft patency after coronary artery bypass grafting, we compared 1) aspirin (325 mg once daily), 2) aspirin (325 mg three times daily), 3) aspirin and dipyridamole (325 mg and 75 mg, respectively, three times daily), 4) sulfinpyrazone (267 mg three times daily), and 5) placebo (three times daily). Therapy with dipyridamole and sulfinpyrazone was started 48 hours before bypass graft surgery, and aspirin treatment was begun 12 hours before surgery as a single 325-mg dose. Postoperative treatment was started 6 hours after surgery and continued for 1 year. Graft patency data were obtained early (median, 9 days) and late (median, 367 days) after surgery. The early graft occlusion rate was decreased with all aspirin treatment regimens compared with that of the placebo regimen. At 1 year, in 406 patients with 1,315 grafts, the graft occlusion rate in all of the aspirin groups combined was 15.8% compared with 22.6% for the placebo group (p = 0.029). The patients taking aspirin once daily had a lower occlusion rate (13.2%) compared with the patients receiving placebo (p = 0.050). At 1 year, in the vein grafts placed to vessels less than or equal to 2.0 mm in diameter (804 distal sites), the graft occlusion rate in all of the aspirin groups was 20.1% compared with 32.3% for the placebo group (p = 0.008). In the vein grafts placed to vessels greater than 2.0 mm in diameter (511 distal sites), there was no difference in the occlusion rates between aspirin and the placebo group at 1 year (8.7% vs. 9.0%, p = 0.918).(ABSTRACT TRUNCATED AT 250 WORDS)

The misconception of trauma reimbursement

As health care costs increase, hospital reimbursement from trauma victims is decreasing. Thus, the number of institutions dedicated to trauma care continues to decrease in this country. Two hundred eight consecutive patients admitted to a level 1 trauma center were evaluated during a 10-month period. The total bill for 207 patients was $4,044,156, averaging $19,537 per patient. Total reimbursement 6 months after billing was $2,054,090, 51% of the total bill. Methods to improve reimbursement include increasing the ratio of blunt to penetrating trauma victims and by assembling a team knowledgeable in reimbursement options. However, because a major portion of trauma reimbursement comes under federal government regulation, topics such as diagnostic related groups and other classification criteria of critically injured patients need to be reevaluated, or underpayment for trauma patients will continue to be a national plague.

Gastrointestinal complications after human transplantation and mechanical heart replacement

One hundred fifty-three patients underwent 159 heart transplants; 7 of these patients received 8 artificial hearts used as a bridge before implantation. The 1-year survival rate was 81 percent. One hundred forty gastrointestinal complications developed in 70 patients. Thirty-eight operations were required. Twenty-nine were intraabdominal operations. Of these, 22 were elective and 7 were emergency procedures. Five of the seven patients who underwent emergency procedures died, for an overall total mortality rate of 17 percent for major intraabdominal interventions. There were no complications or deaths in patients who underwent elective procedures. Major elective intraabdominal surgical interventions can be safely carried out in heart transplant patients. Repeated physical examination, aggressive use of endoscopy and imaging techniques, sound surgical judgement and a mutual relationship of trust and respect between cardiac and general surgeons are keys to a successful outcome.

Acute carpal tunnel syndrome in a patient taking coumadin

This is a case report of a 66-year-old female who had been taking coumadin for 4 weeks for deep vein thrombosis. She developed acute carpal tunnel syndrome following minor trauma to her wrist. After conservative therapy failed to relieve her symptoms she underwent release of her carpal tunnel with resolution of her symptoms. While there are many patients taking coumadin, its association with acute carpal tunnel syndrome is quite rare: we were only able to find only one other reported case in the literature. While one is tempted to treat these patients conservatively, operative therapy may be indicated.

The statistical analysis of graft patency data in a clinical trial of antiplatelet agents following coronary artery bypass grafting

Because most coronary artery bypass patients receive more than one graft at surgery, it is most important to determine whether statistical analysis of graft patency should be performed on the premise that the multiple grafts within patients are dependent or independent experimental units. Veterans Administration Cooperative Study No. 207 was a multicenter clinical trial comparing four different antiplatelet regimens to placebo in the prevention of graft occlusion following coronary artery bypass grafting. Using the results from the 1-week postoperative angiograms from the Veterans Administration Cooperative Study No. 207, in which there were 3.2 distal anastomoses per patient, we have tested the hypothesis that grafts within patients tend to act dependently with respect to patency or occlusion by comparing the graft patency data to a binomial distribution (i.e., that distribution that would have been manifest if grafts were independent). Because the graft patency results in Study No. 207 significantly deviated from the binomial distribution (p = 0.0003), a more appropriate analysis for graft patency data was applied using a ratio estimate as applied to cluster sampling. The statistical methods used in 11 previous clinical trials of antithrombotic therapy after coronary artery bypass grafting were examined. Only one of the previous studies used such an analysis, and three additional reports attempted to correct for dependency of grafts within patients in their analyses using other statistical methods. In seven of the studies the investigators did not address the potential problem of a dependent relationship between multiple grafts within patients. We conclude that grafts within patients act as dependent experimental units and that the ratio estimate as applied to cluster sampling may be appropriately applied to these data.

Diabetes and heart transplantation

Diabetes mellitus remains a relative contraindication to heart transplantation. From June 1985 to December 1987, 71 patients underwent heart transplantation. Fifty-seven patients were nondiabetic, and nine had preexisting diabetes mellitus. Four patients were insulin dependent and three were not. All operative survivors (66) from these two groups were compared for survival and numbers of rejection and infection. Actuarial survival in the group with diabetes mellitus was 100% and 97.7% in the group without diabetes. Immunosuppression was maintained with cyclosporine, azathioprine, and low-dosage prednisone. In the group with diabetes two patients were maintained without prednisone. Selected diabetic patients can have successful transplantations. There is no significant difference in survival between the diabetic and nondiabetic patient. There is a tendency toward more rejections and fewer infections among the diabetic patients. In our experience diabetes mellitus is not a contraindication to heart transplantation.

Improvement in early saphenous vein graft patency after coronary artery bypass surgery with antiplatelet therapy: results of a Veterans Administration Cooperative Study

To determine whether specific antiplatelet therapies improved vein graft patency after coronary artery bypass grafting (CABG) we compared (1) aspirin, 325 mg daily, (2) aspirin, 325 mg three times daily, (3) aspirin plus dipyridamole (325 mg and 75 mg, respectively, three times daily), (4) sulfinpyrazone (267 mg three times daily), and (5) placebo (three times daily). Therapy, except aspirin, was started 48 hr before CABG. When aspirin was a treatment, one 325 mg dose was given 12 hr before surgery and therapy was maintained thereafter according to the assigned regimen. Angiographic graft patency data were obtained within 60 days of surgery. Analysis of early graft patency in 555 patients (1781 grafts), revealed the following graft patency rates: aspirin daily, 93.5%; aspirin three times daily, 92.3%; aspirin and dipyridamole, 91.9%; and sulfinpyrazone, 90.2%. All aspirin-containing therapeutic regimens improved (p less than .05) graft patency compared with placebo (85.2%). Chest tube drainage measured within the first 35 hr after CABG revealed that the median loss with aspirin daily (965 ml), aspirin three times daily (1175 ml), and aspirin plus dipyridamole (1000 ml) exceeded (p less than .02) that with placebo (805 ml), while median loss with sulfinpyrazone (775 ml) did not. The reoperation rate was greater (p less than .01) in all the treatment groups that received aspirin (6.5%) compared with the two nonaspirin groups (1.7%). Overall operative mortality was 2.3%, without significant differences among treatment groups. Transient renal insufficiency occurred in 5.3% of patients taking sulfinpyrazone. Thus, early vein graft patency was improved after CABG with all aspirin-containing drug regimens.(ABSTRACT TRUNCATED AT 250 WORDS)

Computed tomography of adrenal abscess

We present a patient with a progressively enlarging adrenal mass detected by CT which extended to the renal hilum and inferior vena cava. Pathologic evaluation revealed an adrenal abscess containing purulent debris.

Dr. Copeland on cardiac transplantation. Interview by Monica Kalker

The following interview is an exchange between Jack Copeland, M.D., Robert Emery, M.D., and Anne Nicholson, R.N., members of the heart transplant team at the University of Arizona Medical Center in Tucson, Arizona. Dr. Copeland currently is the chief cardiac surgeon as well as professor and chief of Cardiovascular and Thoracic Surgery. Dr. Emery is an associate professor in the division of cardiothoracic surgery. Ms. Nicholson is a cardiac transplant coordinator for the Center. The University of Arizona's Heart Transplant program has proven itself in terms of actuarial survival, innovative approaches to recipients, surgical techniques, and with the maintenance of relatively short hospital stays and low costs to the patient.

Quantitative fluorometry as a monitor for microvascular surgery

There is a clear need for effective methods of monitoring for postoperative occlusion of vessels in microvascular surgery. We have evaluated one technique, quantitative fluorometry, in the laboratory and clinically. Our laboratory study used rat abdominal flaps under conditions of controlled occlusion. We found accurate detection of vascular occlusion within 20 minutes, but we were unable to differentiate arterial from venous occlusion. Our clinical review of 34 microvascular cases (14 free flaps and 20 replantations) that employed fluorometry revealed corroboration of occlusion (indicated by another monitoring technique) in six cases and a diagnosis at variance with other monitoring methods in one case, thus preventing an operative exploration. We recommend the use of quantitative fluorometry as a primary or adjunctive method of monitoring when patency is in question and have outlined a protocol for clinical use.

The cardiac donor: a six-year experience

From March 1, 1979, to March 1, 1985, the University of Arizona received 223 cardiac donor referrals. Sixty-two were accepted: 15 local, 23 regional (less than 370 km or 200 nautical miles), and 24 distant (370 to 1556 km or 200 to 840 nautical miles). Thirty-eight donor deaths were due to motor vehicle accidents, 10 to gunshot wounds, 6 to cerebral disease, and 8 to other closed-head lesions. The mean time from injury to brain death was 65 +/- 5 hours (+/- standard error of the mean [SEM]) and from brain death to organ donation, 12 +/- 3 hours. The mean ischemic time for the donor hearts ranged from 30 to 233 minutes (mean +/- SEM, 128 +/- 7 minutes). Fifty patients, otherwise acceptable, were refused as cardiac donors because an ABO-compatible recipient was not available. Two regionally procured hearts failed at operation, 1 because of unrecognized donor sepsis and 1 from a patient on large-dose inotropic support. Although there was no difference in myocardial function, median survival with follow-up through June 30, 1985, of patients receiving locally, regionally, and distantly procured organs was 59 months, 18 months, and 21 months, respectively. Cumulative proportion 1-year survival was 93%, 56%, and 61%, respectively. The 2-year survival was 85% for patients given locally procured hearts, 43% for those with regionally procured hearts, and 38% for those with a heart from a distant donor. Survival curves showed significantly longer survival for locally procured organs than regionally or distantly procured organs (p less than 0.05).(ABSTRACT TRUNCATED AT 250 WORDS)

Influence of the blood-brain pH gradient on brain phenobarbital uptake during status epilepticus

Brain uptake and blood concentrations of phenobarbital were determined in rats during pentylenetetrazol-induced status epilepticus and compared to nonconvulsing controls. Brain phenobarbital concentrations and the brain-to-blood phenobarbital ratio were increased 2-fold in freely convulsing animals as compared to controls. The degree of systemic acidosis during motor convulsions was greater than the degree of brain acidosis. Because phenobarbital is a weak acid, this pH gradient favors movement of phenobarbital into the brain during status epilepticus. Motor paralysis prevented the development of systemic acidosis and the brain-blood partition of phenobarbital was similar to that of nonconvulsing controls. Blood phenobarbital concentrations were slightly higher in animals paralyzed during status as compared to controls, presumably due to hemodynamic effects of convulsions. These studies, as well as our previous studies with lidocaine, support the idea that the brain-blood pH gradient is an important determinant of drug uptake by the brain during seizures.

Legionnaires' disease after heart transplantation

The cases of 8 heart transplant recipients with legionnaires' disease are reviewed. The diagnosis in each patient was made by fluorescent antibody stains or direct culture of the sputum, transtracheal aspirate, or fine needle aspirate of the lung. All patients were successfully treated with erythromycin alone or in combination with rifampin. Radiographic and clinical variations of legionnaires' disease as seen in the immunocompromised host are presented.

Psychological aspects of heart transplantation

In the past, psychological problems associated with HTx have not been well documented. We have identified six stages of psychological adjustment associated with the initial hospitalization and eight problem areas that develop after the initial hospitalization. Our approach has been to utilize psychiatric services for the initial evaluation and for intervention on an individual basis. This approach was extended in June, 1983, to include a family members support group, and we are now planning a support group for the HTx patients. The data from our multicenter survey indicates that other centers in the United States and England have had similar experience with their HTx recipients. The approach has been a "traditional" one, and there are no support groups like the ones we created at this time, although several centers are in the planning stages of this type of therapy. This inquiry represents the first attempt to address the psychological problems associated with HTx. It is a first step in learning to treat these patients as a whole. However, many issues remain unaddressed because the methods of this investigation were subjective. The patient population has yet to be studied intensely to identify how it perceives its own problems, and how those problems evolve during prolonged survival, one to five years after HTx. Are these latter problems the same as those experienced during that first post-operative year? Lastly, if other centers organize support groups, it would be useful to form a network that would allow a patient to attend the group closest to his home when he leaves the HTx center.

Pulmonary and aortic punctures--complications of an attempt at internal jugular venipuncture

A case of pulmonary and aortic punctures occurred during an attempted internal jugular venipuncture in a patient with a dilated aortic arch. Procedural errors contributing to the complications included an inexperienced operator, inappropriate medial and caudal angulation of the needle, and failure to use a "finder" needle or Seldinger technique. Use of proper procedural technique will reduce the risk of complications in performing this procedure.

Increased regional myocardial perfusion after intracoronary papaverine in patients after coronary artery bypass grafting

The objective of coronary artery bypass grafting (CABG) is to increase blood flow to ischemic areas of the myocardium. To determine if this was achieved, anterior wall myocardial perfusion was measured at rest and during intracoronary papaverine (5 mg), with the use of xenon-133 washout in 35 patients. Twelve control patients had no significant diameter narrowing (0% to 25%) of the left anterior descending coronary artery (LAD), 13 patients had greater than 50% narrowing of the LAD, and 10 patients had greater than 50% narrowing of the LAD with patent saphenous vein bypass grafts to the LAD. There was no significant difference in age. LVEDP, and global ejection fraction among the patients. There was no significant difference in anterior wall myocardial perfusion at rest between control subjects (61.0 +/- 3.7 ml/min/100 gm) and non-CABG LAD patients (60.2 +/- 5.4 ml/min/100 gm), or CABG LAD patients (63.4 +/- 4.8 ml/min/100 gm). After coronary arteriolar vasodilatation with papaverine, anterior wall perfusion increased in the CABG patients to 140.6 +/- 6.8 ml/min/100 gm. This was significantly greater (p less than 0.001) than the increase in the non-CABG LAD patients (72.8 +/- 8.1 ml/min/100 gm) but not different from the increase in the control subjects (145.3 +/- 8.4 ml/min/100 gm). In three cases, the same patients were studied before and after CABG with identical results. These data indicate that in patients with coronary disease, increases in myocardial perfusion are limited by the resistance of the proximal stenosis independent of vasodilatation distal to the stenosis. After successful CABG, the patent vein graft restores control of myocardial perfusion to the arteriolar bed.

The histopathologic evolution of recurrent herpes simplex labialis

In a study of the natural history of recurrent herpes simplex labialis, we examined hematoxylin and eosin-stained sections of biopsies taken from lesions at various clinical stages. The earliest specific findings which could be recognized were changes within the epidermal cell nuclei, including peripheral clumping of chromatin, development of homogeneous "ground glass" appearance, and ballooning of nuclei. Eosinophilic intranuclear inclusion bodies were unusual and occurred in late lesions. Vacuolization was the earliest cytoplasmic alteration within keratinocytes. The herpes-induced changes began focally along the basal cell layer, but the entire epidermis was rapidly altered. Pilosebaceous units were commonly affected. Within the dermis, no cells with typical herpesvirus-induced changes were seen. In early lesions, mononuclear and polymorphonuclear inflammatory cells were equally prominent; in later lesions neutrophils were most numerous. Histopathologic changes of recurrent herpes simplex begin multicentrically within the epidermis and are present prior to the onset of physical findings.

Legionnaires' disease following cardiac transplantation

The first two cases of Legionnaires' disease in heart transplant patients are reported. Of interest in these cases were culture of the organism from sputum, diagnosis by percutaneous lung aspiration, bronchopleural fistula formation in the first case, which was then successfully treated with multiple-tube thoracostomies, early cavitation of lesions in both cases after the start of antibiotic therapy, positive direct fluorescent antibody staining from transtracheal aspirate 42 days after starting appropriate antibiotic therapy in the first case, apparent superiority of intravenous erythromycin therapy in the first case, and survival of both patients. Our laboratory isolated and identified the organism in both cases.

Assessment of the older person in the community

The Cross-National Geriatric Community study is being conducted by the United States-United Kingdom Cross-National Project. Semi-structured interviews have been completed with over 850 community residents over the age of sixty-five years randomly selected from the metropolitan regions of New York and London. The assessment techniques described in this section may be of interest not only to other research workers conducting geriatric community surveys but also to health professionals concerned with the clinical examination of the older ambulatory patient and the early detection and appropriate referral of the need for health and social services.

The geriatric mental status interview (GMS)

The Geriatric Mental Status interview (GMS) is a semi-structured interview technique for assessing psychopathology in elderly patients. It is administered by a trained interviewer in a session of less than one hour. Between 100 and 200 question are asked and almost 500 items are rated. Twenty-one factor scores have been identified and the reliability of the ratings has been established. The interview is acceptable to the patient and is useful for making diagnostic distinctions and evaluation progress

Assessment of the older psychiatric inpatient

Instruments, whether used in psychometrics or in other fields, must have a practical application if they are to repay the care spent in their use and development. The Geriatric Mental State schedule was developed in response to the need to answer the question whether functional psychiatric disorders were being misdiagnosed as organic brain syndrome and, if so, to what extent this influenced treatment and outcome. In the hospitals studied it was found that American psychiatrists were more likely to diagnose organic brain syndrome than British psychiatrists. Although elderly patients with affective disorder were less likely to be given American patients was as good, if not better, than the outcome in the British patients.

Reliability of psychiatric assessment in older patients

A number of the causes of psychiatric diagnostic disagreement are discussed in this paper. The use of the Geriatric Mental Status interview to achieve diagnostic reliability is examined in three studies in which U.S.--U.K. Cross-National Project psychiatrists rated and diagnosed thirty-two British and twenty-one American patients. There were no systematic differences between U.S. and U.K. team members in their diagnoses; and agreement on six principal diagnostic categories was achieved in about three-quarters of the cases. The reliability fo the ratings of psychopathology that formed the basis for the diagnoses was satisfactory and is reported in detail.

Postoperative hemodynamics following aortic cross-clamping during aortocoronary bypass surgery

Forty-one patients undergoing aortocoronary bypass surgery were divided into two groups: an "unclamped" group (17 patients) in whom the aorta was not cross-clamped during operation and a "clamped" group (24 patients) in whom the ascending aorta was cross-clamped during performance of distal anastomoses. Myocardial protection was provided during aortic clamping by cooling the anoxic heart with cold saline immersion. Immediate postoperative hemodynamic function was assayed in both groups, as was cardiopulmonary bypass time and cardiopulmonary bypass time/graft. Cardiopulmonary bypass time was 107 minutes in the unclamped group and 87 minutes in the clamped group (P less than 0.05). Cardiopulmonary bypass time/graft was 48 minutes in the unclamped group and 40 minutes in the clamped group (P less than 0.01). Results of hemodynamic studies with values for the unclamped group listed first were as follows: cardiac index (L/min/m2) 2.3 and 2.5 (NS), stroke index (ml/beat/m2) 23 and 25 (NS), left ventricular minute work index (kg-m/min/m2) 3.03 and 2.81 (NS), and stroke work index (g-m/min/m2) 31 and 30 (NS). These data indicate that aortic cross-clamping during performance of distal anastomoses expedites the performance of aortocoronary bypass surgery and does not adversely affect postoperative hemodynamics.

Early functional and ultrastructural recovery of canine cadaver hearts

Simulation of sudden death in a potential heart graft donor was accomplished by producing acute anoxic arrest in canine hearts that were then maintained at cadaver temperature for periods of from 15 to 60 minutes prior to reperfusion with oxygenated blood. Functional recovery of reperfused hearts measured by contractile force was more rapid for hearts that had undergone shorter periods of anoxic arrest. The rates of recovery were nearly identical within the group for 15 to 25 minutes and for 30 to 45 minutes of anoxic arrest, but not for the 60-minute anoxic arrest group in which two of four hearts made no recovery at all.

Ultrastructural reactions to anoxic arrest were evident at 15 minutes and found to progress in a predictable manner as the duration of anoxia increased. Changes occurring during anoxic periods of up to 30 minutes were for the most part reversed within 1 hour of perfusion during which time characteristic nuclear, cytoplasmic, and mitochondrial "recovery patterns" were encountered. With a "pump-dog" preparation, these reperfused hearts were well kept for up to 7 hours. Anoxic arrest of 45 minutes or more produced ultrastructural changes that were less consistently reversed by reperfusion of 1 hour. The sensitivity of mitochondrial structure to anoxic arrest and reperfusion was demonstrated, and suggested that irreversible cell damage (i.e., cell death) in anoxia is due to mitochondrial failure. The techniques of perfusion and ultrastructural sampling employed in these experiments should prove useful in studying the effects of hypothermia, drug application and other measures in the preservation and restoration of isolated hearts.