Femoral venoarterial extracorporeal membrane oxygenation for severe reimplantation response after lung transplantation

Severe pulmonary reimplantation response after lung transplantation is not very common, although the mortality can be high. We present a patient who developed an extremely severe reperfusion injury after bilateral lung transplantation. Because of severe hypoxia and hemodynamic instability, despite aggressive ventilator settings, venoarterial extracorporeal membrane oxygenation (ECMO) was instituted using the femoral approach at the bedside. During ECMO, the patient developed a thoracic wall hematoma that was treated with transfusion alone. After 50 h of ECMO, his chest radiograph had dramatically improved, his oxygen need had been reduced to 50%, and he was successfully weaned from ECMO. Two years later, he is doing extremely well. Therefore, institution of ECMO using the femoral approach can be performed safely at the bedside in the ICU, and can be lifesaving in the context of a very severe reimplantation response after lung transplantation.

Reliability and validity of the Critical Care Family Needs Inventory in a Dutch-speaking Belgian sample

OBJECTIVE

The purpose of the study was to provide psychometric evaluation of the Dutch version of the Critical Care Family Needs Inventory.

SETTING

The study took place in an intensive care unit of a university hospital.

PARTICIPANTS

The participant group included 200 adult family members visiting a patient within the 72-hour interval after admission to the intensive care unit.

RESULTS

Principal factor analysis with varimax rotation resulted in a 5-factor solution distinguishing 5 need types: need for information, need for comfort, need for support, need for assurance and anxiety reduction, and need for proximity and accessibility. The internal consistency of the resulting subscales ranged from 0.80 to 0.62, and all factors were significantly related to each other. The Critical Care Family Needs Inventory subscales were found to be clearly related to the demographic variables age, sex, and education level.

CONCLUSION

The reliability and validity of the Dutch-language Critical Care Family Needs Inventory as a diagnostic tool in family needs assessment are supported.

Stapled versus hand-sewn vascular anastomoses. An experimental study in the rabbit

OBJECTIVE

Narrowing of vascular anastomoses is a frequently encountered surgical problem, with intimal hyperplasia being one of its most important causes. The aim of the present study was to compare in a rabbit model 'manual' (hand-sewn) with 'stapled' anastomoses (using a staple device) with respect to occurrence and severity of intimal hyperplasia.

MATERIALS AND METHODS

Twenty-four male rabbits (mean weight 2,849 g) were randomly allocated to one of two groups (n = 12). An end-to-end anastomosis of the left femoral artery was performed in all animals under general anesthesia. The anastomosis was hand sewn in group 1, while a vascular closure stapler (VCS) was used in group 2. Both anastomotic time and total operation time were recorded. After 28 days, the rabbits were sacrificed. The femoral artery of operated and nonoperated sides were removed and prepared for anatomopathological examination. The I/M ratio (= difference between tunica intima and tunica media) was determined on hematoxylin-eosin stained slides. All results were analyzed using Student's t test.

RESULTS

Mean anastomotic times were 25 +/- 7 min for the 'manual' group and 17 +/- 9 min for the 'stapled' group (p = 0.02). There was no significant difference in the total operation time (55 +/- 15 vs. 41 +/- 18 min, p = 0.057). All animals survived the anastomosis procedure. In the group of 'manual' anastomosis, morbidity was significantly higher. At the moment of sacrifice, all anastomoses were patent. There was no difference in the I/M ratio between the groups.

CONCLUSIONS

The use of VCS is a promising alternative to hand-sewn anastomoses. It takes less time to perform a stapled anastomosis, the technique has a shorter learning period and morbidity seems to be lower when vascular anastomoses are applied with the VCS in this rabbit model.

Lamellar bone formation in an atherosclerotic plaque of the carotid artery, with a review of histogenesis--a case report

Longer existing atherosclerotic lesions may contain calcifications; lamellar bone rarely develops within them. A 59-year-old man was referred with a progressive stroke. A high-grade stenosis of the left common carotid artery, formed by an ulcerating atherosclerotic plaque with a free-floating thrombus, was detected on angiography. An urgent endarterectomy was performed. Surprisingly this plaque contained pieces of lamellar bone, proved by histologic examination.

The effect of CO2 pneumoperitoneum on the growth of a solid colon carcinoma in rats

BACKGROUND

In order to investigate the effect of carbon dioxide (CO(2)) pneumoperitoneum on solid colon carcinomas, we used a colon anastomosis tumor model in 30 male syngeneic WAG rats, which were divided, at random into three groups.

METHODS

In all rats, 10(6) CC531 S colon carcinoma cells were injected as an enema into the colon. Subsequently, a transection and a reanastomosis of the colon descendens was performed via laparotomy. After 2 weeks, group 1 (n = 10) was anesthetized as an anesthesia control group. Group 2 (n = 10) had a laparotomy that was closed after 20 min. In group 3 (n = 10), a CO(2) pneumoperitoneum of </=6 mmHg was created and maintained during 20 min. After 2 weeks, all rats were killed, and total tumor weight and volume was measured.

RESULTS

At necroscopy tumor growth was found in 16 rats (group 1: six; group 2: five; group 3: five). No difference in tumor growth (weight or volume) was found between the three groups.

CONCLUSION

In our solid colon carcinoma model, CO(2) pneumoperitoneum did not enhance tumor growth.

Effects of suramin on anastomotic colon tumors in a rat model

BACKGROUND

The development of antiangiogenic drugs offers new promise in the treatment of malignancy. Suramin has been reported to inhibit tumor growth by blocking angiogenesis and has been used in clinical trials. The aim of the present study was to examine the effects of suramin on colonic anastomotic tumors in the rat.

METHODS

(a) Colonic anastomotic tumor was induced in 120 WAG/RIJ rats. Half of the animals were given 100 mg/kg of suramin intraperitoneally at the time of tumor induction. Rats were sacrificed after 2, 4 and 8 weeks; tumor take and tumor weight were evaluated. (b) The number of red blood cell clusters per x 400 field was counted in each tumor. (c) A lymphocyte transformation test was performed in four groups of animals, 2 weeks before and 2 weeks after tumor implantation and/or suramin administration.

RESULTS

(a) A significant enhancement of tumor growth was observed in the suramin-treated animals. (b) This was accompanied by a significant increase in functional blood vessels. (c) Suramin-treated rats had markedly decreased lymphocyte stimulation, pointing to a possible immunosuppressive effect.

CONCLUSIONS

The growth of an anastomotic colon tumor is rather enhanced by a single intraperitoneal administration of 100 mg/kg suramin in the rat, possibly by an unexpected immunosuppressive effect.

Comparison between plain and gentamicin containing collagen sponges in infected peritoneal cavity in rats

OBJECTIVE

To study the usefulness of gentamicin-containing sponges in the infected peritoneal cavity in rats.

DESIGN

Controlled study.

MATERIAL

83 Male Wistar rats, 36 of which were treated by plain sponge, 36 by gentamicin-impregnated sponge, and 11 acted as controls.

INTERVENTIONS

A standard model of intraperitoneal infection was developed by making a 1 cm long incision in the caecum.

MAIN OUTCOME MEASURES

Postoperative mortality, macroscopic and microscopic features of infection, and bacterial concentrations in the abdomen on days 3, 6, and 9.

RESULTS

In the respective groups 2, 3 and 2 animals died during operation and 4/34 (11%), 3/33 (9%); and 0/9 died before day 3. There were appreciable reductions in the number of animals with features of infection after 3 days but these were not significant at 6 or 9 days.

CONCLUSION

Gentamicin-containing collagen sponges placed on a septic focus in the abdomen reduce local infection for at least 3 days.

Neuroendocrinology of prolonged critical illness: effects of exogenous thyrotropin-releasing hormone and its combination with growth hormone secretagogues

The catabolic state of prolonged critical illness is associated with a low activity of the thyrotropic and the somatotropic axes. The neuroendocrine component in the pathogenesis of these low activity states was assessed by investigating the effects of continuous intravenous infusions of TRH, GH-releasing peptide-2 (GHRP-2), and GHRH. Twenty adult patients, critically ill for several weeks, were studied during two consecutive nights. They had been randomly allocated to one of three combinations of peptide infusions, each administered in random order: TRH (one night) and placebo (other night), TRH + GHRP-2 (one night) and GHRP-2 (other night), or TRH + GHRH + GHRP-2 (one night) and GHRH + GHRP-2 (other night). The peptide infusions were started after a 1-microgram/kg bolus and infused (1 microgram/kg per h) until 0600 h. Blood sampling was performed every 20 min, and pituitary hormone secretion was quantified by deconvolution analysis. Reduced pulsatile fraction of TSH, GH, and PRL secretion and low serum concentrations of T4, T3, insulin growth factor-I (IGF-I), IGF-binding protein-3 (IGFBP-3), and the acid-labile subunit (ALS) were documented in the untreated state. Infusion of TRH alone or in combination with GH secretagogues augmented nonpulsatile TSH release 2- to 5-fold; only TRH + GHRP-2 increased pulsatile TSH secretion (4-fold). Average rises in T4 (40-54%) and in T3 (52-116%) were obtained with all three combinations, whereas reverse T3 levels did not increase, except when TRH was infused alone. Pulsatile GH secretion was amplified > 6- and > 10-fold, respectively, by GHRP-2 and GHRH + GHRP-2 infusions, generating mean increases of serum IGF-I (66% and 106%), IGFBP-3 (50% and 56%), and ALS (65% and 97%) within 45 h. The addition of TRH did not alter the GH secretory patterns. TRH infusion increased PRL release only when combined with GH secretagogues. No effects on serum cortisol were detected. In conclusion, the pathogenesis of the low activity state of the thyrotropic and somatotropic axes in prolonged critical illness appears to have a neuroendocrine component, because these axes are both readily activated by coinfusion of TRH and GH secretagogues.

Thyrotrophin and prolactin release in prolonged critical illness: dynamics of spontaneous secretion and effects of growth hormone-secretagogues

OBJECTIVE

Infusion of GH secretagogues appears to be a novel endocrine approach to reverse the catabolic state of critical illness, through amplification of the endogenously blunted GH secretion associated with a substantial IGF-I rise. Here we report the dynamic characteristics of spontaneous nightly TSH and PRL secretion during prolonged critical illness, together with the concomitant effects exerted by the administration of GH-secretagogues, GH-releasing hormone (GHRH) and GH-releasing peptide-2 (GHRP-2) in particular, on night-time TSH and PRL secretion.

PATIENTS AND DESIGN

Twenty-six critically ill adults (mean +/- SEM age: 63 +/- 2 years) were studied during two consecutive nights (2100-0600 h). According to a weighed randomization, they received 1 of 4 combinations of infusions, within a randomized, cross-over design for each combination: placebo (one night) and GHRH (the next night) (n = 4); placebo and GHRP-2 (n = 10); GHRH and GHRP-2 (n = 6); GHRP-2 and GHRH + GHRP-2 (n = 6). Peptide infusions (duration 21 hours) were started after a bolus of 1 microgram/kg at 0900 h and infused (1 microgram/kg/h) until 0600 h.

MEASUREMENTS

Serum concentrations of TSH and PRL were determined by IRMA every 20 minutes and T4, T3 and rT3 by RIA at 2100 h and 0600 h in each study night. Hormone secretion was quantified using deconvolution analysis.

RESULTS

During prolonged critical illness, mean night-time serum concentrations of TSH (1.25 +/- 0.42 mlU/l) and PRL (9.4 +/- 0.9 micrograms/l) were low-normal. However, the proportion of TSH and PRL that was released in a pulsatile fashion was low (32 +/- 6% and 16 +/- 2.6%) and no nocturnal TSH or PRL surges were observed. The serum levels of T3 (0.64 +/- 0.06 nmol/l) were low and were positively related to the number of TSH bursts (R2 = 0.32; P = 0.03) and to the log of pulsatile TSH production (R2 = 0.34; P = 0.03). GHRP-2 infusion further reduced the proportion of TSH released in a pulsatile fashion to half that during placebo infusion (P = 0.02), without altering mean TSH levels. GHRH infusion increased mean TSH levels and pulsatile TSH production, 2-fold compared to placebo (P = 0.03) and 3-fold compared to GHRP-2 (P = 0.008). The addition of GHRP-2 to GHRH infusion abolished the stimulatory effect of GHRH on pulsatile TSH secretion. GHRP-2 infusion induced a small increase in mean PRL levels (21%; P = 0.02) and basal PRL secretion rate (49%; P = 0.02) compared to placebo, as did GHRH and GHRH + GHRP-2.

CONCLUSIONS

The characterization of the specific pattern of anterior pituitary function during prolonged critical illness is herewith extended to the dynamics of TSH and PRL secretion: mean serum levels are low-normal, no noctumal surge is observed and the pulsatile fractions of TSH and PRL release are reduced, as was shown previously for GH. Low circulating thyroid hormone levels appear positively correlated with the reduced pulsatile TSH secretion, suggesting that they have, at least in part, a neuroendocrine origin. Finally, the opposite effects of different GH-secretagogues on TSH secretion further delineate particular linkages between the somatotrophic and thyrotrophic axes during critical illness.

The somatotropic axis in critical illness: effect of continuous growth hormone (GH)-releasing hormone and GH-releasing peptide-2 infusion

Prolonged critical illness is characterized by protein hypercatabolism and preservation of fat depots, associated with blunted GH secretion, elevated serum cortisol levels, and low insulin-like growth factor I (IGF-I) concentrations. In this condition, GH is readily released in response to a bolus of GHRH and GH-releasing peptide-2 (GHRP-2) and, paradoxically, to TRH. We further explored the altered somatotropic axis and cortisol secretion in critical illness by examining the effects of continuous GHRH and/or GHRP-2 infusion. Twenty-six critically ill adults (mean age +/- SEM, 63 +/- 2 yr) were studied during 2 consecutive nights (2100-0600 h). According to a weighed randomization, they received one of four combinations of infusions within a randomized cross-over design for each combination: placebo (one night) and GHRP-2 (the other night; n = 10), placebo and GHRH (n = 4), GHRH and GHRP-2 (n = 6), and GHRP-2 and GHRH plus GHRP-2 (n = 6). The peptide infusions (duration, 21 h) were started after a bolus of 1 microgram/kg at 0900 h and infused (1 microgram/kg/h) until 0600 h. Serum concentrations of GH were determined every 20 min, cortisol every hour, and IGF-I at 2100 and 0600 h on each study night. The placebo profiles showed pulsatile GH secretion with low secretory burst amplitude [0.062 +/- 0.008 microgram/L distribution volume (Lv)/min], high burst frequency (6.6 +/- 0.4 events/9 h), and detectable basal secretion (0.041 +/- 0.009 microgram/L/min) in the face of low serum IGF-I (106 +/- 11 micrograms/L). IGF-I correlated positively and significantly with the basal component, the pulsatile component, and the total amount of nightly GH secretion. GHRH elicited a 2- to 3-fold increase in the mean GH concentration (P = 0.006), the GH secretory burst amplitude (P = 0.007), and basal GH secretion (P = 0.03). GHRP-2 provoked a 4- to 6-fold increase in the mean GH concentration (P < 0.0001), the GH secretory burst amplitude (P = 0.002), and basal GH secretion (P = 0.0007), which were associated with a 61 +/- 13% increase in serum IGF-I within 24 h (P = 0.02). Compared to GHRP-2 alone, GHRH plus GHRP-2 elicited a further 2-fold increase in the mean GH concentration (P = 0.04) and GH basal secretion (P = 0.02), and an additional 40 +/- 6% rise in serum IGF-I (P = 0.04). GHRH and GHRP-2 infusion did not alter elevated cortisol levels. In critically ill adults, low serum IGF-I levels were positively correlated with diminished pulsatile and increased basal GH secretion. Both basal and pulsatile GH secretion were moderately increased by continuous infusion of GHRH, substantially increased by GHRP-2, and strikingly increased by GHRH plus GHRP-2. GHRP-2 alone or combined with GHRH elicited a robust rise in circulating IGF-I levels within 24 h without altering serum cortisol levels. These findings open perspectives for GH secretagogues as potential antagonists of the catabolic state in critical care medicine.

Randomized, controlled trial of selective digestive decontamination in 600 mechanically ventilated patients in a multidisciplinary intensive care unit

OBJECTIVE

To evaluate the efficacy of two regimens of selective decontamination of the digestive tract in mechanically ventilated patients.

DESIGN

Prospective, randomized, concurrent trial.

SETTING

Multidisciplinary intensive care unit (ICU) in a 1,800-bed university hospital.

PATIENTS

Consecutive patients (n = 660) who were likely to require mechanical ventilation for at least 48 hrs were randomized to one of three groups: conventional antibiotic regimen (control group A); oral and enteral ofloxacin-amphotericin B (group B); and oral and enteral polymyxin E-tobramycin-amphotericin B (group C). Both treatment groups received systemic antibiotics for 4 days (ofloxacin in group B and cefotaxime in group C).

INTERVENTIONS

Patients were randomized to receive standard treatment (control group A, n = 220), selective decontamination regimen B (group B, n = 220), and selective decontamination regimen C (group C, n = 220). After early deaths and exclusions from the study, 185 controls (group A) and 193 (group B)/200 (group C) selective decontamination regimen patients were available for analysis.

MEASUREMENTS AND MAIN RESULTS

Measurements included colonization and primary/secondary infection rate, ICU mortality rate, emergence of antibiotic resistance, length of ICU stay, and antimicrobial agent costs. The study duration was 19 months. The patient groups were fully comparable for age, diagnostic category, and severity of illness. One third of patients in each group suffered a nosocomial infection at the time of admission. There was a significant difference between treatment group B and control group A in the number of infected patients (odds ratio of 0.42, 95% confidence interval of 0.27 to 0.64), secondary lower respiratory tract infection (odds ratio of 0.47, 95% confidence interval of 0.26 to 0.82), and urinary tract infection (odds ratio of 0.47, 95% confidence interval of 0.27 to 0.81). Significantly more Gram-positive bacteremias occurred in treatment group C vs. group A (odds ratio of 1.22, 95% confidence interval 0.72 to 2.08). Infection at the time of admission proved to be the most significant risk factor for subsequent infection in control and both treatment groups. ICU mortality rate was almost identical (group A 16.8%, group B 17.6%, and group C 15.5%) and was not significantly related to primary or secondary infection. Increased antimicrobial resistance was recorded in both treatment groups: tobramycin-resistant enterobacteriaceae (group C 48% vs. group A 14%, p < .01), ofloxacin-resistant enterobacteriaceae (group B 50% vs. group A 11%, p < .02), ofloxacin-resistant nonfermenters (group B 81% vs. group A 52%, p < .02), and methicillin-resistant Staphylococcus aureus (group C 83% vs. group A 55%, p < .05). Antimicrobial agent costs were comparable in control and group C patients; one third less was spent for group B patients.

CONCLUSIONS

In cases of high colonization and infection rates at the time of ICU admission, the preventive benefit of selective decontamination is highly debatable. Emergence of multiple antibiotic-resistant microorganisms creates a clinical problem and a definite change in the ecology of environmental, colonizing, and infecting bacteria. The selection of multiple antibiotic-resistant Gram-positive cocci is particularly hazardous. No beneficial effect on survival is observed. Moreover, selective decontamination adds substantially to the cost of ICU care.

Oesophagopleural fistula--a rare sequel of pneumonectomy

Postpneumonectomy oesophagopleural fistula (OPF) is a devastating situation occurring in 0.2-1.0% of the patients undergoing pneumonectomy. Distinction is made between OPF appearing after pneumonectomy for chronic inflammation and suppuration, and OPF after pneumonectomy for lung cancer. Early and late fistulas (the former appearing within three months of the operation) are found in both groups. We report a case of OPF occurring almost five years after pneumonectomy for malignant lymphoma of the lung. Common signs of OPF are postpneumonectomy empyema and presence of previously ingested food particles in the empyema cavity. Treatment is extremely difficult and prolonged, and often not successful. Amelioration of the nutritional status, drainage of the postpneumonectomy space and closure of the fistula by injecting a sclerosing substance should be attempted. If this fails, the fistula should be closed by direct suture reinforced by a muscular or omental flap.

Pituitary responsiveness to GH-releasing hormone, GH-releasing peptide-2 and thyrotrophin-releasing hormone in critical illness

OBJECTIVE

Protein hypercatabolism and preservation of fat depots are hallmarks of critical illness, which is associated with blunted pulsatile GH secretion and low circulating IGF-I, TSH, T4 and T3. Repetitive TRH administration is known to reactivate the pituitary-thyroid axis and to evoke paradoxical GH release in critical illness. We further explored the hypothalamic-pituitary function in critical illness by examining the effects of GH-releasing hormone (GHRH) and/or GH-releasing peptide-2 (GHRP-2) and TRH administration.

PATIENTS AND DESIGN

Critically ill adults (n = 40; mean age 55 years) received two i.v. boluses with a 6-hour interval (0900 and 1500 h) within a cross-over design. Patients were randomized to receive consecutively placebo and GHRP-2 (n = 10), GHRH and GHRP-2 (n = 10), GHRP-2 and GHRH+GHRP-2 (n = 10), GHRH+GHRP-2 and GHRH+GHRP-2 + TRH (n = 10). The GHRH and GHRP-2 doses were 1 microgram/kg and the TRH dose was 200 micrograms. Blood samples were obtained before and 20, 40, 60 and 120 minutes after each injection.

MEASUREMENTS

Serum concentrations of GH, T4, T3, rT3, thyroid hormone binding globulin (TBG), IGF-I, insulin and cortisol were measured by RIA; PRL and TSH concentrations were determined by IRMA.

RESULTS

Critically ill patients presented a striking GH response to GHRP-2 (mean +/- SEM peak GH 51 +/- 9 micrograms/l in older patients and 102 +/- 26 micrograms/l in younger patients; P = 0.005 vs placebo). The mean GH response to GHRP-2 was more than fourfold higher than to GHRH (P = 0.007). In turn, the mean GH response to GHRH+GHRP-2 was 2.5-fold higher than to GHRP-2 alone (P = 0.01), indicating synergism. Adding TRH to the GHRH+GHRP-2 combination slightly blunted this mean response by 18% (P = 0.01). GHRP-2 had no effect on serum TSH concentrations whereas both GHRH and GHRH+GHRP-2 evoked an increase in peak TSH levels of 53 and 32% respectively. The addition of TRH further increased this TSH response > ninefold (P = 0.005), elicited a 60% rise in serum T3 (P = 0.01) and an 18% increase in T4 (P = 0.005) levels, without altering rT3 or TBG levels. GHRH and/or GHRP-2 induced a small increase in serum PRL levels. The addition of TRH magnified the PRL response 2.4-fold (P = 0.007). GHRP-2 increased basal serum cortisol levels (531 +/- 29 nmol/l) by 35% (P = 0.02); GHRH provoked no additional response, but adding TRH further increased the cortisol response by 20% (P = 0.05).

CONCLUSIONS

The specific character of hypothalamic-pituitary function in critical illness is herewith extended to the responsiveness to GHRH and/or GHRP-2 and TRH. The observation of striking bursts of GH secretion elicited by GHRP-2 and particularly by GHRH+GHRP-2 in patients with low spontaneous GH peaks opens the possibility of therapeutic perspectives for GH secretagogues in critical care medicine.

Integrating digital ICU viewing into the global working environment

We illustrate that to benefit from the advantages of Picture Archiving and Communication Systems (PACS) for the Intensive Care Unit (ICU), the PACS must be strongly integrated within the overall working environment. This includes adaptation of the PACS toward specific working patterns and integrating it with the Hospital Information System (HIS). This is reflected in our prototype system in different ways. The user interface of the viewing station is centered around often used patterns in ICU viewing. Information about bed occupancy is retrieved from the HIS and exploited in the viewing station. A digital connection between the phosphorplate scanner and the HIS ensures that images are correctly related to other patient information and to previous images. Using minor adaptations to the existing HIS, PACS and HIS have been made to cooperate in integrated presentation of images and radiological reports, as a step towards a multi-media medical information system. We discuss the relation between PACS and the global information environment, emphasizing organizational issues rather than technological aspects.

Thyrotropin-releasing hormone in critical illness: from a dopamine-dependent test to a strategy for increasing low serum triiodothyronine, prolactin, and growth hormone concentrations

OBJECTIVE

The aim of this study was to examine the effect of dopamine infusion on the thyrotropin (TSH), thyroid hormone, prolactin, and growth hormone responses to thyrotropin-releasing hormone (TRH) in critically ill patients.

DESIGN

Prospective, randomized, controlled, open-labeled clinical study.

SETTING

The intensive care unit, University Hospital Gasthuisberg, Leuven, over a 1-month period.

PATIENTS AND INTERVENTIONS

In 15 critically ill patients receiving dopamine treatment (5 micrograms/kg/min) for a mean of 43.3 +/- 1.2 (SEM) hrs after trauma or cardiac surgery, we studied the TSH, thyroid hormone, prolactin, and growth hormone responses to the administration of two consecutive intravenous TRH boluses of 200 micrograms, with a 6-hr interval. The dopamine infusion was continued in the control group and discontinued in the study group. Serum concentrations of TSH, prolactin, and growth hormone were measured before and 20, 40, 60, and 120 mins after TRH administration. Serum concentrations of thyroxine (T4), triiodothyronine (T3), reverse T3, and thyroid hormone binding globulin were determined before and 120 mins after each TRH injection.

MEASUREMENTS AND MAIN RESULTS

There was a > 100-fold interindividual variation in the baseline TSH concentration and in the TSH peak value after TRH administration. Two consecutive doses of TRH evoked a mean 16% increase in serum T4 concentration (p = .003) and a mean 47% increase in T3 (p = .001), whereas serum reverse T3 and thyroid hormone binding globulin values remain unaltered. Each of the TRH boluses increased serum growth hormone concentrations in the continued dopamine and discontinued dopamine groups, by a median of 60% (p = .001) and 68% (p = .001), respectively. Three hours after dopamine withdrawal, there was a three-fold increase of the peak TSH response (p = .001), a higher T3 response (p = .01), and a ten-fold increase of the peak prolactin value (p = .001) in response to TRH administration.

CONCLUSIONS

The TSH response to TRH administration in critical illness presents a striking interindividual variation and dopamine dependent. Repeated TRH administration results in a repetitive increase of TSH, prolactin, growth hormone, T4, and T3, without increasing reverse T3. These observations point toward a potential for TRH as a strategy for reversing the euthyroid sick syndrome, growth hormone deficiency, and immune dysfunction associated with critical illness.

[Return to work following myocardial infarct. effect of certain socioeconomic factors]

The influence of several socioeconomic factors in return to work following myocardial infarction has been evaluated for 55 male patients. Age, employment status and educational level are among the most determinant factors. Whereas, the financial resources appear less significant as an incentive to resumption of work.

Dehydroepiandrosterone sulphate in critical illness: effect of dopamine

OBJECTIVE

As part of a study on the effect of dopamine therapy on pituitary dependent hormone secretion in critical illness, we documented the impact of this inotropic and vasoactive catecholamine on the serum concentrations of dehydroepiandrosterone sulphate (DHEAS). Concomitantly, serum levels of PRL and cortisol were determined.

PATIENTS AND DESIGN

In a prospective, randomized, controlled, open-labelled clinical study, 20 critically ill, adult polytrauma patients receiving dopamine treatment (5 micrograms/kg/mi i.v. for a median 109 hours (range (21-296 hours)), were studied to evaluate the effect of dopamine withdrawal on serum concentrations of DHEAS, PRL and cortisol. The median age of the studied patients was 37 years (range 18-83 years).

MEASUREMENTS

Serum DHEAS and cortisol concentrations were measured by RIA and PRL by IRMA. The assessed serum samples were obtained at 0300 h on each of two consecutive study nights.

RESULTS

Withdrawal of dopamine infusion was found to elicit a median 25% increase of serum DHEAS concentrations within 24 hours whereas no significant change in DHEAS levels was observed when dopamine infusion was continued throughout both study nights (P = 0.01 continued vs interrupted dopamine). Prolactin levels were undetectable as long as dopamine was infused, and increased to a median of 317 IU/l after 24 hours of dopamine withdrawal (P = 0.0007). Elevated serum cortisol levels remained comparable with continued and interrupted dopamine infusion.

CONCLUSIONS

Dopamine infusion appears to suppress serum DHEAS concentrations in critically ill patients without affecting their elevated serum cortisol levels, suggesting a differential regulation of DHEAS and cortisol metabolism in critical illness. The lowering effect of dopamine on DHEAS levels could be linked to the concomitant suppression of circulating PRL. The simultaneous suppression of circulating PRL and DHEAS by dopamine infusion may be an iatrogenic factor maintaining or aggravating the anergic state of prolonged severe illness.

Severe liver rupture and tricuspid valve rupture in a patient with multiple trauma

A patient with a severe liver injury and an acute cardiac failure due to a traumatic tricuspid valve failure is presented. During liver surgery, massive venous bleeding was caused by regurgitation of blood through the insufficient tricuspid valve. Right ventricular failure, leading to persistent hemodynamic instability, and caused by massive posttraumatic tricuspid regurgitation, has been treated with biological valve replacement. Diagnosis and management of posttraumatic tricuspid insufficiency are discussed.

Risks of rhG-CSF treatment in drug-induced agranulocytosis

Nine patients with drug-induced agranulocytosis received recombinant human granulocyte colony-stimulating factor (rhG-CSF) to accelerate myeloid recovery because of life-threatening infections related to neutropenia. All patients showed a quick recovery of their granulocyte counts. Side effects were substantial, however. Three patients, two with a severe infection and one with preexisting pulmonary infiltrates, developed worsening of their respiratory status during neutrophil recovery, resulting in clinical manifestations of the adult respiratory distress syndrome (ARDS). In view of these major complications, the exact place of hematopoietic growth factors in the treatment of drug-induced agranulocytosis remains to be determined.

Dopamine and the sick euthyroid syndrome in critical illness

OBJECTIVE

The sick euthyroid syndrome is a poorly understood hallmark of critical illness. Dopamine is a natural catecholamine with hypophysiotrophic properties, that is used as an inotropic agent of first choice in intensive care medicine. We explored the effect of dopamine infusion (5 micrograms/kg/min) on the sick euthyroid syndrome of critically ill patients.

PATIENTS AND DESIGN

In a prospective, randomized, controlled and open-labelled study of critically ill, adult polytrauma patients (n = 12), we evaluated the effect of prolonged (83-296 hours) dopamine infusion (5 micrograms/kg/min i.v.) on the thyroid axis. The effect of brief (15-21 hours) dopamine administration was documented in an additional randomized, controlled, cross-over study involving 10 patients. The median age of the studied patients was 29 (16-83) years.

MEASUREMENTS

Serum TSH concentrations were measured by IRMA. The TSH profiles were obtained by blood sampling every 20 minutes for 9 hours during two consecutive nights. Serum T4, T3 and reverse T3 concentrations were measured by RIA once per study night.

RESULTS

Withdrawal of prolonged dopamine infusion was found to elicit a tenfold increase of serum thyrotrophin concentrations, a 57 and 82% rise of T4 and T3 respectively, and an increase of the T3/rT3 ratio, resulting in virtual normalization of the thyroid axis within 24 hours. The brief dopamine infusion was documented to have a suppressive effect on the thyroid axis within 24 hours.

CONCLUSIONS

Dopamine infusion appears to induce or aggravate the sick euthyroid syndrome in critical illness. As a consequence, the sick euthyroid syndrome of severely ill patients receiving dopamine may be not an adaptive mechanism, but a condition of iatrogenic hypothyroidism.

Dopamine suppresses pituitary function in infants and children

OBJECTIVES

Dopamine, a natural catecholamine with hypophysiotropic properties, is used as a first choice drug for inotropic and vasoactive support in pediatric intensive care. In infants and children, the pituitary gland plays a crucial role as a regulator of growth, metabolism, maturation and, possibly, immune function. We evaluated the effect of dopamine infusion (5 micrograms/kg/min i.v.) on the dynamics of prolactin, growth hormone, and thyrotropin secretion and on the thyroid axis in critically ill infants and children.

DESIGN

Prospective, randomized, controlled, open-labeled, clinical study.

SETTING

Intensive care unit of a university hospital over a 9-month period.

PATIENTS AND METHODS

The study population consisted of infants and children recovering from cardiovascular surgery. The group was stratified into two age groups (infants aged 12 to 90 days [n = 18] and children aged 0.3 to 6.7 yrs [n = 15]) and was studied dynamically (blood sampling every 20 mins for 3 hrs) on two consecutive days, after randomization for dopamine withdrawal on the first or the second day. Serum prolactin, growth hormone, insulin-like growth factor-1, thyrotropin, thyroxine (T4), triiodothyronine (T3), and reverse triiodothyronine (reverse T3) concentrations were measured.

MEASUREMENTS AND MAIN RESULTS

In the newborns, dopamine was found to suppress prolactin, growth hormone, and thyrotropin secretion consistently, rebound releases starting within 20 mins after dopamine withdrawal. One day later, prolactin concentrations were ten times higher, pulsatile growth hormone secretion was augmented, thyrotropin was unchanged, but T3 was increased by 30% and the T3/reverse T3 ratio was inverted. In the children, dopamine suppressed prolactin and thyrotropin (but not growth hormone) secretion, rebound releases starting within 20 mins after dopamine withdrawal. One day later, prolactin concentrations were at least twice as high, thyrotropin was increased ten-fold, T4 was augmented by 14%, T3 by 30% and the T3/reverse T3 ratio had doubled. Neither in newborns nor in children did dopamine withdrawal appear to affect the low serum insulin-like growth factor-1 concentrations.

CONCLUSIONS

The data indicate that dopamine infusion induces or aggravates partial hypopituitarism and the euthyroid sick syndrome in critically ill infants and children.

Luteinizing hormone secretion and hypoandrogenaemia in critically ill men: effect of dopamine

OBJECTIVE

Critical illness has been associated with decreased LH secretion and lowering of testosterone. Dopamine is often used for vasoactive support in these patients. We therefore aimed to investigate LH secretion during severe illness and particularly the effect exerted by dopamine on LH in such patients.

PATIENTS AND DESIGN

In a randomized, controlled study of critically ill adult male polytrauma patients (n = 9), we evaluated the effect of prolonged (83-296 hours) dopamine infusion (5 micrograms/kg/min i.v.) on the dynamics of LH secretion and on serum testosterone concentrations. The effect of brief (15-21 hours) dopamine administration was documented in an additional randomized, controlled, cross-over study involving 6 patients.

MEASUREMENTS

Serum LH concentrations were measured by IRMA. The LH profiles, obtained by blood sampling every 20 minutes for 9 hours during two consecutive nights, were examined by deconvolution analysis. Serum testosterone concentrations were measured by RIA once per study night.

RESULTS

We found that before dopamine initiation and within 24 hours of dopamine withdrawal, the mean serum LH concentrations, the LH secretory amplitude, the amount of LH secreted per burst, the mean LH secretion rate and the number of LH pulses were higher than during dopamine infusion, being increased by a median of 161% (P = 0.006), 98% (P = 0.03), 106% (P = 0.03), 164% (P = 0.01) and 25% (P = 0.008) respectively. However, without dopamine administration the amplitude and mass of the LH secretory bursts still appeared to be low, whereas the pulse frequency remained elevated. After dopamine withdrawal, LH secretion increased significantly within 3 hours. Serum testosterone levels were very low and dopamine infusion appeared not to affect them within 24 hours.

CONCLUSION

We documented decreased LH secretory pulse amplitude and mass with increased pulse frequency, as well as very low serum testosterone concentrations in critically ill men. Dopamine infusion further suppressed LH release by decreasing secretory burst amplitude, mass and frequency, possibly through an inhibitory action at both the pituitary and the hypothalamic level.

Growth hormone secretion in critical illness: effect of dopamine

The catabolic state is a major contributor to the morbidity and mortality of critical illness. The underlying mechanism is poorly understood. We examined the endogenous secretion of an anabolic protein, GH, and studied the effect exerted on its secretion by dopamine, a catecholamine that is frequently administered for cardiovascular purposes in critical care. In a randomized controlled study of critically ill adult polytrauma patients (n = 11), we evaluated the effect of prolonged (83- to 296-h) dopamine infusion (5 micrograms/kg.min, iv) on the dynamics of GH secretion and on serum insulin-like growth factor-I, cortisol, and insulin concentrations. The effect of brief (15- to 21-h) dopamine administration was documented in an additional randomized controlled cross-over study involving nine patients. The GH profiles, obtained by blood sampling every 20 min for 9 h during 2 consecutive nights, were examined by deconvolution analysis. GH release was found to be exclusively pulsatile in all patients. Prolonged and brief dopamine infusions appeared to have similar effects. Twenty-four hours before initiation or after withdrawal of dopamine infusion, mean serum GH concentrations, mean secretion rate, amount of GH per secretory burst, and secretory burst amplitude were low, but, respectively, a median of 17% (P = 0.028), 36% (P = 0.046), 40% (P = 0.008), and 94% (P = 0.002) higher than those during dopamine infusion. After dopamine withdrawal, increased GH secretion was detectable within 3 h. Dopamine's effect on GH release was specific, as this agent had no discernable effect on the elevated serum cortisol and insulin concentrations or the low plasma insulin-like growth factor-I levels within 24 h. In conclusion, the present data suggest that pulsatile GH secretion is low during critical illness and that dopamine infusion further attenuates GH secretion through amplitude modulation, possibly as a result of a direct inhibitory action on the somatotropes. The latter iatrogenic effect might further aggravate the catabolic state of critical illness.

Combining fast response and low cost in an intensive care unit viewing station

This paper describes a prototype viewing station for the Intensive Care Unit (ICU) that combines a low cost with a fast response for the primary viewing tasks. A single monitor is used together with the possibility to switch to another image on the same screen instantaneously. To reduce the time for image retrieval and display, the viewing station anticipates the need for particular images, and preloads these from the disk into the internal memory whenever the computer has some idle time. Preliminary experience suggests that the use of a single monitor is no fundamental limitation for this application. Most of the time, the system can anticipate which images will be required shortly. This has an important impact on the user efficiency.

Design for user efficiency in a dedicated ICU viewing station

The intensive care unit (ICU) is one application where significant benefit is expected from the use of digital technology in the acquisition, management and presentation of images. However, the potential benefits should not be outweighed by disadvantages of current digital technology. One of the bottlenecks is the efficiency of image viewing using a workstation, especially if this viewing station is implemented using affordable commonly available hardware. In this paper we describe the design concepts of a relatively low-cost but efficient viewing station for chest images, and discuss clinical experience with this system at an ICU ward. The user interface has been optimized towards the specific patterns of ICU image viewing. By anticipating user requests and preparing images during idle times of the computer, the mean image access time could be reduced by a factor of 4, while most images could be presented instantaneously. Information from the hospital information system (HIS) is exploited in the user interface, and a simplified PAC-HIS coupling has been implemented for the simultaneous presentation of images and reports.

Planned relaparotomies for advanced, established peritonitis from colonic origin

Patients presenting diffuse, advanced, established peritonitis due to free perforation of the colon, in whom an adequate abdominal debridement cannot be obtained in one operative session were selected. We report results of the planned relaparotomy approach in 44 patients as compared with an historical series of 9 analogous patients treated by on demand exploratory relaparotomies. Planned relaparotomies were performed every 2 days until the abdominal cavity became macroscopically clean. This approach significantly reduced both the incidence of multiple organ failure and the mortality rate (31%) as compared with the regimen of on demand relaparotomy. The mortality rate in the planned relaparotomy group is related to the age of the patient and to the nature of peritonitis. Faecal peritonitis carries a higher mortality rate than purulent peritonitis. The mortality rates of severe postoperative peritonitis and advanced primary peritonitis were not significantly different. Surgery for severe, diffuse peritonitis has to be prompt, moderately aggressive and repeated if necessary. Therefore, planned relaparotomies have a place in the treatment of selected patients presenting diffuse, advanced, established peritonitis.

The use of midazolam versus propofol for short-term sedation following coronary artery bypass grafting

Midazolam and propofol were compared in an open randomized study for postoperative sedation during 12 h of mechanical ventilation in 40 patients following coronary artery bypass grafting. After an intravenous loading dose of midazolam (50 micrograms.kg-1) or propofol (500 micrograms.kg-1), a titrated continuous infusion was administered of midazolam (mean dose 38.1 micrograms.kg-1.h-1 (SEM 2.6)) or propofol (mean dose 909 micrograms.kg-1.h-1 (SEM 100)) together with a narcotic analgesic infusion. During mechanical ventilation midazolam and propofol produced a similar quality of sedation, but recovery (midazolam 66 min (SEM 16); propofol 24 min (SEM 7)) and weaning from the ventilator (midazolam 243 min (SEM 44); propofol 154 min (SEM 33)) where faster with propofol. In the 2 groups administration of an intravenous loading dose caused a significant decrease in mean arterial pressure but hemodynamic tolerance during maintenance infusion was good.

Effects of urapidil, ketanserin and sodium nitroprusside on venous admixture and arterial oxygenation following coronary artery bypass grafting

Thirty patients who developed arterial hypertension following coronary artery bypass grafting, despite sedation, were treated randomly with sodium nitroprusside (SNP), ketanserin or urapidil. All drugs significantly decreased arterial pressure. Two patients were withdrawn because hypertension failed to respond to ketanserin. Significant tachycardia was noted only in the SNP group. An increase in Q and significant decreases in systemic and pulmonary vascular resistances were seen in all groups. Following administration of SNP, (PaO2-PaO2) and Qs/Qt increased significantly, whereas PaO2 decreased significantly. Three patients were withdrawn from the SNP group because Qs/Qt was greater than 30%. (PAO2-PaO2) and Qs/Qt showed no significant changes following the administration of ketanserin or urapidil. These drugs may have advantages over SNP in the management of hypertension following coronary artery bypass surgery.

[The effect of urapidil and sodium nitroprusside on intrapulmonary right-left shunt and arterial oxygenation in the treatment of hypertension following coronary surgery]

20 patients who developed arterial hypertension following coronary artery bypass grafting were randomly treated with either sodium nitroprusside (SNP) or urapidil. Both drugs led to a significant decrease in blood pressure. A significant tachycardia was noted only in the SNP-group. A decrease in peripheral and pulmonary vascular resistance was seen in both groups. Following application of SNP, alveolarterial oxygen difference and venous admixture increased significantly, whereas PaO2 showed a significant decrease. Three patients had to be taken out of the SNP group because of an increase of venous admixture. Alveoloarterial oxygen difference and venous admixture showed no significant changes following application of urapidil.

[Ketanserin versus sodium nitroprusside in the treatment of hypertension following coronary surgery. Effect on intrapulmonary right and left shunt and arterial oxygenation]

Twenty patients requiring management of postoperative arterial hypertension following coronary artery bypass grafting (CABG) were randomly treated with either ketanserin (n = 10) or sodium nitroprusside (SNP) (n = 10). After surgery all patients were mechanically ventilated in the intensive care unit (F1O2:0.5; PEEP: +5 cm H2O). During the therapy with either drug F1O2 was adjusted to achieve normal blood oxygen tensions (F1O2 always greater than 0.3). Samples of arterial and mixed-venous blood were obtained simultaneously before administration of either drug and at each time point. Data acquisition followed over 12 h. Both drugs led to a significant decrease in arterial blood pressure, although 2 patients had to be withdrawn from the ketanserin group because there was no adequate decrease in systolic arterial pressure. A significant increase in heart rate was noted only in patients receiving SNP. In the SNP-treated patients F1O2 had to be increased because of a marked decrease in paO2, resulting in a significant increase in alveolar-arterial oxygen difference (A-aDO2). In 3 patients SNP had to be stopped because of an increase in intrapulmonary shunt (Qsp/Qt) more than 30%. No significant changes in Qsp/Qt, A-aDO2, or paO2 were seen in the ketanserin-treated patients.

Pulmonary function tests after different techniques for coronary artery bypass surgery. Saphenous vein versus single versus double internal mammary artery grafts

Pulmonary function tests were measured in 33 male patients undergoing elective coronary artery bypass surgery. Three modes of surgical technique were used: Bilateral internal mammary artery graft (BIMA), single internal mammary artery graft (SIMA) and saphenous vein grafts (VS). Following parameters were recorded: patient's age, length, body weight, preoperative forced vital capacity (FVC) and forced expiratory volume at one second (FEV 1), preoperative end-diastolic pressure and function of the left ventricle, smoking habitus, the fact that the pleural cavity was entered, duration of the cardiopulmonary bypass period, perioperative fluid balance and postoperative FVC and FEV 1 on the first eight postoperative days. In the BIMA group two pleural cavities, the SIMA group one pleural sac and the VS group none of the pleural cavities was entered. The BIMA group was younger (50.1 +/- 7.6 versus 57.7 +/- 7.28 and 60.1 +/- 6.9 years (p less than 0.05)) than the SIMA and VS group. Postoperative external blood loss was lower in the VS group compared to the SIMA and BIMA groups (839 +/- 255 ml versus 1346 +/- 654 ml and 1259 +/- 396 ml (p less than 0.05)). The FVC shows a dramatic decrease especially on the second postoperative day and was most markedly diminished in the BIMA and SIMA compared to VS (31% +/- 9% and 35% +/- 8% versus 45% +/- 10% of preoperative values (p less than 0.05)).(ABSTRACT TRUNCATED AT 250 WORDS)

Surgical treatment of acute, massive lung embolism. Results and follow-up

Between 1970 and 1984 the diagnosis of acute, massive lung embolism was made 30 times in our department. In 29 patients the clinical diagnosis was correct and a Trendelenburg operation under extra-corporeal circulation was performed. In 18 cases there was an operation in the immediate preoperative course. In 1 case there was a combination of operation and the use of contraceptives. 3 cases were immobilized by a plaster of Paris cast. In 4 cases the use of oral contraceptives and in 3 patients the history of chronic recurrent lung embolism were evident. The mean immobilisation time was 15 days. In 24 cases the diagnosis was made only on the base of the clinical anamnesis, and examination, E.C.G. and chest radiography. In 4 cases angiography and in 1 patient the scintigraphy confirmed the diagnosis. Preoperatively 28 patients were in severe shock. One patient was operated electively. 14 patients needed external cardiac massage. In all cases clots were found in the left pulmonary artery, 28 in the right pulmonary artery, in 3 cases clots in the right atrium, 3 in the right ventricle and three in the inferior caval vein. Nine De Weese caval vein clips were inserted and one Mobin-Uddin filter. Postoperatively 18 patients were alive and well without sequelae. Two patients developed a cerebro-vascular accident (CVA) with one complete recovery. Ten patients died. Postoperative treatment consisted of I.V. heparin administration immediately after surgery and 6 months of oral anticoagulants. Except for chronic recurrent lung embolism the pulmonary function tests were excellent postoperatively without recurrence of the disease.

The use of continuous arteriovenous hemofiltration in intensive care medicine

Acute renal failure still remains an important and challenging problem in the ICU. Hemodialysis is not always feasible because of hemodynamic instability in critically ill patients. In this circumstances continuous arteriovenous hemofiltration (CAVH) can be an efficient alternative as this method has less detrimental hemodynamic effects. Moreover, within certain limitations, CAVH proves to be an effective "artificial kidney" (control of body fluid, electrolyte and acid-base homeostasis and uremia) and this without serious side-effects. Special emphasis is made on the problem of anticoagulation, which can cause life-threatening complications in posttraumatic and surgical patients. A protamine infusion on the venous line can diminish these complications.

Haemodynamic changes in heart failure induced by a new vasodilator tolmesoxide

The haemodynamic effect of Tolmesoxide, a new sulphoxide chemically dissimilar from other vasodilators, was investigated in eight patients with chronic heart failure subsequent to ischaemic heart disease and/or hypertension. Tolmesoxide significantly increased the cardiac output and reduced the indices of systemic vascular resistance, the mean pulmonary arterial pressure and left ventricular filling pressure in most patients studied. These changes were observed both as acute and chronic effects. No significant effect on the mean arterial pressure, heart rate or myocardial oxygen supply/demand was observed. Tolmesoxide appeared to be therapeutically potent by both intravenous and oral routes.

[Temporal evolution of fibrinogen and platelets in reaction to various stressors in coronary and non-coronary subjects (author's transl)]

Twenty-one postmyocardial infarction patients are compared with twenty-one matching non-coronary subjects. Fibrinogen level as well as whole blood platelet count were measured six times for each subject in a timespan of 2 hours, during which two stress situations are induced. Throughout the experiment, non-coronary subjects show significantly lower levels of fibrinogen and higher blood platelet count. These two variables follow a specific temporal evolution. Stressfull situations are directly related with a significant decrease in the whole blood platelet count. Films inducing a directional anxiety match a lower blood platelet count, as compared to films inducing a diffuse anxiety. A link may be hypothesized between the stress-induced decrease in blood platelet count and the relative thrombopenia of coronary patients.

[Temporal evolution of lipids in reaction to various stressors in coronary and non-coronary subjects (author's transl)]

In order to assess the impact of coronary disease on sequential physiological reactions to stress, this study compares 21 post myocardial infarction patients with 21 matching non-coronary subjects. In each group, levels of phospholipids, triglycerides, cholesterol, FFA, alpha-, beta, pre-beta-lipoproteins and the ratio cholesterol/triglycerides are assessed, six times consecutively in a timespan of 2 hours. Concomitantly, two stressful situations are induced: the first stress is catheterization, the second is a film implementing either a focused-or diffused anxiety. Phospholipids react essentially to catheterization stress. While the ratio cholesterol/triglycerides turns out to be sensitive to psychological stress, neither cholesterol nor triglycerides alter individually when psychological stress is present. Throughout the experiment, levels of beta-lipoproteins very significantly in time and with respect to the theme of the film attended; coronary patients do not show the same sequential variations as normal subjects do. Variations in alpha-lipoproteins differentiate coronary from normal subjects. Levels of FFA vary according to the nature of the film attended and differ in normal and coronary subjects: extreme values are observed in normal subjects rather than coronary patients. Hyperlipidemia, as a reaction to stress, is a process interlinked with many factors, each increasing the liability of coronary disease.

[Temporal evolution of blood pressure and heart rate reaction to various stressors in coronary and non-coronary subjects (author's transl)]

The temporal evolution of systolic and diastolic blood pressure and heart rate in reaction to several stresses is measured in a group of 21 post myocardial infarction and 21 non coronary subjects. Heart rate modifications depend essentially upon the nature of stress: catheterization induces tachycardia while a stressing film induces bradycardia. These observations can be connected to environmental intake or rejection. During catheterization stress, the systolic blood pressure is high in both groups but returns to its normal values as soon as the intervention ends. In response to anxiety films, it persists higher in coronary patients than in normal subjects, who do not seem to react to this kind of stress. These results arise the question of either a longer recuperation, or a different reactivity to symbolic stressors (films).

[Temporal evolution of neuro-endocrine secretions in reaction to various stressors in coronary and non-coronary subjects (author's transl)]

The purpose of this study is a comparison of sequential physiolocical reactions to different stressors in 21 post-myocardial infarction and 21 non-coronary subjects. Two stressful situations are induced in a timespan of 2 hours; the first stress is catheterization, the second is a film implementing either a focused or a diffuse anxiety. Throughout the experiment, the following physiological parameters are assessed six times consecutively: levels of catecholamines, cortisol, TSH, insulin and the ratios: adrenalin/fnor-adrenalin and adrenalin/cortisol. Results indicate that levels of adrenalin and cortisol show specific variations with time and are most sensitive to catheterization. Levels of nor-adrenalin very differently with time among coronary patients, as well as they do in normal subjects. Individuals submitted to focused anxiety show increased levels of catecholamines and cotisol, as well as a lower level of insulin than subjects submitted to diffuse anxiety. The sequential evolution of cortisol differs in coronary patients and normal subjects and in function of the type of film attended. Physiological reactions to stress and far more specific and interdependent than prior studies stated in the past. They vary with the degree and the nature of stress. It is our belief that there is no standardised response to stress.

[Psychological links and coronary diseases. II. Psychological correlations of certain physiological variables (author's transl)]

In this study, correlations were tabulated between physiological and psychological measurements drawn from a group of 21 infarct patients and a matching group of 21 normal subjects. The physiological variables taken under consideration are the number of platelets, the beta-lipoproteines and the systolic blood pressure; all these variables were tested under stress and at rest. On the top, fibrinogene at rest, cortisol under stress and heart rate under conditions of "intake" and "rejection" were also measured. The psychological assessment was achieved by the MMPI. Several psychological traits link with physiological parameters to be considered as cardiovascular risks. However, these links are mostly specific; moreover, they vary under different experimental conditions. In other words, different neuro-behavioral patterns seem to operate at rest and under stress. The links between psychological and physiological variables vary also between normal subjects and infarct patients. Normal subjects as well as infarct patients show a relationship between neurotic traits and genuine physiological reactions. However, among the formers, these neurotic traits are in closer relationship with inhibitions as among heart patients. Psychological risk factors in cardiovascular disorders appear to be related with a genuine expression of conflictual affects leading to inadequate physiological responses; when these reactions are repeated in time, functional disorders may induce organic lesions.

[Psychological links and coronary diseases. I. Physiological correlations of certain psychological variables (author's transl)]

Twenty-one infarct patients were compared with 21 normal subjects regarding several hemodynamic, lipidic and neuroendocrine variables, in various stress situations and at rest. Correlations were tabulated between those bioclinical measurements and various personality patterns drawn from the MMPI. This study shows that the physiological reactions to stress vary in subjects with psychological cardiovascular risk factors as compared to subjects without psychological risk factors. The bearers of psychological risk factors show a higher systolic and diastolic blood pressure, a specific lipids pattern and a lower rate of platelets. In summary, psychological risk factors link with physiological reactions to stress which appear to be by themselves cardiovascular risk factors.

[Comparison of carotid pulse in normal subjects and coronary patients]

A comparison of the values of R-R, S1S2, QS1, QS2, LVET, PEP, and ICT recorded from the carotid pulse of 40 coronary patients and 40 normal subjects has shown that the coronary group, when compared with the normals, show: --A significant lengthening of the QS2, PEP and ICT values, and a tendency towards lengthening of the S1S2 interval. --A tendency towards shortening of the LVET period. The ratio of PEP/LVET is a particularly good discriminant factor between the two groups. Because of these differences, assessment of the carotid pulse, which is an easy and non-invasive investigation, has become a good means of diagnosing coronary arterial disease. The results of this study have been compared with those from previous studies, and the clinical significance of the different findings has been analysed.