Wiring a medical school and teaching hospital for telemedicine

The planning and installation of a telemedicine system for communication within a teaching hospital and its academic and hospital units with a capacity for accommodation of up to 400 video-stations is described. The system is intended for improving the communication between patients and health professionals, and between the health professionals themselves. It also provides the basis for improving pre-graduate teaching, especially problem-based learning, and all aspects of postgraduate teaching.

Enhanced surveillance for pregnancy-associated mortality--Maryland, 1993-1998

CONTEXT

Deaths occurring among women who are pregnant or who have had a recent pregnancy have a devastating impact on the family and community. It is important to understand the magnitude and causes of pregnancy-associated mortality so that comprehensive strategies can be formulated to prevent such deaths.

OBJECTIVE

To ascertain the number and causes of pregnancy-associated deaths using enhanced surveillance techniques.

DESIGN, SETTING, AND SUBJECTS

Retrospective, cross-sectional analysis of death certificate data of reproductive-age women, live birth and fetal death records, and medical examiner records in Maryland during 1993-1998.

MAIN OUTCOME MEASURE

Number of pregnancy-associated deaths, defined as death from any cause during pregnancy or within 1 year of delivery or pregnancy termination, by source of data and cause of death.

RESULTS

A total of 247 pregnancy-associated deaths were ascertained. Twenty-seven percent (n = 67) were identified through cause-of-death information obtained from death certificates, 70% (n = 174) through linkage of death records with birth and fetal death records, and 47% (n = 116) through review of medical examiner records. Homicide was the leading cause of pregnancy-associated death (n = 50; 20%), and cardiovascular disorders were the second-leading cause (n = 48; 19%).

CONCLUSIONS

In this Maryland sample, comprehensive identification of pregnancy-associated deaths was accomplished only after collecting information from multiple sources and including all deaths occurring up to 1 year after delivery or pregnancy termination. This enhanced pregnancy mortality surveillance led to the disturbing finding that a pregnant or recently pregnant woman is more likely to be a victim of homicide than to die of any other cause. By broadening pregnancy mortality to include all possible causes, previously neglected factors may assume increased importance in prenatal and postpartum care.

The magnesium-ene cyclization stereochemically directed by an allylic oxyanionic group and its application to a highly stereoselective synthesis of (+/-)-matatabiether. Allylmagnesium compounds by reductive magnesiation of allyl phenyl sulfides

The first example of a magnesium-ene cyclization stereochemically directed by an allylic oxyanionic group is demonstrated by a highly stereoselective synthesis of the bicyclic terpene matatabiether 10. The synthetic method is particularly valuable, not only because of the stereochemical control and the utility of the versatile hydroxyl group introduced into the product, but also because the precursor of the allylmagnesium is an allyl phenyl sulfide, which is more stable and more easily prepared in a connective fashion than the usual allyl halide precursor. Since the presence of lithium ions encourages undesirable proton transfer to the cyclized organometallic and is detrimental to the stereochemical control, the conversion of the allylic thioether to the allylmagnesium utilizes a lithium-free method involving direct reductive magnesiation in the presence of the magnesium-anthracene complex.

[The effects of intrapleural anti-TNFalpha antibody on chemical pleurodesis induced by talc slurry or doxycycline]

OBJECTIVE

To determine whether the intrapleural injection of TNFalpha neutralizing Fab antibody fragment (anti-TNFalpha Fab) would prevent the pleurodesis that occurs after the intrapleural injection of talc or doxycycline.

METHODS

In a randomized blinded placebo controlled study, 34 New Zealand white rabbits were given 400 mg/kg talc or 10 mg/kg doxycycline intrapleurally as a sclerosant via a chest tube. Half of the rabbits in each group were also given polyclonal affinity purified anti-TNFalpha Fab 2 000 units or saline as placebo immediately before and 12 hours after the injection of the sclerosants. Chest tube were aspirated at 12 hours intervals until their removal at 4 days. Rabbits were sacrificed at 28 days. The pleural fluid volume, cell counts, LDH and pleurodesis scores were compared among groups.

RESULTS

Both talc and doxycycline produced an exudative pleural effusion. The pleural fluid volume and LDH levels were significantly greater in the doxycycline group than talc group. However, the pleural fluid leukocyte counts in talc group were higher than doxycycline group. The administration of anti-TNFalpha Fab had no significant effect on pleural fluid volume, LDH or leukocyte counts in either groups. However, the intrapleural administration of anti-TNFalpha Fab results in a significant decrease in the pleurodesis score for the talc group than doxycycline group (1.8 +/- 0.9 vs 3.2 +/- 0.8). In contrast the pleurodesis score was virtually identical in the doxycycline group with (3.5 +/- 0.5) and without (3.4 +/- 0.7) anti-TNFalpha Fab.

CONCLUSION

The intrapleural administration of anti-TNFalpha Fab diminishes the pleurodesis induced by talc but not that which results from doxycycline. These findings suggest that different mechanisms are involed with the two different sclerosants.

Vascular endothelial growth factor level correlates with transforming growth factor-beta isoform levels in pleural effusions

BACKGROUND

Recent studies have demonstrated high levels of vascular endothelial growth factor (VEGF) in exudative pleural effusions and a possible etiologic role. The factors regulating VEGF accumulation in the pleural space are unknown. Transforming growth factor (TGF)-beta is a potent stimulator of VEGF expression in vitro. We hypothesized that TGF-beta induces VEGF production in pleural tissues, and, hence, the pleural fluid VEGF levels should correlate with the levels of TGF-beta in pleural fluid of different etiologies.

METHODS

Seventy pleural fluid samples were analyzed. These included 20 malignant, 13 post-coronary artery bypass grafting (CABG), 8 parapneumonic, 11 miscellaneous exudative, and 18 congestive heart failure (CHF) pleural effusions.

RESULTS

Pleural fluid VEGF levels showed good correlation with those of TGF-beta(1) (r = 0.58; p < 0. 0001), TGF-beta(2) (r = 0.43; p < 0.001), and lactate dehydrogenase (r = 0.65; p < 0.001). The levels of TGF-beta(1) and TGF-beta(2) also were correlated (r = 0.60; p < 0.0001). The median levels of TGF-beta(1) (2,480 pg/mL) and TGF-beta(2) (266 pg/mL) in the CHF group were significantly lower than those in the malignant (TGF-beta(1), 4,902 pg/mL; TGF-beta(2), 428 pg/mL), post-CABG (TGF-beta(1), 5,456 pg/mL; TGF-beta(2), 377 pg/mL), parapneumonic (TGF-beta(1), 5,024 pg/mL; TGF-beta(2), 464 pg/mL), and miscellaneous exudate groups (TGF-beta(1), 7,690 pg/mL; TGF-beta(2), 369 pg/mL). There was no significant difference in TGF-beta(1) and TGF-beta(2) levels among the four exudate groups.

CONCLUSIONS

VEGF levels in pleural effusions are significantly correlated with the levels of TGF-beta(1) and beta(2) isoforms. VEGF, TGF-beta(1), and TGF-beta(2) levels were all higher in exudative effusions than in effusions secondary to CHF.

P73 gene expression in ovarian cancer tissues and cell lines

Thep73 gene, a homology of p53, is a new candidate of imprinting and tumor suppressor gene. To investigate the role of p73 in ovarian cancer, we studied the allelic expression in 56 cases of ovarian cancer using StyI polymorphism analysis. We also examined p73 expression by semi-quantitative reverse transcription-PCR as well as by Western blot analysis and DNA methylation study of the CpG island in exon 1 in ovarian cancer tissues and cell lines. Loss of heterozygosity was found in 8.3% (2 of 24) of the cases. Biallelic expression was demonstrated in 91.7% (22 of 24) of the tumor samples, in 70.8% (17 of 24) of the normal samples, and in 1 ovarian cancer cell line. Imbalanced expression and monoallelic expression were found in three and two pairs of matched samples, respectively. Overexpression of p73 was found in advanced ovarian cancer rather than in early-stage disease or in borderline ovarian tumor. No significant difference was found in the p53 expression. Three cell lines with absent p73 protein expression and one tumor sample with monoallelic expression were methylated in the CpG island. Demethylation in SKOV3 cell line using 5-azacytidine can reactivate the expression of this gene in both the mRNA and the protein level. Our results indicated that p73 was not imprinted in most of the ovarian cancer and normal tissues, but it could be involved in the advanced ovarian cancer through overexpression. DNA methylation may contribute to the lack of p73 expression.

A controlled study of imagery rehearsal for chronic nightmares in sexual assault survivors with PTSD: a preliminary report

Imagery-rehearsal therapy for chronic nightmares was assessed in a randomized, controlled study of sexual assault survivors with posttraumatic stress disorder (PTSD). Nightmares, sleep quality, and PTSD were assessed at baseline for 169 women, who were randomized into two groups: treatment (n = 87) and wait-list control (n = 82). Treatment consisted of two 3-hr sessions and one 1-hr session conducted over 5 weeks. Of 169 participants, 91 women (Treatment, n = 43, Control, n = 48) completed a 3-month follow-up and 78 did not. At follow-up, nightmare frequency and PTSD severity decreased and sleep quality improved in the treatment group with small to minimal changes in the control group. Treatment effects were moderate to high (Cohen's d ranged from 0.57 to 1.26). Notwithstanding the large dropout rate, imagery-rehearsal therapy is an effective treatment for chronic nightmares in sexual assault survivors with PTSD and is associated with improvement in sleep quality and decreases in PTSD severity.

[Effects of endothelin receptor antagonist on the hypoxic pulmonary hypertension]

This investigation was made to elucidate the role of endothelin (ET) in hypoxic pulmonary hypertension and the preventing effects of BQ-123, an ETA receptor antagonist. Thirty male Wistar rats were divided into three groups and exposed to air, isobaric hypoxia or isobaric hypoxia plus BQ-123 for 3 weeks. The pulmonary artery pressure was measured by right cardiac catheterization. The plasma level of ET-1 was measured by RIA method. Histologic sections of the lungs were examined by a computerized image analyser. In hypoxic rats, the pulmonary artery pressure and the thickness of wall of arteriole were significantly increased, and right ventricular hypertrophy was developed. The plasma level of VEGF in rats treated with hypoxia (192.3 +/- 43.1 pg/ml) was significantly increased as compared with that of normal rats (128.2 +/- 28.1 pg/ml), P < 0.01. Chronic BQ-123 treatment prevented the developments of pulmonary hypertension, thickening of pulmonary arteriole and right ventricular hypertrophy induced by hypoxia. These result indicate that chronic hypoxia can result in hypoxic pulmonary hypertension and increased plasma level of ET-1, and the ETA receptor antagonist can prevent hypoxic pulmonary hypertension.

The intrauterine device: still misunderstood after all these years

The intrauterine device (IUD) is one of the most effective, safe, and economic methods of contraception today. It is used by more women worldwide than any other reversible method of birth control, yet less than 1% of women in the United States use the IUD. Still remembering the tragedy of the notorious Dalkon Shield, American pharmaceutical companies and clinicians have been wary about promoting any IUD, leaving most physicians inadequately trained in the two IUDs available in the United States. Most significantly, misconceptions about the IUD's safety, mechanism of action, complication rates, and liability have severely limited the utilization of the IUD by many practitioners and women in the United States who may greatly benefit from it.

Treatment of severe systemic lupus erythematosus with high-dose chemotherapy and haemopoietic stem-cell transplantation: a phase I study

BACKGROUND

Patients with systemic lupus erythematosus (SLE) who experience persistent multiorgan dysfunction, despite standard doses of intravenous cyclophosphamide, represent a subset of patients at high risk of early death. We investigated the safety and efficacy of immune suppression and autologous haemopoietic stem-cell infusion to treat such patients.

METHODS

From 1996, we selected patients with persistent SLE despite use of cyclophosphamide. Patients underwent dose-intense immune suppression and autologous haemopoietic stem-cell (CD34) infusion. Peripheral blood lymphocytes were analysed by flow cytometry, ELISA, and T-cell-receptor spectratyping before and after transplantation. We mobilised autologous haemopoietic stem cells with 2.0 g/m2 cyclophosphamide and 10 microg/kg granulocyte colony stimulating factor daily, enriched with CD34-positive selection, and reinfused after immunosuppression with 200 mg/kg cyclophosphamide, 1 g methylprednisolone, and 90 mg/kg equine antithymocyte globulin.

RESULTS

Nine patients underwent stem-cell mobilisation but two were excluded before transplantation because of infection. The remaining seven received high-dose chemotherapy and stem-cell infusion. Median time to an absolute neutrophil count higher than 0.5x10(9)/L and nontransfused platelet count higher than 20x10(9)/L was 9 days (range 8-11) and 11 days (10-13), respectively. At a median follow-up of 25 months (12-40), all patients were free from signs of active lupus. Renal, cardiac, pulmonary, and serological markers, and T cell phenotype and repertoire had normalised.

INTERPRETATION

Patients remained free from active lupus and improved continuously after transplantation, with no immunosuppressive medication or small residual doses of prednisone. T-cell repertoire diversity and responsiveness was restored. Durability of remission remains to be established.

[Study on genetic mutations of the vWF in type 2A von Willebrand disease]

OBJECTIVE

To study the molecular pathological mechanism of the type 2A von Willebrand disease(vWD) and the relationship of the phenotypes with genotypes.

METHODS

A total of 126 patients with the hereditary hemorrhagic disease were examined using bleeding time, vWF:Ag, FVIII:CAg, ristocentin induced platelet agglutination assay(RIPA) and multimer analysis of plasma. The exon 28 of authenticity vWF gene was studied by PCR, denaturing gradient gel electrophoresis(DGGE) and sequencing in the type 2A vWD.

RESULTS

Fourteen cases were diagnosed as type 2A vWD. Four cases of point mutations resulting in single animo acid substitutions, Arg611His, Ala737Glu, Arg834Trp, were identified in 3 families of type 2A vWD. Ala737Glu substitution in vWF is caused by a novel missense mutation.

CONCLUSION

The molecular pathological mechanism of the type 2A vWD is very variant.

The calibration of a 2.5x Galilean focusable telescope as an optometer for refraction

A 2.5x Selsi achromatic Galilean focusable telescope was calibrated for refraction at 6 m. In its calibration, minus power trial lens was placed at the objective of the telescope to simulate vergence of a target at a finite distance, before the back vertex power (BVP) of the telescope at each setting (telescope length) was measured by a focimeter. By using a graphical presentation of the results, the BVP of the telescope at each setting could be determined at different selected target distances. For a target vergence of -0.167 D or a distance of 6 m, the common testing distance in clinical practice, this calibrated telescope had a BVP or refraction measuring range of -7.27(-)+7.52 D. When this telescope was used to measure simulated manifest refractive errors at 6 m, it yielded a mean error of +0.13 D with a 95% confidence limit of agreement of -0.38(-)+0.64 D. These results indicated that the accuracy and precision of telescopic refraction were comparable to that of retinoscopy. Therefore, the calibrated telescope could be considered as a reliable and inexpensive instrument for determining spherical refractive errors. Telescopic refraction is applicable in refracting economically disadvantaged population in underserved areas where modern equipment and electricity are not available. In addition, it provides an alternative subjective refraction method for low vision population because the magnification of this calibrated telescope has the advantage of allowing low vision patients to be refracted at the common 6 m testing distance in clinical practice.

[Effect of raw radish on pharmacological action of ginseng]

Ginseng decoction can increase the memory-improvement, weary-resistance, antihypoxia, sedation in mice, and increase the weight of spleen and accessory sexual gland, but reduce the weight of thymus. Raw radish can decrease these pharmacological effects in varying degrees, except the sedation.

[The acute effect of tetrandrine pulmonary targeting microspheres on hypoxic pulmonary hypertension in rats]

OBJECTIVE

To investigate the effect of tetrandrine (Tet) pulmonary targeting microspheres on hypoxic pulmonary hypertension and its selective role on pulmonary circulation.

METHODS

Tet pulmonary targeting microspheres were synthesized by spraying desiccation, the content of tetrandrine in pulmonary targeting microspheres is 32%. Twenty Wistar rats were exposed to hypoxia for three weeks, the rats were given Tet pulmonary targeting microspheres and Tet aqueous solution respectively and another 10 rats were as normal control. The mean pulmonary arterial pressure (mPAP) was measured by a right cardiac catheterization, mean systemic blood pressure (mSBP) was measured by left femoral catheterization.

RESULTS

At the end of hypoxic treatment, rats developed pulmonary hypertension. mPAP in the rats receiving Tet pulmonary targeting microspheres decreased more obviously than the rats receiving Tet aqueous solution (P < 0.05), and the effects maintained for 60 min after administration. However, the mSBP remained normal in rats receiving Tet pulmonary targeting microspheres.

CONCLUSION

Tet pulmonary targeting microspheres can improve the effect of Tet on the hypoxic pulmonary hypertension and Tet has the selective role on the pulmonary circulation.

[Changes of type I collagen in the lungs of rats with hypoxic pulmonary hypertension]

The changes of type I collagen in the lung tissues of rats with hypoxic pulmonary hypertension (HPH) and its relationship to the mean pulmonary arterial pressure (mPAP) were investigated. The blood dynamic indexes of pulmonary circulation were measured by using Swan-Ganz. The distribution of type I collagen in pulmonary arteries, bronchi and plumonary interstitial was observed by using streptavidin peroxidase method (SP). The morphologic changes of small pulmonary arteries and the level of type I collagen were determined by image pattern analysis technique and gray scale scanning, respectively. The results showed, compared with the controls, mPAP of the hypoxic rats elevated (from 2.12 +/- 0.25 to 3.95 +/- 0.43 kPa, P < 0.01), their small pulmonary arteries, walls thickened (MT% from 16.35 +/- 2.64 to 35.83 +/- 3.55, MA% from 26.83 +/- 3.40 to 59.68 +/- 4.90, P < 0.01) and lumen narrowed. The distribution of type I collagen was mainly in the external layer of pulmonary arterial walls; the positive degrees of gray scale scanning increased and had a positive linear relationship to the mPAP and MT%. These findings suggest that the increase of type I collagen contents in pulmonary arteries is closely related to the development of HPH.

Loss of imprinting of the IGF-II and H19 genes in epithelial ovarian cancer

To establish a possible role of genomic imprinting in the carcinogenesis of epithelial ovarian cancer, we determined the imprinting status of both IGF-II and H19 genes in 43 ovarian cancers, 7 low malignant potential ovarian tumors, and their matched normal tissues. In ovarian cancer, loss of heterozygosity (LOH) of IGF-II, H19 RsaI, and H19 AluI was found in 4 of 24 (16.7%), 3 of 20 (15%), and 1 of 16 (6.3%) samples, respectively. All patients with tumor specimens exhibiting LOH are of advanced clinical stages. Loss of imprinting (LOI) was found in 5 of 20 (25%) for IGF-II and in 4 of 17 (23.5%) and 1 of 15 (6.7%) for the RsaI and AluI sites of H19 gene with no LOH. However, no LOH was found in low malignant potential tumors, and only one of them showed LOI in H19 AluI site. Overexpression of IGF-II was demonstrated in all five LOI samples with normal expression of H19. Three of the five tumor specimens exhibiting LOI were transcribed from P1 promoter, whereas the remaining two were from the P3 promoter. These results suggested that LOH of both IGF-II and H19 genes was associated with advanced ovarian cancer. LOI of IGF-II and H19 genes may be involved in the development of ovarian cancer. Transcription of IGF-II from the P1 promoter may account for the biallelic expression of the IGF-II gene.

Sleep breathing and sleep movement disorders masquerading as insomnia in sexual-assault survivors

A descriptive, hypothesis-generating study was performed with 156 female sexual-assault survivors who suffered from insomnia, nightmares, and posttraumatic stress disorder (PTSD). They completed 2 self-report sleep questionnaires to assess the potential presence of intrinsic sleep disorders. Seventy-seven percent of the sample (120 of 156) endorsed additional sleep complaints, besides their insomnia symptoms, that indicate the potential presence of sleep-disordered breathing ([SDB] 81 of 156, 52%) and sleep-related movement disorders ([SMD] 94 of 156, 60%). The potential for SDB was strongly correlated with the body mass index (BMI), an increase in arousal symptoms, and greater total PTSD severity. In some sexual-assault survivors, the relationship between sleeplessness and posttraumatic stress may be caused or exacerbated by intrinsic sleep disorders, and not be solely a function of psychophysiological insomnia--the traditional diagnostic term usually offered to explain the sleep problems associated with PTSD. Prevalence studies that use objective diagnostic evaluations such as polysomnography (PSG) are needed to test these hypotheses.

Interaction in vivo and in vitro between the yeast fimbrin, SAC6P, and a polymerization-defective yeast actin (V266G and L267G)

A mutant yeast actin (GG) has decreased hydrophobicity in a subdomain 3/4 hydrophobic plug believed to be involved in a hydrophobic cross-strand "plug-pocket" interaction necessary for actin filament stability. This actin will not polymerize in vitro but is compatible with cell viability. We have assessed the ability of Sac6p, the yeast homologue of the actin filament stabilizing and bundling protein fimbrin, to restore polymerization in vitro and to facilitate GG-actin function in vivo. Sac6p rescues GG-actin polymerization at 25 degrees C but not at 4 degrees C. The actin polymerizes into bundles at room temperature with a fimbrin:actin molar ratio of 1:4. At this ratio, every actin monomer contacts a Sac6p actin binding domain. Following cold-induced depolymerization, actin/Sac6p mixtures repolymerize beginning at 15 degrees C instead of the 25 degrees C required for de novo assembly, because of the presence of residual actin-Sac6p nuclei. Generation of haploid Deltasac6/GG-actin cells from either diploid or haploid cells was unsuccessful. The facile isolation of cells with either mutation alone indicates a synthetic lethal relationship between this actin allele and the SAC6 gene. Sac6p may allow GG-actin function in vivo by stabilizing the actin in bundles thereby helping maintain sufficient levels of an otherwise destabilized actin monomer within the cell.

[Endarterectomy for carotid stenosis]

OBJECTIVE

To discuss the indications, anesthesia and surgical techniques of carotid endarterectomy (CEA).

METHODS

Twenty-two sides of carotid stenosis were revealed in 20 patients. CEA was performed under general anesthesia in 21 sides and local anesthesia in one. The time of carotid occlusion ranged from 27 to 52 minutes (average 35.5 min) in 20 operations, and intraoperative shunt was used in the other two. Fifteen operations were monitored with EEG.

RESULTS

The postoperative course was uneventful in 17 patients after 18 operations, while transient muscle strength decrease on contralateral side and ipsilateral lower facial paresis occurred after three operations in the other three patients. Nineteen patients were followed-up for 38 months on the average. Among nine patients with TIA, ischemic attacks ceased in eight and decreased in one. Improvement was achieved in six patients with cerebral infarction. One patient without symptoms of carotid ischemia was still normal after operation.

CONCLUSION

Carotid endarterectomy is a safe and effective way for treating carotid stenosis.

Family planning training in Maryland family practice and obstetrics/gynecology residency programs

OBJECTIVE

To examine the extent of family planning and abortion training in Maryland family practice (FP) and obstetrics/gynecology (OB) residency training programs.

METHODS

All final-year residents in every FP and OB residency training program in Maryland were asked in 1998 how many cases (0, 1-10, > 10) of ten methods of contraception and abortion they had managed.

RESULTS

Seventy-five percent (55) of the 73 residents responded. Fifty percent of FP residents had never inserted an intrauterine device (IUD), 43% had never inserted an implant (Nor-plant), 37% had never prescribed emergency contraceptive pills, and 30% had never fitted a diaphragm. Ninety-seven percent of FP residents had no experience with elective termination of pregnancy, and 83% had no experience with sterilization. Twenty percent of OB residents had never inserted an IUD, 16% had never inserted implants or prescribed emergency contraceptive pills, 20% had never fitted a diaphragm, and 36% had no experience in elective termination of pregnancy. Not one FP resident had inserted or fitted more than ten IUDs, implants, diaphragms, or cervical caps. Except for oral and injectable contraception, the majority of OB residents had not managed more than ten cases of any other reversible contraceptive method: 80% had not inserted more than ten IUDs, 72% had not inserted more than ten implants, 88% had not fitted more than ten diaphragms, and 100% had not fitted more than ten cervical caps.

CONCLUSION

These survey results indicate a need for more formal instruction in most contraceptive methods for OB and FP residency programs in Maryland. This study concurs with previous national studies showing deficits in family planning training.

Duration of preoperative amiodarone treatment may be associated with postoperative hospital mortality in patients undergoing heart transplantation

OBJECTIVE

To assess the effect of preoperative amiodarone treatment on patient mortality after heart transplantation.

DESIGN

Retrospective study.

SETTING

Single-institution university hospital.

PARTICIPANTS

One hundred six consecutive patients with heart transplants.

INTERVENTIONS

None.

MEASUREMENTS AND MAIN RESULTS

Patients were grouped according to duration of preoperative amiodarone treatment, and posttransplant mortality before hospital discharge was compared with patients not treated with amiodarone. The authors collected cardiovascular data in the preoperative and postoperative periods. There was a significant increase in posttransplant mortality before hospital discharge in patients treated with amiodarone for more than 4 weeks in the preoperative period (p < 0.05). Patients treated with amiodarone had significantly lower (p < 0.05) heart rates (mean heart rate, 103+/-19 beats/min) in the early postoperative period than patients not treated with amiodarone (mean heart rate, 111+/-15 beats/min), but there was no relationship with mortality (p = not significant). Patients who died had a significantly lower (p < 0.05) postoperative cardiac index (2.2+/-0.7 to 2.5+/-0.7) in the first 24 hours after cardiopulmonary bypass compared with patients who survived to hospital discharge (3.0+/-0.7 to 3.1+/-0.9), but there was no relationship to amiodarone treatment (p = not significant).

CONCLUSION

Preoperative amiodarone treatment for more than 4 weeks may be associated with a significant increase in postoperative mortality in patients undergoing heart transplantation. Therefore, the indications for amiodarone must be carefully considered and, if needed, the maintenance dose should be kept to a minimum.

Etiology of preoperative anemia in patients undergoing scheduled cardiac surgery

PURPOSE

Ten percent of our cardiac surgical patients have preoperative anemia. Anemia diagnosed before scheduled cardiac surgery is a strong predictor of the need for homologous blood transfusion (RBC) perioperatively but the cause of this preoperative anemia is not known. The purpose of this study was to evaluate the etiology of preoperative anemia.

METHODS

Seventy-five consecutive anemic cardiosurgical patients (Hb = < 120 g x L(-1) the day before surgery) were studied prospectively. All had multiple diagnostic blood tests done in the preoperative period to diagnose the cause of the anemia and subsequently underwent non-emergency cardiac surgery. Anesthesia and RBC transfusion were standardized according to the protocol. Data in respect to operation, RBC and other blood product transfusion during operation and hospital stay were recorded.

RESULTS

Hospital-acquired anemia was present in 37.3% of anemic patients (hemoglobin decrease during hospitalization before surgery > or =9 g x l(-1)). The second most common diagnosis was iron deficiency anemia (29.3% patients) followed by anemia of chronic renal disease (10.7% patients). When coronary angiography was performed close to operation time, patients had a higher decrease in hemoglobin concentration during hospitalization --suggesting that blood loss during angiography was, in part, responsible for anemia. Seventy-five percent of anemic patients were transfused with RBC perioperatively compared with our overall transfusion rate of 30% of cardiac surgery patients.

CONCLUSIONS

In the majority of patients, preoperative anemia is potentially preventable. Investigation and treatment of anemia before cardiac surgery should be a priority in preparing the patient for surgery.