The evaluation of hemorrhage in cardiac patients who have undergone extracorporeal circulation

The present study defines excessive bleeding in patients who undergo cardiopulmonary bypass, and evaluates the use of coagulation testing to predict those patients that bleed excessively. Evaluation of 774 consecutive patients undergoing aortocoronary bypass surgery was carried out. Cardiopulmonary bypass consisted of a bloodless prime and a Harvey bubble oxygenator. In the postoperative period, excessive hemorrhage was defined as that exceeding 600 ml chest tube drainage in the first eight hours. One hundred and sixty-three patients (21%) were noted to be in this category. Excessive bleeding postoperatively was best predicted by a PTT greater than 45 seconds, a PT greater than 19 seconds, a fibrinogen level less than 225 mg/dl and a TFT equal to or less than 1:32. These laboratory findings occur singly or in combination. The assessment of platelet, numbers or function and fibrin(ogen) split products were of no prognostic value. Using these criteria, the re-exploration rate for excessive hemorrhage and/or tamponade was 0.6 per cent (5 out of 774 patients). No preoperative laboratory test of hemostatic function was useful in predicting coagulopathies resulting from cardiopulmonary bypass.

Collagen heterogeneity in systemic scleroderma and other diseases

Proportions of collagen type I and type III were investigated in different tissues (kidney, liver, heart muscle, esophagus, lung and skin) in a single case of malignant systemic scleroderma. The proportion of collagen type III was higher than in healthy controls. Similarly, an increase in the proportion of collagen type III was shown in tissues affected by other inflammatory diseases. Further the authors suggest that the increase in total kidney collagen, especially type III, has important consequences for kidney function; in the described case it had the critical influence on the fatal course of the disease, and the patient died from uremia.

Ways of collagen separation in pathologically altered tissue

A system of chromatographic methods using two successive DEAE-cellulose chromatographic steps and two successive separations on Bio-Gel A-1.5 m has been worked out for the separation of individual collagen types. The success of the procedure is based on the preliminary removal of proteoglycans during the first DEAE-cellulose run. Alternatively it is possible to replace chromatographic steps, following the removal of proteoglycans, with fraction precipitation.

Effect of cartilage bone-marrow extract on articular cartilage collagen formation

Cartilage bone-marrow extract has stimulated the collagen formation of articular as well as sternal cartilage collagen in chick embryo. Collagen biosynthesis has been stimulated also in other investigated tissues, i.e. in cornea and sclera of chick embryo as well as in sponge granuloma of rats, where mainly formation of collagen type I was stimulated. Glycosaminoglycans formation has also been increased after administration of cartilage bone-marrow extract.

Treatment of severe coronary artery disease with 5, 6, and 7 saphenous vein bypasses: review of 131 consecutive patients

One hundred thirty-one consecutive patients who received 5, 6, and 7 bypass grafts are analyzed. Ages ranged from 31 to 74 years. The male-to-female ratio was 7:1. As an indication of severity of disease, 25% were classified as having impending myocardial infarction and 46.6% were classified in New York Heart Association Functional Class IV. Left ventricular function was impaired in 37.4%, and 30% of the patients had left main coronary obstruction. Nonfatal perioperative myocardial infarction occurred in 4.6%. The hospital mortality was 3%. One hundred percent follow-up (5 to 55 months) revealed 4 late deaths, 3 presumably of cardiac origin. Only 7 patients in the postoperative follow-up group have complained of angina; 1 has since undergone successful reoperation.

Rheumatoid arthritis and collagen antibodies

By using the complement fixation test, antibodies against collagen were examined. Pronase-solubilized insouble collagen served as antigen (20 degrees, 24 hours, collagen: enzyme ratio 10:1). Of 79 patients suffering from rheumatoid arthritis, the presence of collagen antibodies was demonstrated in 8 cases. 56 patients with degenerative joint disease served as the control group, in which collagen antibodies were detected in only one single patient.

Quantitative changes in insoluble collagen during ontogeny in rodents (collagen type I and type III)

It has been proved in three rodent species that in the insoluble collagen fraction which accumulates in skin collagen with age of the two categories of collagen present (collagen type I and collagen type III), their proportion alters in favour of collagen type I with the advancing age. Since it has also been shown that collagen type I is less resistant towards proteolytic cleavage than is collagen type III its accumulation can be explained either by rapidly advancing cross-linking of this collagen type or more likely by different proteosynthesis. The second alternative is preferred since a step-wise polymerization of collagen type III was also observed. No information revealing to what extent the lysine derived cross-links can combine both collagen types is at present available. On the basis of this information the rapid decrease in insoluble collagen in very early ontogeny (rats below 8 weeks of age) is explained.

Cartilage collagen in osteoarthrosis

Pronase digestion of osteoarthrotic cartilage collagen indicated that this type of pathological collagenous structure is more susceptible to proteolytic degradation than human controls or bovine and calf articular cartilage. There were some differences between individual patients in the collagen susceptibility to pronase cleavage. Also, different zones of the same diseased femoral head exhibited varied susceptibility. It is suggested that changes in collagen stability are reflected in cartilage permeability and in this way also in alterations in the supply of nutrients.

Fibrillation of tropoelastin induced by proteoglycan

Electrostatic interaction between tropoelastin, the native precursor of elastin, and proteoglycan results in tropoelastin fibrillation. The finding suggests a possible involvement of proteoglycans in elastogenesis.

The effect of diftalone on collagen and glycosaminoglycans metabolism

Diftalone showed a distinct inhibition effect on the collagen formation in sponge granuloma as well as in chick embryos articular cartilage. The inhibitory effect was expressed even in corneal and articular cartilage glycosaminoglycans (GAG) sulphation and GAG formation in granulation tissue. According to our previous results diftalone showed a similar inhibition of collagen and GAG biosynthesis as other effective antirheumatic drugs.

Myocardial revascularization in patients with poor ventricular function

Eighty patients with evidence of impaired ventricular function by ventriculography were reviewed. On the basis of the ejection fraction, these patients were divided into three groups. Those with ejection fractions less than 0.2 were considered in very poor condition, those with ejection fractions of 0.2 to 0.4 were considered in poor condition, and those with ejection fractions with between 0.4 and 0.6 were considered fair. Suitability of vessels for bypassing and the presence or absence of collateral cirulation on the cinearteriograms was also noted for possible influence on result. Operative mortality rate in patients having complete repair, defined as bypassing all major vessels with significant obstruction, was 7 per cent. In 26 patients having incomplete repair, the operative mortality was 30 per cent. However, the late mortality rate was not favorably influenced by complete repair, 75 per cent are in improved or good clinical condition, as compared with 65 per cent in the incomplete repair group. As patients with impairment of ventricular contractility are at high risk, it is believed that they should continue to be evaluated on an individual basis for bypass surgery and not categorically denied treatment.

Hyperinfection syndrome with Strongyloides stercoralis in malignant lymphoma

Hyperinfection with Strongyloides stercoralis occurred in three patients with malignant lymphoma. The probable cause in each case was alteration of the immune responses either as a result of the malignant lymphoma or by the treatment given. Though thiabendazole (Mintezol) has produced reasonable results in the treatment of the hyperinfection syndrome, preliminary data suggest that the new broad-spectrum anthelmintic levamisole (Ketrax) is more effective. All patients who live or have lived in an area where strongyloidiasis is endemic should be investigated to detect the presence of the nematode before and during treatment with drugs with immunosuppressive properties. In view of the high mortality with S. stercoralis hyperinfection, vigorous therapy should be instituted before the use of immunosuppressive drugs.