Perioperative use of iloprost in cardiac surgery patients diagnosed with heparin-induced thrombocytopenia-reactive antibodies or with true HIT (HIT-reactive antibodies plus thrombocytopenia): An 11-year experience.

Thrombocytopenia and thromboembolism(s) may develop in heparin immune-mediated thrombocytopenia (HIT) patients after reexposure to heparin. At the Onassis Cardiac Surgery Center, 530 out of 17,000 patients requiring heart surgery over an 11-year period underwent preoperative HIT assessment by ELISA and a three-point heparin-induced platelet aggregation assay (HIPAG). The screening identified 110 patients with HIT-reactive antibodies, out of which 46 were also thrombocytopenic (true HIT). Cardiac surgery was performed in HIT-positive patients under heparin anticoagulation and iloprost infusion. A control group of 118 HIT-negative patients received heparin but no iloprost during surgery. For the first 20 patients, the dose of iloprost diminishing the HIPAG test to ≤5% was determined prior to surgery by in vitro titration using the patients' own plasma and donor platelets. In parallel, the iloprost "target dose" was also established for each patient intraoperatively, but before heparin administration. Iloprost was infused initially at 3 ng/kg/mL and further adjusted intraoperatively, until ex vivo aggregation reached ≤5%. As a close correlation was observed between the "target dose" identified before surgery and that established intraoperatively, the remaining 90 patients were administered iloprost starting at the presurgery identified "target dose." This process significantly reduced the number of intraoperative HIPAG reassessments needed to determine the iloprost target dose, and reduced surgical time, while maintaining similar primary clinical outcomes to controls. Therefore, infusion of iloprost throughout surgery, under continuous titration, allows cardiac surgery to be undertaken safely using heparin, while avoiding life-threatening iloprost-induced hypotension in patients diagnosed with HIT-reactive antibodies or true HIT.

Ischemia-modified albumin in acute aortic dissection.

BACKGROUND: Acute aortic dissection (AOD) is associated with high mortality and early diagnosis and treatment are essential. Ischemia-modified albumin (IMA) is a marker of myocardial ischemia whereas cardiac enzymes are released when myocardial necrosis occurs. We investigated, for the first time, whether IMA increases in AOD either at presentation or after surgery. METHODS: We studied 46 consecutive patients with documented AOD; we also evaluated 13 consecutive patients with dilated ascending aortas scheduled for elective surgery and admitted for preoperative coronary angiography; 46 age-matched normal subjects served as controls. Only patients with acute onset of symptoms were included. We evaluated IMA, cardiac enzymes, N-terminal pro-B-type natriuretic peptide, albumin, C-reactive protein (CRP), and D-dimers on admission, 24 hr post-operatively and 4 days post-operatively. Duration from symptom onset to the first sample was 23±17 hr. RESULTS: IMA did not differ between patients with AOD at presentation (93±19 U/ml), patients with chronic aneurysms (90±14 U/ml) and normal controls (91±9 U/ml). In addition, IMA did not change significantly after surgical repair. IMA, at baseline, however, correlated positively with time from symptom onset as well as CRP levels (P=0.05 and P=0.007, respectively). CONCLUSION: IMA is not elevated in AOD when blood sampling is performed within 23±17 hr after symptom onset nor increases after surgery.

A Ptolemaic mummy reveals evidence of invasive dentistry in ancient Egypt.

Over the last decades, it has been confirmed that computerized tomography (CT) is a valuable tool for studying mummies. In joint efforts put forth by the Mummy Research Project of the Hellenic Institute of Egyptology, the National Archaeological Museum, and the Athens Medical Center, a mummy was transported to the Radiology Department of the Athens Medical Center for study. Thus, a complete CT scanning was performed of this Ptolemaic mummy (AIG 3343: Sekhem, male, 150-30 BCE), belonging to the Egyptian Collection of the National Archaeological Museum of Athens. The most significant finding is an interproximal carious cavity packed with protective material. This is the second case of dental packing in the literature among ancient Egyptian mummies studied to date. Its remarkable resemblance to the previously published study may indicate a common dental intervention performed by ancient Egyptians. Despite the well-known early medical traditions of ancient Egypt, spanning from the Old Kingdom to the Ptolemaic and Roman Periods, little evidence remains of their practices in dentistry. Our finding represents a rare perspective on the origins of what remains today a major allied health field discipline.

Chronic maxillary atelectasis under the wrappings of an Egyptian mummy.

OBJECTIVES: In the context of a joint Mummy Research Project of the National Archaeological Museum, the Hellenic Institute of Egyptology and the Athens Medical Centre, an Egyptian mummy of the mid-Ptolemaic Period was transferred to our hospital and was thoroughly investigated with Computed Tomography. METHODS: The mummy was carefully removed from its coffin and scanned in a 64-detector row computed tomographic scanner. Multiplanar and anthropometric measurements were obtained using advanced software. RESULTS: The mummy appeared to be well-preserved and belonged to a young male adult. Among the findings, the most interesting and uncommon one was the asymmetry of the maxillary sinuses and the orbits. There were no signs of trauma. CONCLUSIONS: Computed Tomography revealed in a non-destructive way a rare, based on the published data, facial deformity in an Egyptian mummy attributed to chronic maxillary atelectasis.

Preventing strategy of multidrug-resistant Acinetobacter baumanii susceptible only to colistin in cardiac surgical intensive care units.

OBJECTIVE: The study aimed to determine the incidence and mortality of multidrug-resistant Acinetobacter baumannii in cardiac surgery, to elucidate the effectiveness of colistin treatment and to identify if the additional measures to the recommended procedures were able to control the dissemination of the pathogen. METHODS: A prospective observational cohort was conducted among cardiac surgical patients from 1 September 2005 to 31 December 2006. We reviewed the prophylactic measures of the surgical intensive care unit and implemented a two scale multiple program. Scale I included classical infection control measures, while Scale II referred to the geographic isolation of multidrug-resistant Acinetobacter baumannii patients and environmental intense surveillance. RESULTS: Among 151 out of 1935 infected patients 20 were colonized and infected by strains of multidrug-resistant A. baumannii susceptible only to colistin. Seventeen patients presented respiratory tract infection, one patient suffered deep surgical site infection and two patients catheter related infection. Transmission of the pathogen occurred via two patients transferred from two other institutions. They were all treated with colistin. Cure or clinical improvement was observed only in four patients (20%). Scale I measures were implemented for the whole 16-month period while scale II for two separate periods of 3 weeks. Environmental specimens (n>350) proved negative. CONCLUSIONS: The increasing prevalence of multidrug-resistant A. baumannii in surgical intensive care unit patients creates demand on strict screening and contact precautions. Following this infection control strategy we were able to achieve intermittent eradication of the pathogen during a 16-month period with continuous function of the intensive care unit. Despite the significant in vitro activity of colistin against multidrug-resistant Acinetobacter baumannii the results were discouraging.

Pseudomonas aeruginosa susceptible only to colistin in intensive care unit patients.

BACKGROUND: Gram-negative bacilli, including multi-drug-resistant (MDR) Pseudomonas aeruginosa, are responsible for severe intensive care unit (ICU)-acquired infections, mainly pneumonia and bacteremia. The aim of this study was to determine the incidence of MDR strains of Pseudomonas in patients undergoing cardiac surgery, to elucidate the effectiveness of treating these patients with colistin, and to assess the safety of the drug. METHODS: A prospective study was conducted among 1,452 patients who underwent surgery for a variety of cardiac lesions over a one-year period, and who spent a portion of the recovery period in the surgical ICU. Their case histories were analyzed to identify infectious complications. Diagnosis of infection was based on clinical data, and the pathogen was tested with respect to its susceptibility to colistin (polymyxin E). The clinical response to the antibiotic was evaluated. RESULTS: Over the 12-month period, among 115 infected patients, 15 were affected by strains of P. aeruginosa. In 10 patients, this pathogen proved resistant to all potentially active antibiotics except colistin. All of the affected patients were being ventilated mechanically, and eight of them presented with ventilator-associated pneumonia (VAP), whereas one patient suffered a deep incisional surgical site infection and bacteremia and the remaining patient had a superficial infection of a lower-extremity vein graft donor site. The MDR pathogen was introduced to the hospital by three patients transferred from three institutions. All patients were treated with intravenous colistin. In cases of VAP, aerosolized colistin was added. Deterioration of renal function occurred in three patients (30%), all of whom had a history of renal insufficiency. Cure or clinical improvement was observed in seven patients (70%), whereas four patients, including one who improved initially, developed sepsis and died with multiple organ dysfunction syndrome (mortality rate 40%). CONCLUSIONS: The increasing prevalence of MDR P. aeruginosa in ICU patients has rekindled interest in polymyxins, which had been abandoned because of toxic side effects. Colistin retained significant in vitro activity against this virulent organism, had an acceptable safety profile, and should be considered as a treatment option in critically ill patients with infection caused by MDR gram-negative bacilli. Aerosolized colistin may merit further consideration as a therapeutic intervention for patients with refractory pulmonary infections.

Complications involving gall bladder and biliary tract in cardiovascular surgery.

BACKGROUND/AIMS: This study aimed to ascertain the frequency of biliary complications following cardiac surgery, to determine preoperative risk factors and to identify the significance of prompt diagnosis and institution of therapy. METHODOLOGY: All patients who underwent open-heart surgery (4588 patients) during a period of 3 years were examined prospectively for complications involving gall bladder and biliary tract. Patients with preoperative hepatic dysfunction or biliary disorders were excluded from this study. RESULTS: Biliary complications occurred in 14 patients. Gangrene of gallbladder (n=5) and acute acalculous cholecystitis (n = 5) were the most common complications followed by distension of the common bile duct (n = 2), cholelithiasis (n = 1) and empyema (n = 1). The majority of complications presented within the 3rd postoperative week. Chole cystectomy was performed in 5 patients and percutaneous drainage of the gallbladder in 7. Mortality rate was 43%. Biliary complications correlated with advanced age, the male sex, combined surgical procedures, preoperative low cardiac output syndrome, prolonged bypass and aortic cross-clump time, mechanical ventilation, the usage of Intra-Aortic Balloon Pumping, multiple transfusions and the administration of inotrops. CONCLUSIONS: Biliary complications after cardiac surgery are uncommon but life threatening and may result from hypoperfusion. Clinical features are often subtle, and a high index of suspicion is necessary for an early diagnosis and appropriate treatment.

Eurasianism versus IndoGermanism: Linguistics and mythology in the 1930s' controversies over European prehistory.

In 1935, the Russian linguist Prince Nicolai S. Trubetskoi and the French mythologist Georges Dumézil engaged in a vicious debate over a seemingly obscure subject: the structure of Northwest Caucasian languages. Based on unknown archival material in French, German, and Russian, this essay uses the debate as a pathway into the 1930s scientific and political stakes of IndoEuropeanism - the belief that European cultures emerged through the spread of a single IndoEuropean people out of a single "motherland." Each of the two authors held strong commitments to visions of European order and its origins - in "Eurasia" for Trubetskoi and a Northern European Heimat for Dumézil. The North Caucasus, long a privileged site for Russian and European scholars, now became key to the renegotiation of the origins and reach of imagined prehistoric IndoEuropean conquerors, but also the 1930s' debate over the value of different disciplines (linguistics, mythology, archaeology, folklore studies) for the origins of language, myth, and the European deep past. As a moment in the history of modern speculations about prehistory, pursued in the shadow of Nazi scholarship, the debate transformed fields of research - notably linguistics, comparative mythology, and structuralism - and the assumptions about the shape of Europe.

Postoperative jaundice after cardiac surgery.

BACKGROUND: The frequency and pattern of hyperbilirubinemia after open-heart surgery and its severe perioperative complications are not well clarified. The purpose of this study was to investigate the incidence and nature of postoperative jaundice in patients undergoing cardiac operation, to analyze the determinants, and to identify the clinical significance of this complication with regard to the associated morbidity and mortality. METHODS: A prospective observational study was made during the period of 2003-2004 in a Surgical Intensive Care Unit of a Cardiac Surgery Center, Athens. One hundred twenty-eight adult patients for open heart surgery were divided into three groups. Group A included 50 patients who underwent coronary artery bypass crafting (CABG), group B 31 patients who were subjected to aortic valve replacement (AVR)+CABG and group C 47 patients who underwent mitral valve replacement (MVR)+CABG. Aminotransferases, alkaline phosphatase, gamma-glutamyl-transpeptidase and both types of bilirubin were determined at admission, 24 hours after the operation and thereafter according to clinical evolution. The presence of jaundice was associated with elevated serum bilirubin above 3 mg/dl. RESULTS: Hyperbilirubinemia developed in 34 patients (26.5%). The incidence of postoperative jaundice was higher in patients who were subjected to MVR+CABG than to CABG and AVR+CABG. Hyperbilirubinemia was correlated with prolonged cardiopulmonary by-pass time (P<0.001), aortic cross-clamping time (P<0.001), the use of intra aortic balloon pumping (P<0.001), the administration of inotrops and the number of blood and plasma transfusions. Postoperative jaundice resulted mainly from an increase in conjugated bilirubin. CONCLUSIONS: Although hyperbilirubinemia seems to be multifactorial, the type of operation, the preoperative hepatic dysfunction due to advanced heart failure (NYHA II-III) and the decreased hepatic flow during the operation seem to determine the incidence of jaundice.

Frequency, characteristics, and predictors of microbiologically documented nosocomial infections after cardiac surgery.

OBJECTIVE: Nosocomial infections still remain a serious problem in patients undergoing open heart surgery. The objective of this study was to evaluate frequency, characteristics, and predictors of nosocomial infections after cardiac surgery. METHODS: This prospective case-control study was conducted in adult patients who underwent open heart surgery with use of extracorporeal circulation over a period of 16 months. Cases were patients who developed microbiologically documented nosocomial infection. Controls were patients who had open heart surgery within a randomly selected two-month period of the study (defined before the start of the study) and did not develop nosocomial infection. Various variables, available before, during or within the first two days after operation, were examined as possible risk factors of nosocomial infections in bi-variable analysis. Then, variables that were found to be statistically associated with nosocomial infections in the bi-variable analysis were included in a multivariable logistic regression model to identify independent risk factors associated with nosocomial infections after open heart surgery. RESULTS: One hundred and seven of 2122 (5.0%) patients developed microbiologically documented nosocomial infection after open cardiac surgery. The majority of nosocomial infections were respiratory tract infections (45.7%) and central venous catheter-related infections (25.2%). All cause hospital mortality was 16.8% in patients with nosocomial infection and 3.5% in the control group (p=0.005). Out of 20 variables studied as possible risk factors, 12 had a statistically significant association with postoperative infection. History of immunosuppression (OR=3.6, 95% CI 1.2-11.0%), transfusion of more than five red blood cell units in both the operating room and during the first ICU postoperative day (OR=21.2, 95% CI 11.9-37.8%), and development of acute renal failure within the first two days after operation (OR=49.9, 95% CI 22.4-111.0%), were found to be independent predictors of nosocomial infections after cardiac surgery in a multivariable logistic regression model. CONCLUSIONS: Postoperative nosocomial infections are a considerable problem in cardiac surgery patients. The identified independent predictors of nosocomial infection may be useful in identifying those at high risk for development of such infection in cardiac surgery patients.

Joseph Strnad (1889-1962): handmaker of surgical tools.

Joseph Strnad was a charismatic person who lived in Vienna and Zurich in the first half of the 20th century. He created surgical instruments that are still famous for their functionality and quality. His life story and his contribution to surgery were told by his daughter on the occasion of the donation of her father's tools to the Museum of History of Medicine at the University of Ioannina, as well as in thank you letters to Strnad from famous surgeons.

Determinants of candidemia and candidemia-related death in cardiothoracic ICU patients.

STUDY OBJECTIVES: To develop and prospectively validate models of independent predictors of candidemia and candidemia-related death in cardiothoracic ICU (CICU) patients. DESIGN: (1) An initial, prospective, one-center, case-control, independent predictor-model determining study; and (2) a prospective, two-center, model-validation study. SETTING: The initial study was performed at the 14-bed CICU of the Onassis Cardiac Surgery Center, Athens, Greece; the model-validation study was performed at the Onassis Cardiac Surgery Center CICU and the 12-bed CICU of Henry Dunant General Hospital, Athens, Greece. PATIENTS: In the initial study, 4,312 patients admitted to the Onassis Center CICU between March 1997 and October 1999 were considered for enrollment; 30 candidemic and 120 control patients (case/control ratio, 1/4) matched according to potential confounders were ultimately enrolled. In the model-validation study, 2,087 patients admitted to the Onassis and Henry Dunant CICUs between November 1999 and May 2002 were prospectively enrolled. MEASUREMENTS AND RESULTS: Models of predictors of candidemia and associated death were constructed with stepwise logistic regression and subsequently validated. Independent candidemia predictors were ongoing invasive mechanical ventilation (IMV) > OR =10 days, hospital-acquired bacterial infection and/or bacteremia, cardiopulmonary bypass duration > 120 min, and diabetes mellitus. Model performance was as follows: sensitivity, 53.3%/57.9%; specificity, 100%/100%; positive predictive value (PPV), 100%/100%; negative predictive value (NPV), 88.9%/99.6%; and accuracy, 90.1%/99.6% (initial/model-validation study values, respectively). IMV > or =10 days and hospital-acquired bacterial infection/bacteremia were the two strongest candidemia predictors. APACHE (acute physiology and chronic health evaluation) II score > or =30 at candidemia onset independently predicted candidemia-related death with 80.0%/85.7% sensitivity, 80%/75% specificity, 66.7%/66.7% PPV, 88.9%/88.9% NPV, and 80.0%/78.9% accuracy (initial/model-validation study values, respectively). CONCLUSIONS: We provided a set of easily determinable independent predictors of the occurrence of candidemia in CICU patients. Our results provide a rationale for implementing preventive measures in the form of independent predictor control, and initiating antifungal prophylaxis in high-risk CICU patients.

Methicillin-resistant Staphylococcus aureus preventing strategy in cardiac surgery.

OBJECTIVES: The aim of this survey was to elucidate the efficacy of methicillin-resistant Staphylococcus aureus (MRSA) preventing strategy in our institution by investigating the incidence and evaluating the morbidity and mortality associated with this multi-resistant virulent organism. METHODS: A prospective observational cohort among patients submitted to cardiovascular surgical procedures was conducted from 1 January 1997 to 31 December 2005. Preventing strategy included active screening programs by nasal swabs for all patients admitted from other hospitals or being at risk for developing infectious complications. Carriers or infected patients remained isolated and were treated promptly. Furthermore, all newly employed health care workers were screened for MRSA and carriers were treated with mupirocin until the eradication of the pathogen. RESULTS: Throughout the 9-year study period 826 infectious complications were registered among 15,270 cardiac surgical patients. Total infection rate was 5.4%. MRSA was identified in 86 patients; 56 patients proved carriers and 30 infected. The MRSA associated infection rate was 0.2%. During this period of time mean ICU stay was 1.7 days and ICU mortality rate was 2.9%. MRSA infected patients presented a mean ICU stay of 46.5 days and a mortality rate of 30%. In ten patients, MRSA was detected in tracheal secretions, in four patients in swabs taken from donor site infection and in four patients from superficial sternal surgical wound. In ten patients the pathogen was isolated from cultures of the surgical site drainage and the diagnosis of post-sternotomy mediastinitis was confirmed. The remaining two patients were defined as having severe sepsis; MRSA was documented in central venous catheter tips and blood cultures. CONCLUSIONS: The prompt determination, isolation and appropriate treatment of MRSA patients admitted from other institutions combined with the detection and elimination of carriers among new health care workers and patients at high risk of developing infectious complications prevented further spread of the pathogen.

Incidence of postoperative infections in patients undergoing coronary artery bypass grafting surgery receiving antimicrobial prophylaxis with original and generic cefuroxime.

OBJECTIVE: The aim of this study was to compare the incidence of post-operative infections in patients undergoing coronary artery bypass grafting (CABG) surgery who received generic cefuroxime (gCFX) instead of original cefuroxime (oCFX) as antimicrobial prophylaxis. METHODS: The study had two parts, a prospective and a retrospective one (4 weeks with oCFX followed by 4 weeks with gCFX in each part; total study duration of 16 weeks). The studied patient population was 618 consecutive adult patients who underwent on pump CABG surgery. Patients were divided into two groups according to type of formulation they received: 313 patients received oCFX and 305 gCFX. RESULTS: Eight (2.5%) and 39 (12.8%) patients in the oCFX and gCFX group, respectively, developed postoperative infections (p<0.001). There were 6 (1.9%) surgical site infections in the oCFX group and 31 (10.1%) in the gCFX group (p<0.001). Bacteremia occurred in 2 (0.6%) patients in the oCFX group and in 8 (2.6%) patients in the gCFX group (p=0.1). In addition, septic shock occurred in 6 cases (2.0%, p=0.04) and multiple organ failure in another 4 patients (1.3%, p=0.1) in the gCFX group. The most common pathogens isolated were Gram-positive cocci in both groups. CONCLUSIONS: This study revealed a higher incidence of postoperative infections in adult patients undergoing CABG surgery receiving gCFX compared to oCFX as antimicrobial prophylaxis. The findings of our study provide additional evidence regarding the problem of substandard drugs, in our case a formulation of a generic antibiotic, even in developed countries. ULTRAMINI-SUMMARY: The incidence of post-operative infections following CABG surgery was higher in adult patients receiving generic instead of original cefuroxime as antimicrobial prophylaxis. The findings of our study provide additional evidence regarding the problem of substandard drugs, in our case a formulation of a generic antibiotic, even in developed countries.

Orthotopic heart transplantation: ten years' clinical experience.

INTRODUCTION: Heart transplantation is the "gold standard" in the treatment of patients with end-stage heart failure who satisfy strict selection criteria. METHODS: We reviewed ten years' clinical experience (1996-2006) from 53 orthotopic transplants in our centre. RESULTS: Low perioperative (3.7%) and long-term (7.5%) mortality rates yielded a 95% survival rate in the first year, 92% at five years, and 70% at ten years--significantly better than the corresponding rates worldwide. In addition, excellent functional recovery was achieved in all transplant recipients. CONCLUSIONS: The strict application of international criteria in the selection of both candidates and donors, together with uninterrupted, multidisciplinary follow up, have made it feasible to perform heart transplantation with excellent results, despite the curiously low number of potential recipients and the shortage of acceptable donor hearts.