Myocardial anaerobic metabolism during isoprenaline infusion in a cyanotic animal model: possible cause of myocardial dysfunction in cyanotic congential heart disease.

Mongrel dogs were made acutely cyanotic by anastomosis of the inferior vena cava to the left atrium and measurements of high fidelity left ventricular pressure, arterial pressure, blood gases, and myocardial lactate arteriovenous differences were determined before pacing, with atrial pacing at a rate of approximately 240 per minute, and during an infusion of isoprenaline to increase myocardial oxygen demands. The animals were divided into two groups on the basis of the arterial PO2 during isoprenaline: acyanotic or control dogs (n = 4, PO2 greater than or equal to 6.7 kPa [50 mmHg], mean = 52) and cyanotic dogs (n = 5, PO2 less than or equal to 4.7 kPa (35 mmHg), mean = 32). Myocardial lactate arterio-venous difference showed no significant changes in the control dogs with pacing or isoprenaline, but myocardial lactate production occurred in all five cyanotic dogs with isoprenaline infusion. These studies demonstrate that myocardial anaerobic metabolism can be produced during times of stress with isoprenaline infusion in a cyanotic animal model at systemic oxygen levels that can occur clinically.

Complete atrioventricular canal associated with tetralogy of Fallot: clinical experience and operative methods.

Data on 8 children with the combined anomalies of complete atrioventricular canal and tetralogy of Fallot are presented. Six of the children had only a palliative procedure, and only 1 of these patients is doing relatively well at the present time from a clinical standpoint. Two of the remaining 5 children undergoing palliative procedures have not been helped significantly, and 3 of the children in this group subsequently died. Two children have had an attempted total correction of this complicated intracardiac problem. One of these children, in whom the diagnosis of atrioventricular canal was not made preoperatively, died in the early postoperative period. In the other child, the correct diagnosis was made preoperatively, and a satisfactory, totally corrective procedure was achieved. The patient is asymptomatic at this time.

Rheumatoid pericarditis. Clinical significance and operative management.

The incidence of subclinical pericarditis associated with rheumatoid pericarditis may be as high as 50 percent, but significant impairment of cardiac performance owing to this type of pericarditis rarely occurs. In the past 7 years, we have encountered eight men with congestive heart failure owing to rheumatoid pericarditis. Cardiac catheterization and echocardiography were useful in establishing the diagnosis of pericardial constriction. Pericardiocentesis was unsuccessful in relieving symptoms in the three patients in whom the procedure was performed. Seven patients underwent pericardiectomy; six had constrictive pericarditis and one patient had an acute pericarditis with the sudden onset of cardiac tamponade. The other patient died of cardiac tamponade prior to operation. All patients improved after operation and have remained free of cardiac symptoms 3 months to 4 1/2 years later. The frequent occurrence of adhesive and obliterative pericarditis with loculated effusions suggests the need for pericardiectomy rather than pericardiocentesis in the patient with rheumatoid arthritis and symptomatic pericardial involvement. Immediate and lasting relief of this unusual nonarticular manifestation of rheumatoid arthritis can be expected after pericardiectomy.

Preferential atherosclerosis at the aortic junction of the ligamentum arteriosum: clinical significance and pathological correlation.

Clinical experience with 5 patients who had complications of atherosclerosis within the aorta at the site of the obliterated ductus arteriosus suggested the occurrence of clinically significant preferential atherosclerosis at this location. To examine this hypothesis, the clinical findings in these patients (4 with saccular aneurysm and 1 with systemic emboli from an ulcerated plaque at this location) were correlated with postmortem examination of the aortic isthmus in 40 consecutive cadavers. The point of ductal closure was the area of most severe atheromatous involvement in 32 of the 40 cadavers, and 25 of the 40 specimens demonstrated ulcerated plaques at this location. Microscopical examination consistently demonstrated intimal irregularity or disruption and thinning of the aortic media in this area. These studies indicate that preferential atherosclerosis occurs at the aortic end of the obliterated ducts arteriosus and that these atherosclerotic changes can be a clinically significant development.

Candida albicans infection of sternum and costal cartilages: combined operative treatment and drug therapy and 5-fluorocytosine.

Two patients with candidal sternal osteomyelitis have been successfully treated by operative debridement and adjuvant drug therapy with 5-fluorocytosine. One patient had developed postoperative candidal wound infection after sternotomy, and the other acquired candidal sternal osteomyelitis following Candida fungemia. The diagnosis, suggested by culture, was confirmed by identification of Candida pseudohyphae in debrided tissue. Histological confirmation of candidal sternal osteomyelitis indicates the need for operative debridement and specific systemic antifungal therapy. The drug 5-fluorocytosine appears to provide effective oral therapy in this situation.

Contemporary management of myasthenia gravis: the clinical role of thymectomy.

Thirty-six patients with myasthenia gravis have been evaluated and treated over the past five years. Eleven patients had ocular myasthenia gravis and responded well to anticholinesterase medications. Twenty-five patients had generalized myasthenia gravis, and 22 of them were initially treated with anticholinesterase medications; 18(82%) failed to improve or to maintain an initial improvement on medication, and 14 of these 18 patients underwent thymectomy. In addition, 3 patients underwent thymectomy as part of their initial treatment during the later part of this study. All thymectomies were performed through a median sternotomy. All 17 patients manifested sustained improvement as judged by a gain in strength and decrease in medications. Thymectomy is beneficial in the treatment of myasthenia gravis, and it is most efficacious when performed early in the course of the disease.

Unstable coronary artery disease: comparison of medical and surgical treatment.

In eighty-eight patients with arteriographic findings of obstructive coronary artery disease and the clinical picture of unstable angina pectoris, a decision on operative or nonoperative management was made by the attending physician. Fifty-three of them subsequently underwent aortocoronary saphenous vein bypass grafting and 35 were continued on a program of medical therapy. A marked difference in the course after the first 30 days was noted, with most of the surgically managed patients being either asymptomatic or greatly improved following coronary artery bypass. Two-thirds of the medically treated patients had persistent severe angina pectoris and non was asymptomatic in a follow-up period averaging 20 months. There were 2 late deaths in the medical group and none in the surgical group. These findings indicate that coronary artery bypass operations can be performed with low risk during the unstable phase of coronary artery disease and that relief of angina can be anticipated. In contrast, nonoperative management of unstable coronary artery disease carries an appreciable risk of death or myocardial infarction, and the majority of patients treated nonoperatively continue to experience angina.

Operative closure of isolated defects of the ventricular septum: planned delay.

Selection of patients and the timing of operation for closure of ventricular septal defect (VSD) can be difficult because the risk of operation must be balanced against the hemodynamic abnormality and the age and size of the infant. In the past 6 years we have individualized our approach to the timing and necessity of operation in the patient with an isolated VSD. During this period, 133 patients with VSD were evaluated, and 71 underwent operative closure of the VSD. Of the 133 patients, 90 were 2 years old or younger, and 40 of them required operation because of congestive failure and growth retardation. Of the 45 infants who did not undergo operation, 17 have small intracardiac shunts with normal pulmonary vascular resistance while the other 28 infants remain compensated and are growing despite moderate left-to-right shunts. A persistent, large intracardiac shunt was the indication for operation in 31 of the 48 older patients; the other 17 older patients remain well. Although 3 severely growth-retarded infants (2 to 4 kg) died soon after operation, all infants weighing 4 kg or more survive. No child has died during preoperative observation, and irreversible pulmonary vascular changes have not occurred. Most infants with VSD and large intracardiac shunts do require early VSD closure, but the risk of operation remains high in the tiny neonate with profound failure. With appropriate hemodynamic and clinical criteria, operation for selected infants can be delayed so that the risk of operation can be minimized.

Hemoptysis and pulmonary aspergilloma: operative versus nonoperative treatment.

The clinical experience with 42 patients with pulmonary aspergilloma evaluated at the Vanderbilt University Affliated Hospitals in a 22-year period was reviewed to determine the necessity and advisability of pulmonary resection. Twenty-nine patients (69%) had sustained one or more episodes of gross hemoptysis. Eleven of the 42 patients were treated operatively with lobectomy, wedge resection, or cavernostomy. Five of them had had hemoptysis preoperatively, but in only 1 patient was massive hemoptysis the primary indication for operation. The single death among these 11 patients occurred in the patient undergoing operation for control of massive hemoptysis. Nonoperative treatment was selected in 31 patients because of advanced chronic lung disease. Twenty-four of these 31 patients experienced 41 episodes of gross hemoptysis during observation periods up to 8 years (average, 32 months). Superimposed bacterial infection usually accompanied the episodes of hemoptysis, and medical therapy with bedrest, antibiotics, and postural drainage was successful in controlling the hemorrhage in 40 of the 41 episodes. One patient died from massive hemoptysis. On the basis of this experience, pulmonary resection for aspergilloma in patients with hemoptysis seems rarely indicated.

Does testicular mass always require orchiectomy?

Surgical exploration of a testicular mass should follow the basic principles of cancer surgery, including an inguinal approach, occlusion of the spermatic vessels, opening of the tunica vaginalis, and careful exploration of the testicle, epididymis, paratesticular structures, and spermatic cord. In a very few patients, when intratesticular lesion is small and moveable and can be seen through the tunica albuginea, and if there is a long history of scrotal mass, then the tunica albuginea should be opened and intratesticular exploration performed. The opening of the tunica albuginea should be opened and intratesticular exploration performed. The opening of the tunica albuginea does not violate the principles of cancer surgery, and for a few selected cases can prevent unnecessary orchiectomy. The incision of the tunica albuginea should no longer represent a surgical taboo to the urologist. Six cases of rare, benign intratesticular tumors are presented along with a rare indication for intratesticular exploration and testicle-preserving surgery.

Perception of male drinkers as a function of their alcoholic beverage preference.

The present study examined perception of a man's likelihood of driving after drinking and his ability to do so as a function of his choice of beverage. Perceptions of his social characteristics were also examined. The sample was composed of 200 volunteer undergraduate psychology students. Equal numbers of male and female subjects read one of four vignettes which varied only in the male protagonist's choice of beverage: beer, wine, shots of distilled spirits, or cola. After reading the story, subjects answered multiple-choice questions about the character, tapping social judgments, situational judgments and drinking and driving judgments. Subject drinking habits were also assessed. The most notable result was the consistently positive perception of the protagonist portrayed as an abstainer. The lack of a consistent alcoholic beverage distinction implies that the beer-spirits double standard is far from a clear-cut discrimination. Possible explanations for results are discussed. This study questions the robustness of the alcoholic beverage type bias and reflects the need for future research.