Impaired event memory and recollection in a case of developmental amnesia.

A current debate in the literature is whether all declarative memories and associated memory processes rely on the same neural substrate. Here, we show that H.C., a developmental amnesic person with selective bilateral hippocampal volume loss, has a mild deficit in personal episodic memory, and a more pronounced deficit in public event memory; semantic memory for personal and general knowledge was unimpaired. This was accompanied by a subtle difference in impairment between recollection and familiarity on lab-based tests of recognition memory. Strikingly, H.C.'s recognition did not benefit from a levels-of-processing manipulation. Thus, not all types of declarative memory and related processes can exist independently of the hippocampus even if it is damaged early in life.

Transcatheter Aortic Valve-in-Valve Replacement for Degenerated Stentless Bioprosthetic Aortic Valves: Results of a Multicenter Retrospective Analysis.

OBJECTIVES: The purpose of this study was to evaluate the safety and efficacy of valve-in-valve (ViV) transcatheter aortic valve replacement (TAVR) for stentless bioprosthetic aortic valves (SBAVs) and to identify predictors of adverse events. BACKGROUND: ViV TAVR in SBAVs is associated with unique technical challenges and risks. METHODS: Clinical records and computer tomographic scans were retrospectively reviewed for procedural complications, predictors of coronary obstruction, mortality, and echocardiographic results. RESULTS: Among 66 SBAV patients undergoing ViV TAVR, mortality was 2 of 66 patients (3.0%) at 30 days and 5 of 52 patients (9.6%) at 1 year. At 1 year, left ventricular end-systolic dimension was decreased versus baseline (median [interquartile range (IQR)]: 3.0 [2.6 to 3.6] cm vs. 3.7 [3.2 to 4.4] cm; p < 0.001). Coronary occlusion in 6 of 66 procedures (9.1%) resulted in myocardial infarction in 2 of 66 procedures (3.0%). Predictors of coronary occlusion included subcoronary implant technique compared with full root replacement (6 of 31, 19.4% vs. 0 of 28, 0%; p = 0.01), short simulated radial valve-to-coronary distance (median [IQR]: 3.4 [0.0 to 4.6] mm vs. 4.6 [3.2 to 6.2] mm; p = 0.016), and low coronary height (7.8 [5.8 to 10.0] mm vs. 11.6 [8.7 to 13.9] mm; p = 0.003). Coronary arteries originated <10 mm above the valve leaflets in 34 of 97 unobstructed coronary arteries (35.1%). CONCLUSIONS: TAVR in SBAVs is frequently associated with high-risk coronary anatomy but can be performed with a low risk of death and myocardial infarction, resulting in favorable ventricular remodeling. A subcoronary surgical approach is associated with an increased risk of coronary obstruction.

Is Dysphagia After Cardiac Operations a "Preexisting Condition"?

BACKGROUND: Controversy exists about the incidence of dysphagia after cardiac operations, and very little is known about the baseline risk in this patient population. This study evaluated the incidence of dysphagia both preoperatively and postoperatively in patients undergoing cardiac operations. METHODS: Patients undergoing cardiac operations were screened for dysphagia preoperatively using a 90-mL water swallow challenge protocol, a mini cognitive/speech screen, and a modified oral mechanism screen. The tests were repeated after extubation once the patient was alert and oriented. Patient characteristics were analyzed in conjunction with the results of the swallow screens to identify risk factors for dysphagia. RESULTS: Of 176 patients tested, 15 (8.5%) failed the swallow screen preoperatively. Age, gender, and comorbidities were compared. Patients who failed the swallow study preoperatively were slightly older (76.1 vs 73.3 years, p = 0.047) and had a higher incidence of chronic renal failure (13.3% v. 0.6%, p = 0.017), but gender and other comorbidities were not significantly different. Postoperatively, 38 patients failed the swallow screen (21.6%). Those who failed the postoperative screen were also older (75.6 vs 72.9 years, p = 0.012), but other factors (including chronic renal failure) were not significantly different. All of the patients who failed the swallow screen preoperatively also failed postoperatively. CONCLUSIONS: Unrecognized dysphagia in patients who need cardiac operations is a common problem and accounts for a substantial portion of that seen postoperatively. Older patients are at increased risk of dysphagia, but gender and medical comorbidities are not useful predictors of this risk.

Coronary artery bypass performed without the use of cardiopulmonary bypass is associated with reduced cerebral microemboli and improved clinical results.

STUDY OBJECTIVES: Strokes and neurocognitive dysfunction have been correlated with cerebral microemboli produced during cardiopulmonary bypass (CPB). The purpose of this study was to determine whether, and to what extent, off-pump coronary artery bypass (OPCAB) reduces the occurrence of cerebral microemboli compared with traditional coronary artery bypass grafting (CABG) with CPB and to compare clinical results. DESIGN AND PATIENTS: A retrospective review of 137 patients undergoing elective CABG was performed, 70 of whom underwent traditional CABG and 67 of whom underwent OPCAB. Using transcranial Doppler ultrasonography, 40 patients (20 CABG, 20 OPCAB) were continuously monitored intraoperatively for the occurrence and pattern of cerebral microemboli. SETTING: Private, university-affiliated tertiary care hospitals. RESULTS: There was no statistical difference in the age, sex, or underlying comorbidities between those patients undergoing CABG and OPCAB. CABG patients did have a slightly lower preoperative ejection fraction (50.9% vs 55.5%, p = 0.03). Despite these similar preoperative characteristics, the OPCAB group experienced significant reductions in cerebral microemboli (27 vs 1,766, p = 0.003), transfusion requirements (29.9% vs 47.1%, p = 0.04), intubation time (3.3 vs 9.5 h, p < 0.001), ICU length of stay (1.5 vs 2.8 days, p = 0.02), and overall hospitalization (4.9 vs 6.6 days, p = 0.01) without an increase in mortality. Fewer strokes and deaths were observed in the OPCAB group, but these trends failed to reach statistical significance. CONCLUSIONS: In similar patient populations, OPCAB was associated with significantly fewer cerebral microemboli and improved clinical results without an increase in mortality. We believe that these early results support OPCAB as a viable and potentially safer alternative to traditional CABG.

Safety and efficacy of radiofrequency thermal ablation in advanced liver tumors.

HYPOTHESIS: Radiofrequency thermal ablation (RFA) can be performed safely and effectively to control local disease in patients with advanced, unresectable liver tumors. DESIGN, SETTING, AND PATIENTS: Prospective study of 76 patients with unresectable liver tumors who underwent RFA at a private tertiary referral hospital. INTERVENTIONS: Ninety-nine RFA operations were performed to ablate 328 tumors. MAIN OUTCOME MEASURES: Complications and local recurrence. RESULTS: There was 1 death (1%), major complications occurred in 7 operations (7%), and minor complications occurred in 10 operations (10%). Local recurrence was identified in 30 tumors (9%) at a mean follow-up of 15 months. Size (P<.001), vascular invasion (P<.001), and total volume ablated (P<.001) were associated with recurrence but the number of tumors was not (P =.39). CONCLUSION: Radiofrequency thermal ablation provides local control of advanced liver tumors with low recurrence and acceptable morbidity.

The effect on the rat isolated atria of amiodarone in the presence of either ouabain or verapamil.

Amiodarone causes a decrease in the rate of contraction of the rat isolated atria and has a negative inotropic action in the paced preparation. Interactions occur between amiodarone and ouabain and amiodarone and verapamil. It is possible that the clinically reported drug interaction with amiodarone may have a component of direct interactions on the myocardium rather than solely changes in plasma protein binding.

Fifteen years' experience with an antirefluxing biliary drainage valve.

PURPOSE: The aim of this study was to examine the efficacy of the antirefluxing, mucosal-flap valve (AMFV) for biliary drainage relative to technical feasibility, surgical complications, and incidence of ascending cholangitis (AC). METHODS: Twenty-seven infants requiring biliary tract reconstruction underwent valve construction. Twenty biliary atresia (BA) patients received the Kasai procedure, and 7 choledochal cyst (CC) infants had cystectomy and hepatoenterostomy. A retrospective review of all patients was performed including radiographic evaluation of the current valve function in 10 patients. RESULTS: Construction was successful in all cases, and no morbidity was incurred by incorporation of the valve. Of 7 CC patients, there have been no known episodes of AC with mean follow-up of 4.4+/-4.2 years. Of 20 BA patients, there have been 5 deaths (25%), 7 liver transplants (35%), 2 (10%) lost to follow-up, and 6 (30%) survivors. Nine BA patients (45%) have had AC, with patients in all 4 outcome categories represented. Ten patients (5 CC and 5 BA) have been evaluated with barium small bowel radiographs, with no reflux to the liver hilum in all cases. CONCLUSIONS: The AMFV has caused no morbidity and continues to prevent reflux to the liver hilum. Despite functioning as designed, it does not appear to influence the occurrence of AC. Because CC patients had no AC, we feel that infection is related to the underlying atresia rather than to reflux.

Pregnancy and lactation following anorexia and bulimia.

Ten years after her battle with anorexia nervosa and bulimia began, a 26-year-old woman restored her normal body weight to 102 pounds from a low of 47 pounds (21.3 kilograms), became pregnant, delivered a healthy infant at term, and was successfully breastfeeding at five months. Her dietary intake, which was computer analyzed and compared with the recommended dietary allowances for pregnancy and lactation, revealed few nutrient deficiencies. Ample pregnancy weight gain provided an energy reserve for lactation.

Analgesia for venous cannulation: a comparison of EMLA (5 minutes application), lignocaine, ethyl chloride, and nothing.

Three commonly available local anaesthetics were compared, in a controlled trial, for use before venous cannulation. The pain of application of the local anaesthetic, the pain of cannulation, and the rate of successful cannulations were compared. The value of EMLA cream applied for 5 min was questioned. Venous cannulation with a 20G venflon was found to be significantly more painful than the application of any of the local anaesthetics (P < 0.01). Lignocaine 1%, injected subcutaneously, and ethyl chloride spray significantly reduced the pain of venous cannulation (P < 0.01). The use of lignocaine did not result in significantly more failed cannulations than the control group. It was concluded that local anaesthesia should be used before venous cannulation, even for 20G cannulae.

Coronary artery bypass grafting performed with or without a bypass pump: early results.

INTRODUCTION: Traditionally, heart bypass surgery has required stopping of the heart and the use of cardiopulmonary bypass. Numerous complications have been associated with exposure to this extracorporeal circuit. Newer techniques of local cardiac wall stabilization now enable this operation to be performed safely "Off Pump". The early clinical results of Off Pump Coronary Artery Bypass (OPCAB) will be compared to a similar group of traditional Coronary Artery Bypass Grafting (CABG) patients. METHODS: A retrospective review of 137 consecutive patients undergoing elective coronary artery bypass grafting was performed, 68 of who underwent traditional CABG and 69 of who underwent OPCAB. Inclusion criteria consisted of first time cardiac surgical procedures with an ejection fraction > or = 20%, without significant renal failure (creatinine < 2.0). RESULTS: There was no statistical difference in the age, sex, cardiac function or underlying co-morbidities between those undergoing CABG and OPCAB. CABG patients had slightly more vessels bypassed than those in the OPCAB group (3.0 vs 2.6, p = 0.010). Despite similar preoperative characteristics, the OPCAB group experienced a reduction in morbidity without an increase in mortality. CONCLUSION: In similar patient populations, OPCAB was associated with significantly reduced transfusion requirements, intubation time, ICU and overall hospital lengths of stay, with no increase in mortality. Further investigation is warranted to ascertain the role of the OPCAB in the general cardiac surgical community.

Brain stem death testing after thiopental use:A survey of UK neuro critical care practice.

A postal survey was conducted to determine how thiopental is used in UK neurosurgery critical care units. Thirty units were contacted and 26 replied. Thiopental is used in 23 units. The majority (60%) of these units govern the use of thiopental with protocols or guidelines and 74% use cerebral monitoring to guide dosage. When patients have had thiopental, 20 units delay brain stem testing, two will not perform tests and one unit incorporates cerebral angiography into their protocol. Twelve units use serum thiopental assays in their brain stem testing procedures, but there is wide variation in the interpretation of the results. We found inconsistency and confusion surrounding brain stem testing in this patient group, raising the possibility of misdiagnosis of brain stem death.

Alpha 1-antitrypsin phenotype: transient cathodal shift in serum of infant girl with urinary cytomegalovirus and fatty liver.

A 2-month-old white girl had severe liver disease (but without signs of hepatic necrosis, infection or cirrhosis), urinary cytomegalovirus, transient reduction of alpha 1-antitrypsin concentration and transient abnormal alpha 1-antitrypsin phenotype that were not present in her parents. Five serum specimens that were obtained during the 11/2 months of acute phase liver disease indicated, by polyacrylamide gel isoelectric focusing (PAG-IEF), acid starch gel and agarose electrophoresis as well as immunofixation, an unusual alpha 1-antitrypsin phenotype that we labeled delta (delta). It migrated adjacent to Z, i.e., cathodal of Z and Zpratt on PAG-IEF; anodal of Z but cathodal of X, S, Zpratt on starch gel. We labeled the girl's complete phenotype M delta. After clinical recovery, her phenotype was MM and identical to that of her parents. Hepatic electronmicroscopy of the acute phase specimen showed dilated bile canaliculi. We observed the following in hepatocytes: clusters of globular inclusions surrounded by myelin sheets that, to a lesser extent, also appeared in the liver of CMV-infected children with phenotype MM; dilated endoplasmic reticulum cisternae that contained floccular material; and marked steatosis. These changes were less severe in the convalescent liver specimen.

PiZpratt: a new alpha 1-antitrypsin allele in an American Negro family.

A rare alpha 1-antitrypsin phenotype was detected in serum of individuals belonging to three generations of an American Negro family. Following the recommended guidelines of nomenclature, we labeled the new Pi type Zpratt; the corresponding allele is PiZpratt. Alpha 1-antitrypsin concentration and trypsin inhibitory capacity are normal in MZpratt serum.

Sexual dimorphism in trauma? A retrospective evaluation of outcome.

PURPOSE: Multiple studies have demonstrated a heightened immune response in female animals subjected to trauma-hemorrhage models and have implied a subsequent survival advantage. PROCEDURES: A retrospective review of outcome in 15,170 trauma admissions over a 5-year-period (1993-1997) at a level 1-trauma center was performed. A comparison of outcome by gender, age, injury severity score (ISS), mechanism of injury, location of injury (AIS), and length of hospitalization (intensive care unit and total hospitalization) was performed. FINDINGS: There were 12,456 male and 2714 female patients included in the study. Overall survival rates (male = 90.2%, female = 90.8%) and survival of serious (ISS > or = 15) trauma (male = 63.5%, female = 60.5%) were not statistically different. Logistic regression analysis identified age, mechanism and ISS as factors associated with survival. CONCLUSION: Retrospective evaluation of our trauma population failed to show a difference in outcome between male and female trauma patients. Age, mechanism and severity of injury-but not gender-were identified as factors influencing survival.