Traditional sexing methods and external egg characteristics combination allow highly accurate early sex determination in an endangered native turkey breed.

Early sex determination methods are not only crucial in the worldwide massive poultry industry, but also for small-holder producers. The profitability of sexing techniques must be accounted for when aiming to boost management, nutrition, and conservation practices in endangered poultry breeds. This becomes pivotal when the local breed dealt with belongs to an understudied species, such as the turkey. So, the main objective of this study is to identify which method combination may report a higher likelihood of successful sex determination in poults across the three-pattern varieties of the Andalusian turkey breed. A total of 84 one to two days old Andalusian turkey poults (42 black, 28 black-roan, and 14 bronze-roan) were evaluated in this study. Sex determination was performed using 15 methods, which included testing external egg metrics and eggshell color, poult morphological appraisal and phaneroptics, and behavioral traits. Possible differences across plumage varieties and the interaction between sex and plumage were observed when external egg quality was measured. Sex determination through behavioral methods in black base feathered (black and black-roan) male sex individuals showed seven times higher sensitivity when compared to the rest of the studied individuals (χ2 = 7.14, df = 1, P < 0.01). In contrast, for the black-roan plumage females, the method based on the color of down feathers was approximately four times more sensitive (χ2 = 3.95, df = 1, P ≤ 0.05). For the bronze-roan pattern, none of the sexing techniques was reported to efficiently predict sex itself. However, the most proper method combination to determine sex, independent of plumage color, was physical external egg characteristics, the color of down feathers, and behavioral approaches ("English method" and "slap technique"). The specificity values were found to be 49.12, 93.33, and 100%, while the sensitivity values were observed to be 74.64, 91.03, and 100%, which translated into accuracy of 63.10, 92.26, and 100% in black, black-roan, and bronze-roan poults, respectively. Our results suggest that the method combination tested in this study could be considered a highly accurate, simple, and affordable alternative for sex determination in turkeys. This could mean a pivotal advance for small producers of turkeys, as early sex detection can help to plan timely conservational management strategies, which is of prominent importance in the context of endangered poultry breeds.

Algorithm for early discharge after total thyroidectomy using PTH to predict hypocalcemia: prospective study.

PURPOSE: Hypocalcemia is the most common complication after total thyroidectomy. The aim of this study was to determine whether postoperative parathyroid hormone (PTH) levels predict hypocalcemia in order to design an algorithm for early discharge. METHODS: We present a prospective study including patients who underwent total thyroidectomy. Hypocalcemia was defined as serum ionized calcium < 1.09 mmol/L or clinical evidence of hypocalcemia. PTH measurement was performed preoperatively and at 1, 3, and 6 h postoperatively. The percent decline of preoperative values was calculated for each time point. RESULTS: One hundred and six patients were included. Thirty-six (33.9%) patients presented hypocalcemia. A 50% decline in PTH levels at 3 h postoperatively showed the highest sensitivity and specificity to predict hypocalcemia (91 and 73%, respectively). No patients with a decrease <35% developed hypocalcemia (100% sensitivity), and all patients with a decrease >80% had hypocalcemia (100% specificity). CONCLUSIONS: PTH determination at 3 h postoperatively is a reliable predictor of hypocalcemia. According to the proposed algorithm, patients with less than 80% drop in PTH levels can be safely discharged the day of the surgery.

Trivalvular/bivalvular heart: a philosophical, scientific and therapeutic concept.

BACKGROUND AND AIM OF THE STUDY: In 1967, following the replacement of infected tricuspid valves in drug addicts with incurable endocarditis, all patients died. The study aim was to determine if tricuspid valve removal, rather than replacement, might offer these patients an improved outcome. METHODS: Since July 1970, we have operated on 55 patients with intractable right-sided endocarditis. Before surgery, all had a history of intravenous drug abuse (IVDA) (duration range: 2-20 years; 5 years in 38 cases). In 53 patients the tricuspid valve was excised without replacement; the pulmonary valve was also removed in two cases. RESULTS: Six (11%) patients died within six weeks of surgery, and 11 died between six months and 24.5 years. Ten of the late deaths were related to IVDA. Among 49 patients who survived surgery for six months to 29 years, 24 (50%) returned to the use of illicit drugs. Only six patients eventually required insertion of a heart valve prosthesis; of these, four died, two due to repeat IVDA. Of 38 long-term survivors (range: 9-29 years), two have a non-functioning bioprosthesis in the tricuspid position, 35 have a trivalvular heart, and one has a bivalvular heart. Only three patients required diuretics and digitalis. CONCLUSION: IVDA patients with intractable right-sided infective endocarditis have the best chance of cure and long-term survival by undergoing tricuspid or tricuspid and pulmonary valve excision(s), without prosthetic replacement. No published evidence or long-term follow up data indicate better surgical treatment for this patient group. In this day and age of cost containment, these operations are economical. Operations that work well in non-addicted patients become costly and invariably are associated with a second endocarditis and death in inveterate IVDA cases.

Spontaneous right ventricular rupture after sternal dehiscence: a preventable complication?

Mediastinitis and/or sternal dehiscence developed in 143 out of 10,263 patients (1.4%) who underwent cardiac surgery between January 1979-December 1993. Mediastinal drainage, sternal debridement and early wound closure with pectoralis major and/or rectus abdominalis muscle flaps was the treatment employed. Between these two stages of treatment, massive hemorrhage developed in seven patients (0.07%) from a tear of the anterior wall of the right ventricle (RV). Six patients survived. Temporary control of the bleeding was achieved with digital or full palm pressure control of the ventricular tear. This was followed by immediate repair in the operating room (OR). The only death was due to exsanguination in the intensive care unit. The other six patients were taken to the OR. The anterior RV was freed from the underside of the sternum and the RV tear repaired with or without the aid of femoral-femoral bypass. These six then had muscle flap wound closures at that time or shortly after. All six were hospital survivors and are currently alive. We believe that RV rupture results from the sternal edges pulling the anterior surface of the RV apart, since the RV is stuck to the underside of the sternum. This experience indicates that the RV must be freed in all cases during initial sternal debridement. Hopefully this simple maneuver will prevent this horrendous complication.

Sinus of Valsalva aneurysms involving both coronary ostia.

Sinus of Valsalva aneurysms are a rare cause of angina or myocardial infarction. We describe a patient with unstable angina and massive unruptured aneurysms of both coronary sinuses causing severe distortion of both coronary ostia, to our knowledge not previously reported. This unusual patient underwent aortic valve replacement, ascending aortic repair, and coronary artery bypass. At 11-year follow-up, she had developed severe mitral stenosis and prosthetic aortic valve stenosis. Review of the literature reveals 30 reported cases of Sinus of Valsalva aneurysm complicated by coronary insufficiency or infarction, involving either the left (20 cases) or the right coronary sinus (10 cases). We emphasize the poor outcome of these patients, especially if treated conservatively.

Surgical treatment of intractable right-sided infective endocarditis in drug addicts: 25 years experience.

During the past 25 years the authors have performed the following operations in the surgical treatment of intractable right-sided endocarditis in drug addicted patients: 1) Excision of the infected tricuspid valve and replacement with a mechanical or bioprosthetic valve during the same operation. In these patients the overall mortality was 100% due to: (a) inability to control the endocarditis in 80%; (b) re-infection due to a return to drug abuse and (c) fatal complications due to non-compliance with anticoagulant therapy. 2) Tricuspid valvulectomy in 53 patients, tricuspid and pulmonary valvulectomy without replacement in two patients. Six patients (11%) died within six weeks. Five due to the endocarditis and one due to low cardiac output. Ten patients (18%) died six months to 13 years later. In nine of these patients, death was related to continued drug abuse. At 22 years the actuarial survival is 64%. This experience supports the authors conclusion that among drug addicts with intractable right-sided endocarditis, tricuspid valvulectomy or tricuspid and pulmonary valvulectomy without replacement is/are the operation(s) of choice.

Splenic abscess associated with endocarditis.

BACKGROUND: Refractory or recurrent sepsis in patients with endocarditis may be from splenic abscess. The purpose of this review is to assess this relationship. METHODS: Of 564 patients treated for documented endocarditis between 1970 and 1990, splenic abscesses developed in 27 patients. The mean age of the 18 men and nine women was 37 years. Etiologic factors included street drugs, dental abscess, and rheumatic fever. Symptoms included fever, myalgia, chills, and dyspnea; the prodrome averaged 2 weeks. Typical signs were heart murmur, left lower-lobe infiltrate, and leukocytosis. Splenomegaly was found in three patients. All patients had valve lesions, which involved the aortic valve alone in 10 patients, the mitral valve alone in eight patients, and multiple valves in nine patients. RESULTS: A splenic defect on computed axial tomographic scan was diagnosed correctly as an abscess in 10 patients, was indeterminant in three patients, and was incorrectly called an infarct in four patients. Thirteen patients died. All 10 patients treated without splenectomy died, including five patients who underwent valvular replacement. In contrast, only three of 17 patients treated by splenectomy with (11 patients) or without (six patients) valvular surgery died. CONCLUSIONS: Splenic abscess often accompanies endocarditis. The diagnosis is suspected by refractory fever and confirmed by abdominal computed axial tomography scan. Splenectomy is warranted before or after valvular surgery, depending on the patient's clinical response to antibiotics.

Tricuspid valvulectomy without replacement. Twenty years' experience.

Since September 1970, we have operated on 55 patients with intractable right-sided endocarditis. All patients were addicted to heroin. Fifty-three underwent tricuspid valvulectomy without replacement and in addition two had pulmonic valve excision. Twenty-four patients (49%) returned to their drug addiction. Six patients (11%) required prosthetic heart valve insertion 2 days to 13 years later for medically refractory right-sided heart failure, and four of these died. Overall, 16 patients (29%) died, six (11%) within 45 days after the tricuspid valvulectomy. One (2%) of these deaths was related to the operation and five were due to uncontrollable infection. Ten (18%) deaths occurred 9 months to 13 years after the tricuspid valvulectomy. Nine were due to drug addiction and one to progressive right ventricular failure 2 months after prosthetic heart valve insertion and 10 years after the initial valve removal. Of the 39 patients who are alive, 37 (67%) have not required prosthetic heart valve insertion. From our observations we reached the following conclusions: (1) Drug addiction is a recurrent and lethal disease. Among these patients, tricuspid valvulectomy without replacement is the operation of choice for the management of intractable right-sided endocarditis; (2) after tricuspid valvulectomy without replacement, only six of 55 patients (11%) had required prosthetic heart valve insertion to control medically refractory right-sided heart failure; (3) in a small percentage of patients the absence of the tricuspid valve may lead to severe and permanent impairment of right ventricular function.

Physiological manometric tested tricuspid valvuloplasty.

Tricuspid insufficiency associated with severe left-sided valvular heart disease carries a poor prognosis. Twenty-two patients with severe pulmonary hypertension and tricuspid insufficiency underwent a tricuspid valvuloplasty in addition to left-sided single or double valve replacement. The tricuspid valvuloplasty was performed after weaning the patient from cardiopulmonary bypass. The efficacy of the tricuspid valvuloplasty was gauged by continuous right atrial pressure recordings as the annuloplasty was completed. Obliteration of the peak of the V wave of the right atrial pressure recordings indicated that the tricuspid annuloplasty was secured. Twenty-one patients were long-term survivors, and 19 patients are in good condition for an average follow-up of 6.1 years (1 to 12 years postoperatively).

Nonoperative therapy for squamous-cell cancer of the esophagus.

Based on the surgical pathology and survival for patients in previous trials using a neoadjuvant program of chemotherapy (5-fluorouracil [5-FU]-cisplatin) and radiation (3,000 cGy) before surgery for squamous-cell cancer (SCC) of the esophagus, a nonoperative pilot trial was designed to test if survival and recurrence would differ from our historical controls if routine esophagectomy was eliminated. Twenty patients were treated. The protocol called for the delivery of 5-FU infusion (1,000 mg/m2/d X 4 d) days 1 to 4 and 29 to 32 with cisplatin (100 mg/m2) day 1 and 29 sandwiched around external beam radiation (3,000 cGy over 3 weeks). Mitomycin C (10 mg/m2) day 57 was administered with bleomycin infusion (20 U/d X 4 d) days 57 to 60 and 78 to 81. A radiation boost of 2,000 cGy was administered 200 cGy/d days 99 to 103 and 106 to 110. Clinical pulmonary toxicity forced withdrawal of bleomycin and mitomycin C in the last four patients treated; two further courses of 5-FU-cisplatin were administered instead. The median measurement of the 20 esophageal lesions by barium swallow was 7 cm. Four patients underwent salvage surgery to prevent life-threatening aspiration pneumonia. The median survival for the 20 patients is 22 months, with a range from 6 to 39+ months. The six patients clinically without cancer are alive 22+ to 39+ months (median, 35+ months). Three patients died manifesting only local (infield) recurrence; five died manifesting only distant recurrence; and five developed local and distant recurrence. While the toxicity of the four drug regimen as administered was prohibitive, the survival and quality of survival is superior to the regimen previously used, which routinely used surgery after preoperative chemotherapy and radiation.

Management of infective endocarditis: seventeen years' experience.

Infective endocarditis remains a serious illness with a high mortality. In more than 75% of 417 patients, the infection was due to gram-positive microorganisms. The non-drug-addicted patients (33%) were elderly and debilitated with advanced illness that preceded the endocarditis. The drug-addicted patients (67%) were young and were infected with multiple kinds of microorganisms. The blood cultures grew strains of Staphylococcus aureus resistant to methicillin sodium and nafcillin sodium in a majority of patients. Gram-negative microorganisms and fungi were cultured almost exclusively from samples from the drug-addicted patients. The high mortality among the non-drug-addicted patients (28%) was related to their advanced age and debilitating illness. The high mortality among the drug-addicted patients (21%) was related to the complex bacteriology of their infections and the severe anatomical disruption of the valvular complexes of the heart. When cured of their disease after treatment with intravenously administered antibiotics or a valve procedure or both, their long-term survival was related to whether or not they abstained from their habit. If the patient abstained from the use of drugs, the chances of survival were good; if not, death invariably ensued. This experience strongly supports our contention that if a patient returns to the use of drugs and reinfects the valve after initial cure, a second valve operation is contraindicated.

Double traumatic rupture of the thoracic aorta.

A 23-year-old woman was involved in an automobile accident and sustained a double traumatic rupture of the aorta, at the isthmus distal to the left subclavian artery and at the base of the innominate artery. A successful repair was accomplished within 4 hours of the injury using profound hypothermia and total circulatory arrest. To our knowledge, this case represents the first successful surgical repair of a double traumatic rupture of the aorta. Followup at 2 years showed an excellent postoperative recovery and the patient gainfully employed.

Accelerated renovascular hypertension following intra-aortic balloon counter-pulsation.

A 62-year-old man developed high serum renin arterial hypertension following thoraco-abdominal dissection which resulted from insertion of an intra-aortic balloon pump (IABP). Nephrectomy resulted in cure of medically unmanageable hypertension.

Improved surgical palliation of advanced carcinoma of the esophagus.

Fifty-four patients with far-advanced carcinoma of the esophagus were operated on between the years 1974 and 1976. No attempts were made to resect the lesion. The stomach was used fifty-three times to bypass the lesion and the right colon was used once. In twenty-eight patients the stomach was placed substernally and the anastomosis was done in the neck. Twenty-five patients had the anastomosis to the esophagus done in the chest. The thirty day operative mortality was 7.4 per cent and the average survival was five months. These figures compared favorably with a group of thirty-five patients with far-advanced carcinoma of the esophagus seen between the years 1971 and 1973 and handled with a variety of modalities. In this group the thirty day mortality was 31.4 per cent (11/35) and the average survival was three and a half months.