[Misinterpreted lymphadenopathy and thrombocytopenia as unrecognised initial symptoms of an HIV-infection]. / Onbegrepen lymfklierzwellingen en trombopenie als niet herkende eerste symptomen van een hiv-infectie.

In a 28-year-old woman and a 30-year-old man with lymphadenopathy, shown by histopathology to be follicular hyperplasia, and in a 40-year-old woman and a 40-year-old man with a thrombocytopenia, HIV-infection was not diagnosed until years later. Three of the four patients did not belong to a 'classical high-risk group' for HIV/AIDS. All patients, meanwhile, suffered from minor or major complications. Moreover, the number of CD4+ cells had decreased to < or = 200/microl before antiretroviral therapy was started. After treatment, all four patients were in reasonable to good condition. An HIV-infection should be considered in every case of reactive lymphadenopathy or thrombocytopenia.

[An unusual cause of meningo-encephalitis: Japanese encephalitis]. / Een ongewone oorzaak van meningo-encefalitis: Japanse encefalitis.

Two women, 29 and 30 years of age, who had visited Indonesia and Thailand, respectively, during the summer, presented with diarrhoea, headache, fever and later neurological symptoms. The first patient had to be sedated because of restlessness and was admitted to the intensive-care unit for intravenous antimicrobial therapy; the second became comatose and received intravenous rehydration and antipyretics. No diagnosis was made during the acute phase ofthe illness, but later there was serological evidence of Japanese encephalitis. Both patients recovered, but memory and concentration difficulties persisted for a long time. Due to the increase in travelling, we see more and more cases of (rare) imported diseases. Japanese encephalitis is a viral infection that causes 50,000 cases each year in Asia with a mortality of 30%. The risk of transmission for tourists is very low. Most infections with Japanese encephalitis virus do not lead to symptomatic disease; only 0.1-5% of infections lead to clinical disease. The symptoms are initially non-specific, consisting of general discomfort and diarrhoea. After this, patients can develop headache, decreased consciousness and sometimes convulsions. Therapy consists of supportive care. For travellers at high risk of exposure, a formalin-inactivated vaccine is available. For the proper diagnosis of rare imported diseases, it is advisable to consult an infectious-disease specialist or microbiologist at an early stage when evaluating a patient who has recently returned from the tropics.

A comparison of internal mammary artery and saphenous vein grafts after coronary artery bypass surgery. No difference in 1-year occlusion rates and clinical outcome. CABADAS Research Group of the Interuniversity Cardiology Institute of The Netherlands.

BACKGROUND: Superior patency rates for internal mammary artery (IMA) grafts compared with vein coronary bypass grafts have been demonstrated by retrospective studies. This difference may have been affected by selection bias of patients and coronary arteries for IMA grafting. METHODS AND RESULTS: To estimate the difference between IMA and vein grafts, we analyzed graft patency data of 912 patients who entered a randomized clinical drug trial. In this trial, 494 patients received both IMA and vein grafts (group 1) and 418 only vein grafts (group 2). Occlusion rates of IMA grafts and IMA plus vein grafts in group 1 were compared with those of vein grafts in group 2. Multivariate analysis was used to compare occlusion rates of IMA and vein grafts while other variables related to graft patency were controlled for. In addition, 1-year clinical outcome was assessed by the incidence of myocardial infarction, thrombosis, major bleeding, and death. Occlusion rates of distal anastomoses in group 1 versus group 2 were 5.4% (IMA grafts) versus 12.7% (vein grafts) (P < .0001) and 10.4% (IMA plus vein grafts) versus 12.7% (vein grafts) (P = .14). There was no difference in adjusted risk of occlusion between IMA grafts and vein grafts (P = .089). Type and location of distal anastomosis and lumen diameter of the grafted coronary artery were shown to be predictors of occlusion. Clinical events occurred in 17.8% (group 1) and 16.0% (group 2) of patients (P = .53). CONCLUSIONS: The observed difference in 1-year occlusion rates between IMA and vein grafts can be explained by a maldistribution of graft characteristics by selection of coronary arteries for IMA grafting rather than being ascribed to graft material. One-year clinical outcome is not improved by IMA grafting.

Effects of low dose aspirin (50 mg/day), low dose aspirin plus dipyridamole, and oral anticoagulant agents after internal mammary artery bypass grafting: patency and clinical outcome at 1 year. CABADAS Research Group of the Interuniversity Cardiology Institute of The Netherlands. Prevention of Coronary Artery Bypass Graft Occlusion by Aspirin, Dipyridamole and Acenocoumarol/Phenprocoumon Study.

OBJECTIVES: This study was performed to compare the efficacy and safety of aspirin, aspirin plus dipyridamole, and oral anticoagulant agents in the prevention of internal mammary artery graft occlusion. BACKGROUND: Antithrombotic drugs increase vein graft patency after coronary artery bypass surgery. Their benefit after internal mammary artery grafting has not been established. METHODS: Angiographic internal mammary artery graft patency at 1 year was assessed in 494 patients who received both internal mammary artery and vein grafts. These patients were a subgroup of a prospective, randomized vein graft patency study in 948 patients assigned to treatment with aspirin, aspirin plus dipyridamole, or oral anticoagulant agents. The design was double-blind for both aspirin groups and open for oral anticoagulant treatment. Dipyridamole (5 mg/kg body weight per 24 h intravenously, followed by 200 mg twice daily) and oral anticoagulant agents (prothrombin time target range 2.8 to 4.8 international normalized ratio) were started before operation, and low dose aspirin (50 mg/day) after operation. Clinical outcome was assessed by the incidence of myocardial infarction, thrombosis, major bleeding or death. RESULTS: Occlusion rates of distal anastomoses were 4.6% in the aspirin plus dipyridamole group and 6.8% in the oral anticoagulant group versus 5.3% in the aspirin group (p = NS). Overall clinical event rates were 23.3% and 13.3% in the aspirin plus dipyridamole group and the aspirin group, respectively (relative risk 1.75, 95% confidence interval 1.09 to 2.81, p = 0.025), and 17.1% in the oral anticoagulant group. CONCLUSIONS: Internal mammary artery graft patency at 1 year is not improved by aspirin plus dipyridamole or oral anticoagulant agents over that obtained with low dose aspirin alone. However, there is evidence that the overall clinical event rate increases if dipyridamole is added to aspirin.

Current results of coronary bypass surgery after failed angioplasty.

Percutaneous Transluminal Coronary Angioplasty (PTCA) is a technique in continuous development. Since its introduction indications, number, quality of stenosis amenable to treatment and device employed have evolved leading to a change in the population undergoing treatment. Therefore surgical results obtained in the early 80's may not apply to the beginning of the 90's. This reason prompted us to review our recent experience. In the last 4 years (1989-1992) among 2563 PTCA procedures performed in our Institution, 114 patients (4.3%, CL 3.5%-5%) underwent urgent surgical revascularization because of failed angioplasty. Thirty-four patients (30%, CL 21%-38%) were older than 65 years; 68 patients (60%, CL 50%-68%) had multiple vessel disease; 63 patients (55%, CL 46%-64%) had previous Myocardial Infarction (M.I.); 20 patients (17%, CL 10%-24%) had already undergone a PTCA and 3 patients (2%, CL 0%-6%) had had coronary surgery. In 21 patients (18%, CL 11%-25%) the left ventricular Ejection Fraction (EF%) was below < 50%. Complete revascularization was always performed with an average of 2.2 +/- 1 graft/patient. A Left Internal Mammary Artery (LIMA) was implanted in 20 patients (17%, CL 10%-25%) of the patients and in 52% of cases requiring LAD grafts in the last two years. There were 2 deaths (1.7%, CL 0%-4%), both patients were in cardiac arrest before surgery (p < 0.001), 2 patients required a LVAD to be weaned from ECC and 7 patients (6%, CL 1%-10%) had an IABP inserted at the moment of surgery. Twenty-five patients (21%, CL 14%-29%) showed evidence of a new myocardial infarction.(ABSTRACT TRUNCATED AT 250 WORDS)

Technique of sequential grafting the left internal mammary artery (LIMA) to the circumflex coronary system.

The most common grafting technique performed with the IMA's is to anastomose the LIMA to the Left Anterior Descending (LAD) coronary system. With the expanded use of this conduit, the Right IMA (RIMA) can be used to graft the LAD system and the LIMA can be routed to the Circumflex (Cx) coronary system. This is the most common graft design in case of coronary disease affecting the LAD and the circumflex systems. The technique used at the Medical Center "The Klokkenberg" since 1989 to route the LIMA to the marginal arteries through a pericardial window is described in detail.

Prevention of one-year vein-graft occlusion after aortocoronary-bypass surgery: a comparison of low-dose aspirin, low-dose aspirin plus dipyridamole, and oral anticoagulants. The CABADAS Research Group of the Interuniversity Cardiology Institute of The Netherlands.

Aspirin, alone or in combination with dipyridamole, is known to prevent occlusion of aortocoronary vein grafts. The benefit of dipyridamole in addition to aspirin remains controversial, and the efficacy and safety of oral anticoagulants for prevention of vein-graft occlusion have not been established. We assessed one-year angiographic vein-graft patency after aortocoronary-bypass surgery in 948 patients assigned to receive aspirin, aspirin plus dipyridamole, or oral anticoagulants in a prospective, randomised trial. The design was double-blind and placebo-controlled for the aspirin groups, but open for oral anticoagulant treatment. Dipyridamole (5 mg/kg per 24 h intravenously for 28 h, followed by 200 mg twice daily) and oral anticoagulants (desired prothrombin time range 2.8-4.8 international normalised ratio) were started before surgery, and aspirin (50 mg per day) was started after surgery. Clinical outcome was assessed by the incidence of myocardial infarction, thrombosis, major bleeding, or death. Occlusion rate of distal anastomoses was 11% in the aspirin plus dipyridamole group versus 15% in the aspirin group (relative risk 0.76, 95% CI 0.54-1.05) and 13% in the oral anticoagulants group. Clinical events occurred in 20.3% of patients receiving aspirin plus dipyridamole compared with 13.9% of the aspirin group (relative risk 1.46, 95% CI 1.02-2.08) and 16.9% of the oral anticoagulants group. Our data provide no convincing evidence that addition of dipyridamole to 50 mg aspirin per day improves aortocoronary vein-graft patency. Moreover, there is evidence that the combination increases the overall clinical-event rate. Compared with aspirin, oral anticoagulants provided no benefit.

Morphometrical parameters of gut microflora in human volunteers.

The morphology of faecal microflora of nine healthy human volunteers was studied by digital image analysis of microscopic slides. Weekly specimens were collected during an 8-week period. Seven morphometrical parameters were derived: the means and medians of components 1, 2 and 3, and morphometrical entropy. Statistically significant differences among subjects were found for means of components 1 and 2, medians of components 1, 2 and 3, and entropy. The stability in normal circumstances provides an excellent basis for the detection of pathological change in gut flora balance.

Effects of ceftriaxone on faecal flora: analysis by micromorphometry.

In order to elucidate the effect of ceftriaxone therapy on the morphology of gut microflora, 11 human volunteers were treated with ceftriaxone, 1 g daily, given intramuscularly in one dose. Treatment continued for 5 days. Faecal microflora was analysed by digital image processing before, during and after the treatment period. We derived simple numerical parameters which describe the morphologic composition of the flora. They were significantly influenced by the antibiotic, and returned to their baseline values more than 7 days after treatment was stopped. The procedure holds promise for clinical application.

Comparative study between two prophylactic antibiotic regimens of cefamandole during coronary artery bypass surgery.

In two groups of patients undergoing coronary artery bypass grafting (CABG), two different regimens of antibiotic prophylaxis with cefamandole nafate were compared. In Group 1, 30 mg per kilogram of body weight was administered intravenously during induction of anesthesia. In Group 2, a second dose of 15 mg/kg was administered intravenously shortly before cannulation. Serum and tissue levels in the right atrium, the pericardium, and the sternum were determined using high-pressure liquid chromatography. The results showed that in Group 2 the serum levels were significantly higher from 48 minutes onward after induction and remained at an acceptable level during CABG. The tissue levels in the sternum and pericardium were also significantly higher in Group 2 compared with Group 1. It is concluded that a second dose of cefamandole (15 mg/kg) shortly before the beginning of cardiopulmonary bypass is recommended, particularly for high-risk patients.

Use of an arterial pH catheter immediately after coronary artery bypass grafting.

An arterial pH catheter was inserted into a femoral artery of 15 patients immediately after coronary artery bypass grafting. Catheter pH measurements correlated well with conventional blood gas measurements during the first 12 h postsurgery, and revealed rapid pH changes during weaning and bronchial suctioning. This device is a promising step in the development of a complete on-line blood gas analyzer.

Reduced platelet activation and improved hemostasis after controlled cardiotomy suction during clinical membrane oxygenator perfusions.

Platelet damage and postoperative blood loss are less severe after cardiopulmonary bypass performed with a membrane oxygenator than with a bubble oxygenator. However, this advantage of the membrane oxygenator can be partly negated by the platelet damage caused by cardiotomy suction, which implies the aspiration of air along with suction of blood. In order to reduce platelet damage by cardiotomy suction, we developed an automatic controlled cardiotomy suction system by which the aspiration of air was prevented. We evaluated platelet damage in a group of 28 patients (uncontrolled suction, n = 13; controlled suction, n = 15), and we studied the relationship between increasing volumes of cardiotomy suction and postoperative blood loss in a second group of 80 patients (uncontrolled suction, n = 47; controlled suction, n = 33). All patients underwent a coronary artery bypass operation with a membrane oxygenator. We measured significantly lower beta thromboglobulin concentrations during perfusions of approximately 2 hours and we observed a tendency toward shorter postoperative bleeding times if controlled cardiotomy suction was used. There were no significant differences between uncontrolled and controlled cardiotomy suction in platelet number and adenosine diphosphate-induced platelet aggregation. However, blood loss 18 hours postoperatively was significantly less in the controlled than in the uncontrolled suction group when the total volume of cardiotomy suction exceeded 65 L., which corresponded to perfusion times of over 3 hours. In conclusion, prevention of the aspiration of air along with suction of blood significantly reduced platelet activation and postoperative blood loss, particularly when large volumes of blood were aspirated.

Hemodynamic side effects of prostaglandin E1 in patients before and during cardiopulmonary bypass.

Animal experiments have shown that the administration of prostaglandin E1 (PGE1) during cardiopulmonary bypass (CPB) reduces platelet damage and the tendency to bleeding disorders. Because PGE1 also has a strong vasodilating action, a clinical trial was started to evaluate its hemodynamic side-effects. PGE1 was studied during 3 different periods: 1. a 10-minute period before bypass, 2. a hemodynamically stable period during CPB, 3. during the whole period of CPB. 1. Before CPB, a consistent fall of mean arterial pressure (MAP) was observed (26 mmHg). 2. During the stable period of CPB, the blood pressure fall was dependent on the pre-existing systemic vascular resistance. 3. PGE1 infusion during the whole CPB period was, in general, badly tolerated. Increased perfusion flow was not sufficient to compensate for the resulting blood pressure drop. In most of the 13 cases vasopressors had to be given continuously. In 7 patients PGE1 had to be reduced, and in 4 patients the infusion had to be stopped altogether. Because of the marked vasodilator effects of PGE1 it appears impossible to give patients doses adequate to achieve platelet preservation during clinical CPB with safety.

Standardized induction of myocardial ischaemia in the dog.

Ischaemia in the entire left ventricular wall was induced in dogs by installment of ameroid constrictors on the left anterior descending (LAD) and left circumflex (LC) branches of the left coronary artery (series A). Ischaemia in the anterior left ventricular wall was induced by installment of an ameroid constrictor on LAD and ligation of all (series B) or part of (series C) the subepicardial intercoronary anastomoses between LC and LAD. The effect of the operation was studied by electrocardiography and coronary angiography and, post mortem by radiography of the coronary arteries and histopathology of myocardium and coronary arteries. The high early mortality rate in series A and B precludes the further use of these procedures. In series C the mortality rate was low and in half of the cases lasting myocardial ischaemia of the anterior wall of the left ventricle was produced. The development of a small myocardial infarction was inevitable, but it was healed by the time the sought after state of stable myocardial ischaemia was reached.