Off-pump coronary artery grafting in patients necessitating multiple distal anastomoses.

OBJECTIVES: Off-pump surgery has become a valuable alternative if a small number of distal anastomoses is required. The aim of the present study was to test the hypothesis that outcome is not altered in multiple distal anastomoses. MATERIAL AND METHODS: During a 4 year period, 350 patients were operated off-pump. 187 patients received one or two distal anastomoses (group A), and 163 patients received more than two distal anastomoses (group B). Pre-operative characteristics, intra-operative details and postoperative outcome were reviewed. RESULTS: In group A, 1.8 +/- 0.4 distal anastomoses were performed, versus 3.2 +/- 0.5 in group B (P < 0.001). There were more sequential distal anastomoses in group B (1.09 in group A versus 1.38 in group B) with a wider use of right internal thoracic and radial arteries. There were more anastomoses performed on the lateral (89% vs. 45%) and on the inferior wall (65% vs. 16%) in group B, compared with group A. The operation time was significantly longer (206 +/- 75 minutes versus 158 +/- 33 minutes) and the operative blood loss significantly higher (748 +/- 516 ml versus 509 +/- 361 ml) in group B. Total blood loss, transfusion requirements, neurological disfunction, hospital stay, troponine I level, postoperative infarction and 30 days mortality did not differ significantly between groups. There were 11 conversions (3.1%), 3 patients in group A and 8 patients in group B (NS). Most conversion occurred imperative while performing an anastomosis on the anterior wall. CONCLUSION: Beating heart surgery with multiple distal anastomoses, can be performed without increased myocardial damage, postoperative morbidity or hospital mortality. Lateral wall grafting could not be identified as a trigger for conversion.

Brain structural changes in women and men during midlife.

Brain development during childhood and adolescence differs between boys and girls. Structural changes continue during adulthood and old age, particularly in terms of brain volume reductions that accelerate beyond age 35 years. We investigated whether brain structural change in mid-life differs between men and women. 43 men and 28 women from the Northern Finland 1966 Birth Cohort underwent MRI brain scans at age 33-35 (SD=0.67) and then again at age 42-44 (SD=0.41). We examined sex differences in total percentage brain volume change (PBVC) and regional brain change with FSL SIENA software. Women showed significant PBVC reduction compared with men between the ages of 33-35 and 42-44 years (Mean=-3.21% in men, Mean=-4.03% in women, F (1, 68)=6.37, p<0.05). In regional analyses, women exhibited greater brain reduction than men in widespread areas. After controlling for total percent brain volume change, men show greater relative regional brain reduction than women in bilateral precentral gyri, bilateral paracingulate gyri, and bilateral supplementary motor cortices. The results indicate sex differences in brain changes in mid-life. Women have more total brain reduction, and more reduction on the outer brain surface than men, whereas men exhibit more brain reduction on the mid-line surface than women after co-varying for total brain volume loss. These changes could contribute to sex differences in midlife behaviour and health.

Comparison of the effects of losartan and enalapril on clinical status and exercise performance in patients with moderate or severe chronic heart failure.

OBJECTIVES: This study assessed the feasibility of an efficacy trial comparing angiotensin-converting enzyme inhibition and angiotensin II receptor antagonism in heart failure. Patients with moderate or severe heart failure whose condition had previously been stabilized by treatment with a converting enzyme inhibitor were randomly assigned to receive enalapril or losartan. The study was designed to detect any signs of clinical deterioration during double-blind treatment. BACKGROUND: Losartan is a specific, nonpeptide angiotensin II receptor-1 antagonist with a vasodilator hemodynamic profile similar to that of converting enzyme inhibitors. Although therapy with specific receptor blockade has certain theoretic advantages over nonspecific converting enzyme inhibition, demonstration of a comparable therapeutic effect in patients with congestive heart failure will require a major effort comparing two active agents. METHODS: One hundred sixty-six patients with stable heart failure in New York Heart Association functional class III or IV and an ejection fraction < or = 35% were included in a multicenter, double-blind, parallel, enalapril-controlled trial. After a 3-week stabilization period with optimal therapy, including digitalis, diuretic drugs and a converting enzyme inhibitor, patients were randomly assigned to 8 weeks of therapy with losartan, 25 mg/day (n = 52); losartan, 50 mg/day (n = 56); or enalapril, 20 mg/day (n = 58). Patients were assessed with frequent clinical and laboratory evaluation and exercise testing. RESULTS: No significant differences between groups in terms of changes in exercise capacity (6-min walk test), clinical status (dyspnea-fatigue index), neurohumoral activation (norepinephrine, N-terminal atrial natriuretic factor), laboratory evaluation or incidence of adverse experience were observed. CONCLUSIONS: The results suggest that losartan and enalapril are of comparable efficacy and tolerability in the short-term treatment of moderate or severe congestive heart failure. A trial designed to compare the efficacy, tolerability and effect on mortality of long-term angiotensin II receptor blockade with converting enzyme inhibition is both feasible and ethically responsible.

Association between occupational psychosocial factors and waist circumference is modified by diet among men.

BACKGROUND/OBJECTIVES: Occupational psychosocial stress has been identified as a risk factor for obesity, whereas dietary habits have a key role in weight control. We examined whether dietary habits modify the association between occupational psychosocial factors and waist circumference. SUBJECTS/METHODS: Data comprised 31-year-old men (n=2222) and women (n=2053) in the Northern Finland Birth Cohort 1966. Waist circumference was measured and data on occupational psychosocial factors (demands, control and social support) and other characteristics were obtained through questionnaires. Healthy and unhealthy diet indices were constructed according to the current dietary guidelines. Associations were examined using analysis of variance adjusted for body mass index at age 14, basic education level, leisure-time physical activity, alcohol consumption, smoking, stress-related eating behaviour and parity. RESULTS: Among men, high job demands and high job control were associated with greater waist circumferences, and there were interactions between unhealthy diet and job demands (P=0.043) and job control (P=0.036) in relation to waist circumference. The waist of men with high demands or high control and low consumption of unhealthy foods (red/processed meat, hamburgers and pizzas, fried potatoes, sugar-sweetened soft drinks and white bread) was smaller than that of men with high demands or high control and high consumption of such foods. No associations were found among women. CONCLUSIONS: A diet based on the current dietary guidelines seems to cancel out the adverse effects of occupational psychosocial factors on waist circumference among young men. Longitudinal studies are needed to assess the risks for obesity-related diseases arising from psychosocial work environments and dietary habits.

Surgery of chronic traumatic aneurysm of the aortic isthmus: benefit of direct suture.

OBJECTIVE: Retrospective evaluation of long term results after direct suture repair of chronic traumatic aneurysm of the aortic isthmus. METHODS: From March 1979 to June 1998, a total of 19 patients with chronic traumatic aneurysm of the aortic isthmus were operated on, among whom 12 (63%) underwent direct suture. These 12 patients (age ranging from 19 to 68 years; mean 34.2 years) constitute the subject of this study. All but one suffered traffic accidents. Mean delay between trauma and surgery was 4 years (range 3 months to 12 years). All patients underwent a left posterolateral thoracotomy through the fourth intercostal space. Extracorporeal circulation for spinal cord protection was installed in six patients (five ilio-iliac shunts, one atrio-iliac shunt). Aortic rupture was partial in five and circumferential in seven patients. The mean clamping time was 25 min. The absence of loss of aortic substance and a careful mobilization of the aorta made the repair by direct suture easier; this technique could thus be achieved in 63.2% of all 19 patients operated on of chronic traumatic aneurysm within the same period. RESULTS: There was no in-hospital death and no postoperative paraplegia. With a median follow-up of 15 years 3 months (ranging from 22 to 10 years), there were no late complications. Chest X-ray was normal in all patients; eight of them underwent a control angiography between 18 and 72 postoperative months; all these angiographies but one (20% stenosis without gradient) demonstrated a normal appearance of aortic isthmus. CONCLUSION: Direct suture for repair of chronic traumatic thoracic aneurysm is a safe procedure: long-term outcome was excellent and the complications observed with prosthetic grafts or with aortic endoprosthetic stent-grafts were avoided.

Dependence of cold-related coronary and respiratory symptoms on age and exposure to cold.

Cold causes cardiopulmonary stress often perceived as shortness of breath or chest pain, and causes exacerbation of these symptoms in persons suffering heart or lung disease. We investigated the prevalence of these symptoms and their association with sex, age and cold exposure in a population-based sample of 1,785 persons who lived in three areas of Finland. The exposure to cold was measured by the annual number cold days (mean daily temperature below 0 degree C) in the resident locality and weekly hours spent in the cold in winter. Shortness of breath was 25% and chest pain 52% more common in females than in males, and their prevalence increased by 24% and 77%, respectively, for every 10 years of age. The prevalence of shortness of breath increased by 5% and chest pain by 6% for every 10 cold days in the resident locality, and by 6% and 7% for every 10 hours spent in the cold, respectively. We suggest that environmental cold, measured by the number of cold days throughout the year and weekly hours spent in the cold, may provoke cardiopulmonary symptoms independent of sex and age.

Five years of surgical experience with peritoneal dialysis.

In this study, we evaluate retrospectively five years experience with the Swann Neck Missouri DC catheters. Sixty three catheters are placed in 51 patients. The total observation period is 695.6 months and the average time is 13.6 months per patient. The last 21 catheters are coiled type. Infectious complications remain the most worrisome problem in peritoneal dialysis. Exit site infections are seen in 24%, tunnel infections in 8%, peritonitis in 38% and abdominal hernias in 16% of the patients. The results in our series (peritonitis every 29.0 patient-months) are in accordance with data from the literature. The combination of a good surgical technique and an efficient postoperative attendance have reduced this frequency. In the situation of a tunnel infection, surgical removal remains the treatment of choice. To prevent an exit site infection, the entry port must be well nursed and protected. A coexisting abdominal hernia can be repaired during the implantation procedure. Fourty six peritoneal dialysis catheters have been removed. Transplantation and death are the main reasons (59%).

Cardiorespiratory fitness of finnish adolescents.

We evaluated the accuracy of a submaximal cycle ergometer test to assess cardiorespiratory fitness in adolescents and provided population-based reference values. In a health study of the Northern Finland birth cohort born in 1985 - 1986 (NFBC 1986), cardiorespiratory fitness of 5375 males and females aged 15 to 16 years was measured by a submaximal cycle ergometer test by using a two-stage exercise protocol designed for this survey. A total of 4903 subjects performed two work stages. Maximal workload and peak oxygen consumption were calculated on the basis of heart rate responses by the WHO extrapolation method. An additional 472 subjects were able to finish only one work stage. For them, peak oxygen uptake was calculated by the Astrand nomogram. To evaluate the accuracy of submaximal testing, a validation sample of 90 subjects carried out both a submaximal test and a maximal cycle ergometer test with direct measurement of peak oxygen uptake. The WHO method proved to estimate peak oxygen uptake with reasonable accuracy. The Astrand nomogram method overestimated peak oxygen uptake considerably, and therefore a new single-stage regression method was applied to calculate maximal workload and peak oxygen consumption. Reference values of cardiorespiratory fitness were provided for 2690 males and 2685 females aged 15 to 16 years.

Usefulness of M-mode echocardiography in the diagnosis of heart failure.

The utility of M-mode echocardiography in the diagnosis of heart failure (HF) was evaluated in a study of 70 patients with suspected HF (26 men and 44 women) and 63 control persons (26 men and 37 women), all aged 45-74 years. The patients were classified according to the certainty of HF diagnosis using the Boston criteria: 27 patients were defined as 'unlikely' to have HF, 19 as having 'possible' HF, and 24 as having 'definite' HF. In calculations of the sensitivities and specificities for echocardiographic variables in detecting 'definite' HF, the 95% confidence limits in the control group were used as cut-off point values. Sensitivities thus attained were 91% for mitral valve E point-septal separation (EPSS), 73% for left ventricular (LV) fractional shortening (FS), and 64% for peak rate of increase of LV diameter (PLR), respectively, and the specificities were 73, 88, and 78%, respectively. When EPSS, FS and PLR were all normal, the likelihood of 'definite' HF was as low as 7%. We conclude that M-mode echocardiography is actually a useful method in the diagnostic evaluation of patients with suspected HF, and it is more reliable in excluding than confirming the presence of HF.

Cardiopulmonary exercise testing has limited value in diagnosing heart failure.

Usefulness of cardiopulmonary exercise testing in the diagnosis of heart failure was evaluated in a study of 59 patients with clinically suspected heart failure (22 men and 37 women) and 75 healthy control persons (34 men and 41 women), aged 45-74 years. Patients were classified according to certainty of the diagnosis by the Boston criteria: 27 patients were "unlikely" to have heart failure (group I), 19 had "possible" (group II) and 13 had "definite" heart failure (group III). Oxygen consumption at peak exercise and at the appearance of the ventilatory threshold was lower in group III than in the control group (15.6 +/- 1.5 versus 26.0 +/- 0.8 ml/min/kg, p less than 0.001 and 11.8 +/- 1.5 versus 18.0 +/- 0.4 ml/min/kg, p less than 0.001, respectively). However, the distribution of oxygen consumption values was wide in both the control and patient groups, and considerable overlapping of values between study groups was observed. Thus, cardiopulmonary exercise testing appeared to be of limited value in the diagnosis of heart failure.

Residual marrow damage: possible explanation for idiosyncrasy to chloramphenicol.

The effect of oral administration of chloramphenicol was studied in normal mice and mice having residual marrow damage. In the concentration used the drug had no detectable effect on the marrow of normal mice but caused a progressive fall in the numbers of pluripotential stem cells and granulocytic progenitor cells in mice bearing residual marrow damage. However, cells taken from such mice were no more sensitive than normal cells to the in vitro action of chloramphenicol. The results suggest that unrecognized residual marrow damage can be an aetiological factor in marrow failure due to drug idiosyncrasy.

A controlled trial of androgen therapy in experimental chronic hypoplastic marrow failure.

A controlled trial of an androgen, 17-nortestosterone decanoate, was carried out to test its effect as therapy in an experimental model of chronic hypoplastic marrow failure. No effect was detected.

Validity of clinical diagnosis of heart failure in primary health care.

Validity of heart failure (HF) diagnosis was studied in 88 patients (37 men and 51 women), aged 45-74 (mean 61) years, in whom HF diagnosis had been newly made by primary health care physicians. Boston criteria for HF and a supplementary classification, based on information from clinical examinations and a 6-month follow-up, were used to define HF diagnosis as 'definite', 'possible' or 'unlikely'. Twenty-eight (32%) patients (21 men and seven women) had 'definite' HF and 46 (52%) (28 men and 18 women) had either 'definite' or 'possible' HF by both classifications. In 30 (34%) patients (six men and 24 women) HF diagnosis was 'unlikely' by both classifications. In conclusion, false-positive diagnosis of HF was common in primary health care, and HF diagnosis was more difficult in women than in men. Obesity, unrecognized symptomatic myocardial ischaemia without HF and pulmonary diseases were the most important conditions leading to false-positive HF diagnosis.

Neuroendocrine activity in untreated heart failure.

Neuroendocrine activity was studied in 60 consecutive untreated patients with dyspnoea and a clinical suspicion of heart failure. On the basis of the so-called Boston clinical criteria the diagnosis of heart failure was regarded as unlikely in 26 patients, possible in 15 patients, and definite in 19 patients. These groups were studied before any drug treatment was started and were compared with a control group of 69 healthy individuals. Plasma atrial natriuretic peptide concentration was clearly raised in patients with definite heart failure and slightly raised in patients with possible heart failure. Plasma adrenaline concentration was somewhat raised in patients with definite or possible heart failure, whereas plasma noradrenaline concentration was raised only in patients with definite heart failure. Plasma renin activity was not increased in any of the patient groups and plasma aldosterone concentration was slightly increased only in patients with definite heart failure. In the total patient series there were significant correlations between plasma atrial natriuretic peptide concentration and markers of the severity of left ventricular dysfunction. There was some evidence of neuroendocrine activation in untreated heart failure: plasma concentrations of atrial natriuretic peptide and catecholamines were increased but the renin-angiotensin-aldosterone system showed little or no activation.

Incidence of heart failure in eastern Finland: a population-based surveillance study.

Heart failure is a frequent disorder, but there is little population-based data available on its incidence. We have studied the incidence of heart failure in 45-74-year-old inhabitants in four rural communities in eastern Finland (total population 37,600; 11,000 45-74 years of age). The aim was to identify all patients in whom symptoms had started and in whom a diagnosis of heart failure had been established during a 2-year study period. General physicians, working in community health centres in the study area, referred all their patients with suspected heart failure to the study. A register of drug reimbursement, hospital discharge and other health care registers were used to identify patients who had not been referred. The Boston criteria were used to verify the diagnosis. One hundred and thirteen subjects (51 men and 62 women) were enrolled, of whom 51 (38 men and 13 women) had definite heart failure. Age-adjusted incidence rate of heart failure (per 1000 . year-1) was 4.0 in men and 1.0 in women, and the incidence rates increased with age in both sexes. Coronary heart disease or hypertension was evident in 41 (80%) cases. The striking difference in the incidence rates between men and women is probably explained by the excessive occurrence of coronary heart disease among men in eastern Finland.