Open lung biopsy. Its effects on therapy in the pediatric patient.

The records of 35 pediatric patients who had open lung biopsies at Columbus Children's Hospital, Columbus, Ohio, were analyzed to determine the results and the effects on therapy. Twenty-two (63 percent) of these patients were immunocompromised, and they are compared to the non-compromised group. A diagnosis was obtained in all cases. An infectious agent was identified in 13 (37 percent) of the patients. Ten of these were immunocompromised. In 43 percent (15 patients) of the total group and 55 percent (12 patients) of the immunocompromised group, the results of the biopsy effected a change in therapy. Five patients died, all of whom were immunosuppressed. None died as a direct result of the open lung biopsy. The total morbidity rate was 23 percent (eight patients). We concluded that open lung biopsy can be accomplished safely in the pediatric patient and that the results affect the therapeutic decision-making process a significant portion of the time.

A technique for postembolectomy streptokinase infusion.

Despite successful arterial thromboembolectomy, some extremities may have progressive ischemic necrosis due to persistent arterial occlusion. Streptokinase infusion can be valuable in this situation. We have developed a clinically applicable technique that is of value in lysing residual thrombi.

Excellence and low case volume: an example of the inapplicability of volume-based credentialing.

BACKGROUND: Health care reform, public disclosure of hospital and surgeon-specific results, plus changes in reimbursement patterns have raised the specter of volume-based credentialing. METHODS: Using The Society of Thoracic Surgeons Cardiac Database, we examined the data for all coronary artery bypass graft-only patients (n = 615) operated on by us from July 1991 to June 1997. RESULTS: The observed mortality was 0.33% and the observed-to-expected ratio was 0.12 (p<0.005). Morbidity was low as well. CONCLUSIONS: Excellent results can be obtained for patients undergoing coronary artery bypass grafting in the presence of both low surgeon and low hospital case volume.

Simplified method of left ventricular thrombectomy.

Postinfarction left ventricular thrombi are at risk for embolization with resultant injury. Surgical removal is recommended especially if they are pedunculated or mobile. We describe an easily applied transatrial method that can allow avoidance of a ventriculotomy.

Autotransfusion of unwashed mediastinal shed blood fails to decrease banked blood requirements in patients undergoing aortocoronary bypass surgery.

Infusion of unwashed mediastinal shed blood (MSB) is one technique advocated for decreasing use of donor blood in cardiac surgery patients. A commercially available system was prospectively evaluated in 96 consecutive patients. The control group was comprised of 78 consecutive patients. All underwent elective aortocoronary bypass surgery. Student's t-test, chi-square analysis, multivariate analysis, and Fisher's exact test were used where appropriate. There was no decrease in the amount of banked blood required or percentage of patients who received transfusions in the MSB autotransfusion group.

Anxiety in ambulatory emergency patients.

The anxiety level of ambulatory emergency department patients without a diagnosis of a physical illness was studied. These patients were compared to a group with a diagnosis of nontraumatic surgical disease. Both the study group and the comparison group were found to have elevated anxiety levels. In addition, those with nonphysical illness had elevated levels of covert anxiety when compared to their overt levels (p less than .03) and when contrasted with the comparison group's covert levels ( p less than .03). In the treatment of all a patient's problems the psychosomatic illnesses evidenced by raised covert anxiety levels may require intensive treatment both within and without the emergency department.

Anxiety levels and cancer fear in patients admitted for elective operations.

Patients who are to have elective operations project varying degrees of anxiety, and many spontaneously express fear (without basis) that their operation involves a diagnosis of malignancy. To measure total, covert, and overt anxiety objectively, we gave the Institute for Personality and Ability Testing anxiety test to 125 consecutive patients admitted for elective general surgical procedures. A simple survey of cancer fear was also completed. Chi-square and Fisher's exact test were used to compare categoric data, and linear regression and analysis of variance were used where appropriate. Total anxiety scores were in the upper quartile compared to the general population. Scores indicating fear of cancer were elevated in 75% of patients who had no history of or reason to suspect malignancy. Covert anxiety scores correlated with cancer fear scores, and both significantly decreased as age increased (P less than .05). Also, as age increased, the cancer fear scores decreased (P less than .002). Obese patients had higher scores of cancer fear than all other patients (P less than .0001).

Colonoscopic removal of a gallstone obstructing the sigmoid colon.

For the patient with a single gallstone obstructing the colon, this technique offers nonoperative relief of the obstruction, allowing definitive operative therapy to be accomplished at a later time on a more elective basis. The patient should be carefully observed during the interval for intervening recurrent gallstone ileus.