Prevalence and characteristics of post coronary artery bypass graft surgery pain (PCP).

Coronary artery bypass grafting (CABG) is one of the most common surgical procedures performed worldwide. However, its frequent complication, the post-CABG pain (PCP) syndrome, remains poorly documented. This retrospective cohort study was aimed to investigate the prevalence and characteristics of this syndrome. Five hundred and four of 540 subjects, who underwent CABG surgery at our institution between January 1995 and December 1996 and who could be identified, were mailed questionnaires regarding the presence and characteristics of chest wall pain. Eighty of 217 patients, who were defined as having PCP based on these questionnaires, were evaluated in detail. Main outcome measures included a preliminary pain questionnaire, pain localization on a body scheme, a five-point verbal scale and the Visual Analogue Scale (VAS) for measuring pain intensity. Pain qualities, disability and depression were measured by the McGill Pain Questionnaire (MPQ), the Pain Disability Index (PDI), and the Beck Depression Inventory (BDI), respectively. Medical and neurological examinations were also conducted, as well as quantitative thermal testing (QTT) of the chest wall. The preliminary pain questionnaires indicated that 219 of the 387 respondents (56%) reported chest wall pain, which was categorized as PCP. One hundred and forty-two (65%) of the patients with PCP reported pain of at least moderate severity, and 151 (72%) reported that the pain interfered with their daily activities. Eighty PCP patients were available for a detailed evaluation. Left-sided chest wall pain was noted by 53 subjects, midline scar pain by 47, and right-sided pain by nine subjects. Pain intensity (VAS) was 35 +/- 22 (mean +/- SD), MPQ score was 4.9 +/- 3.7, PDI score was 2.0 +/- 0.7, and BDI score was 9.3 +/- 7.3. The neurological examination and the QTT indicated three subcategories of PCP: (1) left-sided chest wall pain often associated with hypoesthesia, mechanical allodynia, and elevated thermal thresholds; (2) midline scar pain accompanied primarily by mechanical allodynia; (3) right-sided, relatively infrequent pain. While the first two subcategories seem to have a neurogenic etiology, this later subcategory of pain is of a mal-defined etiology. This study indicates that PCP is a group of pain syndromes with a high prevalence, and with a negative effect on mood and performance of daily activities. The risk of developing PCP and its potential consequences should therefore be discussed with every patient prior to CABG surgery. These results will need to be confirmed in larger, multi-center studies.

Clamping of the atherosclerotic ascending aorta during coronary artery bypass operations. Its cost in strokes.

In 632 consecutive primary operations for coronary bypass grafting, the effect of instrumentation of the ascending aorta on the prevalence of stroke was evaluated. There were five surgical pathology groups: group A: soft aorta with no palpable disease, 463 patients; group B: distinctly palpable aorta with focal atheromas necessitating minor surgical modifications, 132 patients; group C, unclampable aorta (no plane for crossclamping the aorta without compression of atheromas was present), 16 patients; group D, untouchable aorta, in which the entire ascending aortic wall was involved by atheromatosis (these aortas were not touched), 14 patients; group E, aneurysmal aorta with soft walls, 7 patients. There were four strokes (0.63%), all related to instrumentations of the aorta. There were no cerebrovascular accidents in patients in whom precautions were taken. Of all risk factors studied, age was the only predictive one for major atheromatosis of the aorta (chi 2 test, p less than 0.001). Of the 30 patients in groups C and D, only one was younger than 60 years.

Potentially dangerous negative intrapleural pressures generated by ordinary pleural drainage systems.

OBJECTIVE: Clinical observation has identified cases in which the negative pressures exerted on patient chest drains have appeared to far exceed the level of suction intended. This study was designed to test whether the use of high rates of airflow in typical pleural/mediastinal drainage systems exerts excessively high negative pressures on the chest drainage tube. METHODS: Three pleural drainage systems were tested in vitro at negative pressure settings ranging, in 5-cm H(2)O increments, from 5 to 35 cm H(2)O. At each negative-pressure setting, each device was tested with three different rates of airflow. The negative pressures exerted in the chest drain were measured by water manometer and were compared with the initial pressure settings. RESULTS: When a high rate of airflow was used, all three systems produced negative pressures that exceeded the pressure level initially set; two of the systems exerted negative pressures that were approximately double those intended, for all pressure settings. CONCLUSIONS: Pleural drainage systems may exert excessive and potentially dangerous high negative pressures if high airflow is utilized. The risk to patients will be minimized if the airflow through the pressure-regulating chamber of the drainage system is adjusted to produce slow, consistent bubbling. High rates of bubbling and turbulence in the water column indicate that the negative pressure level may be excessively high, particularly for patients who do not have air leakage.

Synergism between infarct-borne left ventricular dysfunction and cardiomegaly in increasing the risk of coronary bypass surgery.

The effect of cardiomegaly on operative and late mortality in patients with left ventricular dysfunction undergoing coronary bypass operation was investigated. The study group consisted of 178 patients whose left ventricular ejection fraction was below 45% and who were operated on from 1978 through 1985. Forty-five patients (group A) had severe left ventricular dysfunction (ejection fraction < 30%) and 133 (group B) had moderate dysfunction (30% > ejection fraction > 45%). Twenty-four of group A (53%) and 54 of group B (41%) patients had cardiomegaly (cardiothoracic ratio on chest x-ray films > 0.5). There were 10 (6%) hospital deaths, four in group A (9%) and six in group B (4.5%). All four deaths in group A and the six deaths in group B were patients who had cardiomegaly. Regardless of the severity of the left ventricular dysfunction, there was no operative death among patients with normal heart size (p < 0.001). Age over 65, bypass time longer than 2 hours, and incomplete revascularization emerged as risk factors. Follow-up ranged from 5 to 13 years (mean 7.8 years). Overall 5-year actuarial survival, including hospital mortality, was 80% +/- 3%. Reduced 5-year survival was observed in patients with cardiomegaly (67% +/- 5% versus 91% +/- 3%, p < 0.05). Five- and 10-year survival of patients from group A with cardiomegaly was 53% +/- 7% and 18% +/- 13%, respectively.

Early clinical experience with a new sutureless anastomotic device for proximal anastomosis of the saphenous vein to the aorta.

BACKGROUND: Avoiding aortic side clamping is useful to avoid local particulate embolization. A device that allows a saphenous vein graft to be anastomosed to the aorta without aortic manipulation is clinically evaluated. METHODS AND RESULTS: From July 1999 to March 2000, 17 patients who underwent myocardial revascularization had an aorta-saphenous vein graft anastomosis performed by means of an aortic anastomotic device. Eight were operated on with cardiopulmonary bypass and 9 without. The proximal anastomoses created by the aortic anastomotic device were performed before the institution of cardiopulmonary bypass or before the related distal anastomosis was performed. In 11 patients transcranial Doppler ultrasound was used. In 1 (6%) patient the saphenous vein graft was not deployed, and in 2 (12%) a single suture was added for minor bleeding. None of the 11 patients evaluated with transcranial Doppler ultrasound had evidence of particulate embolization during the procedure. No patient died or was reoperated on for bleeding. Six (35%) patients had a postoperative angiogram 48 +/- 26 days after the operation that showed widely patent proximal anastomoses. CONCLUSIONS: Use of an aortic anastomotic device allows a sutureless anastomosis to be created between the aorta and saphenous vein graft. The device could be used in totally endoscopic myocardial revascularization. A second-generation device is ready to solve the problems encountered and to increase the ease in handling the device.

Vancomycin versus cefazolin prophylaxis for cardiac surgery in the setting of a high prevalence of methicillin-resistant staphylococcal infections.

OBJECTIVE: This study was undertaken to compare the efficacy of vancomycin prophylaxis with that of cefazolin in preventing surgical site infections in a tertiary medical center with a high prevalence of methicillin-resistant staphylococcal infections. METHODS: All adult patients (> or = 18 years) scheduled for cardiac surgery requiring sternotomy were randomly assigned to receive vancomycin (1 g every 12 hours) or cefazolin (1 g every 8 hours). Prophylaxis was started during the induction of anesthesia and continued for only 24 hours. Patients were followed up for at least 30 days (1 year for those receiving a cardiac implant). Surgical site infections were stratified according to the National Nosocomial Infections Surveillance System risk index. RESULTS: Of the 885 patients included in the study, 452 received vancomycin and 433 received cefazolin. The overall surgical site infection rates were similar in the two groups (43 cases in the vancomycin group, 9.5%, vs 39 cases in the cefazolin group, 9.0%, P =.8). Superficial and deep incisional surgical site infection rates were also similar in the two groups. There was a trend toward more frequent organ-space infections and infections with beta-lactam-resistant organisms among patients receiving cefazolin, but this trend did not reach statistical significance. In contrast, surgical site infections caused by methicillin-susceptible staphylococci were significantly more common in the vancomycin group (17 cases, 3.7%, vs 6 cases, 1.3%, P =.04). The durations of postoperative hospitalization and the mortalities were similar in the two groups. CONCLUSIONS: This trial suggests that vancomycin and cefazolin have similar efficacy in preventing surgical site infections in cardiac surgery.

Altered regulation of gene and protein expression of hypothalamic-pituitary-adrenal axis components in an immature rat model of chronic stress.

Chronic stress early in postnatal life influences hormonal and behavioural responses to stress persistently, but the mechanisms and molecular cascades that are involved in this process have not been clarified. To approach these issues, a chronic stress paradigm for the neonatal rat, using limited bedding material to alter the cage environment, was devised. In 9-day-old rats subjected to this chronic stress for 1 week, significant and striking changes in the expression and release patterns of key molecules that govern the neuroendocrine stress responses were observed. The presence of sustained stress was evident from enhanced activation of peripheral elements of the neuroendocrine stress response, i.e. increased basal plasma corticosterone concentrations, high adrenal weight and decreased body weight. Central regulatory elements of the neuroendocrine stress response were perturbed, including reduced expression of hypothalamic corticotropin-releasing hormone that, surprisingly, was accompanied by reduced glucocorticoid receptor expression. Thus, the effects of chronic sustained stress in the neonatal rat on the hypothalamic-pituitary-adrenal axis included substantial changes in the expression and activity of major regulators of this axis. Importantly, the changes induced by this chronic stress differed substantially from those related to acute or recurrent stress, providing a novel model for studying the long-term effects of chronic, early life stress on neuroendocrine functions throughout life.

Modified urinary collecting bags for prolonged underwater chest drainage.

We describe a method by which a modified urinary collecting bag is used as part of a chest drainage system. This system is especially suitable for patients who require prolonged periods of drainage.

Punch pulmonary valvectomy: another alternative to treat critical pulmonary stenosis.

For neonates with severe valvar stenosis, or valvar pulmonary atresia with an imperforate pulmonary valve, we present a simple but effective closed procedure using a specially designed valvectomy punch. Seven neonates, who were not suitable for any type of transcatheter procedure, were treated. There were two late deaths, neither directly related to the operation; 4 patients are developing well. This approach using the valvectomy punch is a fast, safe, and effective procedure.

End-tidal CO2 levels are a reliable indicator of band tightness in pulmonary artery banding.

BACKGROUND: Monitoring of end-tidal CO2 levels, performed routinely nowadays in most operating rooms, is obligatory in our hospital for all anesthesia patients. Levels are dependent on pulmonary blood flow, ventilation, and CO2 content of blood. When ventilation is kept constant, the end-tidal CO2 closely follows pulmonary blood flow. METHODS: Reduction of end-tidal CO2 in the expired air was used to adjust tightness of the pulmonary band in 10 patients with complex cardiac anomalies, all including ventricular septal defect, who underwent pulmonary artery banding. Other parameters were systemic blood pressures and distal pulmonary artery pressures. RESULTS: There were no operative deaths. Average reduction was 3.8 mm Hg (range, 2 to 10 mm Hg; p < 0.001 by paired t test), average increase in systolic blood pressure was 14 mm Hg (range, 4 to 20 mm Hg; p < 0.03 by Wilcoxon sign rank test), distal pulmonary artery pressure was reduced from 56 mm Hg (range, 37 to 79 mm Hg) to 29 mm Hg (range, 20 to 38 mm Hg; p < 0.03 by t test), and postoperative pulmonary artery to systemic pressure ratio averaged 0.36 mm Hg (range, 0.24 to 0.49 mm Hg, difference from preoperative value, p < 0.06). CONCLUSIONS: End-tidal CO2 tension is a simple and convenient, yet highly reliable parameter for adjusting pulmonary artery band tightness.

Maintenance medication for schizophrenia and schizoaffective patients.

This study assesses the different approaches to treating patients with schizoaffective and paranoid schizophrenia in remission. Individualized treatment of 220 outpatient schizophrenia patients was conducted for 4 years. The choice of treatment was based on the course of the disease and the frequency of relapses. The influence of changes in treatment on the patterns of relapses is presented. The results of this prospective followup open study were evaluated by comparing data received during our research with data from the two preceding 4-year periods and with data from the control group. Compared with routine methods, special treatment tactics led to a significantly decreased frequency of relapses in patients with frequent relapses (p < 0.001). In patients with rare relapses, full cessation of treatment did not lead to increasing mean frequency of relapses. Treatment in remission should be based on the peculiarities of the course of disease, specifically, frequency of relapses, type of schizophrenia, and presence or absence of positive psychopathological signs in remission.

Vancomycin sequestration during cardiopulmonary bypass surgery.

OBJECTIVE: The present study was designed to analyze vancomycin disposition in adult patients undergoing coronary bypass grafting during and following cardiopulmonary bypass (CPB). METHODS: Coronary bypass surgery was performed on 11 adults with a mean age (SD) of 62.9 (9.0) years old, who received a mean (SD) vancomycin prophylactic dose of 12.7 (1.0) mg/kg in a mean period of 41 (0.7) min. Using a two-compartment open model for pharmacokinetic analysis, the following parameters were obtained: alpha half-life, minutes (t(1/2alpha)); beta half-life, hours (t(1/2beta)); apparent volume of distribution, (V(d) l/kg); volume of the central compartment, (V(c) l/kg), constant between the "central to the peripheral" compartment, (k(12)); constant between the "peripheral to the central" compartment, (k(21)); total area under the concentration-time curve, (AUC mg/lxh) and a vancomycin clearance, (Cl(van) ml/min), respectively. RESULTS: The mean (SD) calculated pharmacokinetic parameters were: t(1/2alpha)17.6 (6) min, t(1/2beta) 8.4 (3.8) h, V(d) 0.803 (0.259) l/kg, V(c) 0.270 (0.162) l/kg, k(12) 0.03 (0.015), k(21) 0.012 (0.012), total AUC 10377.2 (3687.6) mg/lxh. The mean (SD) vancomycin clearance by the CPB machine was 9.51 (2.66) l/h, and the mean (SD) total vancomycin sequestrated by CPB was 331.7 (84) mg. A significant difference (6.3%; p = 0.001) was measured between the mean measured AUC during CPB (1088.1 +/- 253.9) and the same calculated parameter (1160.2 +/- 282). Five minutes after starting CPB, a decrease in vancomycin level was detected; this difference was found to be nearly 11% in absolute values. CONCLUSIONS: This confirmatory study demonstrated that the vancomycin blood concentrations obtained during the study allow recommending a safety prophylactic dose of 12mg/kg in adults who undergo open-heart surgery under CPB conditions. Sequestration of vancomycin by the oxygenator or/and tubing system of the CPB machine had occurred and had been measured in this study.

Alternative techniques for surgical management of recoarctation.

OBJECTIVE: To evaluate the different surgical options in patients with recoarctation and minimal collaterals. METHODS: Thirty-three cases operated on between January 1980 and January 1995 were reviewed. Initial repair was end-to-end anastomosis in 16 patients, subclavian artery aortoplasty in 10, synthetic patch aortoplasty in 4 and bypass conduit in 3 patients. Age at reoperation was 7.5 +/- 5.2 years (1-17 years). Pressure gradient was 20-48 Torr (33 +/- 9). Upper extremity resting or exercise systemic hypertension was present in all. In 18 patients recoarctation was repaired using subclavian artery aortoplasty (n = 15) or synthetic patch aortoplasty (n = 3); alone in 9, with temporary heparinized bypass in 2, or in addition to placement of ascending aorta to descending aorta conduit as a permanent bypass through a left thoracotomy in 9. In 13 patients a conduit was interposed between ascending aorta and descending aorta through a right thoracotomy. In one patient recoarctation segment was patched on cardiopulmonary bypass through a midsternotomy. RESULTS: There was no mortality or complications. All patients had no echocardiographic pressure gradients across recoarctation on 5 +/- 3.4 years follow-up. Persistent systemic hypertension following recoarctation repair was present in 3/8 patients (37%) operated on at age greater than 10 years, but has been resolved in all 25 patients less than 10 years of age (P = 0.02). CONCLUSIONS: Use of ascending aorta to descending aorta conduit, either alone through a right thoracotomy, or as permanent bypass in combination with patching the recoarctation through a left thoracotomy provides safe and excellent relief of obstruction.

Myocardial protection in operations requiring more than 2 h of aortic cross-clamping.

OBJECTIVE: Long periods of aortic cross-clamping time during cardiac surgery are associated with high rates of morbidity and mortality because of damage to the myocardium. Recently, we have used a method of myocardial protection based on the principles of hyperkalemic cardioplegic arrest. We use antegrade administration of warm, undiluted blood followed by continuous retrograde infusion of tepid, undiluted blood supplemented with potassium and magnesium. In this study, we have retrospectively reviewed our experience with this method of cardioprotection in operations requiring more than 2 h of cross-clamp time. METHODS: We retrospectively reviewed the medical records of 1280 patients who underwent myocardial revascularization, valve repair or replacement, or a combination of both operations between January 1, 1994 and December 31, 1997. Patients were divided into two groups: the short cross-clamp group (SXC) (n = 1144) had cross-clamp times < 120 min (mean, 78 +/- 20 min; range, 35-119 min) and the long cross-clamp group (LXC) (n = 136) had cross-clamp times > 120 min (mean, 154 +/- 31 min; range, 120-277 min). We compared preoperative, operative, and postoperative variables between the two groups. RESULTS: Significantly more patients in the long cross-clamp group (43.4%) underwent the combined operation than in the short cross-clamp group (2.3%), and the rate of reoperation was significantly higher in the long cross-clamp group (12%) than in the short cross-clamp group (5%). Despite these differences in operative complexity, we found no difference in hospital mortality rates between the two groups. The only significant postoperative differences were that the long cross-clamp group had a greater need for inotropic agents (43 vs. 29%), higher serum levels of creatine kinase (880 +/- 583 vs. 613 +/- 418) and CK-MB (10.9 +/- 6.4 vs. 5.9 +/- 5.2), and a longer hospital stay (9.6 vs. 6.1 days). CONCLUSION: Long, complex operations requiring more than 2 h of cross-clamping can be performed safely with our method of cardioprotection based on continuous retrograde infusion of tepid, hyperkalemic, undiluted blood.

Evaluation of compulsory ambulatory treatment in Israel.

The effectiveness of Israel's compulsory ambulatory treatment order was evaluated based on a one-year follow-up of the 326 orders served during the first four years of implementation. Demographic, epidemiological, clinical, and legal data were obtained from patient records. Success was defined as continuous treatment for the entire six-month period of compulsory ambulatory treatment, or as voluntary hospitalization during or after the compulsory treatment period. The compulsory ambulatory treatment order was found to be efficacious in 43.3 percent of the cases; in 32.5 percent it did not succeed in preventing compulsory hospitalization, and in the remaining cases (22.1 percent), success was partial.

The sheep as a model for coronary artery bypass surgery.

The sheep is considered to be a suitable model for cardiovascular surgery because of its ease of handling, size, and vascular anatomy which bears close resemblance to the human. Several difficulties, however, have limited the use of the sheep for such a purpose-mainly the high infection rate resulting from median sternotomy incision and its susceptibility to intractable ventricular fibrillation (VF) with the slightest manipulation of the heart, and even the risk of short periods of myocardial ischaemia. We have used the sheep model extensively to perform coronary artery bypass surgery and were successful in overcoming these difficulties. Fifty-seven adult female sheep were used to test a new anastomotic device for the creation of a sutureless connection between venous and arterial grafts and the coronary arteries. The study required full access to the heart and great vessels and mobilization of one of the internal mammary arteries. Changing to the left lateral thoracotomy (LLT) approach solved the initial fatal problems of postoperative infected median sternotomy incisions. Aggressive prophylactic treatment with anti-arrhythmic drugs, maintenance of normothermia and myocardial preconditioning rendered the heart much less vulnerable to manipulations and ischaemia. These measures have reduced the mortality rate from 45% to 0% (P <0.0001). With specific operative techniques and pharmaceutical interventions, the sheep can be effectively and safely used as a model for coronary artery surgery.

Jacob--the case of a serial killer.

This paper describes a rare forensic psychiatric syndrome which has been the subject of massive publicity in the last decade. Despite the widespread interest, the psychodynamic process whereby a person becomes a serial murderer remains largely unknown. "Jacob" was convicted of a series of murders that he carried out over a decade. The case material is based on the psychiatric reports that were presented to the court and the many articles published in the local press at the time. Despite the limitations imposed by the material, the available information on "Jacob" bears some similarity to the phenomenological and psychodynamic models described in the literature. An attempt is made to understand the transformation of a person into a serial killer considering the life events, psychopathology and stressors that lead to the emergence from the world of imagination and fantasy of a potential murderer to the deeds that comprise the syndrome.

Laurence-Moon-Bardet-Biedl syndrome in combination with Cotard's syndrome. Case report.

Laurence-Moon-Bardet-Biedl (LMBB) syndrome is a symptom complex that usually presents with retinitis pigmentosa, poly- or syndactyly, mental retardation, obesity and hypogenitalism. Cotard's syndrome is a state in which the central symptom is a delusion of negation. The case reported here is a combination of these two rare conditions.

The district psychiatrist: a merger of psychiatric and legal authority.

Some of the wide powers and extensive functions of the District Psychiatrist are described, and the dilemma of maintaining the crucial and delicate balance between civil rights and psychiatric treatment is emphasized.

[Compulsory, ambulatory psychiatric treatment].

The Treatment of Mentally Sick Persons Law of 1955, was repealed and replaced by the Law of 1991. Under the latter, the Order for Compulsory Ambulatory Treatment (OCAT) was addressed for the first time (Section 11, a-d). According to this law, the district psychiatrist instead of issuing a hospitalization order, may issue an OCAT, under which the required treatment is given within the scope of a clinic which he designates, for up to 6 months and under conditions which he specifies. This is done on the basis of psychiatric examination, or an application in writing from the director of a hospital or clinic, when continued ambulatory treatment is needed after discharge from hospital or instead of compulsory hospitalization. The district psychiatrist may extend the period of treatment for further periods, none of which is to exceed 6 months. Compulsory ambulatory treatment is to enable patients to benefit from the positive aspects of living freely in the community, while receiving prompt treatment under compulsory conditions. The concept offers a partial solution, achieving a balance between civil liberties and clinical needs, between over-confinement and under-treatment which might be dangerous or neglectful. The clinical impression has been that the OCAT has not fulfilled expectations. The purpose of this study was to examine the topic in a systematic way in Jerusalem and the southern districts for the 4 years since inception of the law. In 44.4% of cases OCAT was proven to be effective, while in 33.1% it was found to be ineffective and did not prevent compulsory hospitalization, one of its main goals. It was partially effective in the rest of the cases. It is recommended that suitable means for the enforcement of the law be allocated and that the subject of forceful hospitalization and OCAT be made a mandatory subject in the residency program of psychiatrists.