The reversal of amiodarone-induced perioperative reduction in cardiac systolic reserve in dogs.

There is controversy about the myocardial depressant effects of amiodarone in patients with decreased cardiac function undergoing surgery. Some surgeons believe that these effects complicate the discontinuation of cardiopulmonary bypass. Accordingly, the hemodynamic effects of amiodarone were evaluated in two groups of anesthetized mongrel dogs that had undergone a median sternotomy. A control group of 10 dogs and an amiodarone-treated group (15 mg/kg per day for 3 weeks) of 10 dogs were studied, and serum (0.26 to 1.09 micrograms/ml) and tissue (cardiac 2.97 to 11.60 micrograms/ml) levels of amiodarone were measured by liquid chromatography. Hemodynamic measurements were made at baseline and after administration of routine therapeutic intravenous doses of dobutamine (10 micrograms/kg per min), isoproterenol (0.06 micrograms/kg per min) and epinephrine (2 micrograms/min). The amiodarone-treated dogs had a smaller increase in cardiac output compared with baseline than did control dogs. For each drug when the amiodarone-treated group was compared with the control group, increases in cardiac output (liters/min) were: dobutamine, 1.32 +/- 0.24 versus 1.73 +/- 0.31; isoproterenol, 0.84 +/- 0.26 versus 1.43 +/- 0.28; epinephrine, 0.25 +/- 0.15 versus 0.44 +/- 0.53. Amiodarone-treated dogs were also given higher doses of drugs, dobutamine (50 micrograms/kg per min), isoproterenol (1.2 micrograms/kg per min) and epinephrine (20 micrograms/min). Increases in cardiac output were 1.24 +/- 0.24, 1.62 +/- 0.25 and 2.82 +/- 0.64, respectively. All cardiac outputs were significantly increased from the baseline values (p less than 0.05) except those measured in the amiodarone group receiving the lower dose of epinephrine. Thus, amiodarone-treated dogs have a relative reduction of perioperative cardiac systolic reserve.(ABSTRACT TRUNCATED AT 250 WORDS)

Change in endothelial cell morphology at arterial branch sites caused by a reduction of intramural stress.

Arterial branch sites have very high intramural stresses at physiologic intraluminal pressures; the same sites have a predilection for atherosclerosis. The effect of intramural stress on endothelial cell morphology was investigated. Five rabbits had permanent casts placed around a segment of the abdominal aorta-left renal artery branch area during controlled hypotension, thus reducing intramural stress without narrowing the lumen. These five animals, and three normal rabbits, were sacrificed after 4-8 weeks, and the vessels were perfused with buffered 2.5% glutaraldehyde for 2 h at 100 mm Hg pressure. The aortas were examined by scanning electron microscopy. In normal aortas, the distal region of the ostia of the left renal and celiac arteries just beyond the flow divider displayed many morphologically altered endothelial cells ranging from spindle shape to cobble-stone shape. The same aortic area of casted rabbits, as well as the straight abdominal aorta in all rabbits, showed a smooth surface of endothelial cells with intact cell borders and no morphologically altered cells. At branch sites, the occurrence of morphologically altered endothelial cells may be due to increased intramural stress. When intramural stress is reduced, the morphology of branch endothelial cells changes to resemble that of the unbranched regions. In conclusion, endothelial cell morphology changes in response to changes in intramural stress.

Elevated plasma antidiuretic hormone levels in status asthmaticus.

Elevated plasma antidiuretic hormone (ADH) levels were noted in seven patients with status asthmaticus during the acute illness. These values returned to normal with resolution of the disease. The mechanism of this release is not completely understood but is consistent with the hypothesis that bronchospasm leads to decreased pulmonary blood flow, decreased volume return to the left atrium, and stimulation of the atrial volume receptors regulating ADH release. Planning for fluid therapy in patients with status asthmaticus should take into account a high probability of increased plasma ADH concentration during the acute illness. Water intoxication as well as hypoxia and hypercarbia should be considered as a possible cause of an altered state of consciousness associated with status asthmaticus.

Effect of long-term salmeterol therapy compared with as-needed albuterol use on airway hyperresponsiveness.

STUDY OBJECTIVES: To determine the effect of long-term salmeterol aerosol therapy on airway hyperresponsiveness measured by methacholine challenge. DESIGN: Randomized, double-blind, placebo-controlled, multicenter study. SETTING: Thirty-one clinical centers in the United States. PATIENTS: Four hundred eight asthmatic patients > or = 12 years of age with baseline FEV1 of > or = 70% of predicted values. Patients were not using inhaled corticosteroids. INTERVENTIONS: Twice-daily salmeterol aerosol, 42 microg, or placebo via metered-dose inhaler for 24 weeks. Backup albuterol was available. MEASUREMENTS AND RESULTS: Pulmonary function tests were performed before, during, and after treatment. Subjects recorded asthma-related symptoms, morning and evening peak expiratory flow (PEF) levels, and use of supplemental albuterol daily on diary cards. Methacholine challenges were performed 10 to 14 h postdose at weeks 4, 12, and 24, and 3 and 7 days posttreatment. Over 24 weeks of treatment, salmeterol provided significant (p < 0.001) protection against methacholine-induced bronchoconstriction of approximately one doubling dose of methacholine when compared to placebo with no evidence for a progressive decrease in protection. A rebound increase in airway hyperresponsiveness was not observed 3 and 7 days after cessation of salmeterol therapy. Salmeterol treatment resulted in sustained improvements of 0.21 to 0.26 L in morning premedication FEV1 and an improvement of 26.2 L/min in morning PEF when compared to placebo (p < 0.001). The use of salmeterol significantly reduced combined daytime asthma symptoms by 20% when compared to placebo (p = 0.005). A total of 34 and 48 exacerbations, respectively, were reported in the Salmeterol and placebo groups, and no evidence was present for a difference in the severity of asthma exacerbations between groups. Adverse event profiles were similar for the salmeterol and placebo groups. CONCLUSIONS: Regular long-term use of salmeterol aerosol resulted in sustained improvements in pulmonary function and asthma symptom control over the 24-week treatment period. There was no increase in bronchial hyperresponsiveness or loss of bronchoprotection at 24 weeks from that seen following 4 weeks of therapy. There was no evidence of rebound airway hyperresponsiveness after cessation of salmeterol treatment. Regular treatment with the long-acting beta-agonist salmeterol does not lead to clinical instability or vulnerability to unpredictable asthma attacks.

Pleural anesthetics given through an epidural catheter secured inside a chest tube.

Pain management after thoracic surgical procedures is a difficult clinical problem. A variety of pain management methods are used with variable efficacy. This paper presents an effective method of pleural anesthetic administration using a pleural catheter inserted through a chest tube.

A technique for spray application of fibrin glue during cardiac operations.

Fibrin glue can be a useful adjunct to hemostasis in surgical patients. An effective technique for spray application of fibrin glue during cardiac operations is described.

Reduction of perioperative hemorrhage by anterior mediastinal spray application of fibrin glue during cardiac operations.

A variety of published techniques for the production of concentrated fibrinogen from units of screened single-donor human plasma have led to increasing clinical use of fibrin glue in the United States. We have adapted a method of applying this material with a disposable plastic sprayer. In 20 consecutively treated patients, fibrin glue was sprayed on the anterior mediastinum before closure of the median sternotomy incision. A control group of 20 patients undergoing the identical cardiac operations (13 coronary artery bypass grafting procedures [CABG], 4 valve replacements [including 1 reoperative procedure], and 3 combined valve replacements and CABG) by the same surgeon within a one-year period was chosen for comparison of chest tube outputs. Specifically, chest tube outputs were as follows for treated and untreated patients, respectively: at 12 hours, 461 +/- 40 ml (mean +/- 1 standard error of the mean versus 731 +/- 80 ml; at 24 hours, 714 +/- 73 ml versus 1,016 +/- 109 ml; and at 48 hours, 863 +/- 93 ml versus 1,187 +/- 137 ml. The differences between control and spray chest tube output are statistically significant by unpaired t test (p less than 0.05) at both 12 and 24 hours. Thus, this method can reduce perioperative hemorrhage from the anterior mediastinum after cardiac operations.

Mediastinal fibrin glue: hemostatic effect and tissue response in calves.

There is continued controversy regarding the effectiveness and potential adverse effects of fibrin glue. Thus, we chose to evaluate it in a model of experimental calf aortic valve replacement that has been previously well established. Concentrated fibrinogen and topical thrombin were sprayed to form a thin layer of fibrin glue over the mediastinal tissues of 20 consecutive calves undergoing aortic valve replacement. Chest tube outputs of these animals were compared with those of the preceding 20 consecutive calves undergoing aortic valve replacement without fibrin glue. All procedures were performed by the same surgeon, and no other technical changes were made between the two series. Total postoperative chest tube output (mean +/- standard error) was 553 +/- 50 mL for the calves treated with fibrin glue and 1,155 +/- 103 mL for the control calves (p less than 0.001). On histological examination of mediastinal tissues from 5 treated calves killed 6 weeks after operation, there was no evidence of inflammation, fibrosis, or residual fibrin. To our knowledge, this is the first controlled laboratory study to show that fibrin glue spray is an effective hemostatic agent and that it produces no long-term tissue reaction.

Successful treatment of postoperative chylothorax using an external pleuroperitoneal shunt.

We report 3 patients with chylothorax who were successfully managed as outpatients using external pleuroperitoneal shunts. This external shunt has the advantage over subcutaneously placed shunts of pumping large volumes of fluid with each compression of the pumping chamber, of not causing the discomfort associated with pumping a subcutaneous chamber, of not becoming difficult to find in the subcutaneous space, and of being constructed of larger components which do not kink or become easily clogged with fibrinous debris.

Synthesis and antimicrobial properties of 3-substituted 1,2-benzisothiazole 1,1-dioxides.

Twenty aromatic alcohols and thiols were derivatized by reaction with 3-chloro-1,2-benzisothiazole 1,1-dioxide. The resulting 3-substituted 1,2-benzisothiazole 1,1-dioxides were tested against Staphylococcus aureus, Salmonella typhosa, and Aspergillus niger, and their activities were compared with the activities of the precursors.

Combined treatment of advanced cancer of the laryngopharynx and cervical esophagus.

Advanced cancer of the laryngopharynx and cervical esophagus is difficult to treat because of the malnutrition produced by pain and obstruction and the problems related to reconstruction. This paper presents the initial results of a regimen used in 14 patients in which there is rapid reversal of nutritional deficiencies, radical resection, and reconstruction using the gastric pull-up technique and administration of postoperative radiotherapy. Excellent overall palliation and decreased hospitalization have been achieved using this regimen without diminishing chances for cure.

Functional evaluation of pharyngoesophageal reconstructive techniques.

This work represents a 12-year experience from the Eastern Virginia Medical School, Norfolk, with 115 patients who had pharyngoesophageal resections for cancer treatment. Each patient received reconstruction by one of four major techniques: deltopectoral flaps (n = 43), pectoralis myocutaneous flaps (n = 36), gastric pull-ups (n = 19), and free jejunal autografts (n = 17). An analysis of the procedures with emphasis on the functional results indicates that each technique has advantages in specific circumstances. Guidelines for the application of these techniques are presented.

Successful use of fibrin glue during 2 years of surgery at a university medical center.

A method for producing concentrated fibrinogen, an essential component of fibrin glue, from individually stored, single-donor units of human plasma is reported. The plasma is screened for hepatitis B antigen and HIV-1 virus to reduce the risk of transmission of hepatitis and acquired immunodeficiency syndrome (AIDS). This material is routinely stocked in some operating rooms. It is thus readily available when requested by a surgeon for use in combination with topical bovine thrombin to produce fibrin glue. From April 1985 to March 1987 this material was used by surgeons from eight different surgical specialties on 413 patients with a 91 per cent success rate (376/413). Uses have included sealing vascular suture lines, reinforcing pulmonary and esophageal staple lines, closing dural cerebrospinal fluid leaks, fixing split-thickness skin grafts, reducing lymphatic leakage, and controlling bone bleeding. Additional uses include closure of bronchopleural fistulas by means of the flexible bronchoscope, reduction of perioperative hemorrhage by spraying fibrin glue on the anterior mediastinum during cardiac surgery, and reduction of bleeding during debridement of burn eschars. Careful monitoring and patient follow-up detected no cases of transmission of blood-borne diseases. Only one complication, a local wound infection, has been documented. This material has been an important adjunct for the surgical services and may be safely used at hospitals with local blood bank facilities.

Repair of major defects of the chest wall and spine with the latissimus dorsi myocutaneous flap.

The latissimus dorsi myocutaneous flap is a remarkably durable and versatile flap. Flap necrosis did not occur in any of our patients. One can safely carry with it skin segments as narrow as 3 cm, or as wide as 30 cm. In addition to the 5 cases presented, we have used the flap to repair axillary burn contractures, for breast reconstruction after a transverse incision, and for coverage of the upper arm and shoulder. The applications of this flap challenge the creative imagination of the surgeon and allow a simplified reconstruction, compared to other good methods. The newly described posterior advancement of a latissimus dorsi myocutaneous flap is suggested as the preferred method to repair meningomyelocele defects.

Analgesia and anaesthesia in labour.

In recent years, great advances have been made in the development of new drugs and techniques for the relief of pain in the obstetric patient. Many of the older drugs, if they have not already been discarded, are in the process of being discarded at the present time. I intend to describe the individual drugs that are useful in obstetrics today and briefly mention the part that I consider "psychoprophylaxis" (if I may use this term) has to play in present-day obstetric practice.

The role of combined surgery and radiotherapy in the management of stage I and II carcinoma of the cervix.

The results are presented of 100 patients with stage I B, II A or II B carcinoma of the cervix treated by combined surgery and radiotherapy. The actuarial five year survival rates for FIGO stage I B (74 patients) was 85%, for selected stage II A (8 patients) 100%, and for selected early stage II B (18 patients) 72%. Within FIGO stage I B the five year survival for patients with negative nodes was 93% and for those with positive nodes 36%. The radiotherapy complication rate for patients treated with pre-operative radiotherapy followed by Wertheim's hysterectomy was 5%. However, when additional post-operative radiotherapy was given, the complication rate was 60%. It is concluded that pre-operative intracavitary radiotherapy followed by Wertheim's hysterectomy is suitable treatment for early-stage disease with negative nodes, but is unsatisfactory treatment for poor risk patients requiring additional post-operative radiotherapy, as their survival rate is poor and the complication rate is high.

Providing public health services through an integrated delivery system.

This article examines a recently implemented strategy to transfer responsibility for local public health service delivery from a county health department to a hospital-based integrated delivery system. Innovative quality management efforts at both local and state levels offer opportunities for sustained improvement in the availability and adequacy of public health services under this arrangement.

Filing for bankruptcy: a sign of failure or hope for the hospital?

Hospitals that file for bankruptcy are usually viewed as admitting failure or defeat. However, bankruptcy can become a constructive financial management tool if used appropriately. Under Chapter 11 of the Bankruptcy Code, hospital management can use bankruptcy to reorganize the failing financial situation of the hospital into one that is financially stable and able to continue operations indefinitely.

The risks and opportunities of acquiring a distressed facility.

Often, distressed healthcare institutions have salvaged their deteriorating situations by merging or consolidating with or selling their assets and operations to a neighboring institution. This article reviews the analysis that should be undertaken by a financially sound institution when it considers acquiring a distressed institution. Acquiring a failing institution provides many good opportunities as well as many great risks. A healthy institution must depend upon good planning and execution to ensure a successful venture.