[Effect of air pollutants on the health of the Annaberg district population with special reference to acute respiratory tract diseases]. From 1978 to 1988 in the district of Annaberg (Saxony, state frontier to Czechoslovakia) investigations were accomplished to assess the state of health in people living there. The southern part of the district rises to a crest (Saxon Ore Mountain). It is influenced by air pollution from Northern Bohemia. The incidence of acute infections of the upper airways showed a remarkable dependence on the degree of air pollution in the age groups up to 18 years, especially in the group of infants. In the polluted area (high overload) the morbidity of infants was 7-fold in relation to the unpolluted area of the district. In the polluted area when temperature was lower than -5 degrees C the incidence of acute respiratory infections in infants closely correlated (r = 0.90) with the concentration of SO2 in ambient air. In the town Annaberg (urban air pollution) the frequency of absence of children from school caused by acute respiratory infections was elvated in relation to the rural parts of the district, but there were no differences among these rural parts. In the polluted area the severe stages of cardiorespiratory diseases were passed through with evident acceleration. In healthy adults living there the mean values for immunoglobulins of class A and class M tended to be elevated, and in school children the antibody titers against influenza A and B were increased.


Epidemiological and clinical study of autistic children in Yogyakarta, Indonesia. This epidemiological study of autistic children was carried out in Yogyakarta, Indonesia. The approaches considered included the analysis of cross-sectional data on non-verbal intelligence, social maturity behavior or adaptive skills test by using statistical or sampling controls. The 5,120 children studied were all Javanese. Doctors, nurses of Public Health Centers and school teachers assisted in assessing the above subjects. The Bryson's screening scale for evaluating autistic children was used. A total of 66 children who scored above 16 were identified. Final diagnosis was done by means of CARS. Six children, who lived within Yogyakarta Municipality, were identified. The prevalence rate of autism within the birth cohort who were born between June 1984 and May 1991 was 12 per 10,000. Observations of the social interactions of 6 autistic and 6 normal children of equivalent mental age were carried out during a free play situation and reunion situation with mother and a stranger. A comparison of the two groups during social interaction made it clear that the autistic children showed more attachment, directed more social-interaction and more physical contact toward their mothers than to strangers during the reunion situation.


A comparison of the bone mineral density of the vertebral bodies and the hip in elderly females with hip fractures. Assessment using dual photon absorptiometry. The influence of decreasing bone mineral density with age and the occurrence of hip fractures in elderly females was investigated. Normal hips were studied in 287 healthy women whose ages ranged from 20 to 90 years old. The normal hip in 61 patients who had all suffered a femoral neck or intertrochanteric hip fracture, and were over 60 years old, were also studied and compared. The bone mineral density (BMD) of the lumbar vertebrae and the hip was measured with dual beam photon absorptiometry, for all patients. There was no correlation between the bone mineral density of the lumbar vertebral bodies, and the bone mineral density of the proximal femur. The peak bone mass in e lumbar vertebrae was seen in the thirties, but the peak bone mass in the hip was seen in the twenties. Bone mineral density in the lumbar vertebrae and in the hip was decreased in the patients who had sustained a hip fracture when compared to the control patients. The bone mineral density in the proximal femur was significantly reduced in patients who had sustained a hip fracture, especially in the region of Ward's triangle. These findings suggested that decreased bone mass in the hip at Ward's triangle may be correlated with the occurrence of hip fractures.


The stimulatory GDP/GTP exchange protein for ras p21-related small GTP-binding proteins. We have purified a novel type of regulatory protein for smg p21s, designated as smg p21 GDP dissociation stimulator (GDS), to near homogeneity from bovine brain cytosol. Moreover, we have isolated the cDNA of this protein from a bovine brain cDNA library, determined the complete nucleotide and deduced amino acid sequences, and characterized the kinetic properties. The cDNA of smg p21 GDS has an open reading frame encoding a protein of 558 amino acids with a calculated M(r) value of 61,066, similar to the M(r) value of 53,000 estimated for the purified smg p21 GDS by sodium dodecyl sulfate-polyacrylamide gel electrophoresis and sucrose density gradient ultracentrifugation. smg p21 GDS stimulates the dissociation of [3H]GDP from and also stimulates the binding of [35S]guanosine 5'-(3-O-thio)triphosphate (GTP gamma S) to smg p21s. These actions of smg p21 GDS were specific for smg p21s and inactive for other ras p21/ras p21-related small G proteins including c-Ha-ras p21 and smg p25A. Neither smg p21 GDS stimulate the GTPase activity of smg p21s nor by itself showed [35S]GTP gamma S-binding or GTPase activity. These results indicate that bovine brain contains regulatory proteins for smg p21s that stimulate the GDP/GTP exchange reaction of smg p21s in addition to smg p21 GAP. It is likely that the conversion from the GDP-bound inactive form of smg p21s to the GTP-bound active form is regulated by smg p21 GDS and that its reverse reaction is regulated by smg p21 GAP.


An analysis of vitreous tamponade effect in encircling surgery by means of finite element method. The vitreous tamponade effect in encircling surgery was investigated by means of a finite element method. We performed the simulated encircling surgery on a computer program, which could have alternative band positions, i.e. anterior or posterior band position. Computed results revealed that the band position has a great influence on the vitreous stress distribution, and that the anterior band position is more advantageous than the posterior band position with regard to the vitreous tamponade effect. To our knowledge, this is the first numerical experiment to demonstrate the advantage of the anterior band position in encircling surgery.


Effect and limitation of intra-aortic balloon pumping following valve replacement surgery. To evaluate the effect and the limitation of intra-aortic balloon pumping (IABP) in patients with severe left ventricular failure (LVF) following valve replacement surgery, we assessed the results of 282 patients who underwent such surgery. Among 25 patients in whom IABP was used after valve replacement, 17 patients could be weaned from IABP, and 14 of them achieved long-term survival. The durations of IABP support for patients who were weaned from IABP were shortened and were mostly within 48 hours, whereas those in patients not weaned from IABP tended to be prolonged. Among 25 IABP patients, 8 had definite causes of LVF such as perioperative myocardial infarction, but the other 17 patients experienced LVF despite uneventful operation. In the latter group of patients, preoperatively depressed left ventricular function was observed in 10 patients. In the former group of patients, the duration of IABP was much longer, and the weaning rate, as well as survival rate, was significantly poorer. On the other hand, in the latter-group patients, the duration of IABP was shortened and the survival rate was excellent. In conclusion, IABP support for patients with postoperative LVF of unknown causes, which might include patients with preoperatively depressed left ventricular function, was sufficiently effective, whereas no significant effect of IABP was noted for patients experiencing LVF after definite and serious perioperative complications.


Cardiac transplantation after prolonged graft preservation with the University of Wisconsin solution. We tested the ability of University of Wisconsin solution to extend hypothermic preservation of the nonperfused heart during orthotopic baboon allotransplantation. Seven baboons received hearts after cardioplegia and storage (4 degrees C) with University of Wisconsin solution, with a preservation time of 14.2 +/- 1.6 hours. One animal died as a result of a technical error. Six survivors were immunosuppressed for 45 days and then put to death. Preservation did not alter heart weight or histologic features according to light and electron microscopy. Animals were weaned from bypass and returned to their cages without intravenous support within 3.9 +/- 0.8 hours. Weekly biopsies, electrocardiograms, enzyme analyses, echocardiograms, and right heart catheterizations demonstrated excellent cardiac function. University of Wisconsin solution can extend hypothermic cardiac preservation and has no deleterious effects on long-term myocardial function (up to 45 days). This study validates the rationale for human trials with preservation and storage in University of Wisconsin solution toward the goal of improving and prolonging donor heart preservation.


[A study of the effectiveness of the bereavement program of Severance Hospice]. Grief that is not acknowledged and worked through may manifest itself in some emotional, mental or physical problem. In recent years much as been learned about coping with grief which the hospice program can utilize to help family members cope with their grief. This study was carried out to determine the helpfulness of the bereavement care of Severance Hospice and to learn more about the grief response of the bereaved. The tools used to collect data were an assessment form used in the bereavement program and the Grief Experience Inventory developed by Sanders and revised and translated by the researcher. Data was obtained from bereaved family members (54 for the final grief assessment and 39 for the grief response assessment) receiving bereavement follow-up, from July 1989 to March 1991. Results of the study were as follows: 1. Final Grief Assessment Regarding the resolution of their grief the majority of the bereaved accepted the reality of the death of their family member, while slightly more than three-quarters were able to express their feelings toward their loss. A large majority had returned to activities of daily living well or fairly well and had reinvested their energy in a person other than the deceased. In addition, the physical condition of the majority was good or fairly good. A majority of the bereaved considered the bereavement care to be helpful and almost three-quarters were not considered to be in need of more follow-up. 2. Grief Response Assessment Age was found to have a moderately positive correlation to appetite disturbance (r = .41, P less than .01) and loss of vigor (r = .37, P less than .01) A moderately positive correlation was found between the number of contacts and sleep disturbance (r = 2.38, P less than .01) Significant differences were found between men and women in regard to guilt (t = 2.38, P less than .05), social isolation (t = 2.44, P less than .05) and depersonalization (t = 2.07, P less than .05) with men having the more intense grief. Significant differences were found in the grief responses of somatization (F = 5.82, P less than .001), physical symptoms (F = 5.87, P less than .001), appetite disturbance (F = 4.40, P less than .01), despair (3.79, P less than .01), anger (Fp2.83, P less than .05), social isolation (F = 3.61, P less than .05), guilt (F = 3.62, P less than .05) and depersonalization (F = 2.58, P less than .05).(ABSTRACT TRUNCATED AT 400 WORDS)


Superior qualities of University of Wisconsin solution for ex vivo preservation of the pig heart. The components of the University of Wisconsin solution have the potential to enhance and extend heart preservation. We have evaluated University of Wisconsin solution by comparing it with St. Thomas' Hospital cardioplegic solution in the isolated pig heart subjected to 8 hours of ischemia at 4 degrees C (n = 6 in each). The hearts were perfused ex vivo with enriched autologous blood for the control and the postpreservation assessments. Morphologic, metabolic, and functional evaluations were performed. Left and right ventricular function as assessed by the slope values of systolic and diastolic pressure-volume relationships of isovolumically contracting isolated heart was better preserved by University of Wisconsin solution (percent reduction: left ventricular systolic, 52.4% +/- 5.5% versus 17.7% +/- 6.7% [p less than 0.001]; right ventricular systolic, 125.6% +/- 46.4% versus 65.5% +/- 31.4% [p less than 0.05]; right ventricular diastolic, 112.3% +/- 48.7% versus 40.2% +/- 31.3% [p less than 0.02] after St. Thomas' Hospital and University of Wisconsin preservation, respectively). Postischemic recovery of left ventricular rate of rise of pressure and myocardial oxygen consumption were significantly improved after University of Wisconsin preservation (percent reduction, rate of rise of pressure: St. Thomas' Hospital 39.3% +/- 8.1%; University of Wisconsin 18.1% +/- 4.6%; percent reduction, myocardial oxygen consumption St. Thomas' Hospital 55.1% +/- 6.9%, University of Wisconsin 24.8% +/- 6.7%; p less than 0.001). Microvascular functional integrity as assessed by coronary vascular resistance was well maintained throughout the postischemic period and was similar to the preischemic control value in the University of Wisconsin group. By contrast, a significant increase was found at the beginning of postpreservation reperfusion, with a progressive rise thereafter in the St. Thomas' Hospital group (p less than 0.001). Preservation of myocardial adenosine triphosphate was improved and energy charge was unchanged after 8 hours of ischemia and reperfusion in the University of Wisconsin-preserved hearts compared with the St. Thomas' Hospital-preserved hearts (p less than 0.01). Electron microscopic examination revealed substantially better preservation of the contractile apparatus after preservation with University of Wisconsin solution. Myocytes from hearts receiving University of Wisconsin solution, unlike those given St. Thomas' Hospital solution, showed relaxed myofibrils with prominent I-bands. We conclude that University of Wisconsin solution has the potential to improve the preservation of the heart and possibly prolong the ischemic period in clinical cardiac transplantation.


The determinants of elevated total plasma cholesterol levels in cardiac transplant recipients administered low dose cyclosporine for immunosuppression. Elevated total plasma cholesterol level is a frequent finding after cardiac transplantation. To identify risk factors for the development of hypercholesterolemic states, we applied multivariate statistics in a logistic and linear manner. Six-month posttransplantation levels of total plasma cholesterol in 57 adult heart recipients were available for analysis. Maintenance immunosuppression was carried out with either cyclosporine and azathioprine or both agents plus low-dose steroids. Total plasma cholesterol levels were dichotomized for the logistic analysis (1) by the age- and sex-matched 75th and 90th percentiles of a reference population according to National Institutes of Health treatment guidelines and (2) by the cut point 250 mg/dl. Twelve potential risk factors were evaluated as covariates: recipient age, body weight after 6 months, body weight gain over 6 months, body mass index after 6 months, body mass index gain over 6 months, current cyclosporine dosage, trough level of cyclosporine in whole blood according to high-performance liquid chromatography after 6 months, cumulative cyclosporine dosage over 6 months, serum bilirubin, type of original cardiac disease, maintenance steroids, and steroid bolus treatment. Multivariate logistic regression yielded the type of original cardiac disease as a significant predictor of posttransplantation hypercholesterolemia exceeding the 90th percentile (p = 0.019) and of hypercholesterolemia exceeding 250 mg/dl (p = 0.032). Maintenance steroids were identified as a second significant cofactor (p = 0.069) for total plasma cholesterol levels exceeding 250 mg/dl. Multiple linear regression again revealed the type of original cardiac disease and maintenance steroids as significant predictors by p values of 0.005 and 0.013, respectively. Patients with coronary artery disease as the original cardiac pathology and low-dose maintenance steroids had the greatest risk for the development of elevated total plasma cholesterol levels after cardiac transplantation. However, the overall predictive quality of the linear model was limited (multiple r value 0.43), which indicates that other variables besides the tested ones attributed to elevated total plasma cholesterol levels. These results confirm the adverse role of maintenance steroids on posttransplantation hypercholesterolemia and demonstrate the type of original cardiac disease as the most important risk factor. They suggest that abnormalities of lipoprotein metabolism and dietary factors continue to affect total plasma cholesterol levels after cardiac transplantation.


[A study on Korean concepts of relaxation]. Relaxation technique is an independent nursing intervention used in various stressful situations. The concept of relaxation must be explored for the meaning given by the people in their traditional thought and philosophy. Korean relaxation technique, wanting to become culturally acceptable and effective, is learning to recognize and develop Korean concepts, experiences, and musics of relaxation. This study was aimed at discovering Korean concepts, experiences and musics of relaxation and contributing the development of the relaxation technique for Korean people. The subjects were 59 nursing students, 39 hospitalized patients, 61 housewives, 21 rural residents and 16 researchers. Data were collected from September 4th to October 24th, 1991 by interviews or questionnaires. The data analysis was done by qualitative research method, and validity assured by conformation of the concept and category by 2 nursing scientists who had written a Master's thesis on the relaxation technique. The results of the study were summarized as follows; 1. The meaning of the relaxation concept; From 298 statements, 107 concepts were extracted and then 5 categories "Physical domain", "Psychological domain", "Complex domain", "Situation", and "environment" were organized. 'Don't have discomforts, 'don't have muscle tension', 'don't have energy (him in Korean)', 'don't have activities' subcategories were included in "Physical domain". 'Don't have anxiety', 'feel good', 'emotional stability', 'don't have wordly thoughts', 'feel one's brain muddled', 'loss of desire' subcategories were included in "physical domain" 'Comfort body and mind', 'don't have tension of body and mind', 'be sagged' 'liveliness of thoughts' subcategories were included in "Complex domain". 'Rest', 'sleep', 'others' subcategories were included in "Situation domain". And 'quite environment' & 'comfortable environment' subcategories were included in "Environmental domain". 2. The experiences of the relaxation; From 151 statements, 59 experiences were extracted. And then 9 categories--at rest after physical activities, after problem solving, fancy, bathing in the bed, situation, rest, particular time, others--were organized. 3. The musics of the relaxation; From 229 statements, 108 musics were extracted, and the 9 categories--Western classical music, semi classical music, Korean song, Korean popular classical music, song, western popular song, hymn, characteristics of music, others--were organized. In conclusion, There are some differences between Korean concepts, experiences and musics of relaxation and western concepts, experiences and musics of relaxation.


Hemodynamic evaluation of heterotopic heart transplantation. To assess the relative contribution of native and donor hearts to total circulatory performance after heterotopic transplantation, we used cardiac catheterization to examine 10 patients. Left and right ventricular filling pressures significantly decreased by 41% and 36%, respectively, cardiac index increased by 25%, and pulmonary arteriolar resistance was reduced by 61%. Patients were subdivided into two groups according to the presence of one (group I) or two (group II) peaks on the aortic pressure curve. In group I, the donor left ventricle assumed total left ventricular work and 80% of right ventricular work. Because the native left ventricle could not generate enough pressure to open the aortic valve, its entire stroke volume was ejected into the common left atrium. In addition, in all four patients a native aortic regurgitation occurred in diastole and systole. In contrast, in group II, native left ventricular systolic pressure always exceeded aortic diastolic pressure. The donor left ventricle contributed 68% to systemic blood flow and the donor right ventricle 51% to pulmonary blood flow. Mild native aortic regurgitation was demonstrated in two patients only. Native left ventricular function deteriorated postoperatively in all patients (ejection fraction decreased from 0.22 +/- 0.09 to 0.14 +/- 0.08), but this deterioration was more marked in group I. Postoperative depression of native left ventricular function could not be ascribed to progression of coronary artery disease but was mainly due to reduced preload (competitive filling) and increased afterload. Thus in group I patients with more severe preoperative left ventricular dysfunction, the donor heart behaved like a total biventricular assist device. In contrast, in group II patients the donor heart acted like a partial biventricular assist device.


Pharmacologic interventions for prevention of spinal cord injury caused by aortic crossclamping. The efficacy of pharmacologic agents for prevention and control of oxygen-derived free radical damage in ischemia-reperfusion injury of the spinal cord was assessed in a swine model of thoracic and thoracoabdominal aortic crossclamping. Animals were exposed to 30 minutes of ischemia that induced lethal, irreversible injury and paraplegia. The experimental groups were as follows: group A (n = 7), control group, receiving no pharmacologic intervention; group B (n = 7), deferoxamine 50 mg/kg/day administered intravenously over 3 to 4 hours before ischemia; group C (n = 7), allopurinol pretreatment 50 mg/kg/day for 3 days; and group D (n = 7), superoxide dismutase 60,000 units administered with 50,000 units before removal of the aortic crossclamp and 10,000 units over 10 minutes of reperfusion. Proximal hypertension was controlled with sodium nitroprusside and volume depletion. The methods of assessment were neurologic by a modified Tarlov criteria and blood flow by radiolabeled microspheres. Results of blood flow assessment confirmed a true ischemic episode of 30 minutes for all animals in all groups. The blood flow fell significantly during ischemia (p less than 0.01) and a hyperemic response was evident in the early reperfusion period. All animals in control group A were paraplegic. The group B (deferoxamine) results were superior; 85% had grade III function on a modified Tarlov scale, with animals in the group standing and even walking with difficulty. Only one animal in this group had good movements of hind limbs but was unable to stand or walk. Neurologic recovery was limited in the allopurinol group (group C), with 85% showing slight neurologic recovery with limited movement of the hind limbs. The animals in the superoxide dismutase group (group D) all had good recovery, with strong motor response of hind limbs, but were not able to stand. In summary, the results of this experimental protocol confirmed the possible role of oxygen-derived free radicals in the pathophysiology of spinal cord injury, induced by aortic crossclamping. Moreover, it proved that ischemia-reperfusion injury could be altered by pharmacologic interventions.


Correlation of motor-evoked potential response to ischemic spinal cord damage. The prevalence of morbidity is a major deterrent to the success of aortic aneurysm replacement operations. We have developed a model of spinal cord ischemia, based on the amplitude reduction of the motor-evoked potential, which produces approximately a 90% prevalence of paraplegia. Regional blood flow was studied with the use of radioactive microspheres, and results showed that there was a significant decrease in flow to the lumbar cord (85% reduction) during aortic occlusion, followed by a twofold to threefold hyperemia that persisted for 24 hours. Histopathologic examination of the cord revealed that the greater portion of microgliosis, spongiosis, and neuronal damage was confined to the gray matter of the cord, and its severity increased as one progressed caudally. The somatosensory-evoked potential disappeared before the motor-evoked potential L-2 signal in all dogs, with a mean disappearance time of 10.9 +/- 5.6 minutes, compared with 21 +/- 6.6 minutes for the motor-evoked potential. Both the sensory-evoked potential and the motor-evoked potential cord signal were present 24 hours later in all dogs tested. The peripheral nerve motor-evoked potential disappeared within 1 minute of cord ischemia, was not present 24 hours later, and hence appears to be too sensitive to use as an indicator of spinal cord damage. Plotting spinal cord motor-evoked potential amplitude reduction versus both histopathologic damage and regional blood flow revealed a positive correlation between motor-evoked potential amplitude reduction, decreased cord perfusion, and increased histopathologic damage. In addition, it may be possible to make inferences about the neurologic status of a subject based on the magnitude and time-course of the motor-evoked potential's amplitude reduction and wave morphology.


Changes in plasma free thyroid hormones during cardiopulmonary bypass do not indicate triiodothyronine substitution. Concentrations of free and bound thyroid hormone in plasma during cardiopulmonary bypass were determined in 10 patients. Ages ranged from 50 to 76 years (median 61 years). Apart from thyroxine and triiodothyronine, a number of other variables that might contribute to an altered thyroid state or binding of thyroxine and triiodothyronine to plasma proteins were measured (thyroid stimulating hormone, reverse triiodothyronine, albumin, nonesterified fatty acids, and cortisol). At the end of the observation, total triiodothyronine and total thyroxine concentrations were 86% and 70% (mean) of initial levels, respectively, and reverse triiodothyronine and albumin concentrations were both 74%. On the contrary, free triiodothyronine and free thyroxine levels rose to a maximum of 137% and 203% (mean), but normalized after heparin neutralization (86% and 102%). Thyroid-stimulating hormone concentration declined insignificantly during cardiopulmonary bypass, reaching a minimum at the time when body temperature was maximally depressed (74%), and then it normalized (101%). Plasma cortisol level did not rise above normal limits despite the major stress stimulus. In conclusion, total triiodothyronine and total T4 concentration in plasma of patients undergoing cardiac operations is lowered, while the exchangeable pool concentrations (plasma free triiodothyronine and free thyroxine) are elevated during bypass but return to control levels at the end of the operation. If serum changes truly reflect intracellular events, it does not seem likely that the myocardial cell is depleted of thyroid hormones after cardiopulmonary bypass, as recently claimed by others. This finding does not, however, exclude the possibility that a pharmacologic dose of triiodothyronine may be convenient for improvement of cardiac performance.


The effect of augmented atrial hypothermia on atrial refractory period, conduction, and atrial flutter/fibrillation in the canine heart. The purpose of this study was to test the assumption that the cause for postoperative atrial flutter/fibrillation after cardiopulmonary bypass is inadequate atrial myocardial protection. Dogs were subjected to cardioplegic arrest for 60 minutes without augmented atrial hypothermia (seven dogs, control group) or augmented atrial hypothermia with topical atrial cooling (seven dogs, study group). Twenty-five electrodes (15 on the right atrium and 10 on the left atrium) were fixed on the atria to measure effective refractory period and conduction time. Data were taken before bypass, immediately after bypass, and 2 hours after bypass. During cardioplegic arrest the mean temperatures measured in the atria were significantly lower (p less than 0.001) in the study group (13.5 degrees +/- 7.0 degrees C) than in the control group (23.7 degrees +/- 3.2 degrees C). There was no significant change in the mean effective refractory period after bypass in the control or study groups or in the prevalence of inducibility of atrial flutter/fibrillation by extrastimulation (3/7 dogs in the control group and 2/7 in the study group). During right atrial pacing, total conduction times were significantly longer (p less than 0.025 at cycle lengths of 300 and 350 msec) in the control group (74 +/- 5 msec and 75 +/- 7 msec, respectively) than in the study group (65 +/- 9 msec and 64 +/- 8 msec, respectively) immediately after bypass. Two hours after bypass, however, there were no significant differences under the same conditions between the two groups. There were no significant differences in conduction during left atrial pacing after bypass. Comparing those atria that were inducible with those not inducible demonstrated a significantly increased dispersion of effective refractory period (90 +/- 23 msec versus 74 +/- 18 msec, p less than 0.05) and increased conduction time in the inducible group. We concluded that augmented atrial hypothermia during cardioplegic arrest had no effect on the inducibility of fibrillation, had no effect on repolarization, and had only a small effect on conduction, which resolved within 2 hours after bypass. However, the study demonstrates that when the atria are inducible the substrates are an increased dispersion of refractoriness and a prolongation of conduction time.


Comparison of two transfusion strategies after elective operations for myocardial revascularization. We performed a prospective, randomized trial of two different strategies for postoperative packed red blood cell replacement in 39 autologous blood donors undergoing elective myocardial revascularization. The "liberal" group received blood to achieve a hematocrit value of 32%, and the "conservative" group received transfusions for a hematocrit value less than 25%. Although the groups had significantly different mean hematocrit values from the fourth postoperative hour (28.7% versus 31.2%) through the fifth postoperative day (28.4% versus 31.3%), there were no significant differences in fluid requirement, hemodynamic parameters, or hospital complications. Significantly fewer units of packed cells were required in the conservatively transfused group (20 units/20 patients) compared with the liberally transfused group (37 units/18 patients) (p = 0.012). Exercise tests were performed on the fifth and sixth postoperative days, with a transfusion being given to the conservative group between tests. Although a significant improvement in exercise endurance occurred in the conservative group receiving a transfusion (p = 0.008), no significant difference in duration or degree of exercise was demonstrated between the two groups on either day. In comparing these two groups of profoundly anemic patients, we identified no adverse consequence associated with the greater degree of hemodilution and could identify no correlation between hematocrit value and exercise capacity. We conclude that although the limits of hemodilution are still poorly defined, postoperative blood transfusion in revascularized patients should be guided by clinical indications and not by specific hematocrit values.


Continuous thermodilution cardiac output measurement in sheep. A technique has been developed to continuously measure cardiac output by means of the principles of thermodilution. Pulmonary artery catheters were modified by placing a 10 cm filament near the usual injectate port. Small amounts of heat were infused according to a randomly repeating binary on-off sequence. The distal blood temperature was recorded and cross-correlated with the heat waveform to produce a dilution curve and calculate cardiac output. The technique was compared with bolus thermodilution in seven sheep. Cardiac output ranged from 1.5 to 13.2 L/min, and heart rate varied from 59 to 180 beats/min. The linear regression between the data obtained by the two methods is represented by the equation y = 1.00x + 0.13; the correlation coefficient, R, is 0.97, and the p value is less than 0.0001.


Transesophageal echocardiography in hypotensive patients after cardiac operations. Comparison with hemodynamic parameters. Because it is sometimes difficult to determine the cause of hypotension in patients after cardiac operations, we assessed the value of transesophageal echocardiography in this respect, and we studied 60 consecutive patients who had hypotension despite positive inotropic medication and, in some patients, mechanical support. Echocardiographic diagnoses were compared with diagnoses based on hemodynamic parameters. Follow-up examinations were completed in all patients to confirm the final diagnoses. Echocardiographic signs of hypovolemia were present in 14 patients, tamponade in six, left ventricular failure in 16, right ventricular failure in 11, and biventricular failure in eight. Echocardiographic examination proved to be inconclusive in five patients. Comparison with hemodynamic parameters showed agreement on diagnoses (hypovolemia versus tamponade versus cardiac failure) in 30 patients (50%). Echocardiography correctly identified two patients with tamponade and six with hypovolemia; these conditions were not suspected by standard hemodynamic data; in five patients unnecessary reoperation was prevented, although hemodynamic values were suggestive of tamponade. Echocardiography also identified subcategories of patients at high risk of death (those with signs of right ventricular and biventricular failure). These findings suggest that transesophageal echocardiography performed on patients after cardiac operations, at the bedside in the intensive care unit, can readily elucidate the cause of hypotension in the large majority of patients and is a valuable adjunct to hemodynamic evaluation in patient management. Furthermore, it appears to be possible to identify subcategories of high-risk patients, based on these echocardiographic findings.


The effect of calcium on pulmonary vascular resistance and right ventricular function. Calcium chloride is frequently administered to patients immediately after separation from cardiopulmonary bypass to improve the contractile state of the myocardium. Animal studies suggest that calcium chloride may produce increases in pulmonary vascular resistance, which can precipitate right ventricular failure. In an attempt to determine the effect of calcium chloride administration after cardiopulmonary bypass on right ventricular function, this study was designed to evaluate patients with normal and elevated pulmonary vascular resistance. Fifty patients scheduled for elective cardiac surgery were prospectively studied for changes in ionized calcium levels before and after bypass. The impact of calcium administration on right ventricular function was assessed by a pulmonary artery catheter modified for the measurement of right ventricular ejection fraction. In all patients the level of ionized calcium decreased during bypass from a mean of 4.91 to 4.29 mg.dl-1. However, the infusion of calcium chloride (10 mg.kg-1) after bypass resulted in increasing the ionized calcium levels to prebypass levels. Administration of calcium chloride after bypass to patients with normal right ventricular function resulted in a transient increase in both cardiac output and right ventricular ejection fraction without any change in pulmonary vascular resistance. Eight patients with both elevated pulmonary vascular resistance and depressed right ventricular function were evaluated to determine the effect of calcium chloride after bypass on pulmonary vascular resistance and right ventricular ejection fraction. Administration of calcium chloride (10 mg.dl-1) to these patients did not result in any significant increase in pulmonary vascular resistance or depression of right ventricular performance. More important, in these patients, right ventricular ejection fraction and cardiac output were significantly increased after calcium chloride administration. In summary, the results of this study fail to demonstrate any increase in pulmonary vascular resistance or deterioration of right ventricular function with the administration of calcium chloride (10 mg.kg-1) after bypass in patients with elevated pulmonary vascular resistance.


The effect of intramyocardial pH on functional recovery in neonatal hearts receiving St. Thomas' Hospital cardioplegic solution during global ischemia. The experiments in the present study were designed to address two issues: Is it possible to manipulate intramyocardial pH in neonatal hearts with different buffers in cardioplegic solution and, if so, do differences in intramyocardial pH during ischemia influence functional recovery? Isolated working hearts from 7- to 10-day-old rabbits underwent 60 minutes of cardioplegic arrest at 37 degrees C with cardioplegic washouts at the onset of ischemia and at 30 minutes. Hearts were reperfused with oxygenated physiologic saline solution (pH = 7.4), returned to the working mode for 30 minutes, and hemodynamic measurements were obtained to compare with baseline values. Intramyocardial pH was held constant during the ischemic interval by infusing cardioplegic solution containing different buffers: histidine (pK 6.0 at 37 degrees C), bicarbonate (pK 6.4), or tromethamine (pK 8.1). The intramyocardial pH was measured continuously with a Khuri glass electrode system (Vascular Technology, Inc., North Chelmsford, Mass.). Cardioplegic solutions buffered to pH values of 6.0 (histidine), 7.4 (bicarbonate), and 8.0 (tromethamine) were associated with ischemic intramyocardial pH values of 6.3 +/- 0.03, 7.02 +/- 0.05, and 7.88 +/- 0.06, respectively. Functional recovery was best in the acidic (histidine) and worst in the basic (tromethamine) groups. Recoveries of developed pressure, the rate of rise of pressure over time, and aortic flow were significantly better for each parameter in the bicarbonate-treated compared with the tromethamine-treated hearts (p less than 0.005). Recovery in the histidine group, however, was superior to that in both the bicarbonate-treated and the tromethamine-treated hearts (p less than 0.005). Regression analysis demonstrated that a significant inverse relationship existed between functional recovery and intramyocardial pH, supporting the conclusions that intramyocardial pH is an important determinant of functional recovery in the neonatal heart and that acidic conditions during normothermic ischemia optimize preservation of myocardial function.


Transient hypocalcemic reperfusion does not improve postischemic recovery in the rat heart after preservation with St. Thomas' Hospital cardioplegic solution. We used the isolated perfused working rat heart to investigate the effects of transient hypocalcemic reperfusion after cardioplegic arrest with the St. Thomas' Hospital cardioplegic solution and 25 minutes of global normothermic (37 degrees C) ischemia. Hearts were reperfused (Langendorff mode) transiently (20 minutes) with solutions containing various concentrations of calcium; this was followed by 30 minutes of reperfusion with standard (1.4 mmol/L, the physiologic concentration) calcium buffer (10 minutes in the Langendorff mode and 20 minutes in the working mode). Recovery of cardiac output in control hearts (calcium concentration 1.4 mmol/L throughout) was 51.7% +/- 4.6%; in hearts transiently reperfused with hypocalcemic buffer (0.25, 0.5, 0.75, or 1.0 mmol/L) the recoveries of cardiac output were 49.3% +/- 6.4%, 52.2% +/- 7.2%, 58.7% +/- 3.2%, and 47.2 +/- 4.7%, respectively (all not significant), whereas recovery was only 14.7% +/- 2.8% (p less than 0.05) in hearts transiently reperfused with calcium 0.1 mmol/L. Creatine kinase leakage was significantly (p less than 0.05) greater in the group reperfused with calcium 0.1 mmol/L, but it did not vary significantly between the other groups. Tissue high-energy phosphate content was similar and in the normal range in all groups except for the group reperfused with calcium 0.1 mmol/L. In further experiments, the duration of hypocalcemic (0.5 mmol/L) reperfusion was varied (0, 5, 10, 15, 20, or 30 minutes). No significant differences in recovery of cardiac output were observed (58.2% +/- 5.0%, 52.3% +/- 5.7%, 52.0% +/- 8.2%, 61.2% +/- 5.0%, 62.2% +/- 4.3%, and 66.2% +/- 3.2%, respectively). In additional studies, the standard calcium concentration (1.4 mmol/L) used before and after ischemia was replaced by hypercalcemic solution (2.5 mmol/L). Despite this, transient (10 minutes) hypocalcemic (0.5 mmol/L) reperfusion did not improve recovery. Finally, studies were undertaken with a longer duration of ischemia (40 minutes), and although recovery of cardiac output in the hypocalcemic group (0.5 mmol/L for 10 minutes) tended to be higher than in the control group (29.7% +/- 4.8% versus 18.5% +/- 4.9%, respectively), statistical significance was not achieved. We conclude that in these studies transient hypocalcemic reperfusion did not afford any additional protection over and above that afforded by cardioplegia alone.


Altered effects of vasopressin on the coronary circulation after ischemia. Ischemia and reperfusion alter the reactivity of large coronary arteries, but the effect of ischemia and reperfusion on the coronary microcirculation has been less well defined. Elevated circulating levels of vasopressin are associated with cardiopulmonary bypass and numerous other clinical states in which vascular ischemia and reperfusion may occur. We examined the effects of ischemia with and without reperfusion on the responses to vasopressin of both large coronary arteries and coronary arterial microvessels. Studies were performed on vessels from control dogs (n = 8), dogs undergoing 1 hour of ischemia only (n = 8), and dogs undergoing 1 hour of ischemia followed with 1 hour of reperfusion (n = 9). Rings of proximal obtuse marginal coronary arteries distal to the site of circumflex coronary artery occlusion were studied in isolated organ chambers. Coronary microvessels (110 to 220 microns in diameter) were studied in a pressurized (20 mm Hg), no-flow state with a microvessel imaging apparatus and electronic dimension analyzer. Microvessels were preconstricted with the thromboxane A2 analog U46619. Responses of large vessel rings were studied in the nonpreconstricted state and after preconstriction with prostaglandin F2 alpha. Large vessel response to vasopressin was minimal and not altered by ischemia with or without reperfusion. In contrast, ischemia markedly affected the coronary microvascular response to vasopressin (10 to 1000 microU/ml). Control coronary microvessels constricted minimally to vasopressin (4% +/- 2% of the baseline diameter), while microvessels after either ischemia alone or ischemia followed by reperfusion constricted 22% +/- 5% and 21% +/- 3%, respectively (p less than 0.05 versus control for both). Hemoglobin, which inactivates the endothelium-derived relaxing factor, augmented microvascular constrictions to vasopressin in all groups to a similar extent. Relaxations to the endothelium-independent agent nitroglycerin were not altered by ischemia. Constrictions of the coronary microcirculation to vasopressin in conditions such as cardiopulmonary bypass or myocardial ischemia, in which circulating levels of vasopressin are increased, may predispose to persistent myocardial ischemia in the perioperative setting.


Myocardial oxygen consumption of fibrillating ventricle in hypothermia. Successful account by new mechanical indexes--equivalent pressure-volume area and equivalent heart rate. We studied the effects of cardiac hypothermia on myocardial oxygen consumption of a fibrillating ventricle and evaluated whether myocardial oxygen consumption of a fibrillating ventricle in hypothermia can be accounted for by new mechanical indexes: equivalent pressure-volume area and equivalent heart rate in the isolated cross-circulated canine heart preparation. Equivalent pressure-volume area is the area that is surrounded by a horizontal pressure-volume line at the pressure of a fibrillating ventricle and the end-systolic and end-diastolic pressure-volume relations in the beating state in the pressure-volume diagram. Equivalent pressure-volume area is an analog of the pressure-volume area of a beating heart and has been proposed to be a measure of the total mechanical energy of a fibrillating ventricle. Equivalent heart rate was calculated from myocardial oxygen consumption per minute in both beating and fibrillating states under unloaded conditions as an estimate of the frequency of contractions of individual myocytes on the assumption that individual myocytes during ventricular fibrillation have the same contractility as that in the beating state. We estimated myocardial oxygen consumption per minute of the fibrillating ventricle at various ventricular volumes as a function of both equivalent pressure-volume area and equivalent heart rate. The myocardial oxygen consumption-equivalent pressure-volume area relation during ventricular fibrillation in hypothermia was highly linear, with a correlation coefficient of 0.90 (mean). The relation between estimated and directly measured myocardial oxygen consumption values of a fibrillating ventricle in hypothermia was highly linear (r = 0.98), and the regression line (y = 0.80x + 0.48) was close to the identity line in the working range. Therefore we conclude that equivalent pressure-volume area is the primary determinant of myocardial oxygen consumption during ventricular fibrillation in hypothermia, and myocardial oxygen consumption of a fibrillating ventricle in hypothermia can be accounted for by the combination of equivalent pressure-volume area and equivalent heart rate as in normothermia.


Congenital respiratory-esophageal fistula in the adult. Report of nine cases and review of the literature. Congenital tracheoesophageal or bronchoesophageal fistulas, if not associated with esophageal atresia, may not appear initially until adult life. Nine such cases (two tracheoesophageal and seven bronchoesophageal) are reported. The chief presenting symptoms were recurrent bouts of coughing, after drinking, and hemoptysis. In the majority of cases the duration of symptoms exceeded 15 years. The diagnosis was confirmed in seven patients by esophagography, in one patient by bronchoscopy, and in one patient the fistula was discovered incidentally during thoracotomy. The esophageal opening of the fistula was in the lower third in seven patients and in the middle third in two. Bronchoesophageal fistulas communicated with a segmental bronchus in four patients and with a main or lobar bronchus in three. Treatment involved excision of the fistula (five patients) or division and suturing (four patients). Postoperative follow-up revealed no long-term sequelae except persistent chronic respiratory failure in one patient. The respiratory failure had developed before treatment of the fistula. The analysis of this series and a review of the literature underline the high index of suspicion required in all cases of chronic cough and lung suppuration, to diagnose this benign condition before life-threatening complications occur.


Usefulness of perioperative pulsed Doppler flowmetry in predicting postoperative local ischemic complications after ileocolic esophagoplasty. Regional ischemia may induce cervical anastomosis leakage or stenosis or graft necrosis after esophageal reconstruction by retrosternal interposition of an ileocolic graft. These complications may be related to systemic or local hemodynamic alterations. This study was designed to evaluate the relationship between immediate postoperative arterial blood supply to the graft, arterial patency monitored by angiography, and clinical outcome. Eight patients (mean age 30 +/- 4 years; standard deviation) were studied. Miniaturized Doppler implantable microprobes were sutured to the single artery supplying the graft and connected to an 8 MHz pulsed Doppler flowmeter. Systemic hemodynamic parameters and mesenteric hemodynamic data were collected 3 hours after the end of the surgical procedure. These data were compared with the angiogram of the right superior colic artery supplying the graft, systematically performed on the fifteenth postoperative day, and with the clinical course of follow-up for 3 months. Five patients (group 1) had excellent clinical and angiographic results. Mean mesenteric blood flow in these patients was 51 +/- 49 ml.min-1 (+/- standard deviation, ranging from 9 to 122). Three patients (group 2) had a poor clinical outcome. One had early complete graft necrosis and the two others had leakage of the cervical anastomosis with poor distal arterial vascularization of the graft on the angiogram. Mean mesenteric blood flow was nul in the first patient and, respectively, 24 and 28 ml.min-1 in the two others. Cardiac output and mean arterial pressure were in the same range for all patients. Phasic velocity shape analysis revealed that the three group 2 patients had an end-systolic or end-diastolic reverse flow pattern that was not observed in the five group 1 patients, which suggested a submaximal increase in downstream vascular resistance. This reverse flow pattern seems to be a good predictor of ischemia-related complications. We conclude that perioperative pulsed Doppler blood flow monitoring in an ileocolic graft may be useful for the diagnosis and prevention of ischemic complications.


Quality of life three years or more after esophagectomy for cancer. The quality of life and alimentary comfort of 17 patients with esophageal cancer who were disease free more than 3 years after an esophageal resection were evaluated by analyzing responses to a follow-up questionnaire. Fourteen patients had subtotal esophagectomy and gastric pull-up to the neck. Three patients underwent a total esophagopharyngolaryngectomy, the digestive continuity being restored by means of an isoperistaltic colon segment interposed between the base of the tongue and the stomach. Current body weight, when compared with that existing postoperatively, was increased in 13 patients and unchanged in four. The number of meals per day was an average of 2.8, but 12 patients took additional snacks between main meals (2.3 as a mean). The major long-term complaints were a sensation of early fullness during eating in 11 patients, dysphagia in three, diarrhea in two, cough-induced vomiting in two, and postprandial sweating in two. Ratings given by self-evaluation of current alimentary comfort in comparison with that predating the initial esophageal symptoms ranged from 3 of 10 to 10 of 10 (mean 7.1/10). Thirteen patients led active lives, seven at home and six employed outside the home. The present survey suggests that most disease-free patients may obtain a satisfactory quality of life after esophagectomy and gastric or colonic pull-up; long-term alimentary comfort is conditioned mainly by the small capacity of the esophageal substitute.


Anastomotic complications after esophagectomy for cancer. A comparison of neck and chest anastomoses. Leakage, tumor recurrence, and stricture formation at the anastomosis are serious problems after esophagectomy for cancer of the esophagus or cardia. Because the prevalence of these postoperative complications may be affected by whether an anastomosis is made in the neck or in the chest, a comparison was made between anastomoses made at these two sites. During a period of some 7 years, we studied prospectively 411 patients who underwent resection for cancer of the esophagus or cardia and, after immediate reconstruction, had an anastomosis made in the neck or chest. The anastomotic leak rate for the neck anastomosis group was 4.3% and for the chest anastomosis group, 3.7% (p = not significant). The difference between leak rates of anastomoses fashioned by hand-sewn (5.0%) or stapled (3.0%) techniques was also not significant. The median upper resection margins in the neck and chest anastomosis groups were 4.5 cm and 3.5 cm, respectively. The corresponding rates of anastomotic tumor recurrence were 6.1% and 8.1% (p = not significant). The prevalence of benign stricture formation was significantly higher in the chest anastomosis group (19.2%) than in the neck anastomosis group (9.0%) (p = 0.002). This difference was a reflection of a significantly increased prevalence of stricture formation when an anastomosis was made by the stapler technique than with the hand-sewn method, and whereas most of the anastomoses in the neck were hand sewn (90%) the majority of those in the chest were stapled (80%). There were thus no statistically significant differences between the sites in terms of anastomotic leak and tumor recurrence rates, and the higher stricture rate in the chest anastomosis group was the result of more stapled anastomoses.


Results of surgical treatment for roentgenographically occult bronchogenic squamous cell carcinoma. Ninety-four patients with roentgenographically occult bronchogenic squamous cell carcinoma had surgical resection. Fifty-three reported having no symptoms. In 83 carcinoma was detected by cytologic examination of the sputum during lung cancer screening. The carcinomas were located in segmental bronchi (34 cases), subsegmental bronchi (19 cases), divisional bronchi (17 cases), and subsubsegmental or more peripheral bronchi (15 cases). The number of cases classified by TNM staging were 16 Tis N0 M0, 72 T1 N0 M0, 4 T1 N1 M0, and 2 T2 N1 M0. Extrabronchial invasion of the resected carcinoma was observed in 17 lesions (16 cases). Five of six patients with lymph node metastasis in the resected specimens had carcinoma with extrabronchial invasion. Multiple primary lung cancers were observed in nine patients at the time of operation and in seven subsequently. Four of seven patients with subsequent primary lung cancer had surgical resection, and no recurrence was observed after the second operation. There were two deaths from lung cancer: One was caused by subsequent primary lung cancer and the other by mediastinal lymph node metastasis. In the 75 patients with intrabronchial cancer invasion and without lymph node metastasis who had complete resection, there was no local recurrence or metastasis of cancer. The 5-year survivals were 80.4% (death from all causes) and 93.5% (death from lung cancer). Although subsequent primary lung cancer is troublesome, operation is a reliable treatment for occult bronchogenic squamous cell carcinoma.


Accuracy of computed tomographic scan and surgical assessment for staging of bronchial carcinoma. A prospective study. There is an increasing demand for accurate preoperative and intraoperative staging of bronchial carcinoma with respect to neoadjuvant therapy protocols and parenchyma-sparing operations. This study prospectively evaluated accuracy of computed tomographic scan and surgical assessment for staging of bronchial carcinoma in 108 consecutive patients. The stage of the primary tumor (T stage) was correctly determined in 85% of the patients, and surgical evaluation correctly determined the T stage in 92%. Invasion of major mediastinal structures posed a major problem for computed tomographic scan. On a node-by-node basis, computed tomographic scan predicted involvement of lymph nodes in 81% (sensitivity 29%, specificity 93%, positive predictive value 49%, negative predictive value 85%). The surgeon correctly determined the lymph node status in 69% of lymph nodes (sensitivity 90%, specificity 63%, positive predictive value 39%, negative predictive value 96%). On a patient-by-patient basis, computed tomographic scan correctly predicted the nodal status in 58% of patients. Accuracy of computed tomographic scan and surgical assessment in determination of the lymph node status strongly depended on tumor type and lymph node region (hilar or mediastinal region) studied. This was partly due to the fact that adenocarcinomas exhibited a high proportion of tumor-positive normal-sized lymph nodes, whereas squamous cell carcinomas showed a high proportion of enlarged tumor-free lymph nodes. In conclusion, computed tomographic scan and surgical assessment are sufficiently accurate for determination of the tumor stage but are insufficient in determining the nodal status.


Tumor emboli from lung neoplasms involving the pulmonary vein. Systemic tumor embolization during pulmonary resection for lung neoplasms is an uncommon but potentially catastrophic complication. In recent months, two patients undergoing pulmonary resection for bronchogenic carcinoma were found at operation to have tumor extending into a pulmonary vein. Both patients had systemic tumor embolization, one with a fatal outcome because of occlusion of the superior mesenteric artery. The possibility of systemic tumor embolization should be considered in patients with large, central tumors and particularly those that abut the pulmonary veins. The implications of such pulmonary vein involvement is reviewed, and an algorithm for postoperative evaluation and management of these patients is presented.


Growth of the hypoplastic aortic arch after simple coarctation resection and end-to-end anastomosis. Surgical treatment of a hypoplastic aortic arch associated with an aortic coarctation is controversial. The controversy concerns the claimed need to surgically enlarge the diameter of the hypoplastic arch, in addition to resection and end-to-end anastomosis. The purpose of this prospective study is to determine the fate of the hypoplastic aortic arch after resection of the aortic coarctation and end-to-end anastomosis. Between July 1, 1988, and January 1, 1990, 15 consecutive infants less than 3 months of age with an aortic coarctation were evaluated echocardiographically. A Z-value was calculated, being the number of standard deviations the aortic arch differs from the expected value, derived from a control group. Eight of these 15 infants had a hypoplastic aortic arch with a mean Z-value of -7.14 +/- 1.39. The other seven infants had a "normal" aortic arch with a mean Z-value of -1.85 +/- 1.08. All 15 infants underwent simple coarctation resection and end-to-end anastomosis. Six months after operation the mean Z-value increased significantly in those with a hypoplastic arch to -1.08 +/- 0.69 (p less than 0.0001) and in those with a "normal" aortic arch to 0.106 +/- 0.99 (p = 0.004). No infant died in our series (0%; CL 0% to 12%) and a recoarctation developed once (12.5%; CL 2% to 36%). Therefore we believe that simple resection and end-to-end anastomosis is the operation of choice for aortic coarctation associated with a hypoplastic aortic arch despite the presence of a ventricular septal defect and that enlargement of the hypoplastic aortic arch is not necessary.


Morphology of the ventriculoaortic junction in critical aortic stenosis. Implications for hemodynamic function and clinical management. The clinical presentation of infants with critical aortic stenosis, as well as the results of surgical treatment, differs from obstruction of the left ventricular outflow tract in older children. To investigate a possible anatomic basis for this situation, we performed a detailed morphometric study of 21 hearts from infants who had critical aortic stenosis and 11 normal hearts from infants less than 3 months of age. In each of the hearts with critical aortic stenosis, only one commissure extended to the sinutubular ridge. The other two commissures were represented by folds in the aortic wall that suspended the leaflet below the level of the sinutubular junction. The leaflet thus had a free edge shorter than the circumference of the sinus, in contrast with the normal valve, in which leaflets always were longer than the circumference of their supporting sinus. Analysis of the fibrous triangles on the ventricular aspect of abnormal valves showed a symmetric three-sinus arrangement. In all but one specimen, however, only the triangle related to the mitral valve was fully developed. Although incision of both rudimentary commissures to the aortic wall should achieve some relief of obstruction, these morphologic features strongly mitigate against surgical restoration of normal function or growth in aortic valves having the morphology observed in this series of hearts.


Complete repair of total anomalous pulmonary venous connection in infancy. From 1983 to 1990, 20 infants underwent complete repair of isolated total anomalous pulmonary venous connection. Twelve were male; ages ranged from 1 day to 240 days (mean 32 days). The abnormal anatomic connection was supracardiac in nine, cardiac in four, mixed in five, and infradiaphragmatic in two. In seven patients the pulmonary venous drainage was obstructed. Corrective operations were performed 2.4 days after admission; after medical stabilization, seven patients underwent emergency operations, including extracorporeal membrane oxygenation in one. All operations were performed with the use of circulatory arrest (mean 33 minutes) and cardiopulmonary bypass (mean 54 minutes). There was one hospital death, which occurred in a premature infant (1.5 kg) who had supracardiac drainage. No preoperative risk factors correlated with a poor surgical outcome. Pulmonary hypertensive episodes were expectantly managed after the operation with 100% oxygen, sedation, and hyperventilation. Postoperative arrhythmias occurred predominantly in patients with intracardiac drainage. All survivors (mean follow-up of 42 months) are in sinus rhythm, receiving no medications, and are growing and developing normally. Surgical correction of total anomalous pulmonary venous connection in infancy can be performed at low risk with good results after aggressive preoperative stabilization and postoperative management.


Left main coronary trunk compression by dilated main pulmonary artery in atrial septal defect. Report of three cases. Narrowing of the left main coronary trunk, which was compressed by the dilated pulmonary artery, was associated with atrial septal defect in three adults. One of them had severe pulmonary hypertension. Coronary angiograms revealed localized narrowing of the left main coronary trunk, and the left main coronary trunk had a concave shape. No stenosis of other coronary arteries was observed. In all patients the atrial septal defect was closed with a polytetrafluoroethylene patch. In the patient with 75% narrowing of the left main coronary trunk, aorta-coronary bypass was performed; it was not performed in the two with 50% narrowing. In two survivors postoperative coronary angiograms showed that the narrowing of the left main coronary trunk improved or disappeared. These results suggest that markedly dilated pulmonary arteries easily compress the left main coronary trunk and cause narrowing, which improves after atrial septal defect closure.


Responses of human gastroepiploic arteries to vasoactive substances: comparison with responses of internal mammary arteries and saphenous veins. We examined the responses of human gastroepiploic arteries to histamine, serotonin, and norepinephrine, comparing those of internal mammary arteries and saphenous veins. Fresh specimens of the vessels were obtained intraoperatively from 21 patients. The vessels were suspended in organ chambers to record isometric tensions. With gastroepiploic arteries, histamine induced relaxations in the endothelial rings (85% +/- 7%) but failed to induce any contractions or relaxations in the rings without endothelium. The relaxations were prevented by methylene blue or hemoglobin and the H1-histaminergic receptor antagonist chlorpheniramine. With internal mammary artery rings with endothelium, histamine at a low concentration (10(-8) to 10(-5.5) mol/L) induced relaxations (53% +/- 12%) but evoked contractions at a higher concentration (10(-5) to 10(-4.5) mol/L). With saphenous veins, histamine caused only contractions. Serotonin induced markedly greater contractions in saphenous veins than in either artery. The endothelium inhibited the maximal contraction in response to serotonin in both arteries but not in veins. With the gastroepiploic artery, the responses to norepinephrine and serotonin were similar to those of the internal mammary artery. Histamine induces endothelium-dependent relaxations only, and histaminergic receptors that induce contractions may be absent on vascular smooth muscle cells. These vasoactive properties may contribute to the high patency as a coronary graft.


Similar endothelium-dependent relaxation, but enhanced contractility, of the right gastroepiploic artery as compared with the internal mammary artery. The right gastroepiploic artery is an alternative coronary bypass graft. The excellent graft function of the internal mammary artery has been related to its physiologic properties, particularly to endothelial function. Isolated artery rings were suspended in organ chambers for recording of isometric tension. Norepinephrine and potassium chloride evoked threefold greater contractions in the gastroepiploic artery than in the mammary artery (p less than 0.01 to 0.05), whereas the sensitivity to the catecholamine was comparable. Acetylcholine induced endothelium-dependent relaxations, but the sensitivity (pD2: 6.7 +/- 0.3) and maximal relaxation (81% +/- 9%) were slightly less in the gastroepiploic artery than in the mammary artery (pD2: 7.6 +/- 0.2; 100% +/- 0%; p less than 0.05). Histamine induced endothelium-dependent relaxations with a similar sensitivity (pD2: 7.5 +/- 0.3 and 7.2 +/- 0.1), whereas the maximal relaxation was slightly enhanced in the gastroepiploic artery. The relaxation to the nitric oxide donor SIN-1 was identical in the two arteries. Thus the right gastroepiploic artery exhibits better contractility than the internal mammary artery but comparable endothelium-dependent and endothelium-independent relaxations. The good endothelial function of the gastroepiploic artery might be important for graft function and patency, whereas the enhanced contractility may facilitate vasospasm, especially in the presence of high circulating levels of catecholamines.


Overcoming perioperative spasm of the internal mammary artery: which is the best vasodilator? After mobilization, vasospasm often reduces flow through the internal mammary artery. An established method of relaxing the artery and increasing flow is to wrap it in a papaverine-soaked swab. To our knowledge the ability of other topical vasodilators to overcome spasm of the internal mammary artery has not been studied clinically. In 50 patients in whom the left mammary artery was used for myocardial revascularization, we have investigated the effect of five agents on internal mammary artery free flow. The agents investigated were normal saline, papaverine, nifedipine, glyceryl trinitrate, and sodium nitroprusside. Under controlled hemodynamic conditions, free flow was measured before any pharmacologic intervention and a median of 18.5 minutes after the pedicle had been sprayed with one of the five agents. Normal saline produced a small increase in flow from a median of 23 ml/min (range 17 to 88) to 38 ml/min (20 to 84) (not significant), whereas a significant increase occurred with papaverine, from 25 (16 to 78) to 43 ml/min (34 to 112) (p less than 0.01). Nifedipine and glyceryl trinitrate raised free flow by almost threefold, from 23 (14 to 66) to 71 ml/min (45 to 118) and from 23 (14 to 58) to 62 ml/min (46 to 126), respectively (both p less than 0.001). Sodium nitroprusside, however, with an increase in flow from 26 (10 to 58) to 108 ml/min (46 to 196), 250% over control, proved to be more effective than nifedipine and glyceryl trinitrate (p less than 0.05). We therefore recommend the topical use of sodium nitroprusside to relieve perioperative spasm of the internal mammary artery.


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.


Carcinoid disease of the heart. Surgical management of ten patients. Between 1982 and 1989, 10 patients with carcinoid heart disease underwent tricuspid valve replacement with a mechanical prosthesis at our institution. Pulmonary valvectomy was performed in nine patients and pulmonary valve replacement with a pulmonary homograft was performed in one. Two patients had carcinoid tumor metastatic to the heart, involving the right atrium in one case and both ventricles in the other. One patient had concomitant coronary artery bypass with the saphenous vein, and one patient had a quadruple valve replacement for histologically proved carcinoid disease of all four valves. The 30-day mortality was 10% and the late mortality was 30%. The remaining six patients were alive 4, 4, 4, 7, 24, and 46 months postoperatively. A review of the English literature identified 28 additional patients who underwent tricuspid valve replacement for carcinoid heart disease. There was no significant difference in the survival of patients with a bioprosthesis versus a mechanical valve in the tricuspid position. The 4-year survival for the 38 patients undergoing tricuspid valve replacement for carcinoid heart disease was 48% +/- 13%. Symptomatic patients who have carcinoid heart disease and whose metastatic malignant disease is not an imminent threat to life should be offered valve replacement. Operating soon after the onset of increasing cardiac symptoms, before the often rapid deterioration in right ventricular failure, optimizes the benefits.


Cardiac operations during active endocarditis. Between December 1982 and March 1990, 65 patients with active infective endocarditis underwent cardiac operations. Their mean age was 28.6 years (range 1 to 65 years). The most common infecting organisms were staphylococcus (33.8%), streptococcus (18.5%), and brucella (16.9%); 11 patients (16.9%) had cultures negative for infection. A rheumatic, native valve, most commonly the aortic, was involved in 40 patients, a prosthetic valve (with the mitral most common) in 18 patients, and in seven patients the infection involved a congenitally abnormal valve. Aortic root abscess developed in 21.5% of patients. In 30 patients operation was performed within 3 days of the start of intravenous antibiotic therapy, usually within 3 days of admission (group A); this resulted in fewer preoperative complications and a significantly lower postoperative complication rate than in those 35 patients who underwent operations more than 3 days after starting antibiotic therapy (group B). Preoperative embolic phenomena occurred in eight (12.3%) of the 31 patients who had large, mobile vegetations (2/16 [12.5%] in group A and 6/15 [40%] in group B). Overall there was no reinfection. No postoperative paravalvular leaks developed in group A. Nine patients died in the hospital (13.8%) (four in group A and five in group B); in all patients the infecting organism was staphylococcal or fungal. There was one late death. Early operation should always be considered in active infective endocarditis, especially when a prosthetic valve is involved or the infecting organism is staphylococcal or fungal. The disclosure of moderate to large vegetations by two-dimensional echocardiography is an indication for operation.


Treatment of tachyarrhythmias in a patient with the long QT syndrome by autotransplantation of the heart and sinus node-triggered atrial pacing. The case history of a 37-year-old woman with the long QT syndrome and drug-refractory paroxysmal ventricular tachyarrhythmias is reported. She was resuscitated eight times between 1980 and 1987. The duration of these attacks increased from a few minutes to 8 hours and the interval between them decreased from 2 years to 4 weeks. An autotransplantation was performed of the anatomically and hemodynamically normal heart. She has had normal QT intervals and has been free of tachyarrhythmias since the operation in June 1987. Because of a slow escape low atrial rhythm, she was treated with a dual-chamber pacemaker programmed in the VDD mode with a coupling interval of 15 msec. The pacemaker wires were connected to the nontransplanted atrial cuff ("atrial" wire) and the transplanted atrium ("ventricular" wire). The hemodynamic effect of the resultant sinus node-driven low atrial pacing was restoration of normal values. This is the first report of successful autotransplantation of the heart for ventricular tachyarrhythmias caused by the long QT syndrome.


Limitations and pitfalls in the assessment of prosthetic valves with Doppler ultrasonography. Normal Doppler-derived data for new prosthetic designs are currently gathered after marketing. Therefore the cardiologist needing to assess a new valve may need to equate Doppler results with data gathered invasively during premarket testing. This invites error because catheterization and Doppler ultrasonography are not always directly comparable. This review discusses difficulties in defining normal prosthetic function and problems arising from the comparison of catheter and Doppler data. It concludes that (1) the hemodynamic formulas in current use have limitations when applied to normally functioning prosthetic valves, (2) patterns of normal regurgitation differ widely between different valve designs and may occasionally resemble paraprosthetic leaks, (3) there is a good case for reporting only raw Doppler data rather than derived pressure drop or effective orifice area, (4) a new prosthetic design should be tested in vivo with Doppler ultrasonography before marketing, and (5) nonprosthetic factors affecting Doppler data and flow information should always be given.


Aortic valve infection. Risk factors for death and recurrent endocarditis after aortic valve replacement. Patients (n = 195) undergoing aortic valve replacement (n = 209) for native or prosthetic valve endocarditis were studied to determine risk factors for death and recurrent endocarditis and also to determine the valve type least likely to be associated with recurrent endocarditis. Ten-year survival was 60%, the highest risk of dying occurring within the first 3 postoperative months. Risk factors for death in this early phase included increased urea concentration, higher New York Heart Association functional class, prosthetic valve endocarditis, infection status (lower in patients with healed endocarditis), longer duration of cardiopulmonary bypass, and nonuse of an allograft valve. In the late phase (beyond 3 months), risk factors included age at operation and Staphylococcus aureus infection (only in New York Heart Association functional class V). Ten years after aortic valve replacement, 79% of valves were free of recurrent endocarditis. The highest risk of recurrence was in the first 4 months. Longer duration of cardiopulmonary bypass was a weak risk factor for recurrent endocarditis in the early phase, and in the late phase risk factors were S. aureus infection (only in New York Heart Association functional classes III, IV, and V) and the use of now discontinued biologic valves. Allograft aortic valve replacement was shown to be associated with a low and constant risk of recurrent endocarditis, whereas other valve types were associated with a high early risk. The allograft valve should be the preferred replacement device for aortic root infection.


Transesophageal color flow Doppler imaging for aortic insufficiency in patients having cardiac operations. Transesophageal color flow Doppler findings were studied in 30 patients with aortic insufficiency who had cardiac operations. Measurements were expressed as ratios of corresponding left ventricular outflow tract dimensions. Regurgitant jet proximal width ratio was significantly related to jet area ratio (r = 0.92) and correlated poorly with the degree of jet penetration into the left ventricular cavity (r = 0.32). The vectors of the regurgitant jets were variable. Nine patients had undergone aortography. Regurgitant jet proximal width and area ratios were significantly related to angiographic grade (r = 0.88 and 0.87, respectively) in these patients. We concluded that the esophagus offers a satisfactory transducer orientation for color flow Doppler assessment of aortic insufficiency.


Acupuncture at otoacupoint heart for treatment of vascular hypertension. The immediate, short-term and long-term depressor effects, the immediate effects on cardiac functions in grade II and grade III vascular hypertension, and the effects on angiotensin II in grade III vascular hypertension by acupuncture at otoacupoint Heart were studied in 30 cases of vascular hypertensive patients. The immediate depressor effect of acupuncture at otoacupoint Stomach was also recorded for comparison. It was found that acupuncture at otoacupoint Heart produced marked immediate depressor effect, and the short-term effective rate was 100%, the long-term effective rate was 63.3%, as well as evident immediate effects on cardiac functional activities in grade II and grade III hypertension and marked effects on angiotensin II in grade III hypertension. Acupuncture at otoacupoint Stomach produced no depressor effect on vascular hypertension.


Effects of atropine on the changes of pain threshold and contents of leucine-enkephalin and catecholamines of the brain in rats induced by EA. After rats received electroacupuncture (EA), leucine-enkephalin (LEK) content in striatum and dopamine (DA) concentration in both brain stem and diencephalon markedly increased, and noradrenaline (NA) level in telencephalon definitely decreased with an obvious elevation of pain threshold. However, a previous intraperitoneal injection of atropine, a blocker of muscarinic receptor, not only partially blocked the analgesic effect of EA, but also changed the effects of EA on LEK, NA and DA contents of the brain. The results indicate that cholinergic system plays an important role in electroacupuncture analgesia (EAA), which may be fulfilled partially through the central LEK and catecholamine (CA) systems.


Esthesioneuroblastoma: the UCLA experience 1970-1990. A retrospective review was conducted of all esthesioneuroblastoma cases treated at UCLA Medical Center from 1970 through 1990. Patients were staged according to the staging systems of Kadish, et al., Biller, et al., and a new staging system proposed by the authors. Of 26 patients treated, 74% were alive at 5 years and 60% were alive at 10 years. Combined treatment with surgery and radiation is advocated since a recurrence-free status was achieved in 92% of the patients, compared with 14% for surgery alone and 40% for radiation alone. A craniofacial resection was performed in 7 patients, all of whom have remained disease free. Negative prognostic factors included: age over 50 years at presentation, female sex, tumor recurrence, and metastasis. The proposed new staging system predicted disease-free status better than the other staging systems.


Thin malignant melanomas of the head and neck. Historically, Breslow classified thin melanomas as invasive lesions less than 0.76 mm in depth with rare instances of recurrence and mortality. From 1970 to 1990, 87 patients with thin head and neck melanoma were treated at Duke Medical Center. A computer-aided retrospective analysis was performed. Recurrence occurred in 30% of these patients; however, of the 66 patients seen at this institution prior to recurrence, only 8% recurred. Recurrence significantly shortened survival. Compared to an overall 84% 5-year survival, there was less than a 50% 5-year survival after recurrence. For thin melanomas, thickness did not affect survival. There was no difference in survival between thin melanomas and those ranging from 0.76 to 1.5 mm. A multivariate analysis was performed. The data suggest that thin melanomas of the head and neck may recur at a higher rate than previously reported and in addition, that they can be lethal.


Ornithine decarboxylase activity in tumor and normal tissue of head and neck cancer patients. Tumorigenesis requires increased biosynthesis of polyamines and elevated levels of ornithine decarboxylase, which is the rate-limiting enzyme in the polyamine synthesis pathway. Previous animal studies have noted a marked increase in ornithine decarboxylase after exposure to tumorigenic stimuli and that pretreatment with vitamins A and E provides protection against the carcinogenic action. However, studies of ornithine decarboxylase activity in human oral cavity carcinoma have not been as specific. The goal of this study was to determine whether a specific difference in ornithine decarboxylase activity occurs in tumor versus adjacent normal tissue in head and neck squamous cell carcinoma patients. Ornithine decarboxylase activity was measured in 30 consecutive head and neck cancer patients undergoing surgical therapy. Ornithine decarboxylase levels were found to be significantly elevated in tumor tissue samples when compared to adjacent normal mucosa samples (P less than .004). This finding confirms the previous findings noted in animal models and implies that the protective effects of vitamins A and E will extend to human head and neck cancers.


Laryngeal chondrosarcomas: a clinicopathologic study of 11 cases, including two "dedifferentiated" chondrosarcomas. Laryngeal chondrosarcomas are uncommon, and those that contain a distinct, nonchondroid, high-grade spindle cell sarcoma (the so-called "dedifferentiated" chondrosarcoma or chondrosarcoma with additional malignant mesenchymal component [CAMMC]) are extremely rare. Laryngeal CAMMC merit special attention, as CAMMC in other sites portends a poor prognosis. Eleven patients with laryngeal chondrosarcomas are reported on; 2 of these patients had CAMMC. On follow-up, 3 of the 11 patients had recurrences. The first had recurrence 4 and 11 years after tumor enucleation; that patient died disease free 2 years after salvage total laryngectomy. The second had recurrence 2 years after partial laryngectomy and was lost to follow-up after salvage total laryngectomy. The last patient recurred 13 years after partial laryngectomy and underwent salvage total laryngectomy; that patient was one of the two who developed CAMMC, and he also developed stomal recurrence of the "dedifferentiated" component 3 years after total laryngectomy. The other 8 patients are disease free after partial laryngectomy (6) or total laryngectomy (2) 10 months to 12 years later (mean: 51 months). This includes the 1 other patient with CAMMC, who is disease free 60 months after total laryngectomy. Laryngeal CAMMC has been shown, in at least one of the two patients, to be associated with a poor outcome. Patients with recurrent laryngeal chondrosarcomas do not have a poorer outcome after salvage total laryngectomy. The authors advocate partial laryngectomy if technically feasible.


Biodistribution of rhodamine-123 in nude mice heterotransplanted with human squamous cell carcinomas. Rhodamine-123 uptake and release was determined in nu/nu mice heterotransplanted with P3 human squamous carcinomas to assess its value as an in vivo laser photosensitizer for treatment of solid tumors. Following intraperitoneal injection of Rh-123 (1 micrograms/g of body weight), mice were killed at 2, 4, 6 and 24 hours, and 3 and 7 days postinjection. The peak concentrations of Rh-123 per milligram of tissue measured by fluorescence spectrophotometry was distributed as follows: kidneys greater than spleen greater than intestine greater than stomach greater than liver greater than tumor greater than skin greater than skeletal muscles greater than lung greater than heart greater than blood greater than brain. No preferential uptake or retention of Rh-123 by tumors was observed. However, a longer retention with higher concentrations of the dye was seen in normal skin as opposed to P3 tumors from 4 hours to 7 days postinjection with Rh-123. The elimination of Rh-123 was rapid, with the dye falling to less than 2% of peak concentration at 7 days postinjection. Knowledge of Rh-123 biodistribution in tumors and other tissues suggests that optimal timing after injection of this dye may allow selective photodiagnosis and photodynamic therapy of tumors with the argon laser.


Gross morphologic and functional effects of postoperative radiation on free jejunal autografts. Twenty adult mongrel dogs underwent free jejunal transplants to the neck; 10 either died of or had to be sacrificed as a result of postoperative complications, 5 received a 55-Gy-equivalent dose of radiation after 3 weeks, and 5 were followed as controls. Serial manometric and endoscopic evaluations were performed over a 9-month period. Progressive deterioration of the quality and amplitude of peristalsis of the jejunal autografts was observed only in the radiated group. In addition, all dogs in the radiated group developed severe jejunal circumferential constriction and stricture formation. These delayed effects of irradiation on revascularized jejunal autografts should be considered in planning the method of pharyngoesophageal reconstruction as well as the timing of adjuvant radiotherapy.


Postoperative radiation therapy for cervical lymph node metastases from an occult squamous cell carcinoma. One hundred thirteen patients with cervical metastases from a squamous cell carcinoma and no evidence of the primary tumor were treated for cure by surgery and routine large-field postoperative irradiation. Patients were staged according to the 1987 American Joint Committee on Cancer (AJCC) classification. There were 24 N1, 54 N2, 29 N3, and 6 Nx lesions. One hundred four patients underwent cervical lymph node dissection and 9 had adenectomy. All patients received postoperative external beam therapy to the entire naso-oro-pharyngo-larynx and all cervical lymphatics. The overall nodal failure rate was 13.7%. Nodal failure was significantly correlated with N staging (P = .01) and with the number of histologically involved nodes (P = .05). NOdal failure was 21% when nodes were initially fixed versus 7.5% when they were not (P = .07) and 18% when there was extracapsular spread versus 4.3% when the capsule was intact (P = .11). Eleven patients (9.7%) developed a subsequent primary lesion. In 3 patients (2.6%), this primary was located in the previously irradiated area and, in 2 cases, under the anterior block of lateral fields. Metastases occurred in 18 patients (16%). The five-year overall survival rate was 38%. Survival was correlated with N staging (P less than .02), nodal fixation (P = .05), extracapsular spread (P = .01) and loosely with the number of histologically involved nodes (P = .08). On the contrary, histological differentiation did not influence the local control rate, nor the development of metastases or subsequent primary lesions. Large-field prophylactic radiation therapy appears to be effective in preventing the emergence of initially occult primary lesions. However, control of disease in the neck and survival remain disappointing in patients with advanced nodal disease, even after combined surgery and radiation therapy.


Neoplastic infiltration of laryngeal cartilages: histocytochemical study. The relationship between cartilage and invading neoplastic cells was studied in 32 cases of laryngeal cancer by histological and cytochemical methods. Cartilage invasion was present in 12 cases, 10 of which were in proximity or in contact with areas of calcification and ossification. It was significantly correlated only to tobacco consumption (P less than .05) and, in regard to glottic tumors, to tumor diameter greater than 3 cm (P less than .01). Histologically, neoplastic invasion in cartilage was massive in 2 cases, occurred in areas of ossification in 4, between cartilage and bone in 4, and in epiglottic cartilage in 2. In 3 of the cases with bone invasion, there was also new bone formation. Hyaline cartilage and bone resorption was due to tartrate-resistant acid phosphatase (TRAP)-positive giant cells; in epiglottic cartilage only mononuclear cells were present, some of which were TRAP-positive. These results show that neoplastic cells can promote not only resorption and formation of bone, but also resorption of cartilage, which is considered resistant to neoplastic invasion. The different types of resorbing cells in contact with hyaline cartilage and bone in laryngeal cancer, and elastic cartilage in epiglottic cancer, suggest that the structure of the tissue being resorbed can influence the type of resorbing cells.


T1 squamous cell carcinoma of the arytenoid. Twenty-two cases of early squamous cell carcinoma of the arytenoid cartilage staged as T1 according to the 1983 American Joint Committee for Cancer Staging Classification system were reviewed. Eighteen percent of the patients showed no symptoms. In the remaining 82%, the main presenting symptom was pain in the form of sore throat, odynophagia, or otalgia. Radiotherapy and partial laryngeal surgery were the options retained for the treatment of the larynx. A "watch and wait" policy or preventive treatment of the ipsilateral jugulocarotid lymph nodes were the treatment options retained for the neck. Significant differences were noted in terms of local and nodal recurrence between the two programs. Results indicate that partial laryngeal surgery with total arytenoidectomy and preventive treatment of the neck appear to be advisable for this particular type of primary lesion.


Results of endoscopic sinus surgery for the treatment of inverted papillomas. Fifty-one patients suffering from inverted papillomas of the nose and paranasal sinuses were reexamined in a retrospective study. Thirty-five had undergone surgery by an intranasal endoscopic approach and 16 had undergone surgery by an extranasal approach. The recurrence rate following endoscopic interventions was 17% (6/35), as compared to 19% (3/16) after extranasal operations. Endoscopic surgery proved to be successful even in the treatment of large lesions affecting the posterior ethmoidal sinus, the nasofrontal duct, or the sphenoidal sinus. Its indication thus no longer needs to be restricted to limited lesions of the anterior nasal cavity. Patients with inverted papillomas will benefit from this surgical technique which remains minimally invasive and thus retains the paranasal bony framework, preserves unaffected mucosa capable of recovery, and prevents damage to the patients' cosmetic features.


Effectiveness of salvage neck dissection for advanced regional metastases when induction chemotherapy and radiation are used for organ preservation. The recently completed VA Cooperative Study (CSP #268) of induction chemotherapy (cisplatin/5-FU) and definitive radiation (6600 to 7600 cGy) for organ preservation in advanced (stage III or IV) laryngeal cancer demonstrated that, although larynx preservation could be achieved in 64% of randomized preservation could be achieved in 64% of randomized patients, overall survival rates were not improved over conventional treatment (surgery/postoperative radiation). Of 166 patients randomized to induction chemotherapy, 46 had N2 or N3 disease and were analyzed to determine the effectiveness of the organ preservation treatment strategy on control of neck disease and survival. The clinical response of neck metastases to induction chemotherapy was significantly associated with subsequent salvage neck dissection (P = .008). The overall death rate was increased (P = .014) and survival time decreased in patients with less than a complete response in the neck after chemotherapy (P = .15). This was related primarily to failure to control the disease in the neck. The overall survival of patients achieving a complete response in the neck was improved over the randomized group of N2 or N3 patients treated with primary surgery. The findings suggest that response of neck nodes should be assessed independently of primary tumor response in trials of organ preservation strategies using induction chemotherapy, and that failure to achieve a clinical complete response in the neck warrants planned early salvage neck dissection in order to achieve improved overall survival.


Zenker's diverticulotomy using the KTP/532 laser. Multiple forms of surgical treatment exist for Zenker's diverticulum. Appropriate treatment needs to be tailored based on the needs of the patient and the resources and skills of the surgeon. We have reviewed the available surgical options and presented a series of 10 patients treated with a new technique, the KTP/532 laser diverticulotomy. The diverticulotomy is particularly well-suited to the debilitated patient who cannot tolerate a prolonged operation or a prolonged postoperative recovery. The results of the technique are comparable with those of other forms of diverticulotomy, and it is concluded that the KTP/532 laser is a simple, safe, and effective form of surgical treatment with exciting potential for future use.


Transurethral incision of the prostate using the holmium:YAG laser. Transurethral incisions of the prostate were made endoscopically in 5 dogs under a fluid medium using a holmium:YAG (Ho:YAG) laser operating at a wavelength of 2.1 microns and with delivery of 1.0 J/pulse in 15 Hz (15 W). Histopathologic examination of tissues collected immediately after surgery revealed irregular crevices outlined by a narrow zone of coagulative necrosis. Ulcerated fissures persisted at 5 and 7 days with the initial stages of epithelial regeneration partially re-epithelializing the ulcerated surfaces. A modest inflammatory response characterized by edema, hemorrhage, and a mixed inflammatory cell infiltrate was also associated with the laser incision sites at 5 and 7 days. Three weeks postlasing, the ulcerated surfaces of the fissures were completely re-epithelialized. At 5 weeks only a slight indentation persisted at the incision sites with minimal changes in the subjacent submucosa and prostatic glandular architecture. Although the results of these investigations are preliminary, we believe that the Ho:YAG laser warrants further clinical evaluation for treating patients with benign prostatic hyperplasia (BPH), urethral strictures, bladder neck contractures, and constrictions of the upper urinary tracts.


Neodymium:YAG laser treatment of bladder neck contracture following prostatectomy. A total of 21 patients with postprostatectomy bladder neck contracture underwent treatment with Nd:YAG laser irradiation. A new 800-microns hemispherical optical quarz fiber was used in contact technique to produce linear incisions in the scarred tissue. Within 11.2 months, median of follow-up, there was improvement in the obstructive voiding symptoms in all the patients. Two patients who had still mild contracture in the first follow-up cystoscopy were managed successfully with a second treatment. Endoscopic application of laser energy in the contact mode enables the immediate vaporization and disintegration of the fibrous area and secondary reepithelization of the bladder neck without scarring.


Erb:YAG and Hol:YAG laser ablation of meniscus and intervertebral discs. Erb:YAG and Hol:YAG laser ablation rates of fibrocartilage and nucleus pulposus were measured in vitro simulating clinical conditions. After ablation macroscopic and microscopic appearance of the ablation site was investigated. Hol:YAG and Erb:YAG laser mean ablation rates increased almost linearly with rising energies, showing higher total ablation rates for the Hol:YAG laser due to its higher achievable energy density. At comparable energy densities the Erb:YAG laser appears to be more effective with respect to the corresponding ablation rates. Consequently, the ablational threshold proved to be lower for the Erb:YAG laser. Whereas during Hol:YAG laser ablation, some smoke formation and considerable tissue shrinking occurred, these effects could not be observed during Erb:YAG laser ablation. Consequently macroscopic and microscopic inspection showed some thermal damage after Hol:YAG and only minimal alterations after Erb:YAG laser ablation. Adjacent thermal damage was determined and proved to be lower for the Erb:YAG laser. In our opinion the characteristics of each laser system provide certain advantages for special clinical indications.


Holmium-laser synovectomy of immune synovitis in rabbits. Holmium-laser synovectomy was carried out to remove allergically inflamed synovial membranes in rabbit knee joints. The healing process was then investigated at different periods. Left knee joints of 12 rabbits were exposed to Ho:YAG-laser radiation at a wavelength of 2.1 microns, pulse energy of 600 mJ, pulse length of 1 ms, and repetition rate of 3 Hz. Twelve others were treated conventionally and 12 served as controls. After 1 day, 1 week, and 1 and 3 months, respectively, 3 animals from each group were sacrificed and the synovialis grossly and microscopically examined. Coagulation necrosis, inflammation, and edema resulted following laser therapy. After 1 week, the synovial layer consisted of a scarlike formation of fibers and within 1 month, its surface appeared smooth. The mechanical abrasion caused hemorrhage and necrosis. Fibrosis developed in the capsular layers, and after 3 months, the surface appeared coarse and villous. Based on these preliminary findings, holmium-laser synovectomy may offer an alternative method to existing therapeutic techniques.