Open heart surgery in adults at Ramathibodi Hospital

Two hundred and thirty consecutive adult patients underwent open heart surgery at Ramathibodi Hospital from January 1, 1994 to December 31, 1995. The patients were categorised into 4 groups, A, B, C and D; consisting of 52 (22.4%) with adult congenital heart disease, 121 (52.2%) with acquired valvular heart disease 52 (22.4%) with coronary heart disease and 7 (3%) with diseases of the aorta. The mortality in various groups were analyzed separately each year, in 1994 and 1995. The overall mortality, in adult congenital heart disease, was 5.7 per cent consisting of acquired valvular heart disease (6.6%), coronary artery disease (CAD) (3.8%) and diseases of the aorta (14.2%). We found that the incidence of CAD and the patients underwent CABG were increasing. The overall mortality for open heart surgery in adults was 6 per cent. Though the number of patients who underwent open heart surgery did not truly represent all heart diseases, trends of coronary artery disease seem to be increasing. Risk factors of coronary artery disease and low mortality from CABG might be the main reasons that CABG has increased obviously.     

Acid-base balance in chronic peritoneal dialysis patients

Endogenous acid production has never been measured directly in dialysis patients and an empiric formula is used to estimate acid production from their protein catabolic rate. We have studied acid-base balance in 19 stable CAPD patients attending the peritoneal dialysis clinic of Mount Sinai Hospital. They obtained a 24 hour collection of peritoneal dialysis fluid and urine while consuming their usual diet and performing their usual activities. Total alkali gain was calculated from net GI alkali absorption plus urinary net acid excretion plus alkali gain from dialysate, while total acid production was measured directly from the urinary and dialysate excretions of sulfate and organic anions. Net GI alkali absorption was estimated from the difference between cations (Na + K+Ca + Mg) and anions (Cl + 1.8P) in the 24 hour dialysate and urine collections minus the daily total amount of lactate infused. All of our patients had a normal or high serum bicarbonate concentration, which was stable with time. Total alkali gain was virtually identical to total acid production (54.2 vs. 52.4 mEq/day) which suggests that these patients were in neutral acid-base balance. Net GI alkali absorption (22.7 mEq/day) was one of the same range as that of chronic renal failure patients not on dialysis and represented almost one half of the total daily alkali gain. The daily acid production of 52.4 mEq/day was numerically equal to 84% of the protein catabolic rate expressed as g/day, which is similar to the predicted value of 77% of PCR reported in the literature.(ABSTRACT TRUNCATED AT 250 WORDS)     

Hypogeusia and zinc depletion in chronic dialysis patients

Dialysis patients generally have a poor appetite, do not enjoy eating, and complain of food, particularly protein, as being disagreeable. Twenty dialysis patients with the above symptoms were tested for taste acuity, serum zinc (Zn), Zn concentrations in hair samples (intracellular Zn), and daily caloric intake. A double-blind, cross-over study was instituted using a Zn supplement and a placebo. After supplementation with Zn, taste acuity markedly improved in 95% of patients and Zn concentrations in hair increased in 85% of patients. The patients' appetites were improved; the average caloric intake increased by 675 kcal/day, and intolerance to protein diminished. In addition 10 normal control subjects were studied pre- and post-Zn supplementation for fasting blood glucose, serum Zn levels, and hair Zn concentration. Side effects were noted, and these usually correlated with elevated serum Zn levels and were minimized or disappeared with decrease in dosage or cessation of therapy.     

Interleukin-8 in chronic renal failure and dialysis patients

A total of 105 patients participated in this study, including 10 with chronic glomerulonephritis with normal renal function (CGN patients), 36 uraemic patients (CRF patients), 19 continuous ambulatory peritoneal dialysis patients (CAPD) without peritonitis, three CAPD patients with peritonitis, 37 patients undergoing chronic haemodialysis (HD) divided into short-term HD, 15 patients; medium-term HD, 12 patients; and long-term HD, 10 patients. IL-8 and two other proinflammatory cytokines, IL-6 and TNF alpha were tested using a specific immunoassay. IL-8, IL-6, and TNF alpha serum levels were significantly increased in patients with chronic renal failure compared to their levels in normal individuals (P < 0.0001, P < 0.05 and P < 0.0001 respectively). The most pronounced increment in IL-8, IL-6 and TNF alpha serum levels was observed in CAPD patients (P < 0.0001). CAPD patients without peritonitis showed relatively low levels of IL-8 or IL-6 in peritoneal dialysate effluents (PDE), whereas PDE-TNF alpha were not detectable in almost all patients tested. Patients with peritonitis showed very high serum and PDE levels of IL-8, IL-6 and TNF alpha. The clinical recovery from peritonitis was characterized by a rapid fall in IL-8, IL-6 and TNF alpha in serum and dialysate. HD patients showed a significant increase in serum levels of IL-8 and also IL-6 and TNF alpha compared to normal individuals (P < 0.05, P < 0.05 and P < 0.01 respectively).(ABSTRACT TRUNCATED AT 250 WORDS)     

Gastroenterological surgery for patients with chronic respiratory insufficiency

BACKGROUND/AIMS: The aim of this study was to clarify the surgical indications for patients with chronic respiratory insufficiency. METHODOLOGY: Fourteen patients with chronic respiratory insufficiency who underwent abdominal surgical procedures, were retrospectively studied. The surgical indications were carefully determined based primarily on the performance status (PS) of each patient and cardiopulmonary function tests. A PS of equal to or less than 3, which meant the patient's status required bed rest > 50% of the time, and the need for assistance in performing normal activities were all factors considered for surgical indications. RESULTS: During the period studied, two patients were excluded from the surgical indications due to the fact that one was at a terminal stage of pulmonary disease and was completely bedridden (PS = 4), while the other demonstrated active pneumonia with a considerable amount of purulent sputa. Regarding the pulmonary function tests for patients who underwent surgery, the lowest limits of those examinations were as follows: 810 ml of vital capacity (VC), 23.8% of predicted VC, 610 ml of forced expiratory volume in one second (FEV1.0), 38.6% of predicted FEV1.0, 50.5 mmHg of PaO2 while inhaling 4 liters of oxygen and 73.8 mmHg of PaCO2. No surgery related mortality or hospital death within 30 days after operation was observed. Only two patients had cardiopulmonary complications (consisting of pulmonary edema with atrial fibrillation in one patient, and acute myocardial infarction in another patient). However, neither pneumonia, prolonged ventilatory support for more than 2 days, nor the need for a tracheostomy after surgery was observed. CONCLUSIONS: Gastroenterological surgery is thus considered to be indicated even for patients with chronic respiratory insufficiency, as long as the PS can be maintained (PS of equal to or less than 3) and no active pneumonia with a considerable amount of purulent sputa is present.     

Aortoiliac surgery in chronic hemodialysed patients

Thirty eight patients on chronic hemodialysis were operated on for treatment of complicated aortoiliac atherosclerosis: 31 had aneurysms and 7 had stenotic or obstructive lesions. The 35 male and three female patients ranged in age from 39 to 78 years (mean: 55.3). The duration of hemodialysis treatment before the operation ranged from one month to 22 years but 80% of the patients were operated on during the first five years following the beginning of maintenance hemodialysis. The surgical repairs consisted of long aorta to femoral artery prosthesis in obstructive lesions and of short prostheses in cases of aneurysms so as not to make more difficult subsequent renal transplantation. All patients were operated on from 6 to 18 hours after a dialysis. Hemodialysis was resumed on the day of surgery in few patients or later according to the level of kalemia. Postoperative mortality rate was 10.5% and morbidity 13.5%. Only seven patients underwent secondary renal transplantation. The long-term survival rate was 43% at five years and 11% at ten years. Late deaths were due to coronary artery disease or to worsening of arterial lesions in the lower limbs.     

Open heart operation in patients suffering from hereditary spherocytosis

Hereditary spherocytosis is a clinically heterogeneous, genetically determined red blood cell membrane disorder resulting in hemolytic anemia. Structural or functional disorders of the cytoskeletal proteins result in the formation of spherocytes, which lack the strength, durability, and flexibility to withstand the stresses of the circulation. This problem can be accentuated by the deleterious effects of the heart-lung machine. Three patients with hereditary spherocytosis underwent open heart operation with no deaths and no serious complications resulting from the hematologic defect. Splenectomy is recommended, although not essential, before a cardiac operation, and mechanical valves should perhaps be avoided.     

Effect of ramipril on heart rate variability in digitalis-treated patients with chronic heart failure

Bilharzial-related bladder carcinoma (BBC) is the most common malignant neoplasm in Egypt, also occurring with a high incidence in other regions of the Middle East and East Africa. The clinical and pathological features of BBC are different than those described for the conventional transitional cell carcinoma of the bladder, including the high incidence of squamous cell carcinoma reported in BBC and the fact that over 90% of BBC cases at presentation are advanced-stage tumors (P3 and P4). This study was conducted to better define the phenotypic alterations associated with BBC affecting the p53 cell cycle control pathway, including altered patterns of expression of downstream effector proteins such as mdm2 and p21/WAF1. A well-characterized cohort of 125 patients affected with bilharzial-related bladder tumors was studied. Tumors were classified as squamous carcinomas (n = 68), transitional cell carcinomas (n = 55), or adenocarcinomas (n = 2). The products encoded by TP53, mdm2, and p21/WAF1 genes were analyzed by immunohistochemistry. Furthermore, the patterns of expression of these molecules were correlated with the Ki67 proliferative index. In addition, the microanatomical distribution of programmed cell death was assessed in a subset of tumors, using the so-called terminal deoxynucleotidyl transferase-mediated nick end labeling method. p53 nuclear overexpression was identified in 25 (20%) of 125 cases. Nuclear overexpression of mdm2 was detected in 74 (59.2%) of 125 cases. There was a statistically significant association between coexpression of both p53 and mdm2 and detection of lymph node metastases (P = 0.04). p21/WAF1 expression was detected in 87 (72%) of 121 evaluable cases. A high Ki67 proliferative index was observed in 99 (86%) of 115 evaluable cases. There was a statistically significant association between high Ki67 proliferative index and mdm2-positive phenotype (P = 0.005) and deep muscle invasion (P3b; P = 0.026) as well as lymph node metastases (P = 0.039). Apoptosis was observed in terminally differentiated tumor cells identified in the superficial layers of well-differentiated squamous carcinoma or exfoliating cells in transitional lesions. However, only rare apoptotic tumor cells were found in basal or suprabasal layers as well as in the invasive elements of the neoplasms studied. These results suggest that the frequency of p53 nuclear overexpression in BBC is lower than that reported for conventional transitional cell carcinoma. Nevertheless, tumors with p53 alterations have a greater propensity to progress. The prominent number of cases displaying an mdm2-positive phenotype suggests that this may be an early incident in BBC and should be regarded as a potential oncogenic phenomenon. This is supported by the significant correlation between high Ki67 proliferative index and mdm2 overexpression. The association of an aggressive clinical course with the coexpression of both p53 and mdm2 products might be viewed as a cooperative effect that develops in tumor progression.     

Outpatient management program of patients with chronic heart failure

Hospitalization of patients with heart failure is often caused by poor adherence to drug therapy, by suboptimal utilization of ACE inhibitors and beta-blockers, and by the lack of systematic monitoring of patients after discharge. The aim of the study is to verify the impact of an outpatient management program on the hospitalization rate and functional status of patients with chronic heart failure. Over a five-year period, 435 patients entered our outpatient management program, which includes adjustment in medical therapy, patient education and visits timed according to the patient's status. Fifty-six percent of the patients were in New York Heart functional class I-II; 74% were male; mean age was 62 +/- 11 years. Heart failure was due to coronary heart disease in 42%, dilated cardiomyopathy in 35%, hypertensive heart disease in 13%, other etiologies in 10%. The following changes in medical therapy were made compared to the period before referral: ACE inhibitors in 88% of the patients vs 70% (p < 0.05), mean dose of enalapril and captopril respectively 18 +/- 6 mg vs 11 +/- 4 mg (p < 0.05) and 89 +/- 28 mg vs 61 +/- 34 mg (p < 0.05); digoxin in 71 vs 70% (NS); furosemide in 90 vs 87%; beta-blockers in 16 vs 6% (p < 0.05); amiodarone in 24 vs 16% (p < 0.05); oral anticoagulants in 22 vs 12% (p < 0.05); calcium channel blockers in 10 vs 16% (p < 0.05). During the follow-up period (35 +/- 11 months), there were 111 hospital admissions compared to 518 during the year before recruitment (p < 0.05). Seventy-two patients died (65 for cardiac causes) and four patients underwent cardiac transplantation. Functional status improved (301 patients in I-II functional class and 56 in III-IV after referral compared to 225 and 132 before referral, respectively). Our results were obtained through adjustment in pharmacological therapy, intensive patient education and therapeutic continuity made possible by our outpatient heart-failure clinic organization. It is likely that the increase in costs due to therapeutic adjustment and to the increase in the number of visits is counterbalanced by the reduced rate of hospital admissions.     

Echocardiographic evaluation of left ventricular function in patients with chronic renal failure treated with intermittent peritoneal dialysis

As a result of preclinical data demonstrating the antitumour and antimetastatic efficiency of indomethacin in murine models, and the clinical observation of occasional tumour regression in patients with advanced melanoma treated with indomethacin together with ranitidine, a Phase II study was performed of prolonged administration of these two oral agents in combination. Seventeen patients were entered into the study and commenced on indomethacin 50 mg three times daily; the dose was escalated to a maximum of 75 mg three times daily in patients who tolerated the starting dose. Ranitidine was administered concurrently at a dose of 150 mg twice daily. One patient with uveal melanoma metastatic to the liver achieved a partial response, with slow shrinkage of a biopsy-proved liver metastasis (objective response rate 6 percent; 95 percent CI0-29). Another patient demonstrated a minor response in pelvic lymph nodes. The combination of indomethacin and ranitidine has negligible activity in advanced malignant melanoma; a response may require months to be achieved.     

The treatment of ischemic heart disease in patients with chronic kidney failure

An analysis of the initial type of central hemodynamics and the postoperative period in 177 patients aged older than 70 years having calculous cholecystitis has shown that surgical treatment of patients with the normo- and hyperdynamic types of circulation even with concomitant diseases can give positive results. The least favourable regimen of blood circulation proved to be the hypodynamic type characteristic of patients with pronounced disturbances of homeostasis and/or with recent myocardial infarction.     

Use of beta-adrenoreceptor antagonists in treatment of patients with chronic heart failure

Chronic heart failure (CHF) is present in 1-10% of the whole population. From the drugs used in CHF so far only angiotensin converting enzyme inhibitors and nitrate with hydralazine improved the survival which was caused by beneficial influence of these drugs on neurohormonal factors. There is growing interest in beta-blockers which are believed to stop the progress of CHF. Although the first attempts of using beta-blockers in the treatment of CHF took place in 70-ties, only recent years brought better understanding of mechanisms of their action. The beneficial effect of beta-blockers in CHF is related to their protective influence on myocardium and to hampering of apoptosis--programmed cell death--the phenomenon which is exaggerated in CHF. The investigations carried out in last years proved that carvedilol which is beta 1-, beta 2- and alpha 1-blocker and has antioxidant properties improved clinical status and reduced mortality in the cohorts of patients with all-cause CHF. At present great trials estimating various beta-blockers and comparing these drug among themselves are being conducted.     

Amyloid and non-amyloid carpal tunnel syndrome in patients receiving chronic renal dialysis

OBJECTIVE: To determine the prevalence of amyloid deposits among patients with carpal tunnel syndrome (CTS) receiving dialysis, and to investigate the factors associated with amyloid and non-amyloid CTS. METHODS: Subjects for this prospective study were dialysis patients who underwent surgery for CTS in the same surgical unit between 1989 and 1997. CTS was diagnosed from clinical and electromyographic (EMG) findings. Systematic standard radiographs and laboratory data were also obtained. Surgical investigations included systematic macroscopic examination and biopsy of the epineurium, flexor retinaculum, synovium, and flexor tendon sheaths. Samples were stained for amyloid and examined by plain and polarized light microscopy, immunohistochemistry, and electron microscopy. RESULTS: Forty-one samples from 30 patients (11 bilateral cases) were examined. Amyloid deposits were found in 26 samples from 18 patients (7 M, 11 F). Fifteen samples from 12 patients (3 M, 9 F) showed no amyloid deposits. Amyloid CTS was statistically significantly associated with arthralgia and longterm dialysis [mean 13.3 (range 5.5-23) vs 7.5 yrs (range 3 mo-14 yrs)] in non-amyloid CTS. Flexor tenosynovitis and carpal bone erosion occurred more frequently in amyloid CTS. There were no statistically significant differences between the 2 groups in clinical, laboratory or EMG findings, type of dialysis membrane, or frequency of ipsilateral fistula. Only amyloid CTS was recurrent. CONCLUSION: Amyloid deposits were confirmed microscopically in 63.4% of patients. The relatively large number of cases of non-amyloid CTS without signs of dialysis associated arthropathy suggests that CTS is not a satisfactory criterion for diagnosis of dialysis arthropathy or beta2-microglobulin amyloidosis unless the presence of amyloid has been confirmed or duration of dialysis treatment has been at least 15 years.     

Mechanisms facilitating oxygen delivery during exercise in patients with chronic heart failure

The aim of the study was to estimate the relative importance of the Bohr effect and redistribution of blood from the non-exercising tissues on the arterial-venous oxygen content differences across the exercising extremities and the central circulation in patients with chronic heart failure; the relationship among femoral vein, systemic and pulmonary artery oxygen partial pressure and hemoglobin saturation was determined. It has been reported that the maximal reduction in femoral vein pO2 precedes peak oxygen consumption and lactic acidosis threshold in patients with chronic heart failure and normal subjects during exercise. The increase in oxygen consumption at work rates above lactic acidosis threshold, therefore, must be accounted for by increase in blood flow in the exercising muscles and right-ward shift on the oxyhemoglobin dissociation curve. Since the total cardiac output increase is blunted in patients with chronic heart failure, diversion of blood flow from non-exercising to exercising tissues may account for some of the increase in muscle blood flow. Ten patients with chronic heart failure performed a progressively increasing leg cycle ergometer exercise test up to maximal effort while measuring ventilation and gas concentration for computation of oxygen uptake and carbon dioxide production, breath-by-breath. Blood samples were obtained, simultaneously, from systemic and pulmonary arteries and femoral vein at rest and every minute during exercise to peak oxygen consumption. At comparable levels of exercise, femoral vein pO2, hemoglobin saturation and oxygen content were lower than in the pulmonary artery. PCO2 and lactate concentration increased steeply in femoral vein and pulmonary artery blood above lactic acidosis threshold (due to lactic acid build-up and buffering), but more steeply in femoral vein blood. These increases allowed femoral vein oxyhemoglobin to dissociate without a further decrease in femoral vein pO2 (Bohr effect). The lowest femoral vein pO2 (16.6 +/- 3.9 mmHg) was measured at 66 +/- 22% of peak VO2 and before the lowest oxyhemoglobin saturation was reached. Artero-venous oxygen content difference was higher in the femoral vein than in the pulmonary artery; this difference became progressively smaller as oxygen consumption increased. "Ideal" oxygen consumption for a given cardiac output (oxygen consumption expected if all body tissues had maximized oxygen extraction) was always higher than the measured oxygen consumption; however the difference between the two was lost at peak exercise. This difference positively correlated with peak oxygen consumption and cardiac output increments at submaximal but not at maximal exercise. In conclusion, femoral vein pO2 reached its lowest value at a level of exercise at or below the lactic acidosis threshold. Further extraction of oxygen above the lactic acidosis threshold was accounted for by a right shift of the oxyhemoglobin dissociation curve. The positive correlation between increments of cardiac output vs "ideal" and measured oxygen consumption suggests a redistribution of blood flow from non-exercising to exercising regions of the body. Furthermore the positive correlation between exercise capacity and the difference between "ideal" and measured oxygen consumption suggests that patients with the poorer function have the greater capability to optimize blood flow redistribution during exercise.