Coronary angioplasty volume-outcome relationships for hospitals and cardiologists

OBJECTIVE: To assess the relationship between each of 2 provider volume measures (annual hospital volume and annual cardiologist volume) for percutaneous transluminal coronary angioplasty (PTCA) and 2 outcomes of PTCA (in-hospital mortality and same-stay coronary artery bypass graft [CABG] surgery). DESIGN: Cohort study, using data from January 1, 1991, through December 31, 1994, from the Coronary Angioplasty Reporting System of the New York State Department of Health. SETTING: Thirty-one hospitals in New York State in which PTCA was performed during 1991-1994. PATIENTS: All 62670 patients discharged after undergoing PTCA in these hospitals during 1991-1994. MAIN OUTCOME MEASURES: Rates of in-hospital mortality and CABG surgery during the same stay as the PTCA. RESULTS: The overall in-hospital mortality rate for patients undergoing PTCA in New York during 1991-1994 was 0.90%, and the same-stay CABG surgery rate was 3.43%. Patients undergoing PTCA in hospitals with annual PTCA volumes less than 600 experienced a significantly higher risk-adjusted in-hospital mortality rate of 0.96% (95% confidence interval [CI], 0.91%-1.01%) and risk-adjusted same-stay CABG surgery rate of 3.92% (95% CI, 3.76%-4.08%). Patients undergoing PTCA by cardiologists with annual PTCA volumes less than 75 had mortality rates of 1.03% (95% CI, 0.91%-1.17%) and same-stay CABG surgery rates of 3.93% (95% CI, 3.65%-4.24%); both of these rates were also significantly higher than the rates for all patients. Also, same-stay CABG surgery rates for patients undergoing PTCA in hospitals with annual volumes of 600 to 999 performed by cardiologists with annual volumes of 75 to 174 (2.99%; 95% CI, 2.69%-3.31 %) and 175 or more (2.84%; 95% CI, 2.57%-3.14%) were significantly lower than the overall statewide rate (3.43%). CONCLUSIONS: In New York State, both hospital PTCA volume and cardiologist PTCA volume are significantly inversely related to in-hospital mortality rate and same-stay CABG surgery rate for patients undergoing PTCA.     

Morbidity, cost, and six-month outcome of minimally invasive direct coronary artery bypass grafting

BACKGROUND: Minimally invasive direct coronary artery bypass grafting (MIDCABG) promises to reduce the morbidity of coronary bypass, but this has not been proved. METHODS: This retrospective study compares the morbidity, mortality, cost, and 6-month outcome of patients less than 80 years old undergoing elective left internal mammary artery to left anterior descending artery bypass grafting via MIDCABG (n = 60) or sternotomy (n = 55) between January 1995 and December 1996. There were no differences between the groups in mean age, sex distribution, or preoperative risk level. The left internal mammary artery was mobilized from the fifth costal cartilage to the subclavian artery in all patients. The anastomoses were done with a beating heart in the MIDCABG group and with cardioplegic arrest in the sternotomy group. RESULTS: There were no operative deaths in either group. The MIDCABG patients had a lower transfusion incidence (10/60 [17%] versus 22/55 [40%]; p< or =0.02) and a shorter postoperative intubation time (2.1+/-4.2 versus 12.6+/-9 hours; p< or =0.0001). One patient in each group was reexplored for bleeding. Three sternotomy patients (3/55, 5%) required ventilatory support for greater than 48 hours, but no MIDCABG patient was ventilated for more than 24 hours. Median postoperative length of stay was 4 days for MIDCABG and 7 days for sternotomy. Estimated hospital costs were $11,200+/-3100 for MIDCABG and $15,600+/-4200 for CABG (p < 0.001). The reduced morbidity and cost of MIDCABG was found mostly in high-risk patients. At 6-month follow-up, 5 MIDCABG patients (5/60, 8%) had evidence of recurrent ischemia involving the left anterior descending artery, primarily the result of anastomotic stricture. CONCLUSIONS: This analysis shows that MIDCABG reduces the initial morbidity and cost of coronary bypass, but some patients require subsequent reintervention. Long-term follow-up is needed before MIDCABG can be judged better than traditional bypass, but the initial results are promising, especially in high-risk patients.     

Contemporary management of isolated iliac aneurysms

OBJECTIVE: Because isolated common iliac artery aneurysms are infrequent, are difficult to detect and treat, and have traditionally been associated with high operative mortality rates in reported series, we analyzed the outcomes of operative repair of 31 isolated common iliac artery aneurysms in 21 patients to ascertain morbidity and mortality rates with contemporary techniques of repair. METHODS: A retrospective review study was conducted in a university teaching hospital and a Department of Veterans Affairs Medical Center. Perioperative mortality and operative morbidity rates were examined in 17 men and four women with isolated common iliac artery aneurysms between 1984 and 1997. Ages ranged from 38 to 87 years (mean 69 +/- 8 years). Slightly more than half of the cases were symptomatic, with abdominal pain, neurologic, claudicative, genitourinary, or hemodynamic symptoms. One aneurysm had ruptured and one was infected. There was one iliac artery-iliac vein fistula. All aneurysms involved the common iliac artery. Coexistent unilateral or bilateral external iliac aneurysms were present in four patients; there were three accompanying internal iliac aneurysms. Overall, 52% of patients had unilateral aneurysms and 48% had bilateral aneurysms. Aneurysms ranged in maximal diameter from 2.5 to 12 cm (mean 5.6 +/- 2 cm). No patients were unavailable for follow-up, which averaged 5.5 years. RESULTS: Nineteen patients underwent direct operative repair of isolated iliac aneurysms. One patient had placement of an endoluminal covered stent graft; another patient at high risk had percutaneous placement of coils within the aneurysm to occlude it in conjunction with a femorofemoral bypass graft. Patients with bilateral aneurysms underwent aortoiliac or aortofemoral interposition grafts, whereas unilateral aneurysms were managed with local interposition grafts. There were no deaths in the perioperative period. Only one elective operation (5%) resulted in a significant complication, compartment syndrome requiring fasciotomy. The patient treated with the covered stent required femorofemoral bypass when the stent occluded 1 week after the operation. The patient treated with coil occlusion of a large common iliac aneurysm died 2 years later when the aneurysm ruptured. CONCLUSIONS: Isolated iliac artery aneurysms can be managed with much lower mortality and morbidity rates than aneurysm previously been reported by using a systematic operative approach. Percutaneous techniques may be less durable and effective than direct surgical repair.     

Results of directional coronary atherectomy in Northern New England. Northern New England Cardiovascular Disease Study Group

The role of directional coronary atherectomy (DCA) in interventional cardiology remains uncertain. We report the Northern New England regional experience with DCA from 1991 to 1994. Data were collected on 11,178 patients having had an intervention on a single lesion in a single vessel (798 DCAs; 10,380 percutaneous transluminal angioplasties [PTCA]). The use of DCA increased from 1.8% of interventions in 1991 to 10% in 1994. Compared with PTCA, DCA patients were younger, more often men, had more 1-vessel disease and more coronary artery bypass surgery (CABG). DCA was more often used in the left anterior descending artery, in vein grafts, for restenoses, for subtotal occlusions, and with type A lesions. Angiographic success (96.7%) and clinical success (93%) were good. Adverse events were rare: mortality 0.9%, emergent CABG 2.2%, nonfatal myocardial infarction 2.8%. After adjusting for case-mix, there was no difference between DCA and PTCA for in-hospital mortality (odds ratio [OR] = 1.03, 95% confidence interval [CI] 0.44 to 2.43, p = 0.95) or need for emergent CABG (OR = 1.27, 95% CI 0.77 to 2.10, p = 0.34). Atherectomy patients were more likely to have a nonfatal myocardial infarction (OR = 2.0, 95% CI 1.26 to 3.20, p <0.01), to sustain an injury to the femoral or brachial artery (OR = 2.89, 95% CI 1.52 to 5.51, p <0.01), and to have a clinically successful procedure (OR = 1.37, 95% CI 1.01 to 1.88, p = 0.05). Our results support the relative safety and effectiveness of DCA as its use disseminated into the region.     

Decision making by elderly patients with cancer and their caregivers

Compared to patients undergoing elective or urgent coronary artery bypass grafting (CABG), those undergoing emergency CABG (EM-CABG) have a higher morbidity and mortality. The use of heparin-bonded circuits (HBC) has been shown to improve clinical outcomes in nonemergent CABG patients. It is not known, however, whether the improved hemostasis and attenuation of the inflammatory response to cardiopulmonary bypass, conferred by HBC, can overcome the high incidence of comorbid risk factors in (EM-CABG) patients and improve their outcomes. A retrospective analysis of 206 consecutive patients undergoing EM-CABG over 4 years (1993-1997) at one institution was performed. Eighty-one patients were treated with conventional non-heparin-bonded circuits (NHBC) with full anticoagulation protocol (FAP, activated clotting time [ACT] > 480 sec); 125 patients were treated with HBC and a lower anticoagulation protocol (LAP, ACT > 280 seconds). Outcomes and results were collected prospectively and are presented as mean +/- SD. Preoperative risk profiles were similar in both treatment groups. Postoperatively, compared with the NHBC group, patients treated with HBC/LAP required fewer homologous donor units (4.1 +/- 10.7 vs 8.2 +/- 13.6 units, p = 0.005), were less likely to require inotropic support (18.6% vs 38.3%, p = 0.005), and had a lower incidence of perioperative myocardial infarction (MI, 3.2% vs 12.3%, p = 0.04) and pulmonary complications (4.0% vs 12.3%, p = 0.04). The use of HBC/LAP resulted in a decreased incidence of postoperative complications (12.8% vs 28.4%, p = 0.01, odds ratio 0.37 with 95% confidence interval [CI] 0.18-0.76). This resulted in a shorter duration of ventilatory support (30.5 +/- 54.0 vs 72.8 +/- 16.7 hours, p = 0.009), ICU stay (38.2 +/- 36.5 vs 91.5 +/- 68.7 hours, p = 0.009), hospital stay (8.0 +/- 7.1 vs 11.0 +/- 8.9 days, p = 0.008), and therefore cost. In conclusion, the use of HBC/LAP in EM-CABG resulted in a reduction of homologous transfusion and postoperative complications associated with decreased hospital stays and cost.     

Xenogeneic iso-skin graft and mixed lymphocyte reaction studies using HLA-DP transgenic mice

With increased use of catheter intervention, candidates for coronary artery bypass grafting (CABG) have become more severely diseased. In the past 4 years with normothermic cardiopulmonary bypass technique, operative mortality was 1.5% (0.7% for elective and 5.6% for emergency) in 690 primary CABGs. The internal thoracic artery graft was used in 94% of the patients and the patency rate was 98%. The gastroepiploic artery was used in 565 patients since 1986 with 2.3% operative mortality and the patency rate was 96% in early and 92% in mid-term angiography. The inferior epigastric artery was used in 48 patients with 2% operative mortality and 90% patency rate. The radial artery was used in 105 patients with 0.9% operative mortality and patency rate was 88% at 1 postoperative year. Surgical result and angiographic patency of the graft are acceptably good while candidates of CABG have become more severely diseased. With use of arterial conduits, better long term outcome can be expected.     

Permanent cardiac pacing after a cardiac operation: predicting the use of permanent pacemakers

BACKGROUND: The need for permanent cardiac pacing after cardiac operations is infrequent but associated with increased morbidity and resource utilization. We identified patient risk factors for pacemaker insertion to enable development of a predictive model. METHODS: Data were collected prospectively for 10,421 consecutive patients who had cardiac operations between January 1990 and December 1995. Two hundred fifty-five patients (2.4%) were identified as having received a permanent pacemaker during the same hospitalization. Logistic regression analysis was performed to determine the independent, multivariate predictors of permanent pacing. The predictive accuracy and precision of the logistic regression model was evaluated in the 1996 database of 2,236 consecutive patients by the calculation of Brier scores. RESULTS: Eight independent predictors of permanent pacemaker requirement were identified. The factor-adjusted odds ratios (OR) with 95% confidence interval (CI) associated with each predictor are as follows: (1) valve replacement surgery (aortic: OR 5.8, CI 3.9-8.7; mitral: OR 4.9, CI 3.1-7.8; tricuspid: OR 8.0, CI 5.5-11.9; double: OR 8.9, CI 5.5-14.6; and triple: OR 7.5, CI 2.9-19.3); (2) repeat operation: OR 2.4, CI 1.8-3.3; (3) age 75 years or older: OR 3.0, CI 2.0-4.4; (4) ablative arrhythmia operation: OR 4.2, CI 1.9-9.5; (5) mitral valve annular reconstruction: OR 2.4, CI 1.4-4.2; (6) use of cold blood cardioplegia: OR 2.0, CI 1.2-3.6; (7) preoperative renal failure: OR 1.6, CI 1.0-2.6; and (8) active endocarditis: OR 1.7, CI 0.9-3.0. A model for postoperative permanent pacemaker requirement using the eight predictors was formulated and tested (Brier score = 0.017+/-0.003; Z = 0.18). CONCLUSIONS: The proposed predictive model correlated highly with actual pacemaker use, which suggests that the requirement for pacing results from either operative trauma or increased ischemic burden. Preoperative identification of patients at increased risk of conduction disturbances may allow for earlier detection and improved treatment. Patients requiring postoperative pacing had increased morbidity and length of stay.     

Coronary artery bypass graft surgery in dialysis patient

To determine the operative outcome of coronary artery bypass graft surgery (CABG) for severe coronary artery disease in long-term hemodialysis patients, we analyzed a group of 16 patients who underwent CABG over a ten-year period in our institution. Hospital mortality was 12.5% (2 of 16 patients). These two patients died of ischemic colitis and perioperative myocardial infarction, respectively. There were five late deaths: one patient died from myocardial infarction, one from uremia, one from gastro-intestinal bleeding, one from gastric cancer and one from unknown cause. There were four significant postoperative complications (morbidity 25%), consisted of one pulmonary tuberculosis, one sternal dehiscence secondary to mediastinitis, one mediastinal hematoma secondary to late bleeding from the LITA dissection area and one A-V shunt trouble. Graft patency rate within the first two months was 93% (30 to 42 in 13 patients). Hospital survivors experienced complete relief from angina. Actuarial survival was 68.8% at 3 years, 57.3% at 5 years and 28.6% at 7 years. This rate is not significantly different from the survival of all dialysis patients, but seems to be better than that of dialysis patients with not operated coronary artery disease. We concluded that CABG in dialysis patients can be accomplished with acceptable morbidity and mortality and effective relief of symptoms.     

The use of prosthetic meshes in the surgical treatment of inguinal hernia: the costs and profits for the local health screening unit]

BACKGROUND: The appropriate timing of elective coronary artery bypass surgery (CABG) following acute myocardial infarction (AMI) remains uncertain. It is hypothesized that a waiting period allows the myocardium to recover prior to revascularization, thus decreasing morbidity and mortality. This study was designed to determine if a waiting strategy is justified following AMI in patients requiring elective CABG. METHODS: Between 1994 and 1996, 214 patients underwent isolated, nonrepeat, elective CABG. Three groups were evaluated: group I, control, 155 patients with no AMI; group 11, 39 patients with nontransmural AMI; and Group III, 20 patients with transmural AMI. Demographics, intraoperative, and postoperative variables were collected and compared among all groups. RESULTS: Groups were well-matched demographically: group I, patients waited an average of 2.3 days in hospital prior to operation; group II, an average of 4.2 days; and group III, an average of 5.2 days. Except for the use of inotropes, group I 34%, group 11 39%, and group III 70% (P = 0.007), and the intra-aortic balloon pump, group I 0%, group 11 8%, and group III 25% (P = 0.001). There were no differences in complications. Importantly, there was no difference in mortality or postoperative length of stay. The mortality in group I was 2.6%, in group 11 2.6%, and in group III 0%. The length of stay in groups I and II was 8.5 days, and in group III, 8.1 days. CONCLUSION: A waiting period of 3 to 5 days after a nontransmural AMI and 5 to 7 days after a transmural AMI can produce similar postoperative results to non-AMI patients undergoing CABG. Thus, a waiting strategy to allow the myocardium to recover is justified.     

Management and outcomes for black patients with acute myocardial infarction in the reperfusion era. National Registry of Myocardial Infarction 2 Investigators

Data from a national registry of myocardial infarction patients from June 1994 to April 1996 were analyzed to compare the presenting characteristics, acute reperfusion strategies, treatment patterns, and clinical outcomes among black and white patients. Blacks presented much later to the hospital after the onset of symptoms (median 145 vs 122 minutes, p <0.001), were more likely to have atypical cardiac symptoms (28% vs 24%, p <0.001), and nondiagnostic electrocardiograms during the initial evaluation period compared with whites (37% vs 31%, p <0.001). Also, blacks were less likely to receive intravenous thrombolytic therapy (adjusted odds ratio [OR] 0.76, 95% confidence intervals [CI] 0.71 to 0.80), coronary arteriography (adjusted OR 0.85, 95% CI 0.77 to 0.95), other elective catheter-based procedures (adjusted OR 0.87, 95% CI 0.78 to 0.96), and coronary artery bypass surgery (adjusted OR 0.66, 95% CI 0.58 to 0.75) than their white counterparts. Despite these differences in treatment, there were no significant differences in hospital mortality between blacks and whites.     

Induction of IgE antibody production in mice with different DPT-vaccine preparations

A historical cohort study was performed to assess cardiovascular morbidity and mortality in Type 2 (non-insulin-dependent) diabetic patients. The data were collected from 1967 to 1989 in four Dutch general practices performing the Continuous Morbidity Registration Nijmegen. Each newly diagnosed Type 2 diabetic patient fulfilling the WHO criteria (n = 265) was matched to a control patient for practice, sex, age, and social class. Inclusion started in 1967, the first year of the still ongoing, Continuous Morbidity Registration Nijmegen. On average, a follow-up of 6.8 years (range 1 month-22 years) was realized. Compared to the non-diabetic control patients, the Type 2 diabetic patients showed higher cardiovascular morbidity (risk ratio 1.76, 95% CI 1.34-2.30) and a higher mortality rate (risk ratio 1.54, 95% CI 1.07-2.23). Mortality after 10 years was 36% vs 20% (p < 0.01), the median survival time 16 years vs 19 years. The cumulative survival rates were significantly different (p < 0.01) between patients and controls in the age group 65-74 years. The higher mortality in Type 2 diabetic patients was completely due to an excess of cardiovascular death (risk ratio 2.05, 95% CI 1.24-3.37).     

Selective and unselective clamping in cirrhotic liver

BACKGROUND/AIMS: Liver surgery requires a reduction of the operative blood loss especially for patients with cirrhosis. Selective or unselective liver clamping during hepatic resection is performed to minimize the surgical risk for such compromised patients. METHODOLOGY: We carried out elective hepatic resection in 158 patients with the use of total hilar clamping (Pringle's manoeuvre) or selective vascular clamping (Makuuchi's manoeuvre). The clinical outcomes were evaluated according to the clamping method and the condition of background liver. RESULTS: Pringle's manoeuvre was used in 132 patients who underwent all types of hepatectomy, whereas Makuuchi's manoeuvre was applied selectively to 26 patients, most of whom underwent segmentectomy or subsegmentectomy. A modified Makuuchi's manoeuvre was used in eight healthy donors who underwent left-sided hepatectomy for transplantation. The cumulative clamping times and blood losses were 61 +/- 47 min (mean +/- SD) and 831 +/- 716 ml in the Pringle's manoeuvre group, and 95 +/- 47 min and 1.035 +/- 577 ml in the Makuuchi's manoeuvre group. In patients with normal hepatic parenchyma the longest clamping time was 322 min, and in those with cirrhosis it was 202 min. All the patients in this series tolerated vascular clamping well, and their hepatic functional parameters returned, regardless of the presence or absence of cirrhosis, to the baseline levels within a week. As a whole, the operative morbidity and mortality rates were 20.3% and 0%, respectively. CONCLUSIONS: Intermittent total or selective clamping can be an indispensable procedure during hepatic resection for all patients, irrespective of the degree of hepatic dysfunction, to improve safety and resectability.     

Microbiological factors influencing the outcome of nosocomial bloodstream infections: a 6-year validated, population-based model

All patients (n = 1,745) with nosocomial bloodstream infection identified between 1986 and 1991 at a single 900-bed tertiary care hospital were studied to identify microbiological factors independently associated with mortality due to the infection. Patients were identified by prospective, case-based surveillance and positive blood cultures. Mortality rates were examined for secular trends. Prognostic factors were determined with use of univariate and multivariate analyses, and both derivation and validation sets were used. A total of 1,745 patients developed nosocomial bloodstream infection. The 28-day crude mortality was 22%, and crude in-hospital mortality was 35%. Factors independently (all P < .05) associated with increased 28-day mortality rates were older age, longer length of hospital stay before bloodstream infection, and a diagnosis of cancer or disease of the digestive system. After adjustment for major confounders, Candida species were the only organisms independently influencing the outcome of nosocomial bloodstream infection (odds ratio [OR] for mortality = 1.84; 95% confidence interval [CI], 1.22-2.76; P = .0035). The two additional microbiological factors independently associated with increased mortality were pneumonia as a source of secondary infection (OR = 2.74; 95% CI, 1.87-4.00; P < .0001) and polymicrobial infection (OR = 1.68; 95% CI, 1.22-2.32; P = .0014). Our data suggest that microbiological factors independently affect the outcome of nosocomial bloodstream infection.     

Malignancy associated with hepatolithiasis

BACKGROUND/AIMS: Malignancy is known to be associated with hepatolithiasis. The present report summarizes the results of our management of patients with cholangiocarcinoma associated with hepatolithiasis. MATERIALS AND METHODS: Twenty patients with cholangiocarcinoma and associated hepatolithiasis were analyzed retrospectively. There were 12 males and 8 females, with a mean age of 59.3 years. The clinical records of these patients were reviewed to determine demographic characteristics, clinical features, laboratory findings, diagnostic tests, operative management and results of therapy. RESULTS: One patient was moribund on presentation and was treated conservatively. Fourteen patients underwent hepatic resection. Three of them had palliative resection. Hepatic resection was less likely to be performed in patients having right lobe disease (50%) as compared to patients having left lobe disease (90%) (p = NS). The overall operative morbidity and mortality rates after hepatic resection were 36% and 7%, respectively. Non-resective operations were performed in five patients. The overall operative morbidity and mortality rates after non-resective operations were 20% and 0%, respectively. After curative hepatic resection (11 patients), the 1- and 2-year survival rates were 81% and 51%, respectively. CONCLUSIONS: A suspicion of malignancy is necessary in managing patients with hepatolithiasis. Hepatic resection is the treatment of choice for cholangiocarcinoma when it is resectable.     

Chlamydia pneumoniae infection is frequent but not associated with coronary arteriosclerosis in cardiac transplant recipients

We sought to explore the relation between Chlamydia pneumoniae, cytomegalovirus (CMV), and cardiac transplant-associated arteriosclerosis. Serologic evidence of past Chlamydia pneumoniae infection was investigated in 3 patient groups at the time of cardiac catheterization: cardiac transplant recipients (n=49), patients having coronary artery bypass grafting (CABG) (n=39), and a control group free of angiographic coronary artery disease (n=21). High Chlamydia pneumoniae immunoglobulin G titers (> or =1:160) were more frequently observed in cardiac transplant recipients (odds ratio[OR] 13.7; 95% confidence intervals [CI] 1.6 to 117.4, p <0.05) and CABG patients (OR 21.7; 95% CI 1.6 to 287.0, p <0.05) than in controls. However, high Chlamydia pneumoniae titers did not distinguish between cardiac transplant recipients with or without angiographic transplant-associated arteriosclerosis or CABG patients with or without bypass vein graft disease. Furthermore, there was no significant relation between elevated Chlamydia pneumoniae titers and the presence or progression of transplant-associated arteriosclerosis in the subgroup of patients who were also CMV positive. Yet, analysis of the same angiograms demonstrated an association between CMV infection and the recent progression of transplant-associated arteriosclerosis. Thus, patients with cardiac transplantation have evidence of past Chlamydia pneumoniae and CMV infection but Chlamydia pneumoniae does not appear to have an independent role or synergistic relation to CMV in the development of transplant-associated arteriosclerosis.     

Aortic valve replacement after previous coronary artery bypass grafting

BACKGROUND: As the population ages, an increasing number of patients with previous coronary artery bypass grafting (CABG) will require subsequent aortic valve replacement (AVR). This study examined outcome of AVR after previous CABG and reviewed possible indications for valve replacement at the time of initial myocardial revascularization. METHODS: Between March 1975 and December 1994, 145 patients had AVR after previous CABG. Sixty-three patients (43%) had their initial CABG elsewhere. Reoperation for AVR was the second cardiac procedure in 137 patients and the third in 8. Redo CABG with AVR was done in 66 (46%). There were 118 men and 27 women. The mean age at CABG was 64 +/- 7.9 years; for AVR this was 71 +/- 7.6 years. RESULTS: In 2 young patients accelerated calcific aortic stenosis occurred in the setting of renal failure. Significant aortic stenosis did not appear to be addressed at initial CABG in 3 patients. Transaortic valvular gradient, as measured by cardiac catheterization, increased by 10.4 +/- 7.0 mm Hg/y. Twenty-four patients (16.6%) died. The mortality for AVR alone or for AVR + redo-CABG was 15 of 125 patients (12%). For patients having more complicated procedures, the mortality was 9 of 20 (45%). Nine patients (6.2%) suffered a postoperative cerebrovascular accident. Low preoperative ejection fraction measured by echocardiography, sternal reentry problems, complexity of operation, and prolonged cross-clamp and bypass times were significant factors associated with mortality. Age at AVR, interval between operations, the extent of underlying native coronary artery disease, the state of the previously placed bypass conduits, and methods of myocardial preservation were not significant predictors of operative mortality. On multivariate analysis there was only one significant value: prolonged cross-clamp time. CONCLUSIONS: Aortic valve replacement after previous CABG is associated with a mortality that is higher than that seen after repeat CABG or repeat AVR. It seems prudent, therefore, to use liberal criteria for AVR in those patients who require coronary revascularization and who, at the same time, have mild or moderate aortic valve disease.     

Association of secondary and polymicrobial nosocomial bloodstream infections with higher mortality

The objective of this study was to characterize microbiological factors independently associated with higher mortality rates following nosocomial bloodstream infection. All patients admitted to the University of Iowa Hospitals and Clinics between 1 July 1989 and 30 June 1990 who developed a nosocomial bloodstream infection were included. The crude in-house mortality for the 364 patients with nosocomial bloodstream infections was 33%. These deaths accounted for 25% of all in-hospital deaths. Significant risk factors for death from bloodstream infection included diagnoses of cancers and diseases of the cardiovascular and respiratory systems (p < 0.01). Neither previous surgery nor neutropenia was associated with higher mortality rates. Whereas the crude mortality rates associated with gram-negative (33%) and gram-positive (31%) bloodstream infections were similar, that associated with fungemia was higher (54%, p < 0.02). The mortality associated with secondary bloodstream infections (46%) was higher than that associated with primary bloodstream infections (28%, p < 0.001). Furthermore, polymicrobial infections had a worse prognosis than infections from which a single pathogen was isolated (p < 0.05). A multivariate, logistic regression model identified four variables that independently predicted mortality (p = 0.025): age (OR 1.01 per year; CI95 1.00-1.02); cancer (OR 2.35, CI95 1.26-4.37) or diseases of the cardiovascular or respiratory systems (OR 2.20, CI95 1.04-4.67); polymicrobial infection (OR 2.34; CI95 1.21-4.53); and secondary bloodstream infection (OR 2.46; CI95 1.50-4.02). The last variable was the strongest independent predictor. Our study demonstrates the importance of microbiological factors in the outcome of nosocomial bloodstream infections.     

Spectrum of disease among HIV-infected adults hospitalised in a respiratory medicine unit in Abidjan, C?te d'Ivoire

SETTING: Respiratory medicine wards of the University Teaching Hospital, Abidjan, C?te d'Ivoire. OBJECTIVES: To describe the spectrum of opportunistic infection among human immunodeficiency virus (HIV) infected adults hospitalised in the respiratory medicine unit in Abidjan, and the level of immunosuppression at which these diseases occur. DESIGN: Cross-sectional study. RESULTS: Overall, 75% of patients were HIV-positive: among these patients, the most frequent diagnosis was tuberculosis, in 61%, followed by bacterial pneumonia (15%), Gram-negative septicaemia (particularly non-typhoid Salmonella) (9%) and empyema (5%). Atypical pneumonias appeared to be rare. Most HIV-positive patients had CD4 counts indicative of advanced immunosuppression: 36% had CD4 counts below 100 x 10(6)/l, 19% between 100 and 199 x 10(6)/l, 29% between 200 and 499 x 10(6)/l, and 16% above 500 x 10(6)/l. Overall in-hospital mortality was 27% for HIV-positive patients and 22% for HIV-negative patients (P = 0.5). In a multivariate analysis, the strongest independent risk factors for death were cachexia (odds ratio [OR] 7.4, 95% confidence interval [CI] 2.1-26.3), male sex (OR 4.5, 95% CI 1.2-17.4) and age over 40 (OR 4.1, 95% CI 1.0-17.2). CONCLUSIONS: Tuberculosis and bacterial infections are the major causes of respiratory morbidity in immunosuppressed HIV-infected adults in this population. Efforts to improve the management of HIV-related disease need to focus on prevention and treatment of these infections.     

Vascular determinants of epilepsy: the Rotterdam Study

PURPOSE: To investigate the relation between vascular determinants and epilepsy in an elderly population. METHODS: This is a cross-sectional, community-based, case-control study. The total study population was comprised of 4,944 subjects, 65 of whom had epilepsy which conformed to International League Against Epilepsy (ILAE) criteria. Vascular determinants that were evaluated included a history of stroke or myocardial infarction, peripheral vascular disease, hypertension, serum total cholesterol and left ventricular hypertrophy. Multivariate logistic regression analysis was used to calculate prevalence odds ratios (OR), adjusted for age and gender, as a measure of the strength of the associations. RESULTS: A history of stroke was strongly associated with lifetime epilepsy (OR 3.3; 95% CI [Confidence Interval] 1.3-8.5), as well as with late-onset epilepsy (OR 3.1; 95% CI 0.9-10.6). All vascular determinants were associated with lifetime epilepsy and late-onset epilepsy, with odds ratios >1. When stroke patients were excluded, the odds ratios were statistically significant for the relationships between total cholesterol and late-onset epilepsy (OR 1.3, 95% CI 1.0-1.6) and left ventricular hypertrophy and late-onset epilepsy (OR 2.9, 95% CI 1.0-8.6). Furthermore, presence of any of these vascular indicators was twice as common among subjects with late-onset epilepsy as compared with subjects without epilepsy (OR 2.0, 95% CI 0.9-4.2), and this was statistically significant when stroke patients were excluded (OR 2.1, 95% CI 1.0-4.7). CONCLUSIONS: These results suggest that there may be a relationship between vascular factors and the risk of late-onset epilepsy, apart from the relationship that exists through clinically overt stroke.     

Expression of type II cGMP-dependent protein kinase in rat kidney is regulated by dehydration and correlated with renin gene expression

To define the current indications for surgical management of pleuropulmonary tuberculosis and analyze the results of operative procedures, the records of 59 patients operated on between January 1987 and December 1993 were reviewed. Three patient categories were defined. Group I patients (n = 25) underwent operation for diagnostic purposes: solitary mediastinal node or mediastinal adenopathy associated with pulmonary lesions (n = 10), pulmonary infiltrates (n = 4), pulmonary nodules or masses (n = 10), or chronic pleurisy (n = 1). Postoperative mortality and morbidity rates in this group were both 4%. Group II patients (n = 18) underwent operation for active lesions: intrapulmonary cavity (n = 6), destroyed lung parenchyma (n = 6), or chronic loculated pleural effusion (n = 6). Postoperative morbidity and mortality rates were 16.6% and 5.5%, respectively. Group III patients (n = 16) underwent operation for a complication of therapy or for sequelae of previously "cured" tuberculosis: calcified pyothorax (n = 8), empyema (n = 2), fistulized nodes (n = 2), bronchiectasis (n = 3), or aspergilloma (n = 1). Morbidity and mortality rates in this group were 31.25% and 12.5%, respectively. Surgery continues to have both diagnostic and therapeutic indications for management of pleuropulmonary tuberculosis, despite the morbidity and mortality rates associated with operative procedures.