Outcome of cardiac valve ring abscesses after medical treatment: attempt to identify criteria of favorable prognosis

OBJECTIVES: Identify factors predicting favorable outcome after medical management of valve ring abscesses in order to propose a surveillance schedule for conservative treatment. METHODS: A multicentric study conducted from July 1989 to February 1996 included 28 patients (mean age 64 +/- 16 years, range 26-83) hospitalized for active endocarditis and valve ring abscesses diagnosed at transthoracic or transesophageal echography. Conservative medical therapy was given because of a decision of the medico-surgical team (n = 9), high surgical risk (n = 12), or patient refusal of surgery (n = 7). Outcome was favourable in 18 patients (Group I) and unfavorable in 10 (Group II) due to death (n = 9) or subsequent surgery (n = 1). Univariate and multivariate analysis were used to determine differences between the groups in terms of clinical and laboratory data. RESULTS: Mean follow-up in Group I was 33 +/- 18 months and 15 +/- 10 months in Group II. Univariate analysis showed significant differences between Group I and II respectively for age (59 +/- 18 yr vs 72 +/- 10, p = 0.04), delay to apyrexia after antibiotics (4.3 +/- 2.8 vs 8.3 +/- 2.4 days, p < 0.0008), heart failure (5% vs 70%, p = 0.003), grade III or IV valvular regurgitation (5% vs 60%, p < 0.04), and mean surface area of the abscess (1.5 +/- 1.2 vs 5.4 +/- 6.4 cm2, p < 0.03). Independent factors at multivariate analysis were by decreasing order: lack of heart failure at admission, delay to apyrexia, abscess surface area, and age. Outcome was favorable (mean follow-up 33 +/- 10 months) in all patients with an abscess surface area < 1.5 cm2, no signs of heart failure, no grade III or IV valvular regurgitation, apyrexia after less than 8 days on antibiotics and no staphylococcus positive blood culture. CONCLUSION: Medical management of valve ring abscesses may be indicated in selected patients in care units with rigorous surveillance facilities. Further studies are needed to precisely identify surveillance and treatment criteria.     

Study of direct and indirect naphtha recycling to a resid FCC unit for maximum propylene production

To satisfy the increasing propylene demand, direct and indirect naphtha recycling schemes around an existing resid fluid catalytic cracking (FCC) unit were investigated. To this aim, light cracked naphtha (LCN), heavy cracked naphtha (HCN) and a PolyNaphtha (PN) oligomerisation product were cracked under a wide range of operating conditions over a commercial Y zeolite based equilibrium catalyst. Experimental data were acquired in three different units: a fixed bed bench scale unit, a fixed fluidised bed unit and an adiabatic circulating fluidised bed pilot plant. It was shown that FCC naphthas require high operating severities to crack, and that even then their conversion remains relatively moderate. Hence, direct recycling to the main riser does not seem a viable pathway to increase propylene product. Feeding FCC naphthas to a second reaction zone operating at high severity allows to increase the propylene yield in a significant manner. Increasing conversion, however, not only leads to higher LPG and propylene yields, but also results in very high dry gas yields. An alternative scheme was proposed, in which the olefinic C₄ and C₅ fractions are converted into a naphtha fraction through oligomerisation in a dedicated unit before being recracked in the secondary riser. As the highly olefinic oligomerised effluent mainly consist of dimerised and trimerised butenes and pentenes, this feed is more easily cracked and high conversions can be achieved. This indirect interconversion of butenes and pentenes into propylene therefore effectively allows to convert these butenes and pentenes into propylene, resulting in a significant increase in propylene yield. Each of the three main naphtha recycle options (directly to the main riser, directly to a secondary riser or indirectly via a light olefin oligomerisation unit) have been analysed and compared to a base case. In the evaluation of each of these schemes, all heat balance effects, both on the riser and the regenerator side, have been accounted for. The proposed process scheme with an indirect recycle via an oligomerisation unit enhances the already inherent flexibility of the FCC unit. The naphtha recycle can be turned on or off, the second reaction zone can be used to crack naphtha or to crack resid feed to maximise throughput, while the effluent of the oligomerisation unit can be recycled to the FCC unit for propylene production or hydrogenated and sent to gasoline and kerosene pool.     

Clinical and experimental studies of intraoperative autotransfusion using a new filtration device

The Haemocell S-350 device has recently been introduced for intraoperative autotransfusion. The system uses a novel membrane filter to process shed blood. In the first part of this study a 0.2-micron pore size filter was used in a randomized trial comparing the use of autotransfusion (n = 8) with bank blood controls (n = 9) during aortic reconstruction. This part of the trial was abandoned because of unexpected non-surgical bleeding. Bank blood requirements fell from a median of 3.0 (range 0.0-9.0) units to 1.5 (range 0.0-7.0) units when autotransfusion was used, but these patients had a greater perioperative blood loss (1791 (range 932-3104) versus 1140 (range 440-3840) ml). There was evidence of postoperative heparin excess with an activated partial thromboplastin time ratio of 1.3 (range 0.9-3.0) versus 1.0 (range 1.0-1.2) in controls and an activated clotting time of 206 (range 143-280) versus 137 (range 107-142) s. This was confirmed by raised plasma heparin levels and a prolonged thrombin time normalized by protamine. To improve performance a 0.6-micron pore size filter was studied in ten patients. Filtration efficiency doubled from 19 to 38 per cent. Electron micrographs demonstrated better filter clearance, but 44 per cent of the original concentration of heparin remained in the reinfusate. The S-350 device may be an attractive alternative to centrifugation for intraoperative autotransfusion but, until efficiency is improved, it should only be used for cardiovascular surgery when excess heparin can be reversed with protamine.     

Change of foot size with weightbearing. A study of 2829 children 3 to 18 years of age

The change of foot length and width with age has been reported in a few anthropometric studies in the literature. However, the relationship with body height rarely is reported, and the dynamic effect of weightbearing on foot size has not been documented. In this series, 2829 children 3 to 18 years of age of equal gender distribution were included in the study. The foot length and width on weightbearing and nonweightbearing were measured with a special precision electronic caliper. The foot length and width were found to increase linearly from the age of 3 years until 12 years in girls and 15 years in boys. This was followed by a phase during which the increase plateaued. The foot length and width increased significantly on weightbearing at all ages in both genders with a mean of 2.1 to 4.4 mm or 3.1% to 4.8%, respectively. The foot length and width also were found to correlate significantly with the body height in both genders, with a correlation coefficient of 0.96 to 0.98. No significant differences were found between the sizes of the dominant and nondominant foot in either gender.     

Pathogenetic aspects of the L-arginine-NO metabolic pathway in arteriosclerosis and possible therapeutic aspects

A yearly pattern in the occurrence of uterine cervical cancer (UCC), obtained from cytological examinations reported as type V (cases concluding a malignant alteration), has been previously shown for data obtained in the Monterrey Metropolitan Area (state of Nuevo Leon, Mexico) for a span of 10 years (1978-1987), with a peak of relative incidence in the month of February being high stable for consecutive years. With the aim of extending and validating those results, we analyzed the monthly totals of positive detected cases of UCC in the states of Nuevo Leon, Chihuahua, Coahuila, and Tamaulipas (covering most of Northern Mexico) during the same period. To eliminate bias due to the seasonal variation in the number of screening smears, data were first expressed in relation to the number of cytological examinations done the same month. The least-squares fit of a 1-year cosine curve to the data of relative incidence in the four states reveals a statistically significant yearly pattern (p = .008), with a maximum of relative incidence in February almost double that during the rest of the year. Results indicate that the relative incidence of UCC is higher than the yearly average during the winter, with secondary peaks in May and October. In view of the nonsinusoidal waveform in the incidence of UCC, we undertook a multiple-component analysis, allowing several cosine functions to be simultaneously fitted to the data. Results indicate that the yearly pattern in the relative incidence of UCC can be represented by a model that includes two components with periods of 12 and 4 months (p = .004). The same model can be documented as statistically significant independently for each of the four states. These results, summarizing over 2200 positive cases of UCC detected in more than 1,100,000 screening smears, are in full agreement with those found previously for part of the state of Nuevo Leon and reveal a highly stable and predictable yearly pattern of variation in the relative incidence of UCC in Northern Mexico.     

Insulin propeptides in conditions associated with insulin resistance in humans and their relevance to insulin measurements

Routine insulin assays measure not only biologically active insulin but also the relatively inactive propeptides, proinsulin and desdipeptide proinsulin. Such measurements may be misleading if insulin propeptide levels are increased, as has been reported in patients with non-insulin-dependent diabetes mellitus (NIDDM). Inferences regarding insulin resistance, based on hyperinsulinemia, could thus be invalidated where routine insulin assays have been used. We have measured plasma insulin levels using a routine assay, together with measurements of the major circulating insulin propeptides, intact proinsulin and des 31,32proinsulin, in various clinical situations associated with apparently increased insulin levels and insulin resistance. Major increases of insulin propeptide levels relative to insulin levels were not seen in obese subjects or in patients taking oral contraceptives or danazol, or in obese subjects compared with non-obese controls. Although the insulinemic responses observed with routine radioimmunoassay in these situations associated with insulin resistance are not confounded by major changes in the proportion of circulating insulin propeptides, further studies will be necessary to validate investigations in other insulin-resistant states.