Duct-to-duct biliary reconstruction following liver transplantation for primary sclerosing cholangitis.

The biliary complications in patients undergoing biliary reconstruction by duct-to-duct (D-D) anastomosis or with a Roux-en-Y loop (RL) at the time of liver transplantation for primary sclerosing cholangitis (PSC, 16 D-D, 10RL) or primary biliary cirrhosis (PBC, 31 D-D, 1 RL) were reviewed and compared. Patients were followed up for a mean period of 32 months. Extrahepatic biliary strictures occurred in 18.7%, 10% and 9.7% of DD-PSC, RL-PSC and DD-PBC patients, respectively, leaks in 6.2%, 20% and 6.4% DD-PSC, RL-PSC and DD-PBC patients, respectively (P = NS). Four intrahepatic biliary abnormalities developed in the PSC group. Duct-to-duct anastomosis did not significantly increase the risk of stricture formation or bile leaks in PSC patients compared to PBC patients. We conclude that duct-to-duct biliary reconstruction following liver transplantation for PSC is satisfactory unless the distal common bile duct is strictured.

Within-person fluctuations of serum cholesterol and lipoproteins.

The National Cholesterol Education Program has begun a National Campaign to screen millions of adult Americans for serum cholesterol. To determine whether such random samples represent an individual's true lipoprotein status, we measured fasting total serum cholesterol and lipoproteins, on a weekly basis for 4 weeks, in 20 subjects ages 22 to 63 years. Duplicate samples were tested by two standardized laboratories, each on five consecutive days. Variations of more than +/- 20% in the serum levels of total cholesterol, low-density lipoprotein cholesterol, and high-density lipoprotein cholesterol were seen in 75%, 95%, and 65% of the subjects, respectively. On retesting, 40% of the subjects moved in or out of one "risk category"; and in 10% two categories, from "desirable" to "high risk," or vice versa. These data demonstrate that random testing may fall to detect wide fluctuations in the levels of serum lipoproteins, and therefore result in erroneous risk assignment or therapeutic intervention.

Cervical mucus and serum estradiol as predictors of response to progestin challenge.

The present study was undertaken to assess the correlation between and relative predictive value of each of the following variables and progestin-induced withdrawal bleeding: cervical mucus appearance, serum E2 level, patient age, duration of amenorrhea, smoking and exercise habits, and body composition. Of 120 oligomenorrheic and amenorrheic women evaluated, only cervical mucus appearance and serum E2 level were significantly associated with response to progestin challenge. A multivariate logistical regression analysis showed cervical mucus to be the most predictive variable followed by serum E2 level. No absolute E2 level was found to discriminate between those who did and those who did not have withdrawal bleeding after progestin challenge. These data suggest that office examination of cervical mucus may be a useful indicator and guideline in planning therapy.

The Mid-Atlantic Oncology Program's comparison of two data collection methods.

The Mid-Atlantic Oncology Program (MAOP) compared clinical trial data collected by circuit riding data managers (CDMs) from the MAOP statistical center with data collected by local data managers (LDMs) from clinics and practices, the latter being the standard data capture method in cancer clinical trials. LDMs and CDMs filled out identical study forms, using the same patient charts, for randomly selected patients on MAOP protocols. All coded answers on the forms were compared by one of the authors (DJ) and discrepant items were resolved in a blinded manner by the local MAOP physician acting as the principal investigator (PI). Thirty-three patient charts were reviewed with 53 pairs of forms completed and 1023 pairs of codes compared. A total of 129 (13%) pairs of codes were considered discrepant. Of the 100 discrepancies resolved (29 items were answered differently by the CDM, LDM, and PI) the PI's answers matched 66 of 100 codes as recorded by the CDMs and 34 of 100 codes as recorded by the LDMs. This results in chi 2 = 9.61 (p less than 0.005), demonstrating a significant difference between the frequency with which the PI's answers matched data collected by the CDMs and LDMs. It was also determined that CDMs consistently coded toxicities as more severe than did LDMs and were more often correct. Given the results of this study, CDMs should be considered an acceptable alternative to LDMs in the context of regional programs.

Effects of hypothermia and hemodilution on oxygen metabolism and hemodynamics in patients recovering from coronary artery bypass operations.

The coexistence of hypothermia and hemodilution in patients in the intensive care unit immediately postoperatively after coronary artery bypass graft operations presents concerns regarding the adequacy of hemodynamics and oxygen metabolism. We evaluated the hemodynamic status and oxygen metabolism during the postoperative recovery period in six patients with moderate hemodilution (hematocrit value 34% +/- 3%) and in eight patients with marked hemodilution (hematocrit value 23% +/- 2%). All patients were well sedated and paralyzed with pancuronium bromide during the study period, during which their body temperature was slowly returning toward normal. In both groups, cardiac index at 34 degrees C was about 40% lower than at 37 degrees C. This was associated with 50% higher systemic vascular resistance and 30% lower oxygen availability to tissue. Oxygen consumption, however, was proportionally lower (45%) and coronary perfusion pressure was higher (28%) at 34 degrees C than at 37 degrees C; thus neither mixed venous nor coronary sinus blood oxygen saturation was compromised under hypothermic conditions. Although the trends in hemodynamic changes were similar in both groups, cardiac indices in patients with marked hemodilution were higher than cardiac indices in those with moderate hemodilution at all temperatures. This observation indicates that the hemodilution-induced rise in cardiac index remains intact even under hypothermic conditions. Under the conditions we studied, hypothermia with or without hemodilution had no significant adverse effects on hemodynamics and oxygen metabolisms of the whole body or of the heart.

Effects of CGS-13080, a thromboxane inhibitor, on pulmonary vascular resistance in patients after mitral valve replacement surgery.

Pulmonary hypertension with an elevated pulmonary vascular resistance was observed during the immediate recovery period in patients who underwent mitral valve surgery. In eight such patients, intravenous infusion of CGS-13080, imidazo(1,5-a)pyridine-5-hexanoic acid (a thromboxane synthetase inhibitor), at a dose range of 0.08-0.1 mg/kg/hr, effectively reduced pulmonary hypertension (from a mean pulmonary arterial pressure of 36 +/- 2 to 31 +/- 2 torr) and pulmonary vascular resistance (from 339 +/- 38 to 238 +/- 37 dynes.sec.cm-5) within 30 minutes and remained reduced for the entire infusion period (48 hours in five patients and 18 hours in three patients). Mean arterial pressure or systemic vascular resistance were not significantly affected by the drug infusion. Serum thromboxane B2 levels (a stable metabolic product of thromboxane A2) were significantly reduced after administration of the compound, with the maximum effect of greater than 90% reduction. All patients tolerated the drug infusion without significant side effects.

Predictors of length of hospitalization after cardiac surgery.

The cardiac surgical data base at Georgetown University Hospital was reviewed for patients operated on between January 1, 1980, and September 30, 1986, to determine predictors of length of postoperative hospitalization. Mortality among the 1,919 operations was 115 (6%). In the study group of 1,804 operations resulting in survival for at least 30 days, the following factors were analyzed: type of operation, age, sex, New York Heart Association (NYHA) Functional Class, urgency of operation, preoperative myocardial infarction (MI), weight, body surface area, hypertension, diabetes mellitus, previous cardiac operation, smoking history, and family history of cardiac disease. The overall mean length of hospitalization was 10.7 +/- 5.6 days. The analyses indicated that valve operation, age less than 30 and greater than 60 years, female sex, NYHA Class IV, urgent operation, preoperative MI 1 to 4 weeks before operation, and diabetes mellitus requiring medical treatment prolonged hospitalization, but generally by only 2 days. Major prolongation of hospitalization was associated with age in the 20- to 30-year and 80- to 90-year brackets. Unexpectedly, heavy body weight and smoking were not predictive.

Stability of multilead ST-segment "fingerprints" over time after percutaneous transluminal coronary angioplasty and its usefulness in detecting reocclusion.

Multilead ST-segment recordings taken during percutaneous transluminal coronary angioplasty (PTCA) could function as an individualized noninvasive template or "fingerprint," useful in evaluating transient ischemic episodes after leaving the catheterization laboratory. To evaluate the reproducibility of such ST-segment patterns over time, these changes were analyzed in patients grouped according to the time between occlusion and reocclusion. For the patients in group 1, the study required comparing their "fingerprints" in repeat balloon inflation during PTCA (reocclusion in less than 1 hour), for those in group 2, comparing ST "fingerprints" during PTCA with ST changes during spontaneous early myocardial infarction (reocclusion in 24 hours) and in group 3, comparing ST "fingerprints" with ST changes during repeat PTCA for restenosis greater than 1 month after the initial PTCA. The ST "fingerprints" among the 20 patients in group 1 were identical in 14 cases (70%) and clearly related in another 4 (20%). Of the 23 patients in group 2, 12 (52%) had the same and 8 (35%) had related patterns. Of 19 patients in group 3, 8 (42% had the same pattern and 8 (42%) had related patterns. Thus, ST fingerprints were the same or clearly related with reocclusion in the same patient from less than 1 hour to greater than 1 month after initial occlusion in 87% of patients overall, in 90% in less than 1 hour, in 87% in less than 24 hours and in 84% greater than 1 month later. Multilead pattern ST-segment "fingerprints" may serve as a noninvasive marker for detecting site-specific reocclusion.

Approaches to senior care #1. Hip fracture, depression, and cognitive impairment: a follow-up study.

Hip fractures in the elderly are accompanied by depression and cognitive impairment--two factors that impact on morbidity, mortality, and rehabilitation. This follow-up study assesses 35 elderly patients at three and six months post-hip fracture after earlier evaluations in the immediate post-fracture period. Mortality is increased in subjects with cognitive impairment at the time of fracture. Rehabilitation, as measured by activities of daily living, is slowed in subjects with combined depression and cognitive impairment. The study alerts physicians to the need for careful mental status evaluation at the time of trauma and surgery.

Comparison of Maxon suture with Vicryl, chromic catgut, and PDS sutures in fascial closure in rats.

Two hundred ten rats were randomized into one of five study groups to compare standard absorbable sutures with a new synthetic absorbable suture. We evaluated Maxon (polyglyconate), Vicryl (polyglactin), chromic catgut (catgut), and PDS (polydioxanone) with respect to tissue inflammatory reaction, knot security, suture tensile strength, and suture absorption. The results indicate that Maxon and PDS elicited a lower degree of chronic inflammation when compared with Vicryl and chromic catgut. The tensile strengths of Maxon and Vicryl significantly exceeded those of PDS and chromic catgut during the critical period of wound healing. Maxon and PDS retained a larger percentage of tensile strength during the long postoperative period, whereas Vicryl and chromic catgut were mostly absorbed. Maxon is an excellent addition to the armamentarium of the gynecologic surgeon.

Hemodynamics of protamine administration. Comparison of right atrial, left atrial, and aortic injections.

Protamine administration for heparin reversal after cardiopulmonary bypass on occasion is associated with mild to severe hemodynamic deterioration. The route of administration may modify these reactions. A prospective randomized study was done in 68 patients undergoing isolated coronary artery bypass grafting. The route of protamine administration was randomized in a balanced fashion between right atrium, left atrium, and aorta. The preoperative and operative characteristics of the three groups were similar. Hemodynamic measurements were recorded before cannulation, after removal of the venous drainage catheter, and 1 minute, 5 minutes, and 10 minutes after protamine administration. Hypotension occurred in 11 patients with no significant difference among the three groups. The hypotension was immediate in three patients in whom route of administration was the aorta. The overall hemodynamic changes observed for the three treatment groups were not significantly different. An analysis for type II error indicated that it was unlikely that an important difference had been missed. We conclude that the route of administration does not affect the hemodynamic changes associated with protamine administration. We did not observe a case of severe hemodynamic deterioration, so that we cannot assess the effect of route of administration on the severity of an anaphylactic reaction.

Valvular obstruction of blood flow through saphenous veins.

To measure effects of vein valves upon blood flow through venous bypass conduits, 15 human saphenous veins (mean length 40.6 cm, 5.3 valves/vein) were perfused with normal saline at constant pressure (100 mm Hg). Flow through vein was measured before and after valve bisection. Vein valves were bisected using Leather's techniques. After valve bisection, flow in antegrade and retrograde directions was measured in seven veins. These data were analyzed using paired t tests. Antegrade flow through seven veins with intact valves averaged 317.1 cc/min. With valve bisection this increased significantly (P less than 0.001) to 474.3 cc/min. Retrograde flow through veins with valves bisected increased significantly (P less than 0.0001) to 428.3 cc/min. Eleven veins (mean length 42.2 cm, 5.6 valves/vein) perfused simulated capillary beds with banked blood using pulsatile flow (mean pressure 92 mm Hg). Flow, again, was measured before and after valve bisection. Data were analyzed using the paired t test. Antegrade flow increased from 124.4 cc/min in veins with valves intact to 142.5 cc/min once valves were bisected (P = 0.02). These data demonstrate that saphenous vein valves cause significant obstruction to blood flow under conditions similar to those in the arterial system. Bisection of vein valves significantly increases flow through vein. Improved patency of vein grafts using valve bisection techniques may be explained by increased blood flow alone.

Determinants of cardiac failure after coronary bypass surgery within 30 days of acute myocardial infarction.

Timing of coronary artery bypass grafting after acute myocardial infarction (MI) is controversial, especially if myocardial function is depressed. Early coronary artery bypass grafting may result in reperfusion injury causing cardiac failure. Delay, however, may risk a second ischemic event. This study was performed to determine if four preoperative factors--time after MI, ejection fraction, ischemia (need for intravenous administration of nitroglycerin), and failure (need for inotropic support)--independently predict postoperative cardiac failure. Postoperative failure was defined as the need for inotropic support or intraaortic balloon pumping. The study group consisted of 145 patients who underwent isolated coronary artery bypass grafting between January, 1980, and July, 1985, within 4 weeks of an acute MI. Postoperatively 38 patients (26%) had cardiac failure. Five patients, all of whom had postoperative cardiac failure, died. Univariate and stepwise logistic regression analyses showed preoperative failure (p = .0001), ejection fraction less than 45% (p = .002), and preoperative ischemia (p = .02) were predictors of postoperative cardiac failure. Time after MI was not found to be an independent predictor (p = .96). We conclude that if ischemia or threatening coronary anatomy is present early after MI and clinical improvement is not occurring, operative intervention should be strongly considered at that time, as it does not appear that delay itself reduces the risk of cardiac failure and may risk a second ischemic event.

Assessment of depression and cognitive impairment after hip fracture.

Fifty patients, over 60 years of age, were evaluated for mental status change at the time of hip fracture. Specifically, demographic and historical data were gathered and patients were given an assessment battery to evaluate depression and cognitive impairment during hospitalization for femoral fracture. Prevalence of depression was 28%, and cognitive impairment was present in 40% of the patients evaluated. Pre-fracture activities of daily living were estimated. These data provide the first systematically accumulated baseline data for patients in the immediate post-hip fracture period. Patients will be reassessed at three-month intervals to quantify mental status change and to evaluate its effects on morbidity, mortality, and rehabilitative success.

Gallbladder dynamics in response to various meals: is dietary fat restriction necessary in the management of gallstones?

An estimated 20 million Americans have gallstones the majority asymptomatic. Yet traditionally many are often placed on low-fat or fat-free diets, presumably to reduce the risk of biliary colic. To assess the gallbladder dynamics in response to various meals, we studied 15 subjects (ages 21-54), each on 4 separate days. After an overnight fast, each subject was given, at random, either a breakfast containing greater than 30 g fat, less than 15 g fat, totally free of fat, or an infusion of C-terminal octapeptide of cholecystokinin. Gallbladder ejections at regular time intervals were measured using real time ultrasonography and the sum of cylinders technic corrected for the gallbladder shape. Considerable variability in the gallbladder dynamics and time response was noted with all the stimuli. However, among various meals, there were no statistically significant differences in the mean maximum ejection fraction or the mean maximum ejection time (p greater than 0.10). The mean maximum ejection fraction after cholecystokinin was somewhat greater (0.01 less than p less than 0.05) than that after meals, but the mean maximum ejection time was similar (p greater than 0.10). We conclude that the gallbladder dynamics in response to various meals are independent of a meal's fat content. Since the passage of gallstones into the cystic or common duct (biliary colic) is a random event unrelated to the type of food, fat-restricted diets offer no significant therapeutic advantage in the management of the large population with asymptomatic gallstones.

Sleep disorders on a psychiatric consultation service.

Of 100 consecutive patients on a psychiatric consultation service, 80 had sleep disorders; 72 had insomnia. Disturbed sleep was not mentioned in the records of 54% of the 80 patients, indicating a need for more physician education in sleep disorders.

Georgetown Adolescent Psychosocial Rating Scale.

UNLABELLED: The Georgetown Adolescent Psychosocial Rating Scale (GAPRS) was developed as a clinical tool to be used in the evaluation of the psychosocial development of the adolescent. Preliminary findings have shown it to be useful in assessing normal psychosocial development and identifying deviant states. The GAPRS was developed in a clinical setting over a 5-year period as a questionnaire with the statistical ability to assess adolescent psychosocial development. The data from this study support the GAPRS as a promising new clinical tool to be used with the adolescent patient for assessing normal and deviant psychosocial maturation in an efficient and concise manner. SPECULATION: Adolescent psychosocial maturation can be measured using key questions to measure normal development and deviant states.