An uncommon cause of peripheral neuropathy.

The following case report is of a middle aged man with a progressive neurologic disability who was brought to our emergency department. Caregivers could no longer manage him once he lost the ability to ambulate and became incontinent. At that time his neurologic and hematologic parameters were fairly typical of cobalamin deficiency. We are reporting this case to emphasize that cobalamin deficiency is not always due to pernicious anemia in the elderly or the malnourished alcoholic. Deficiency from uncommon causes can manifest at any age and result in severe morbidity.

Follow up of elderly patients after cardiac surgery and intensive care unit admission, 1991 to 1995.

AIMS: To examine the outcome of cardiac surgery and resulting intensive care admission in elderly (> or = 75 years) cardiac surgery patients at Waikato Hospital, 1991 to 1995. METHODS: Clinical records of all elderly cardiac surgery patients admitted to the intensive care unit were reviewed. All survivors were sent a postal questionnaire evaluating cardiac related symptom control and quality of life (QOL). Outcomes in the 'old' (75-79 years) and in the 'very old' (> or = 80 years) were compared. RESULTS: Seventeen of 97 patients had died. Mean survival time was 32.2 months. Survivor followup (100%) was at a mean of 34.8 months. Mean functional class (New York Heart Association or Canadian Cardiovascular Society) improved from 3.0 preoperatively to be 1.7. Cardioactive medications fell by a mean of 0.7 drugs per patient. Twenty-seven percent of survivors became more dependent as assessed by domicile type. Outcomes between the two groups were not different except for some improved individual changes in functional class. The 'very old' group have a similar postoperative QOL to that of the 'old' group. Ninety-two percent of survivors indicated that they would opt for cardiac surgery again if given the time over. CONCLUSIONS: Following cardiac surgery and intensive care admission at Waikato Hospital, surviving elderly patients have experienced a favourable outcome in terms of symptom control and quality of life. Mortality rates are acceptably low.

Open heart surgery: intensive care component, clinical profile and costs over one year.

A profile of 333 patients admitted to the intensive therapy unit, Waikato Hospital, over one year ending 30 June 1990, is presented. A close costing of a representative sample of 30 of those patients was done. The average cost of their intensive care stay was $2948 per patient. Twenty-four of the patients cost an average $2200 and the other six cost an average $5700.

The incidence and significance of early pericardial effusion after open heart surgery.

The presence and severity of postoperative pericardial effusions were studied echocardiographically in 114 consecutive patients (70 males, 44 females; mean age 56 +/- 10 years). An effusion was present in 35 patients at 3-5 days. An effusion was less common when a drainage tube was inserted for 24-36 h in the posterior as well as the anterior mediastinum than when only an anterior drain was used. Patients with effusions differed from those without in having more supraventricular arrhythmias, more wound infections, smaller total blood drainage and longer postoperative hospital stay. Three patients with posterior pericardial effusions developed cardiac tamponade 5-18 days postoperatively. The data show that pericardial effusions are associated with postoperative complications and suggest that effusion formation can be reduced by using posterior as well as anterior chest drains.

Metabolic damage to human saphenous vein during preparation for coronary artery bypass grafting.

Segments of saphenous vein from patients undergoing coronary artery by-pass graft surgery were frozen in liquid nitrogen immediately on dissection (control), after stripping of the adventitia and side branch ligation (manipulation), after distention with blood (distention), or at completion of the last proximal anastomosis (prepared vein). Vein was stored during the operation in patient's heparinised arterial blood at room temperature. Frozen vein was extracted with perchloric acid. ATP, ADP, and AMP, adenosine, inosine and hypoxanthine concentrations were measured by high pressure liquid chromatography. Prepared vein had ca 50% lower ATP concentrations and ATP/ADP ratio than control vein, higher concentrations of inosine and hypoxanthine and lower concentrations of AMP and adenosine. ATP concentration and ATP/ADP ratio did not correlate with the time elapsed between dissection and freezing of the prepared vein. The characteristic changes seen in prepared vein were not seen when control vein was simply stored in arterial blood at 23 degrees C, in normal saline at 23 degrees C or 4 degrees C, in Krebs-Ringer bicarbonate buffer at 37 degrees C or at St Thomas's Hospital cardioplegic solution at 4 degrees C. Distention with unlimited pressure did not distension at less than 300 mmHg gave rise to the same changes in ATP concentration and ATP/ADP ratio as in the prepared vein. These results show that vein suffered metabolic changes during preparation for bypass grafting and suggest that uncontrolled distention may contribute to these changes. Such biochemical measurements provide a quantitative estimate of tissue damage and allow objective comparison of different preparative techniques.

Right coronary artery occlusion by cloth from a Starr-Edwards aortic valve prosthesis.

We report a case of sudden onset of angina 11 years after implantation of a No. 8 Model 2300 Starr-Edwards cloth-covered aortic valve prosthesis for aortic stenosis and insufficiency. At operation the cloth covering one strut of the metal cage was tenuously attached to the ring of the prosthesis, with its free end completely occluding the right coronary artery ostium. The valve was replaced and the obstructing foreign body removed, re-establishing the patency of the right coronary artery.

Comparative study of leg wound skin closure in coronary artery bypass graft operations.

A prospective randomised study of four different methods of leg wound skin closure after removal of the long saphenous vein was carried out in 113 patients undergoing coronary artery bypass grafting. These methods were: (1) continuous nylon vertical mattress suture (27 patients); (2) continuous subcuticular absorbable (Dexon) suture (29 patients); (3) metal skin staples (Autosuture) (27 patients); and (4) adhesive sutureless skin closure ("Op-site") (30 patients). All wounds were examined by two independent observers at five, 10, and 45 days after operation. At five days, inflammation, extent of oedema, discharge, and infection were assessed. At 10 days attention was paid to the state of wound healing and at 45 days to the final cosmetic appearance. The use of continuous subcuticular suture resulted in significantly less discharge than did the use of metal staples, nylon vertical mattress suture, or Op-site. The incidence of established wound infection was 4.5% overall, with no infection in the wounds closed with Dexon. Assessment of the healing process showed subcuticular Dexon to be more effective than metal staples or vertical mattress nylon suture. The final cosmetic result showed continuous subcuticular suture to be superior to nylon vertical mattress suture and skin staples but as effective as Op-site sutureless skin closure.

Voice changes following cricothyroidotomy.

Twenty-four patients underwent cricothyroidotomy at Guy's Hospital between 1977 and 1981. Of these, 13 died during admission or shortly after discharge as a result of their primary disease and three were unsuitable for further examination. The eight remaining patients were examined to assess the effect of cricothyroidotomy on the laryngeal function of voice production. Assessment was made both subjectively and objectively by laryngography. Objective findings were correlated with structural changes seen by indirect laryngoscopy. Six of the eight patients examined had both subjective and objective disturbance of voice production. We report our experience with the surgical procedure of cricothyroidotomy which, in addition to a high incidence of vocal disturbance, includes one case of subglottic stenosis secondary to granulation tissue.

Hypertrophic obstructive cardiomyopathy. The use of a diathermy loop for septal resection.

The report describes the use of diathermy loop to resect the left ventricular component of the hypertrophied septum in hypertrophic obstructive cardiomyopathy (HOCM). The technique is simple to perform and is able to reduce significantly the systolic pressure gradient across the left ventricular outflow tract.

Mitral valve surgery in infants and children.

The pre-operative findings and surgical results of forty-three patients under thirteen years of age undergoing mitral valve surgery, are presented. Eight underwent surgery for mitral stenosis. Four had open mitral valvotomy with a satisfactory result, one developed severe regurgitation which required mitral valve replacement. Two had primary valve replacement and two had excision of a mitral subvalvar diaphragm. Thirty five children underwent surgery for mitral regurgitation. Twelve had a mitral annuloplasty. Two of these developed further regurgitation which required mitral valve replacement. Twenty one children had primary mitral valve replacement. The results and choice of valve replacement are discussed.

The surgery of aortic valve disease in neonates, infants and children.

The pre-operative findings and surgical results of forty-three patients under thirteen years of age undergoing isolated aortic valve surgery are reported. Twenty-six underwent open aortic valvotomy for isolated aortic valve stenosis. Of the nine who died, five were neonates. These deaths are attributed to an underdeveloped myxoid valve and aortic valve ring. Eleven children underwent excision of the subvalvar diaphragm but four developed asymptomatic left ventricular strain on ECG and required re-operation. There was one death. One child underwent successful surgery for supravalvar stenosis. Five children underwent surgery for isolated aortic regurgitation. Two underwent repair, but one required aortic valve replacement for uncontrolled regurgitation. Three had aortic valve replacement as a primary procedure. The management of left ventricular outflow tract obstruction and the choice of replacement valve is discussed.

Preparation of cardioplegic solutions.

The manufacturing methods and quality control procedures for two cardioplegic solutions are described. Procedures for preparing individual bottles or batches of two cardioplegic solutions (one with and one without albumin) and a carbonate-bicarbonate buffer solution are described. Final buffered cardioplegic solutions with albumin are stable for seven days. Cardioplegic solutions without albumin and buffer are stable for 30 days. The chemical and physiological factors affecting the content and preparation of cardioplegic solutions used during intracardiac surgery are reviewed. Because consistency is attained more readily, and because control procedures, including quarantining, are applied more readily to batch production of cardioplegic solutions, it is advised that this method be used.

One-dose antibiotic prophylaxis against wound infection after appendicectomy: a randomized trial of clindamycin, cefazolin sodium and a placebo.

Two hundred and fifty patients were admitted to a prospective randomized trial of single dosage prophylaxis against wound infection after appendicectomy. There were 12 exclusions, 72 patients received placebo, 81 received 600 mg i.m. clindamycin phosphate and 85 received 1 1 g i.m. cefazolin sodium, the agent being given in the anaesthetic room. Clindamycin produced a significant reduction in the overall rate of wound infection from 33 per cent in the controls to 17 per cent. In cases with a gangrenous or perforated appendix the infection rate in controls was 78 per cent; this was reduced to 44 per cent by a single dose of clindamycin. Cefazolin significantly reduced the number of aerobic organisms isolated from wound infections, but did not significantly reduce the incidence of wound infection. We conclude that anaerobic organisms are more important than faecal aerobic organisms in the pathogenesis of wound infection after appendicectomy.