Optimizing off-pump coronary artery bypass graft: technical and metabolic aspects.

PURPOSE: Our purpose was to determine if complete revascularization could be successfully performed off bypass in the majority of coronary artery bypass graft (CABG) patients. METHODS: Using a metabolic protocol and the Medtronic Octopus stabilizer device (Medtronic, Inc., Minneapolis, MN), 285 consecutive patients between July 1, 1997 and July 31, 1999 were successfully revascularized off pump via median sternotomy. A relative contraindication for off bypass CABG was cardiogenic shock. The metabolic protocol was designed to enhance systolic and diastolic cardiac function during surgery. RESULTS: Of 298 patients on whom we attempted off-pump revascularizations, 96% (285/298) were successful. The mean number of grafts per case was 3.3. The mean age of patients was 69.5 years, and 38% (109/285) were 75 years of age or older. Perioperative myocardial infarction (MI) occurred in two patients (0.7%) and operative mortality was 2.8% (8/285). Average Parsonnet score was 4.8. Cost savings were realized through minimal blood product utilization (average 1.5 units per case) and decreased cardiopulmonary bypass supplies. CONCLUSION: Complete revascularization can be performed off bypass in the majority of CABG patients. The concomitant use of the Octopus off-bypass technique with aggressive metabolic support ensures manual manipulation of a beating heart and results in a low incidence of postoperative complications and significant cost savings.

The effect of smoking on implant survival at second-stage surgery: DICRG Interim Report No. 5. Dental Implant CLinical Research Group.

Smoking has been reported to have a deleterious effect on the oral cavity. Research has associated smoking with oral cancer, periodontal disease, leukoplakia, stomatitis nicotina, and impaired gingival bleeding. In 1991 the Dental Implant Clinical Research Group initiated a prospective, randomized clinical study in cooperation with the Department of Veterans Affairs to investigate the influence of implant design, application, and site of placement on long-term clinical performance and crestal bone height. Over 70 dental and medical history variables and exclusion factors were analyzed to determine relationships, if any, with implant failure at the time of second-stage surgery. The variables were analyzed separately for individual implants, cases (prostheses), and patients. The cases ranged from one to five implants each, and more than one case from a single patient could be included in the investigation. At this interim analysis, 2,066 implants have been placed representing 433 cases in 310 patients. With regard to implant failure rates, possible exclusion variable (9) and medical history variables (39) were not found to be statistically significant. For the dental history variables (23), only the question related to smoking was statistically significant on an implant, case, and patient basis (P < 0.007). Results of this interim analysis suggest that smoking is detrimental to implant success.

Polymorphisms and linkage disequilibrium in the COL6A1 and COL6A2 gene cluster: novel DNA polymorphisms in the region of a candidate gene for congenital heart defects in Down's syndrome.

The COL6A1 and COL6A2 (collagen VI) gene cluster on chromosome 21 is a candidate region for defects leading to congenital heart anomalies in Down's syndrome. We report a variable number of tandem repeats (VNTR) and a restriction fragment length polymorphism (RFLP) in this gene region, detected using a COL6A1 cDNA probe. Linkage disequilibrium relationships were studied among the RFLPs of this gene cluster. The RFLP reported here shows no significant linkage disequilibrium with any others in the region. It has a polymorphism information content value of 0.27, raising the informativity of the locus.

Technique for standardization of panoramic radiographs using helium-neon laser guided positioning.

A limitation of the use of panoramic radiography in implant dentistry has been variations in patient positioning, which can produce dissimilar radiographs and is a serious problem in longitudinal investigations. Previous techniques to standardize panoramic radiographs have been cumbersome and technique sensitive. Bilateral helium-neon lasers were mounted on two-axis micrometer translation stages and projected as cross-hairs on a phantom skull. The cross-point of each pattern was superimposed on a facial soft tissue landmark on either side of the skull. Laser coordinates were recorded and an initial radiograph was produced for each of three experimental groups. Two investigators repeated radiographs for each group six times using the original settings. The radiographs were digitized and the variance calculated and compared using a video digital analysis program. Repeat radiographs were compared to the originals by superimposing each pair and measuring the variance in radiographic markers. The variance ranged from 0.1 to 2.2 mm with the experimental groups and from 2.5 to 38.7 mm with the control group. Repeated measures analysis of variance showed no statistical significance (P > 0.125) among each of the experimental groups using the laser system and a significant difference (P < 0.001) when the control group is included in the analysis. Variance for experimental groups was not significant between the examiners (P > 0.45). A laser repositioning system may have application in implant dentistry by standardizing panoramic radiographs for comparisons in long-term investigations.

The HMOs: new models for practice.

New areas of practice are open to innovative social workers in an existing and expanding comprehensive health care delivery system--the health maintenance organization (HMO). In this article, four health plan models are described that document the experience of social workers in established HMOs. These illustrations demonstrate the necessity and opportunity for expanded social work roles in humanizing and corrdinating patient services in complex multidisciplinary health care delivery systems.