Underutilization of echocardiography for patent foramen ovale in divers with serious decompression sickness.

The presence of a patent foramen ovale (PFO) in compressed gas diving has been considered a risk factor for serious decompression illness (DCS) for more than 20 years. We conducted a ten year retrospective chart review aimed at determining if physicians treating DCS in a university medical center setting used echocardiography to assess PFO in patients with severe DCS, and if so whether PFO is over-represented in that population. Over the ten-year period, 113 divers underwent recompression therapy for decompression sickness. Of these patients, 48 had serious DCS defined by at least one objective neurological finding. We reviewed medical records for the presence of agitated saline contrast echocardiogram testing and whether or not PFO was present. Only 12 of 48 patients with serious DCS underwent transthoracic agitated saline contrast echocardiogram testing. Of these 12 patients, 6 (50%) had a resting PFO. Binomial proportion testing yielded 95% confidence limits of 21% and 79%. Given 27% PFO prevalence in the general population, PFO may be over-represented in our group of most seriously injured DCS patients yet 75% of patients with objective neurological signs did not undergo echocardiography.

A simpler, less expensive technique for delayed primary closure of fasciotomies.

A variety of techniques have recently been advanced for delayed primary closure of wounds following emergent fasciotomy for compartment syndrome. We introduce a very simple, effective method for gradual reapproximation of margins using daily reapplication of Steri-strips (3M Surgical Products, St. Paul, Minnesota). This method allows final closure of fasciotomy wounds with simple suture in 5-8 days without scar contractures, marginal necrosis, infection, or significant pain. Moreover, because it requires no specialized equipment and can be applied in skilled nursing centers or at home by trained nurses, this technique could reduce the cost of caring for fasciotomy patients.

Long-term angiographic results of coronary endarterectomy.

BACKGROUND: To evaluate the long-term patency of endarterectomized coronary vessels, we studied patients having recatheterization after coronary artery bypass grafting. METHODS: Forty-one clinical and angiographic variables were analyzed in 97 study patients who had coronary endarterectomy (CE) and in 154 control patients who did not have CE but who had repeat catheterization after coronary artery bypass grafting. RESULTS: Ninety-seven patients had 132 CEs. The right coronary artery was the most commonly endarterectomized vessel (73 of the 132 endarterectomized vessels). At a mean of 7.1 years of follow-up, significantly fewer bypass grafts to endarterectomized vessels were patent compared with nonendarterectomized vessels (40% of endarterectomized vessels compared with 58% of nonendarterectomized vessels in study patients and 65% in control patients, p = 0.0003). The only predictor of long-term CE graft patency is age-adjusted body surface area (p = 0.0068). Patency in grafts to nonendarterectomized vessels is diminished by hypertension (p = 0.046) and current cigarette use (p = 0.024) and improved by use of mammary artery grafting (p < 0.0001). CONCLUSIONS: These results show that long-term patency in bypass grafts to endarterectomized vessels is less common than in nonendarterectomized vessels and that this patency is related to larger body size. Patency in nonendarterectomized vessels is reduced by risks of arteriosclerosis. This suggests that CE should be used with caution in smaller patients and that aggressive control of risk factors for atherogenesis is particularly important in patients who have CE. On the basis of these results, we speculate that the extent of disease is advanced in patients who require CE.

Resolution of experimental pneumothorax in rabbits by graded oxygen therapy.

BACKGROUND: Small pneumothoraces have been treated by observation and tube thoracostomy in asymptomatic patients. Using a rabbit model, we demonstrated previously that inspired oxygen at 60% FiO2 hastened the time to resolution of complete pneumothoraces compared with room air. The present study was designed to evaluate the use of lower levels of inspired oxygen and to establish a dose-response curve for the treatment of experimental pneumothoraces. METHODS: Forty New Zealand White rabbits were divided randomly into four groups: room air (21%) and 30, 40, and 50% FiO2. Experimental pneumothoraces were created in the rabbits, and the animals were placed in cages with the designated level of inspired oxygen. Serial chest radiographs were performed until the pneumothoraces resolved. RESULTS: Pneumothoraces treated with room air resolved in 61.65 +/- 12.30 hours. Those treated with 30% FiO2 resolved in 42.90 +/- 5.97 hours, with 40% FiO2 in 35.80 +/- 4.26 hours, and with 50% FiO2 in 33.80 +/- 4.66 hours. CONCLUSION: These results show a statistically significant (p < 0.01) dose-dependent improvement in the resolution of pneumothoraces with increasing levels of inspired oxygen. Supplemental oxygen therapy may be used to facilitate the resolution of small, uncomplicated pneumothoraces.

Etiology and prevention of topical cardiac hypothermia-induced phrenic nerve injury and left lower lobe atelectasis during cardiac surgery.

Left hemidiaphragm elevation is frequently noted following cardiac surgery employing topical hypothermia. We speculate that contact of the left phrenic nerve with ice causes nerve injury, resulting in left hemidiaphragm paresis or paralysis and left lower lobe atelectasis. Left diaphragm elevation was noted on postoperative chest x-ray examination of 36 of 60 (60 percent) consecutive patients in whom topical cooling of the heart with a cold slush solution was administered prior to use of a cardiac insulation pad (CIP, Shiley Laboratories, Irvine, California). Following the use of the CIP in a similar group of 60 consecutive patients, only five (8 percent) showed evidence of diaphragmatic elevation. The difference in the incidence of diaphragmatic elevation between these two groups is statistically significant (p less than 0.001). A comparison of postoperative left lower lobe atelectasis prior to the use of the CIP was also statistically significant (p less than 0.001). There was no significant difference in the aortic cross-clamp time or the volume of intraaortic cardioplegia used in these two groups. The use of topical cardiac hypothermia has been shown to protect the myocardium. Phrenic nerve injury secondary to the use of ice in this method has been documented. The use of a cold solution without ice chips or slush, or the insertion of a CIP prior to the use of topical cardiac hypothermia (when ice chips or slush are used) decreases the exposure of the phrenic nerve to cold injury and decreases the incidence of paresis of the left diaphragm and resultant atelectasis.

Prospective sensory evaluation of preparatory methods of elemental diets.

Palatability of elemental diets has been the greatest obstacle to their successful long-term oral administration. Two elemental diet products, A and B, were evaluated in four preparatory methods for acceptability in a prospective double-blind study. The elemental diets evaluated were most acceptable when prepared in the form of Jello (57% receiving acceptable scores) followed by frozen Tang (27% receiving acceptable scores) and those prepared with Flavor Packets (18% receiving acceptable scores). The Kool-Aid method of preparation was not accepted well (6% receiving acceptable scores). Product B was more acceptable than A in palatability and overall acceptability in the methods tested. To successfully administer elemental diets when a nasogastric tube is not employed, we recommend that these diets include formulations with Jello, frozen Tang, or Flavor Packets and that they be prepared by the dietary department. It is recognized that alterations in the composition of elemental diets result from the addition of flavoring agents. The significance of these alterations should be considered for each patient.

A lung clamp for use with mechanical staplers.

A special lung clamp has been developed for use with mechanical stapling devices. These stapling instruments have been adopted widely for pulmonary operations. A variety of clamps has been used to grasp the pulmonary tissue. The present instrument was designed with vertical grooves and fine tapered spikes with opposing holes in the jaws of the clamp. This particular lung clamp overcomes the problem of slippage previously encountered when performing pulmonary resections with stapling devices.

Synchronous primary mucinous adenocarcinomas in the descending colon and perianal glands.

The descending colon is a relatively rare site for mucinous adenocarcinoma. Anal ductal malignancy and multiple primary coloperianal mucinous adenocarcinomas are also rare. We have described the unusual finding of multiple primary synchronous mucinous adenocarcinomas in the descending colon and perianal glands. There was no evidence of any metastasis from the Dukes B lesion in the descending colon.

SILENT MYOCARDIAL INFARCTION WITH POSTERIOR INFERIOR PSEUDOANEURYSM OF THE LEFT VENTRICLE PRESENTING AS A POSTERIOR LUNG MASS.

An asymptomatic 62-year-old man developed a density in his left lower hemithorax in the retrocardiac position on chest roentgenogram, which was discovered during a routine evaluation. This was diagnosed in another hospital as a lung tumor, for which he underwent an exploratory left thoracotomy. This case points out the difficulty in the diagnosis of retrocardiac masses and suggests that echocardiography and cardiac angiography should be accomplished before attempting needle aspiration or an open lung biopsy. The absence of a history of myocardial infarction and classical clinical indications of ventricular aneurysms such as electrocardiographic changes, arrhythmias, and congestive heart failure does not exclude a true aneurysm or pseudoaneurysm of the left ventricle.