A spontaneous esophageal perforation and duodenal ulcer perforation resulting in a subpulmonic abscess.

Both spontaneous esophageal perforations (Boerhaave syndrome) and duodenal ulcer perforations are medical emergencies. Spontaneous esophageal perforation (SEP) is the most serious and rapidly lethal perforation of the gastrointestinal tract. Prompt diagnosis and early therapy is needed to prevent death and prolonged serious illness, and the key to the diagnosis is an awareness of its frequent atypical presentations. This article presents a case report of SEP and duodenal ulcer perforation which caused a right-sided subpulmonic abscess and reviews the literature pertaining to this subject.

When the shooting starts.

Why the need for an emergency response plan to deal with health care violence is greater than ever. The author discusses how to set up such a plan.

Noncardiac operations after coronary revascularization.

In 35 patients who had had earlier myocardial revascularization, a total of 44 noncardiac operations under general or spinal anesthesia were carried out. There was one cardiac death and three postoperative complications. Compared with the risk of general anesthesia and noncardiac surgical procedures in patients with coronary artery disease who have not had coronary revascularization, this is a major improvement. We conclude that myocardial revascularization provides significant protection against the risk of cardiac complications and death for patients with ischemic heart disease in whom general anesthesia and noncardiac procedures are needed.

Effect of physical stress on sensitivity of lymphocytes to inhibition by prostaglandin E2.

Physical stress is associated with depressed cellular immune function. We have found that lymphocytes from subjects undergoing either of 2 stressful events, cardiac surgery or childbirth, are more sensitive to inhibition by PGE2. For example, the concentration of PGE2 required for 50% inhibition of 3H-thymidine incorporation (ID50) into phytohemagglutinin-stimulated lymphocytes from patients undergoing cardiac surgery went from 1.5 X 10(-8) M on the day before surgery to 3 X 10(-9) M on the day after surgery. This increase in sensitivity to PGE2 was accompanied by a significantly decreased lymphocyte proliferative response (27 to 68% of control, depending on mitogen dose) and a 50% increase in the percentage of E rosette-positive cells with receptors for the Fc portion of IgG. The increased sensitivity to PGE and the depressed mitogen responses returned to preoperative values by day 10. The depressed mitogen responses of the postoperative patients were completely restored to normal by removal of glass-adherent cells before culture. In addition, the responses of the postoperative patients and the women in labor were partially restored by the addition of indomethacin, a prostaglandin synthetase inhibitor, to the cultures. Thus it would appear that physical stress causes lymphocytes to become more sensitive to prostaglandin E2, and the increased sensitivity to inhibition by this immunomodulator is responsible in part for the depressed cellular immune function after physical stress.

Bedside evaluation of postoperative sinus node function in children.

Sinus node dysfunction in children frequently results from the surgical correction of congenital heart defects. We evaluated postoperative sinus node function at the bedside in 25 children by utilizing atrial epicardial electrodes which were placed near the sinus node at the time of operation. Sinoatrial conduction times (SACTs) and corrected sinus node recovery times (CSNRTs) were determined within 3 days of operation in each patient. Group 1 consisted of 20 patients (aged 1 month to 13 years) with normal postoperative sinus node function. Mean (+/- SD) SACTs and CSNRTs were 122 +/- 33 msec (range 61 to 187 msec) and 165 +/- 54 msec (range 52 to 253 msec), respectively. Preoperative evaluation of sinus node function during cardiac catheterization showed that preoperative and postoperative SACTs and CSNRTs were not significantly different (p greater than 0.05) in any of nine patients. Group 2 was composed of five children (aged 1 to 14 years) with postoperative sinus node dysfunction. Three had abnormal SACTs of 230 msec or greater and two children had first-degree sinus node entrance block. Two patients had prolonged CSNRTs. Electrocardiographic (ECG) monitoring revealed evidence of sinus node dysfunction in four of the five patients in Group 2. This report describes a simple and safe means of evaluating postoperative sinus node function at the bedside. The data are comparable to those obtained using more conventional methods during cardiac catheterization.

Vascular ring due to left aortic arch and right descending aorta.

Two children presented with symptoms suggestive of a vascular ring. Barium esophagrams in each case showed a posterior impression caused by a retroesophageal aortic arch. Angiographic studies defined a rare form of vascular ring resulting from an ascending left-sided aorta, a descending right-sided aorta and a right-sided ligamentum arteriosum. At surgery, the diagnosis was confirmed and the anomaly was corrected in each patient. Left pulmonary anomalies were present in each patient.

Use of atrial epicardial electrodes to diagnose and treat postoperative arrhythmias in children.

Temporary Teflon-coated stainless steel wires were placed on the right atrium of 100 consecutive infants and children undergoing open heart surgery. The patients' ages ranged from 1 day to 17 years. The wires were used for diagnosis or treatment 40 times in 30 patients. Atrial electrograms were recorded 14 times to diagnose arrhythmias and conduction disturbances that were unsuspected or misdiagnosed from the standard electrocardiogram. In 10 patients, atrial pacing was used to treat postoperative arrhythmias. Atrial pacing was also used as an adjunct to therapy in 16 children with postoperative low cardiac output and bradycardia with intact atrioventricular conduction. The wires were removed before discharge and no complications resulted from their use. Previous studies have demonstrated the usefulness of temporary atrial wires after cardiac surgery in adults. This experience confirms that the technique is easy and safe and can be of great diagnostic and therapeutic value in children.

Bilateral bleb excision through median sternotomy.

We believe that when the indications for operation for spontaneous pneumothorax are met, the procedure of choice is bilateral resection of apical blebs and pleural abrasion through a median sternotomy. This approach allows easy access to both lungs and pleural spaces for a condition that is bilateral 100 per cent of the time. The operative morbidity is minimal and it essentially eliminates both ipsilateral and contralateral recurrence of pneumothorax with an operation that is of lesser rather than greater magnitude.