Evolving epidemiology of poliovirus serotype 2 following withdrawal of the serotype 2 oral poliovirus vaccine.

Although there have been no cases of serotype 2 wild poliovirus for more than 20 years, transmission of serotype 2 vaccine-derived poliovirus (VDPV2) and associated paralytic cases in several continents represent a threat to eradication. The withdrawal of the serotype 2 component of oral poliovirus vaccine (OPV2) was implemented in April 2016 to stop VDPV2 emergence and secure eradication of all serotype 2 poliovirus. Globally, children born after this date have limited immunity to prevent transmission. Using a statistical model, we estimated the emergence date and source of VDPV2s detected between May 2016 and November 2019. Outbreak response campaigns with monovalent OPV2 are the only available method to induce immunity to prevent transmission. Yet our analysis shows that using monovalent OPV2 is generating more paralytic VDPV2 outbreaks with the potential for establishing endemic transmission. A novel OPV2, for which two candidates are currently in clinical trials, is urgently required, together with a contingency strategy if this vaccine does not materialize or perform as anticipated.

Possible association between attention deficit hyperactivity disorder and attempted suicide in adolescents - a pilot study.

OBJECTIVE: Both adolescent suicide and attention deficit hyperactivity disorder (ADHD) are troubling phenomena with high comorbidity, including impulsivity, depression and personality disorders (PD). Studies on the association between these two phenomena are relatively rare. This pilot study's aim was to estimate the rate of ADHD in adolescents attempting suicide. METHOD: Subjects constituted consecutive admissions to the psychiatric emergency room (ER) who were admitted as a result of attempting suicide. Assessment included the use of the Kiddie-SADS, Strengths and Difficulties Questionnaire (SDQ) and the Conners' Rating Scale (CRS). Those diagnosed as suffering from ADHD were assessed by a standardized Continuous Performance Test (Test of Variables of Attention [TOVA]) that included methylphenidate (MPH) challenge. Twenty-three (23) adolescents completed the study. M:F ratio was 5:18, respectively. RESULTS: Of the 23 participants who completed the study, 65% were diagnosed with ADHD, 43.5% with depression and 39% with cluster B PD. ADD/ADHD ratio was 66%:34%. Only five of the patients were formerly diagnosed as ADHD, only three had been medicated and 14 out of 15 adolescents responded well to MPH challenge. CONCLUSION: These preliminary results suggest a significant association between ADHD and suicidal behavior in adolescents. Further study is needed to establish this association and assess the causality.

Stability of diagnosis: a 20-year retrospective cohort study of Israeli psychiatric adolescent inpatients.

Outcome according to diagnosis and stability of diagnosis were investigated in a follow-back study of 351 adolescents with various psychiatric disorders hospitalized in a closed psychiatric ward. The duration of follow-back was 15-19 years. All diagnoses were based on the ICD-9. Data were collected from the Health Ministry registry and, in the patients who could be located, by structured telephone interview. Special attention was directed at the diagnosis of transient adolescent psychosis (TAP) vs. schizophrenia and prognostic indicators of suicide. The results showed that the most stable diagnosis was anxiety disorder. The stability of the different diagnoses over time was greater between the second and last admission than between the first and last (for patients with three or more admissions). Number of hospitalizations correlated negatively with prognosis. TAP at second admission was an unstable diagnosis; 66% of these patients had a final diagnosis of schizophrenia. However, patients with a diagnosis of TAP at first admission had a higher predictive index score and a higher outcome score than schizophrenic patients. TAP appeared to be a valid diagnostic entity, distinguishable from schizophrenia in course, frequency of suicidal behaviour and social-occupational outcome. Suicide victims had a higher cumulative length of stay than age- and sex-matched non-suicidal patients. Fifty per cent of the suicide victims had a final diagnosis of schizophrenia, compared to 30 per cent for the whole sample. In conclusion, these findings indicate that TAP is associated with a relatively good prognosis and should probably be differentiated from schizophrenia. Further retrospective and prospective studies of adolescent psychiatric inpatients may help delineate the nature and course of psychosis and other psychopathology in this age group.

Hypnotherapy in adolescents with trichotillomania: three cases.

Trichotillomania is not rare in adolescence. Psychotherapy is often ineffective, and cognitive behavioral therapy in combination with serotonin-specific reuptake inhibitors seems to be the treatment of choice. Some cases are resistant to all therapy. This paper reports on three adolescents with pure trichotillomania who responded to the imaginative hypnotherapy technique with Ericksonian suggestions. The patients described their hair as weak and vulnerable and needy of protection. In therapy, the patient was assigned the role of "patron of the hair" thereby giving him/her control of the situation. Hair pulling was significantly reduced, and the improvement was sustained throughout the 6-month follow-up. These cases suggest that imaginative techniques may be effective in adolescents with trichotillomania. Further controlled studies in adolescent population are needed to confirm this assumption.

Renal dysfunction after cardiac surgery.

OBJECTIVE: To assess the causes and outcomes of patients with postcardiac surgery renal dysfunction. PATIENTS AND METHODS: A large cardiovascular data- base including pre-, peri- and postoperative serum creatinine concentrations from 2214 consecutive cardiac surgery patients was analyzed. RESULTS: Sixty-nine patients developed postoperative renal dysfunction, defined as at least a 15 mL/min decline in the creatinine clearance rate resulting in a value of less than 40 mL/min. These patients were significantly older, and had a higher incidence of previous cardiac surgery, diabetes, obesity, peripheral vascular disease, hypertension and poor ventricular function. Postoperatively, these patients had a higher occurrence of low output syndrome and myocardial infarction. Stepwise logistic regression predictors of postoperative renal dysfunction included the following: postoperative low output syndrome; repeat cardiac surgery; being older than 65 years; having diabetes; having poor left ventricular function; and having had valve surgery. Preoperative renal dysfunction (defined as a creatinine clearance of less than 40 mL/min) was not found to be one of the predictors. The mean creatinine concentrations of patients with mild postoperative renal dysfunction (defined as a creatinine concentration of less than 200 mmol/L on the fourth or fifth postoperative day) decreased significantly at the fifth postoperative day, while that of patients with severe postoperative renal dysfunction rose to a mean of 300 mmol/L six months postoperatively. The incidence of late dialysis (defined as a need for dialysis after postoperative day 10) approached 30% among patients with severe postoperative renal dysfunction and only 2% among patients with mild postoperative renal dysfunction. The early mortality rate (during the first postoperative month) was similar in both groups and approached 30%. CONCLUSIONS: Patients who develop postoperative renal dysfunction have a high mortality rate. Postoperative low cardiac output is the most important cause of postoperative renal dysfunction and, therefore, should be avoided. Patients with creatinine concentrations of less than 200 mmol/L at postoperative day 4 or 5 will probably resume normal renal function. Patients with creatinine concentrations of more than 200 mmol/L at days 4 and 5 have a 30% chance of needing long term dialysis.

The radial artery versus the saphenous vein graft in contemporary CABG: a case-matched study.

BACKGROUND: Although use of the internal thoracic artery has been shown to improve outcomes after coronary artery bypass grafting, the same cannot be said of alternative arterial conduits. To determine the benefit of radial artery (RA) grafting, a case-matched review was undertaken. METHODS: Between March 1994 and March 1999, 2,847 patients underwent isolated coronary artery bypass grafting with a left internal thoracic artery graft, plus saphenous vein grafts (SVGs). Of these patients, 478 also received an RA graft (RA group). The RA patients were matched at a ratio of 1:2 with patients receiving only SVGs and a left internal thoracic artery graft (SVG group; n = 956) using six prognostic risk factors: age, sex, Canadian Cardiovascular Society class, left ventricular grade, number of diseased vessels, and timing of operation. Target vessels were graded according to quality and graftability and were similar between groups. Outcomes were evaluated by univariate and multivariate analyses. RESULTS: There was a significantly higher prevalence of diabetes, hypertension, and peripheral vascular disease in the RA group (p < 0.05). Although stay in the intensive care unit was shorter in the RA group (RA, 30 +/- 2 hours, and SVG, 37 +/- 2 hours; p = 0.0002), total hospital stay was similar between groups. The incidence of perioperative myocardial infarction was higher in the SVG group (SVG, 31 of 956 or 3.2%, and RA, 6 of 478 or 1.3%; p = 0.02). Multivariate analysis revealed RA grafting to be protective against early mortality and morbidity (odds ratio = 0.58; 95% confidence interval, 0.37 to 0.90; p = 0.015) and late mortality and morbidity including late reintervention (risk ratio = 0.60; 95% confidence interval, 0.37 to 0.93; p = 0.02). Actuarial freedom from events at 36 months postoperatively was greater in the RA group (RA, 95% +/- 2%, and SVG, 86% +/- 4%; p = 0.01). CONCLUSIONS: Despite a higher prevalence of preoperative comorbidity, patients in the RA group demonstrated improved outcomes after coronary artery bypass grafting. The RA is a viable and beneficial conduit for this operation.

Rotary International: a partner in polio eradication.

Rotary International remains committed to the goal of global eradication of polio and certification by 2005. The reports of possible sources of virulent vaccine-derived poliovirus, which may persist after the global eradication of wild poliovirus, need to be investigated rapidly. If these sources are confirmed to be significant risks to global polio eradication, methods to eliminate these sources need to be identified and implemented. Final recommendations on the stopping of vaccination need to be made by WHO.

Late results of the Warm Heart Trial: the influence of nonfatal cardiac events on late survival.

BACKGROUND: The Warm Heart Trial randomized 1732 CABG patients to receive warm or cold blood cardioplegia. In the warm cardioplegia patients, nonfatal perioperative cardiac events were significantly decreased and the mortality rate was nonsignificantly decreased (1. 4% versus 2.5%, P:=0.12). The purpose of the present study was to evaluate the late results of these trial patients. METHODS AND RESULTS: Randomization was stratified according to surgeon and urgency of the operation. Seven hundred sixty-two patients recruited from 1 of the centers were followed through the hospital clinic for late events. Late survival (including perioperative deaths) at 72 months was nonsignificantly greater in the warm cardioplegia patients (94.5+/-1.7%, mean+/-SEM) than in the cold cardioplegia patients (90.9+/-2.6%). Independent predictors of mortality by Cox proportional hazards model were redo CABG, diabetes mellitus, renal insufficiency, and increasing age. The influence of nonfatal perioperative events (perioperative myocardial infarction according to computerized ECG readings or low output syndrome as determined by an outcome committee) on late survival was also analyzed. Late survival at 84 months was significantly reduced in the group who experienced nonfatal perioperative outcomes (94.5+/-1.7% versus 84. 9+/-4.5%, P:<0.001) and remained a significant predictor after adjustment for other important variables (risk ratio 6.4, 95% CI 1. 87 to 8.73, P:<0.0001). CONCLUSIONS: Effective myocardial protection through either cold or warm blood cardioplegia is essential, because late survival is significantly reduced in patients with nonfatal perioperative cardiac outcomes.

The influence of gender on the outcome of coronary artery bypass surgery.

BACKGROUND: To assess the impact of gender as an independent risk factor for early and late morbidity and mortality following coronary artery bypass surgery. METHODS: Perioperative and long-term data on all 4,823 patients undergoing isolated coronary bypass operations from November 1989 to July 1998 were analyzed. Of these patients, 932 (19.3%) were females. RESULTS: During the years 1989 to 1998 there was a progressive increase in the percentage of women undergoing coronary artery bypass surgery. The following preoperative risk factors were more prevalent among women than men: age above 70, angina class 3 or 4, urgent operation, preoperative intraaortic balloon pump usage, congestive heart failure, previous percutaneous transluminal coronary angioplasty, diabetes, hypertension, and peripheral vascular disease (all p < 0.05). Men were more likely to have an ejection fraction less than 35%, three-vessel disease, repeat operations, and a recent history of smoking. Women had a statistically significant smaller mean body surface area than men (1.72+/-0.18 versus 1.96%+/-0.26% m2). On average, women had fewer bypass grafts constructed than men (2.9%+/-0.8% versus 3.2%+/-0.9%) and were less likely to have internal mammary artery grafting (76.2% versus 86.1%), multiple arterial conduits (10.1% versus 19.8%), or coronary endarterectomy performed (4.9% versus 8.6%). The early mortality rate in women was 2.7% versus 1.8% in men (p = 0.09). Women were more prone to perioperative myocardial infarction (4.5% versus 3.1% p < 0.05). After adjustment for other risk variables, female gender was not an independent predictor of early mortality but was a weak independent predictor for the prespecified composite endpoint of death, perioperative myocardial infarction, intraaortic balloon counterpulsation pump insertion, or stroke (8.55 versus 5.9%; odds ratio, 1.30; 95% confidence interval, 0.99 to 1.68; p = 0.05) Recurrent angina class 3 or 4 was more frequent in female patients (15.2%+/-4.0% versus 8.5%+/-2.0% at 60 months, p = 0.001) but not repeat revascularization procedures (percutaneous transluminal coronary angioplasty, redo) (0.6%+/-0.3% versus 4.1%+/-0.8% at 60 months). Actuarial survival at 60 months was greater in women then men (93.1%+/-1.7% versus 90.0%+/-1.0%), and after adjustment for other risk variables, female gender was protective for late survival (risk ratio, 0.40; 95% confidence interval, 0.16-0.74; p < 0.005). CONCLUSIONS: Perioperative complications were increased and recurrent angina more frequent in women. Despite this, late survival was increased in women compared with men after adjustment for other risk variables

Combination nucleoside analog reverse transcriptase inhibitor(s) plus nevirapine, nelfinavir, or ritonavir in stable antiretroviral therapy-experienced HIV-infected children: week 24 results of a randomized controlled trial--PACTG 377. Pediatric AIDS Clinical Trials Group 377 Study Team.

One hundred eighty-one antiretroviral-experienced, protease inhibitor-naive, clinically stable HIV-infected children between 4 months and 17 years of age were randomly assigned to receive one of four combination regimens to evaluate the change in plasma HIV RNA, safety, and tolerance when changing antiretroviral therapy to a protease inhibitor-containing combination regimen. All four regimens contained stavudine; in addition children received nevirapine plus ritonavir, lamivudine plus nelfinavir, nevirapine plus nelfinavir, or lamivudine plus nevirapine plus nelfinavir. Twelve additional children chose to receive stavudine plus lamivudine plus nelfinavir, with nelfinavir given bid, rather than tid as for the main regimens. Overall, 51% (89/176; 95% CI 43-58%) of the children on the randomized portion of the study had an HIV RNA response (< or =400 copies/ml) on at least two of the three HIV RNA determinations taken at Weeks 8, 12, and 16. At Week 24 the proportion of children with an HIV RNA response still on initial therapy was 47% (83/176; 95% CI 40-55%) and ranged from 41 to 61% for the four randomized treatment arms. Rash was frequently seen (27%) on the treatment arms containing nevirapine. At Week 24 64% (7/11, 95% CI 31-89%) of the children on the bid nelfinavir combination regimen were still on initial therapy with an HIV RNA response as compared with 46% (23/50; 95% CI 32-61%) on the corresponding tid nelfinavir combination regimen. A change in antiretroviral therapy to a protease inhibitor-containing regimen was associated with a virological response rate of approximately 50% for this patient population.

Trends in coronary artery bypass surgery results: a recent, 9-year study.

BACKGROUND: The demographics of patients undergoing coronary artery bypass grafting (CABG) have changed over time and may contribute to differing operative mortality and the combination of mortality and morbidity (M + M). In this study, the trends in results are analyzed and causes are suggested. METHODS: Prospectively collected data concerning 4,839 CABG operations was divided into three time cohorts (1990 to 1992, 1993 to 1995, 1996 to 1998) and analyzed by univariate and multivariate techniques. RESULTS: Mean age and female gender frequency increased in the later time cohorts (60.7 +/- 9.0 to 63.4 +/- 9.9 years and 16.5% to 21.4%, respectively). The following comorbidities were more prevalent in the later time cohorts: diabetes (26.7% versus 18.6%), renal failure (8.5% versus 2.2%), peripheral vascular disease (20.7% versus 11.0%), previous cerebrovascular accident (6.7% versus 5.0%), urgent procedures (41.5% versus 26.9%), unstable angina (47.8% versus 31.7%), urgent CABG following myocardial infarction (17.1% versus 7.3%), previous percutaneous transluminal coronary angioplasty (8.0% versus 4.5%), ejection fraction less than 35% (20.5% versus 10.4%), (all p < 0.05). Procedurally, increased utilization of the left internal mammary artery, multiple arterial conduits, and warm blood cardioplegia occurred in the later cohorts (91.2%, 22.2%, and 80.4% versus 78.7%, 3.4%, and 38.0%, respectively). The mortality rate was 2.0% and the M + M rate was 15.6% in all 4,839 patients. The mortality and M + M for the three cohorts were 1.6%, 2.0%, and 2.3% and 18.4%, 17.2% and 12.5%, respectively. The risk-adjusted mortality and M + M decreased from 2.4% and 15.9%, respectively, in 1990 to 1992 to 1.8% and 8.4% in 1996 to 1998 (p < 0.001). The difference in adjusted event rates was minimized when the surgical factors were entered into the model. CONCLUSIONS: Over time, there has been a trend toward operating on older patients with more comorbidities. Though hospital mortality has been stable, risk-adjusted M + M has been in a constant decline. This decline was associated with an increased use of left internal mammary artery grafts, multiple arterial conduits, and warm blood cardioplegia during the later years of the study.

Association between HIV in pregnancy and antiretroviral therapy, including protease inhibitors and low birth weight infants.

OBJECTIVE: To determine the incidence of low birth weight infants born to HIV seropositive women and to demonstrate any effects of antiretroviral therapy on birth weight. METHODS: Retrospective review of all obstetrical medical records from January 1, 1995 through June 30, 1998 to identify HIV seropositive women. We evaluated their antiretroviral therapy, CD4 counts, and birth weights of their newborns. We conducted detailed review of the clinical and laboratory findings for the HIV-infected untreated patients, women who received ZDV antepartum alone, and those who received PIs as part of antiretroviral treatment. RESULTS: The frequency of low birth weight infants was significantly increased in HIV seropositive compared to HIV seronegative parturients. Low birth weight infants were more frequent among HIV infected women with lower CD4 counts but the association was not statistically significant. Women who received no antepartum treatment, antepartum only ZDV, and those treated with PIs had significantly more low birth weight infants than did comparison groups. HIV seropositive women also had high frequencies of several obstetrical risk factors for low birth weight infants. CONCLUSION: The present study showed a significantly increased frequency of low birth weight infants among HIV infected women and especially the subgroups of infected women who received no antepartum treatment, antepartum ZDV only, and those treated with PIs. This association, however, may be related to the presence of many other preterm obstetrical risk factors noted in this study. Increasing numbers of HIV seropositive women are being treated with PIs according to the Centers for Disease Control (CDC) guidelines. If PIs are a cause of low birth weight infants, women taking these drugs may have incremental risk of low birth weight.

Hair loss associated with paroxetine treatment: a case report.

Alopecia and hair loss are rare side effects of psychotropic drugs. There are a few case reports on hair loss associated with tricyclic antidepressants and serotonin selective reuptake inhibitors (SSRIs), but none deal specifically with paroxetine. We report on a 37-year-old female who complained of moderate hair loss during paroxetine treatment. Findings on discontinuation and rechallenge supported the assumption that the hair loss was a side effect of the paroxetine. Further investigation is needed to determine the scope of this troubling side effect.

A novel comparison of stentless versus stented valves in the small aortic root.

BACKGROUND: Previous studies have compared prosthetic valves on the basis of industry-labeled valve sizes. Unfortunately, the relationship between the labeled size and the true measured external or internal diameter differs between valve manufacturers. Therefore hemodynamic comparisons between prosthetic valves are inaccurate if based solely on industry-labeled valve sizes. METHODS: We have previously demonstrated that the internal diameter of a 21-mm Carpentier-Edwards pericardial stented valve is similar to that of a 25-mm Toronto stentless porcine valve. Therefore we chose to compare postoperative hemodynamics in patients who received 19-, 21-, or 23-mm Carpentier-Edwards pericardial stented valves (inner diameter 18-22 mm, n = 69) with those in patients who received 23- or 25-mm stentless porcine valves (internal diameter 19-21 mm, n = 41). RESULTS: Patients in the Carpentier-Edwards group were more likely to be elderly and more likely to require concomitant revascularization. Operative mortality was lower in the stentless porcine valve group (0% vs 9%, P =.06). Hospital stay and ventilation requirements were shorter in the stentless porcine valve group. Postoperative hemodynamics were similar in the two groups. CONCLUSIONS: These data provide evidence that stentless and stented valves have similar hemodynamic profiles in the small aortic root when matched on true measured internal diameters. The clinical benefit of the stentless porcine valve may be due to patient selection or the lack of a rigid stent in the small aortic root, but it is not due to hemodynamic superiority over stented aortic valves of similar sizes.

Clinical results of endarterectomy of the right and left anterior descending coronary arteries.

In this study, we examined the clinical outcome of coronary endarterectomy. From 1990 to 1998, 4839 patients underwent surgical revascularization. Coronary artery bypass graft surgery (CABG) was performed alone on 4516 patients, was combined with right coronary artery endarterectomy (RCA-E) in 242 patients, and was combined with left anterior descending coronary artery endarterectomy (LAD-E) in 81 patients. An analysis of preoperative variables revealed a higher proportion of males (90.7% vs 80.2%, p < 0.001), of patients with low ejection fraction (< 35%; 4.6% vs 1.7%, p < 0.001), and of three-vessel disease (47.9% vs 36%, p < 0.001) in the RCA-E versus the CABG patients. There was a higher proportion of unstable angina (51.9% vs 40.3%, p = 0.04) in the LAD-E patients. The 30-day mortality rate for CABG was 2% versus 2.5% for RCA-E and 3.7% for LAD-E (p = NS). Perioperative myocardial infarction (MI) rate for CABG was 3.4% versus 7.0% for RCA-E (p < 0.001) and 4.9% for LAD-E patients (p = NS). Postoperative low cardiac output syndrome was recorded in 11.5% of CABG, 18.6% of RCA-E (p = 0.01), and 11.1% of LAD-E (p = NS) patients. Predictors of postoperative bad outcome (death, MI, low cardiac output, cerebrovascular accident) were preoperative intra-aortic balloon pump, repeat operation, ejection fraction of < 35%, renal insufficiency, female gender, RCA-E, and age over 70. Protective factors included the use of internal mammary artery, multiple arterial grafts, and warm cardioplegia. Actuarial analysis at 6, 12, and 24 months showed late mortality rates of 0.8%, 1.3%, and 2.1% for CABG; 1.2%, 3.7%, and 3.7% for RCA-E; and 2.9%, 2.9%, and 2.9% for LAD-E, respectively. Late MI occurrence was 0.4%, 0.4%, and 0.7% for CABG; 1.5%, 1.5%, and 2.7% for RCA-E; and 0% for LAD-E, respectively. Multivariate analysis found renal insufficiency, ejection fraction of < 35%, repeat operation, female gender, New York Heart Association functional class IV, and diabetes to be predictors for late adverse events (recurrence of angina, MI, and cardiac death), and RCA-E was found to be a predictor of late MI. We conclude that the use of coronary endarterectomy to achieve complete revascularization in patients with diffuse distal coronary artery disease is a reasonable option, associated with a minimal addition in complication rates.

Multiple arterial grafts. Radial versus right internal thoracic arteries.

BACKGROUND: Left internal thoracic artery (LITA) grafts to the left anterior descending coronary artery (LAD) during coronary bypass surgery (CABG) have greater patency rates than saphenous vein grafts and reduce long-term cardiac morbidity and mortality rates. The benefits of multiple versus single arterial grafts and the role of different arterial conduits with respect to short- and medium-term outcome remains controversial. The purpose of this study was to compare the perioperative and intermediate-term results of: (1) patients receiving 2 arterial grafts versus 1 arterial graft and (2) patients receiving a right internal thoracic artery (RITA) versus a radial artery (RA) as the second arterial graft. METHODS AND RESULTS: Retrospective analysis of prospectively gathered data on consecutive patients undergoing isolated CABG at our institution between 1989 and 1996 was conducted. The first section of the study compared outcomes for 1 arterial graft (LITA to LAD, n = 2333) versus 2 arterial grafts (LITA + RA or LITA + RITA, n = 378). The second section of the study compared outcomes for the RITA (n = 132) versus the RA (n = 171) as second arterial grafts since 1992, when the radial series was initiated. Part I: By multivariable stepwise logistic regression, the use of 1 arterial graft was associated with an increased incidence of perioperative cardiac morbidity and mortality (odds ratio 2.2, 95% confidence interval 1.4 to 3.3), with the use of our current patient selection criteria. Double-arterial graft patients had a nonsignificant trend toward increased intermediate-term actuarial survival (P = 0.12) and cardiac event-free survival (P = 0.09). Part II: Comparison of preoperative demographics revealed a higher incidence of diabetes (27% vs 11%, P < 0.001), peripheral vascular disease (16% vs 8%, P = 0.03), and elderly age (13% vs 2%, P = 0.001) in patients receiving an RA versus those receiving a RITA as the second arterial graft. Perioperative outcome analysis revealed a decreased intensive care unit stay in the RA versus RITA group (median 30.4 vs 36.2 hours, respectively, P = 0.005) but no significant difference in hospital length of stay. There was no significant difference in perioperative mortality or cardiac morbidity rates. RITA patients had a higher incidence of sternal wound infection (5.3% vs 0.6%, P = 0.01), however, and tended to have increased blood product transfusion rates (51% vs 40%, P = 0.06). CONCLUSIONS: The use of 2 arterial grafts is safe, with a reduction in perioperative cardiac morbidity or mortality rates compared with 1 arterial graft after adjustment for other risk variables. When comparing RITA to RA as second arterial grafts, patients receiving an RA have a lower incidence of sternal wound infection and decreased transfusion requirements, with no difference in perioperative or intermediate-term cardiac morbidity or mortality rates.

Coronary bypass with arterial conduits.

To assess the efficacy of arterial revascularization 368 patients were studied who underwent myocardial revascularization with two or more arterial conduits (group M) and compared with 2092 patients in whom a single internal mammary artery +/- veins (group S), and to a third group in which only saphenous vein conduits (group V, n = 602) were used. Group M patients were younger (aged 54.0(9.5) years; 4.1% aged > 70 years) than either group V (67.6(8.9) years, 40.7% > 70 years, P < 0.0001) or group S patients (62.0(8.5) years, 15.7% > 70 years, P < 0.0001). Furthermore, this cohort group had the lowest percentage of females (8.4%), of urgent cases (21.7%), of preoperative myocardial infarction (6.0%), and of redo surgery (0.8%). In contrast, patients who received only saphenous vein conduits had the highest proportion of female patients (29.2%), of urgent cases (47.4%), of preoperative myocardial infarction (16.5%), and of redo surgery (5.5%). By multivariate logistic regression analysis (odds ratio in parentheses), redo surgery (6.06, P = 0.0001), preoperative intra-aortic balloon pump assist (6.11, P = 0.0001), diabetes (1.97, P = 0.03), urgent surgery (1.80, P = 0.05), and advanced age (2.14, P = 0.01) were all predictors of operative mortality. In contrast, while choice of conduit appeared to influence outcome by univariate analysis (4.2% mortality in group V, P < 0.001), it was not found to be a predictor of either mortality or morbidity by regression analysis. The present results indicate that, in carefully selected patients, despite increased technical demands with longer periods of aortic occlusion and longer pump times, multi-arterial grafting (compared with conventional revascularization) is a safe and efficacious procedure. Whether or not this approach to revascularization will increase long-term survival and freedom from reoperation will require further study.

Epstein-Barr virus DNA in the blood of infants, young children, and adults by age and HIV status.

Polymerase chain reaction (PCR) methodology was used to detect Epstein-Barr virus (EBV) DNA in peripheral blood mononuclear cells (PBMCs) from children and adults whose HIV status (i.e., infected or uninfected) is known. Initial EBV infections especially occurred in children between the ages of 7 and 24 months. EBV-positive children with vertically acquired HIV infection tended to have a detectable blood level of EBV DNA for a period of years, and their EBV DNA blood levels often exceeded 10,000 copies/0.1 ml of blood--hundreds of times higher than levels typically found in EBV-positive, HIV-uninfected children of the same age. EBV DNA was found in PBMCs in 26% of 49 HIV-infected mothers who were sampled during their pregnancy, but the median EBV DNA level in their EBV-positive samples was low--only 50 copies/0.1 ml blood. In limited tests with specimens from children infected with both HIV and EBV, high blood levels of EBV DNA unexpectedly appeared to be associated with decreased blood levels of HIV DNA (p = .063).

Early experience with stentless versus stented valves.

BACKGROUND: The Toronto stentless porcine valve (SPV) was designed to improve hemodynamics after aortic valve replacement by maximizing available flow area in comparison to stented valves (STD). METHODS: To assess possible hemodynamic differences between STD and SPV, 59 patients undergoing isolated aortic valve replacement (+/-coronary artery bypass graft) were prospectively evaluated by preoperative and 3- to 6-month postoperative echocardiography. Among these, 23 patients received a STD, whereas 36 received the Toronto SPV. RESULTS: The mean size (mm) of SPV implanted was larger (SPV, 26.6+/-2.1; STD, 24.0+/-2.9; P=0.0002). Patients receiving STD valves were older and had a higher prevalence of coronary artery disease and congestive heart failure. There were no preoperative differences in left ventricular mass index (g/mo2), peak or mean pressure gradients (mmHg), effective orifice area (cm2), extent of fractional shortening (%), or velocity of circumferential shortening (cf/sec). ANOVA demonstrated a significant reduction in left ventricular mass index at 3 to 6 months (P=.0001) but no differences in left ventricular mass index regression between groups (STD, -28.8+/-37.5; SPV, -31.2+/-32.4; P=.36). Effective orafice area was increased postoperatively (P=.0001), particularly among SPV cases (STD, 1.5+/-0.4; SPV, 1.9+/-0.7; P=.01). Postoperative left ventricular mass index and mean pressure gradient were reduced (P=.0001) but did not differ between groups. Fractional shortening and velocity of circumferential shortening were greater in the SPV patients at 3 to 6 months after aortic valve replacement (P=.0004 and .0001, respectively), and an interactive effect was seen between time and prosthetic group (P=.0028 and .032, respectively). CONCLUSIONS: In a consecutive series of patients, we identified no hemodynamic differences between STD and SPV, although ventricular function improved after SPV. Because of the nonrandomized nature of the study, selection bias may have accounted for some of the observed results. A prospective, randomized trial is necessary to determine the hemodynamic advantages, if any, of the SPV valve.