Establishing and using a local/regional cardiac surgery database.

BACKGROUND: In 1993, the Minnesota Society of Thoracic Surgeons and the Minnesota Cardiac Surgery Database were organized in response to a third-party payer demand for data about practice protocols and patient outcomes. It has matured to an active organization of 46 cardiothoracic surgeons, 14 institutions, and more than 7,000 patients who have undergone coronary artery bypass grafting. METHODS: Data are validated for completeness and accuracy through a statewide auditing process. They are coded by hospital, analyzed using the standard Society of Thoracic Surgeons National Cardiac Surgery Database format and definitions, and reviewed quarterly in a continuous quality improvement process. RESULTS: Through data review and exchange site visits, variations in practice protocols and outcomes have been identified. For example, our statewide data review and continuous quality improvement process identified prolonged ventilation (more than 24 hours) as one variation. Multidisciplinary teams were defined, and statewide exchange site visits led by cardiovascular surgeons were implemented. An example of the improvement in the accuracy and completeness of the data used to study procedure outcomes is represented by the improved reporting of ejection fraction values that has resulted from this process. CONCLUSIONS: Using the standardized Society of Thoracic Surgeons National Cardiac Surgery Database and the Minnesota Society of Thoracic Surgeons organizational structure to establish a high-quality database will allow for statewide peer review, exchange of practice guidelines, and promotion of standardization, which eventually can improve outcomes and reduce costs. This organization or model can be replicated at any local, state, or regional level. Thoracic surgeons faced with similar challenges for public disclosure of surgical results can learn much from the successful development of the Minnesota Cardiac Surgery Database.

Studies on propafenone-type modulators of multidrug-resistance IV1): synthesis and pharmacological activity of 5-hydroxy and 5-benzyloxy derivatives.

A series of 5-hydroxy and 5-benzyloxy analogs of the antiarrhythmic and multidrug resistance (MDR) modulating drug propafenone was synthesized and the MDR-modulating activity of the compounds was evaluated using a daunomycin efflux assay system. The key step of the synthesis is the selective reduction of the double bond in 1 without cleavage of the benzyl group thus leading to the phenol 3. Alkylation with epichlorohydrine followed by nucleophilic epoxide ring opening gave the benzylated target compounds 5a-d. Subsequent cleavage of the benzyl group gave the 5-hydroxy analogs 6a-d. Structure activity relationship studies showed, that the 5-hydroxy derivates 6a-d fit the log P/log potency correlation line previously established for a series of propafenone analogs. In contrast, all four 5-benzyloxy analogs 5a-d showed almost identical EC50 values, independent of their log P value.

Structural requirements for activity of propafenone-type modulators in P-glycoprotein-mediated multidrug resistance.

The sodium channel blocker propafenone and a series of analogs have been identified as effective modulators of P-glyco-protein-mediated multidrug resistance in human tumor cells. A series of closely related structural homologues showed a highly significant correlation between lipophilicity and pharmacological effect. Reduction of the carbonyl group as well as conversion to a methylether led to a remarkable decrease in activity, whereby lipophilicity lost its predictive character as the main determinant for modulator potency. Similarly, the relative positioning of the acyl- and propanolamine side chains also influences activity, so the distance between carbonyl group and nitrogen atom seems important.

Synthesis, pharmacologic activity, and structure-activity relationships of a series of propafenone-related modulators of multidrug resistance.

A series of [(o-acylaryl)oxy]propanolamines have been prepared and evaluated for multidrug resistance-reverting activity in a human tumor cell model. Structure-activity relationship studies indicate that the phenylpropiophenone moiety as well as the substitution pattern at the nitrogen atom is crucial for activity of the compounds. Incorporation of the ether oxygen into a benzofuran substructure, which renders the compound an arylethanolamine, decreased biologic activity. Highest activity could be observed with the arylpiparazines 4f-h, which not only completely restored daunomycin sensitivity but also showed moderate activity in restoring etoposide toxicity.

Dobutamine in elderly septic shock patients refractory to dopamine.

The hemodynamic effects of dobutamine (2.5-20 micrograms/kg per min) were studied in six elderly patients with septic shock which was refractory to dopamine (15 micrograms/kg per min). Dobutamine infusion resulted in significant increases in cardiac index (CI), stroke index (SI) and left ventricular stroke work index (LVSWI) and similar declines in heart rate (HR), mean pulmonary artery pressure (MPAP), pulmonary capillary wedge pressure (PCWP), systemic vascular resistance (SVR) and total pulmonary resistance (TPR). Dose response curves demonstrated a linear rise in CI with increasing doses of dobutamine and parallel decreases in HR and PCWP. MAP was unchanged. These data indicate that dobutamine may be a useful adjunct to dopamine therapy in the management of elderly patients with septic shock.

Acute trans-rectus traumatic hernia.

Abdominal wall herniae following blunt trauma are rare. Two cases of acute traumatic rectus abdominis muscle and anterior rectus sheath hernia, an apparently unreported entity, are described. Early recognition of the injury by physical examination and sometimes ultrasonography or CT is important. Repair should be early except in selected cases.

Unsuccessful control of abdominal aortic aneurysm by bypass and ligation.

Two patients developed abdominal aortic aneurysm rupture following bilateral iliac artery ligation and axillobifemoral bypass. The first patient developed his rupture several weeks after outflow ligation and apparent thrombosis of the aneurysm. At autopsy, the aneurysmal rupture occurred in the left posterior junction between the thrombosed aneurysm and the normal aorta. In the second case, the aneurysm was not completely thrombosed and plans were in progress for thrombosis of the aneurysm when the patient developed frank rupture, necessitating operative intervention. The authors await the published experience of others with bilateral common iliac artery ligation and extra-anatomic bypass for abdominal aortic aneurysm, but these authors do not currently recommend this management plan.