Effect of combination interleukin-3 (IL-3) and granulocyte-macrophage colony stimulating factor (GM-CSF) on hematopoiesis administered to retrovirus-infected immunodeficient mice receiving dose-escalation zidovudine (AZT).

We have previously demonstrated that continuous administration of dose-escalation zidovudine (AZT) in either normal or LP-BM5 MuLV immunodeficient virus-infected mice (MAIDS) was associated with the development of anemia, neutropenia, and thrombocytopenia. Hematopoietic growth factors/cytokines are being evaluated to determine their efficacy in ameliorating the hematopoietic toxicity associated with AZT. In normal mice receiving AZT, an increase in only plasma erythropoietin and not GM-CSF, Meg-CSF or TNF-alpha has been reported. This article describes studies that investigated the effect of combination interleukin-3 (IL-3) and granulocyte-macrophage colony stimulating factor (GM-CSF) administered in normal non-viral, viral-infected, and viral-infected C57BL6 mice receiving dose-escalation AZT, i.e. 0.1 mg/ml, 1.0 mg/ml, and 2.5 mg/ml placed in the drinking water. Non-viral control mice responded to IL-3/GM-CSF by increasing erythropoiesis, myelopoiesis and platelet production measured by increased bone marrow and spleen derived erythroid, myeloid and platelet precursor stem cells cultured in semi-solid media. Virus-infected control mice not receiving IL-3/GM-CSF developed pancytopenia. Administration of IL-3/GM-CSF to virus-infected mice receiving dose-escalation AZT did not ameliorate the peripheral pancytopenia associated with immunodeficiency disease and AZT treatment, even though erythroid, myeloid and platelet precursor progenitor cells were increased at certain times when compared to either normal or viral-infected mice receiving IL-3/GM-CSF. These results indicate that the combination use of IL-3 and GM-CSF in vivo is only a partially effective growth factor/cytokine treatment to ameliorate the hematopoietic toxicity associated with the use of the anti-viral drug zidovudine.

Treatment of cardiac compression after cardiopulmonary bypass.

A diversity of techniques for delayed closure of the sternum have been advocated for management of hypotension due to cardiac compression after cardiopulmonary bypass. A simple technique utilizing materials readily available in any operating room has been described. It provides for expansion of the cardiac space and sterile coverage of the mediastinum when the skin cannot be approximated.

Diaphragmatic paralysis managed by diaphragmatic replacement.

A neonate had paralysis of the right hemidiaphragm secondary to brachial plexus birth trauma. Conventional diaphragmatic plication, performed on two separate occasions, failed to correct the ventilatory impairment, and mechanical ventilatory dependence persisted. Ventilatory insufficiency was subsequently corrected by total replacement of the right hemidiaphragm with Marlex mesh. This procedure ablated paradoxical motion of the right hemidiaphragm and arrested detrimental shifts of the mobile infantile mediastinum. The good result was immediate and long-lasting; there was no major prosthesis-related growth deformity 31/2 years later. Prosthetic fixation of the paralyzed diaphragm is not indicated as a primary procedure, but should be reserved for the occasional patient in whom conventional plication has failed.

Echocardiographic evaluation of the St. Jude medical prosthetic valve.

M-mode and two-dimensional echocardiographic studies were performed on 19 patients with 25 normally functioning St. Jude Medical prosthetic cardiac valves, in an attempt to define the normal echocardiographic appearance of this new cardiac prosthesis. Satisfactory M-mode echocardiograms were obtained in 17 of the 19 patients, and satisfactory two-dimensional studies were obtained in all. M-mode measurements included the diameter of the orifice ring, leaflet separation, and the opening and closing slopes of the leaflets. The values obtained compared favorably with direct measurements from the prosthesis and were reasonably reproducible. Two-dimensional imaging revealed characteristic systolic and diastolic patterns and provided direct visualization of valvular motion. Echocardiographic evaluation of the prosthesis can be facilitated if it is positioned at implantation so that the open leaflets are perpendicular to the echocardiographic plane of the long axis of the ventricle.

Thrombosis of a St. Jude Medical tricuspid prosthesis. Case report.

Thrombosis of both valve leaflets of a St. Jude Medical tricuspid cardiac prosthesis, resulting in valvular dysfunction, was detected by systolic and diastolic tricuspid murmurs and confirmed by M-mode and two-dimensional echocardiograms. Thrombus formation at both hinge points of the bileaflet valve caused one leaflet to stick in the nearly closed position and the other to have severely impeded motion. Thrombotic involvement of both valve leaflets, not previously reported, occurred in a 17-year-old boy who has undergone six prosthetic cardiac valvular replacements in the past 2 years. Failure to achieve adequate anticoagulation in the early postoperative period appears to be related to the thrombosis in this case.

Isolated chylopericardium after cardiac operations.

Case histories are reported of four patients having chylopericardium following cardiac operations. This entity can be recognized by noting the presence of postprandial milky mediastinal drainage that stains positive for fat with Sudan III. Chylopericardium is caused by operative injury to the thoracic duct, by operative injury to tributaries of the thoracic duct, or by thrombosis at the confluence of the left subclavian and jugular veins with subsequent obstruction of thoracic duct drainage. Appropriate management, which may be either conservative or operative, depends upon the volume and duration of drainage. The conservative approach entails adequate pericardial drainage and institution of a medium-chain triglyceride diet; operative therapy entails ligation of the thoracic duct low in the posterior mediastinum.

Hemodynamic evaluation of the St. Jude Medical valve prosthesis in the small aortic anulus.

The hemodynamic function of the 19 mm and 21 mm St. Jude Medical valve prostheses in the aortic position was evaluated in seven patients who had valve replacement for either severe aortic stenosis or regurgitation an average of 4 months after operation. Cardiac output and simultaneous transvalvular gradient were recorded at rest and during moderate supine arm exercise. The average peak systolic gradient was 14 mm Hg (range 0 to 25 mm Hg) at rest and 32 mm Hg (range 23 to 56 mm Hg) with exercise. The average mean systolic gradient was 20 mm Hg (range 10 to 28 mm Hg) at rest and 38 mm Hg (range 30 to 48 mm Hg) with exercise. The mean effective orifice area was 1.2 cm2 (range 0.9 to 1.4 cm2) at rest and 1.1 cm2 (range of 0.9 to 1.3 cm2) with exercise. Mean cardiac output at rest was 4.4 L/min, and, with exercise, 7.4 L/min. Of the five valves evaluated with root aortography, four demonstrated trivial and one mild aortic insufficiency. We conclude that the St. Jude Medical valve prostheses in the aortic position has favorable hemodynamic function which is particularly evident in the 19 mm and 21 mm sizes when compared with other currently available aortic valve prostheses.

Dipyridamole-aspirin as thromboembolic prophylaxis in patients with aortic valve prosthesis. Prospective study with the Model 2320 Starr-Edwards prosthesis.

In a prospective study, the efficacy of a dipyridamole-aspirin regimen in prevention of thromboembolism was evaluated in 50 patients having isolated aortic valve replacement with the Model 2320 Starr-Edwards prosthesis. These operations were performed between February, 1972, and October, 1974. In 1,380 patient-months of follow-up, there was a 20% incidence of thromboembolism with a rate of 8.7/100 patient-years and a 19% probability of an embolic episode occurring by 3 years. Seven patients had transient episodes, two had permanent neurologic residua, and one patient died. Comparison is made to a similar group of patients having solitary aortic valve replacement but receiving no medication, studied by Starr and associates. There was no statistical difference in the incidence of thromboembolism between the two groups. In November, 1975, all patients were converted to a regimen of warfarin therapy. Since conversion to anticoagulation, there have been two thromboembolic episodes in 2,132 patient-months of follow-up for a rate of 1.1/100 patient-years. We conclude that the use of antiplatelet therapy in the form of dipyridamole-aspirin is inadequate for routine thromboembolic prophylaxis following SE 2320 aortic valve replacement.

Giant coronary pseudoaneurysm. Five-year follow-up after bypass grafting.

A roentgenogram of the shoulder in a 25-year-old man with an athletic injury revealed a large mass along the left heart border. Evaluation with coronary arteriography established the diagnosis of a massive aneurysm of the left anterior descending coronary artery. The aneurysm was excised and a saphenous vein bypass graft was placed into the distal artery. Histologic examination revealed that the excised segment was a false aneurysm. Five years postoperatively, the patient is asymptomatic and the graft remains widely patent.

Intrathoracic ganglioneuroblastoma.

Thirty-one patients treated for isolated intrathoracic ganglioneuroblastoma have been evaluated. The surviving patients (27/31) have been followed for periods up to 25 years. The modes of treatment consisted of complete or partial resection of the tumor, radiation therapy, or chemotherapy. Analysis of the data revealed that four patients treated with radiation alone died within 3 months after the start of treatment. Two patients had complete removal of the tumor without adjuvant therapy. Each is free of recurrent disease at 10 and 11 years postoperatively. The other 25 survivors had complete or incomplete surgical resection followed by radiation and/or chemotherapy. All are free of recurrent disease. Of the 25 patients who received postoperative radiation, 11 developed moderate-to-severe skeletal deformity. There appeared to be a correlation between deformity and the dose of radiation. Our current treatment recommendation consists of immediate operative intervention with an attempt at complete removal of the tumor. Patients with incomplete removal of tumor should be treated with radiation (2,000 r). Chemotherapy consisting of methotrexate or a combination of cyclophosphamide (Cytoxan) and vincristine should be reserved for patients with distant metastasis.

Halophilic vibrios from human tissue infections on the pacific coast of Australia.

Inshore sea waters harbour a variety of halophilic bacteria which increase in the warmer seasons. Ten Vibrio alginolyticus, 3 V. parahaemolyticus and 3 lactose-fermenting (L +) strains of vibrio were isolated in 3 yr from wound and ear infections, salpingitis and sputum in 2 coastal towns; 14 isolations were in summer. Clinically the cases resembled ordinary pyogenic infections. The API 20E kit and determination of NaCl tolerance permitted identification of the strains with reasonable confidence. Only a few characteristics were essential for presumptive identification.

Isolated mitral valve replacement with the Kay-Shiley prosthesis. Long-term follow-up and recommendations.

Eighty patients underwent isolated mitral valve replacement with the Kay-Shiley prosthesis during a 6 year period (September, 1966, in October, 1972) at Walter Reed Army Medical Center. One-hundred percent follow-up has been achieved with this group. Sixty-four percent of this group have experienced one or more thromboembolic episodes (TEEs), for a TEE rate of 28.7 episodes per 1,000 patient months at risk. The 5 year survival rate is 45%. Eleven of 43 (25%) late deaths resulted from TEEs, and 13 of 43 (30%) late deaths were secondary in the hemorrhagic complications of long-term anticoagulant therapy. The dismal TEE rate prompted as to initiate a policy of elective replacement of all Kay-Shiley mitral prostheses. Eighteen of the 26 survivors underwent replacement of the Kay-Shiley mitral prosthesis. The other eight patients either declined reoperation or were not considered suitable candidates. The reoperative mortality rate was 22% (4/18). Fifteen of 18 explained prostheses revealed a yellow disclored, grooved occluder disc with loosely adherent clot. We recommend elective replacement of Kay-Shiley mitral prostheses in all patients in whom the risk of operation is reasonable.

Björk-Shiley mitral valvular dehiscence. Documented by radiography, echocardiography, fluoroscopy, and cineangiography.

This case report presents combined radiographic, echocardiographic, fluoroscopic, and cineangiographic findings of the dehiscence of a Bjork-Shiley mitral prosthetic valve. The valvular dehiscence was confirmed at surgery. A distinct rounding of the opening phase of the valve was recorded on the echocardiogram. Other clinical evidence, documenting the severe valvular dehiscence, is reported in detail. Non-invasive procedures are therefore invaluable in recording prosthetic valvular dysfunction.

Surgical treatment of left main and left main equivalent coronary artery disease.

There is a tendency to equate left main (LM) and left main equivalent (LME) coronary artery disease in terms of the surgical risk and benefit. Eighty-seven patients with LM disease were compared to 78 patients with LME disease as to operative mortality rate and long-term benefits. One hundred percent follow-up was obtained. Although the two groups were similar preoperatively with regard to age, sex, and ventricular function, the operative results in the two groups differed. There was a significantly higher operative mortality rate in the LM group of patients (12.6% versus 2.5%). However, the incidence of graft patency and relief of symptoms was lower in the LME group of patients. The late mortality rate was 4% in both groups. LME disease appears to represent a subgroup of patients with three-vessel disease and cannot be equated with LM disease.