Cervical neoplasia after diagnosis and follow-up of women with atypical squamous cells of undetermined significance.

BACKGROUND: Although the cytological finding of atypical squamous cells of undetermined significance (ASCUS) occurs in around 5% of women undergoing cytological screening, the clinical evolution is unknown. The objective of this study was to evaluate women with a diagnosis of ASCUS and compare the histological findings and clinical evolution over six and 12 months. METHODS: 1244 patients with ASCUS (two diagnostic cytologists) were evaluated in this study with Pap Smears and colposcopy (biopsy if necessary) at the first visit, and thereafter at second and third visits (6 and 12 months after the first visit). Comparisons were made between cytological findings and histological diagnoses at every visit during the study and during evolution. RESULTS: At the first visit, 60.3% of the biopsied patients presented histological findings of CIN I, 17.46% CIN II/III and 6.3% invasive neoplasia. At the second visit, 48.3% of the biopsied patients presented CIN I, 24.1% CIN II/III and none invasive neoplasia. At the third visit, 68.9% of the biopsied patients presented CIN I, 13.8% CIN II/III and none invasive carcinoma. If we consider all visits, a total of 213 colposcopy-guided biopsies were performed, representing 17.1% of all the patients included. Of these, 164 (13.2%) presented a histological diagnosis of cervical intraepithelial neoplasia (CIN) and eight (0.6%) presented with invasive carcinoma. CONCLUSION: We conclude that CIN or invasive lesions frequently occur in women with a diagnosis of ASCUS. Immediate review of the thin sections, new cytological tests or colposcopy and rigorous follow-up should be considered when making a diagnosis of ASCUS.

Unusual foreign body in the esophagus: a challenge for the anesthesiologist.

A foreign body in the esophagus is usually removed by endoscopy. An elder man entered the emergency room dyspneic and dysphagic. A chest X-ray showed that he had a table fork stuck in the upper esophagus. An endoscopist tried to remove it without success. After bilateral block of the superior laryngeal nerve, transtracheal injection, topical anesthesia of the mouth, and sedation, an awake laryngoscopy was carried out. Pushing the laryngoscope into the opening of the esophagus the fork was seen and extracted by the anesthesiologist. This case focuses on the role of the anesthesiologist in the removal of esophageal foreign bodies.

Outcome after combined carotid endarterectomy and coronary artery bypass is related to patient selection.

OBJECTIVE: The optimal management of patients with significant coronary and carotid artery disease remains controversial. Since reporting on a series of 100 patients undergoing combined carotid endarterectomy and coronary artery bypass (CEA/CAB) 4 years ago, we have liberalized our selection criteria for combined operation. We sought to compare outcomes of the recent cohort of 74 patients and the previous group. METHODS: All patients who underwent CEA/CAB since 1984 have been tracked in a database containing identifying information, demographic factors, anatomic information, details of surgery, and short- and long-term follow-up data. We compared the 74 patients (Group 2) undergoing CEA/CAB since 1994 with the previously reported group of 100 patients (Group 1) who underwent CEA/CAB between 1984 and 1994. We examined demographic and comorbidity factors, presence of cerebrovascular symptoms, degree of contralateral carotid stenosis, and perioperative stroke and death. Statistical comparisons were made with the chi(2) test. RESULTS: The groups had similar age and sex distributions and similar incidences of hypertension, diabetes, congestive heart failure, prior myocardial infarction, and hypercholesterolemia. More patients in Group 1 had preoperative transient cerebral ischemia or monocular blindness (55% vs 31%, P <.002) and preoperative stroke (18% vs 7%, P <.03). More patients in Group 2 had unilateral asymptomatic carotid artery stenosis (55% vs 18%, P <.001). The incidence of all perioperative strokes was higher in Group 1 (9% vs 1.4%, P <.035). There were fewer deaths (3% vs 8%) and ipsilateral strokes (0 vs 4%) in Group 2, though these were not statistically significant. CONCLUSION: We have liberalized our criteria for performing combined CEA/CAB, such that more than 50% of our recent patients have asymptomatic unilateral carotid stenosis. This practice is associated with a lower incidence of all perioperative strokes and a trend toward lower ipsilateral stroke and death. These observations suggest that perioperative stroke after CEA/CAB is related to patient selection and that low-risk patients can undergo CEA/CAB with the benefits of low morbidity, patient convenience, and cost savings from avoiding a second hospitalization and operation.

Proper timing of blood cardioplegia in infant lambs: superiority of a multiple-dose regimen.

BACKGROUND: In the pediatric and infant age groups, it is unclear whether repeated infusions of blood cardioplegia solution during ischemic arrest are beneficial or detrimental when compared with a single-dose regimen. METHODS: Twenty lambs (aged 6 to 7 weeks) were placed on cardiopulmonary bypass. A miniature glass-tip electrode measured myocardial pH and hydrogen ion concentration, [H+], in the anterior wall. The aorta was clamped for 2 hours. Group S (n = 10) received a single dose of blood cardioplegia solution. Group M (n = 10) received multiple doses of blood cardioplegia solution at 20-minute intervals. RESULTS: The amount of [H+] generated during the cross-clamp period was greater in group S than in group M (39.2 +/- 10.1 nmol/L versus 0.4 +/- 1.4 nmol/L, p < 0.008). The percent increase in the time constant, tau, an index of diastolic relaxation, was more prolonged after cardiopulmonary bypass in group S when compared with group M (51.4% +/- 2.8% versus 6.4% +/- 3.0%, p < 0.0001). Similarly, the percent decrease in end systolic elastance, a measure of systolic contractility, was greater in group S after cardiopulmonary bypass when compared with group M (29.5% +/- 1.4% versus 7.3% +/- 1.3%, p < 0.0001). CONCLUSIONS: In this infant lamb model, multiple doses of blood cardioplegia solution provided superior metabolic preservation and hemodynamic support after 2 hours of aortic clamping when compared with a single-dose regimen.

Benign lipid envelope of the heart simulating a pericardial hematoma.

The hallmark of diagnosing a pericardial effusion by echocardiography is the presence of relatively sonolucent space outside of the cardiac structures. The location, size, mobility, and consistency of the pericardial space determined by echocardiography are considered to be reliable markers for defining pericardial processes. In certain clinical scenarios, however, it may be difficult to differentiate fluid from other pericardial processes, notably subepicardial adipose tissue. This case of a 76-year-old woman, who presented with possible cardiac tamponade after permanent pacemaker implantation, demonstrates some of the potential pitfalls in the diagnosis of pericardial space abnormalities.

Intraoperative metabolic monitoring of the heart: II. Online measurement of myocardial tissue pH.

Under conditions of ischemia, the hydrogen ion [H+] accumulates in the myocardial tissue in proportion to the magnitude of the ischemic insult. The accumulation of [H+] is the result of both increased anaerobic production of [H+] secondary to decreased substrate and decreased washout of [H+] secondary to decreased coronary perfusion. The Khuri tissue pH electrode/monitoring system has been developed and validated over the past two decades. Its scientific basis and correlates have been established, and it is the only system that has been approved for use in humans. Myocardial tissue pH has been monitored in the anterior and posterior walls of the left ventricle in more than 700 patients undergoing major cardiac surgery. An understanding of the relationship between pH and temperature and between the pH and [H+] in tissues is important for the proper interpretation of the myocardial pH data generated in the course of an operation. Intraoperative monitoring of myocardial pH is the only modality available to the cardiac surgeon for online assessment and improvement of the adequacy of myocardial protection. By defining myocardial protection in terms of protection from myocardial tissue acidosis, this technology provides a new tool with which the comparative efficacy of the various myocardial protection techniques can be assessed. It also provides an online tool for assessing the adequacy of coronary revascularization, and has the potential of improving procedures and outcomes for off-pump coronary artery bypass grafting.

Clinical benefits of endoscopic vein harvesting in patients with risk factors for saphenectomy wound infections undergoing coronary artery bypass grafting.

OBJECTIVE: The influence of endoscopic harvesting techniques on the prevalence of leg-wound complications after coronary artery bypass grafting remains to be defined for patients at high risk for the development of wound infections. METHODS: Among 1473 patients undergoing coronary artery bypass grafting who had the saphenous vein harvested by either a continuous incision or skip incisions leaving intact skin bridges, we determined the prevalence of wound infections to be 9.6%. The following variables were entered into logistic regression analysis to identify significant risk factors that might be predictive of wound infection: diabetes, peripheral vascular disease, obesity, renal failure, steroid use, age, sex, and type of closure. We then prospectively randomized 132 patients found to be at high risk of wound infection to either endoscopic vein harvesting or a continuous open incision. RESULTS: Univariate analysis showed female sex (P =.04), diabetes (P <.001), and obesity (P <.001) to be predictors of wound infection. In a multivariate model diabetes (P =.02) and obesity (P =.001) were independent predictors. In patients at high risk, the prevalence of wound infection was 4.5% for the endoscopic group versus 20% for the open group (P =.01). Vein procurement time was greater in the endoscopic group (65 minutes vs 32 minutes, P <.001), as was the number of vein repairs required (2.5 vs 0.6, P <.001). CONCLUSION: The use of endoscopic vein harvesting decreases the prevalence of postoperative leg-wound infections in high-risk patients with diabetes and obesity. Whether this translates into an economic benefit that justifies the additional cost of that technology requires further analysis.

Left ventricular apical diastolic collapse: an unusual echocardiographic marker of postoperative cardiac tamponade.

A 37-year-old woman was evaluated for signs and symptoms of cardiac tamponade 11 days after mitral valve replacement and tricuspid valve repair. The transthoracic echocardiogram showed a large, compartmentalized pericardial effusion that resulted in left ventricular apical diastolic collapse. Also noted were right ventricular posterior wall diastolic collapse and hemodynamic findings consistent with cardiac tamponade. This case highlights the atypical echocardiographic findings in patients with pericardial effusions after cardiac surgery.

Homograft repair of a tuberculous pseudoaneurysm of the ascending aorta.

A 34-year-old HIV-positive black man with pulmonary tuberculosis developed progressive widening of the mediastinum. Evaluation by CT and two-dimensional echocardiography demonstrated a large saccular aneurysm of the ascending aorta. This was repaired with a 26-mm aortic homograft using deep hypothermic circulatory arrest. The microbiology of the aneurysm contents showed this to be a tuberculous pseudoaneurysm.

Simultaneous carotid endarterectomy and coronary bypass: perioperative risk and long-term survival.

PURPOSE: The purpose of this article is to examine the outcome of simultaneous coronary bypass-carotid endarterectomy (CABG-CEA) and to compare it with the outcome of endarterectomy alone (CEA alone) in patients at high cardiac risk. METHODS: A retrospective review of the records and follow-up data for 100 consecutive patients who had undergone CABG-CEA and were at high risk and 114 patients who had undergone CEA, had overt coronary artery disease (angina, previous infarct, or ischemic electrocardiographic abnormalities), but had not undergone CABG was carried out. RESULTS: Our CABG-CEA group had a high incidence of symptomatic carotid disease (57%) and contralateral occlusion (28%) when compared with patients in other reports. Patients in the CABG-CEA group were older (67.9 +/- 8.3 years vs 63.6 +/- 15.7 years, p = 0.01) and more often smokers (81% vs 52.6%, p = 0.01) than patients in the CEA alone group. Perioperative mortality was 8% for the CEA-CABG group and for 1.8% for the CEA alone group (p = 0.035). Perioperative stroke morbidity was 9% for the CEA-CABG group and 2.6% for the CEA alone group (p = 0.05). Life table survival at 1,3, and 5 years was 90%, 82%, and 73% versus 96%, 84%, and 76% for the CABG-CEA and CEA alone groups, respectively (p = 0.30). CONCLUSIONS: Selection criteria for CABG-CEA greatly influence perioperative risk. Despite the greater age and more advanced coronary artery disease in the CABG-CEA group, long-term outcome differences are accounted for entirely by differences in perioperative morbidity and mortality. Prospective trials of strategies such as staged CEA and CABG to reduce perioperative risk are needed.

Metabolic correlates of myocardial stunning and the effect of cardiopulmonary bypass.

In order to study the metabolic consequences of myocardial stunning, repeated coronary occlusions were performed in dogs. The production of CO2, adenosine triphosphate (ATP), phosphocreatine (PCr), and inorganic phosphate (Pi) by myocardial cells was assessed, along with extracellular and intracellular pH. Our results indicate that regional coronary artery occlusion reduces the ability of the myocardium to produce H+ and CO2 and to replenish ATP post ischemia. These alterations, then, represent the hallmark of metabolic viability during periods of ischemic insult. Decreases in PCr and Pi were completely eliminated during reperfusion and, therefore, are ot reflective of myocardial stunning. When normothermic cardiopulmonary bypass (CPB) is instituted and the coronary artery is occluded three times with reperfusion between each occlusion, alterations in myocardial H+ and high energy phosphates are identical to those observed using only repetitive coronary occlusion. Systemic hypothermia during CPB does not protect against myocardial stunning; however, it is anticipated that interventions that prevent the reduction in H+ and ATP levels may overcome the effects of myocardial stunning that occur during cardiac surgery.

Effect of skin temperature on platelet function in patients undergoing extracorporeal bypass.

Thirty-seven patients undergoing cardiopulmonary bypass operations were studied to assess the effect of skin temperature on platelet function. Differences in skin temperature between the two arms were created during bypass, at the completion of bypass, and at 2 and 24 hours after the completion of bypass. In each of 37 patients the temperature of one arm was increased with a water-filled blanket set at 40 degrees C. In 11 of these patients the other arm was allowed to equilibrate with the environment, and in the other 26 patients the arm was cooled with ice. Except for the differences in local skin temperature between the two arms, all factors known to affect the patient's bleeding time were similar. Measurements were made of bleeding times and the levels of thromboxane B2 and 6-keto-prostaglandin F1 alpha in shed blood obtained at the template bleeding time site. In the 33 patients not treated with aspirin, local hypothermia produced an increased bleeding time and a significant reduction in the thromboxane B2 level at the bleeding time site, but no reduction in 6-keto-prostaglandin F1 alpha level. Local rewarming produced a significant increase in the shed blood thromboxane B2 level. In the four patients treated with aspirin, local hypothermia produced no differences in bleeding times or shed blood levels of thromboxane B2 or 6-keto-prostaglandin F1 alpha. These data show the benefits of rewarming patients with hypothermia who have nonsurgical blood loss to restore to normal both core and peripheral temperatures before resorting to the transfusion of homologous blood products.