Auricular Acupuncture and Cognitive Behavioural Therapy for Insomnia: A Randomised Controlled Study.

Objective. The most effective nonpharmacological treatment for insomnia disorder is cognitive behavioural therapy-insomnia (CBT-i). However CBT-i may not suit everyone. Auricular acupuncture (AA) is a complementary treatment. Studies show that it may alleviate insomnia symptoms. The aim of this randomised controlled study was to compare treatment effects of AA with CBT-i and evaluate symptoms of insomnia severity, anxiety, and depression. Method. Fifty-nine participants, mean age 60.5 years (SD 9.4), with insomnia disorder were randomised to group treatment with AA or CBT-i. Self-report questionnaires, the Insomnia Severity Index (ISI), Dysfunctional Beliefs and Attitudes about Sleep scale (DBAS-16), Epworth Sleepiness Scale (ESS), and Hospital Anxiety and Depression scale (HAD), were collected at baseline, after treatment, and at 6-month follow-up. A series of linear mixed models were performed to examine treatment effect over time between and within the groups. Results. Significant between-group improvements were seen in favour of CBT-i in ISI after treatment and at the 6-month follow-up and in DBAS-16 after treatment. Both groups showed significant within-group postintervention improvements in ISI, and these changes were maintained six months later. The CBT-i group also showed a significant reduction in DBAS-16 after treatment and six months later. Conclusions. Compared to CBT-i, AA, as offered in this study, cannot be considered an effective stand-alone treatment for insomnia disorder. The trial is registered with ClinicalTrials.gov NCT01765959.

Patients' experience of auricular acupuncture during protracted withdrawal.

Over the last decades interest in using auricular acupuncture for substance dependence care has increased. The specific auricular acupuncture protocol used follows the National Acupuncture Detoxification Association (NADA) definition. This paper describes patients' experiences of receiving auricular acupuncture during protracted withdrawal. Interviews were conducted with 15 patients treated at an outpatient clinic for substance dependence. Content analysis was used to analyse the interviews. The analysis resulted in seven categories of positive experiences and seven categories of negative experiences. The positive experiences were: Relaxation and well-being, Peacefulness and harmony, New behaviours, Positive physical impact, Importance of context, Anxiety reduction and Reduced drug and alcohol consumption. The negative experiences were: Nothing negative, Disturbing context, Short-term effect, Depending on someone else, Time-consuming, Physical distractions and Remaining cravings. The conclusion of this study is that all respondents appreciated NADA treatment. This study supports further research on using NADA in addiction treatment to reduce suffering during protracted withdrawal and in other contexts.

A comparison of flat-sheet and hollow-fiber membrane oxygenators: the Shiley M-2000 vs. the Bentley BOS-CM 40.

To compare new flat-sheet and hollow-fiber membrane oxygenators for use in cardiopulmonary bypass, we randomly divided 40 coronary artery surgery patients into 2 groups of 20 patients each. The Shiley M-2000 flat-sheet membrane oxygenator was used in 1 group, and the Bentley BOS-CM40 hollow-fiber membrane oxygenator was used in the other group. Both oxygenators allowed for adequate transfer of oxygen and carbon dioxide. At the end of perfusion, the platelet counts were significantly lower and the arterial pH significantly higher in the Shiley group than in the Bentley group. The other hematologic parameters, as well as postoperative blood losses, were similar in the 2 groups, but were also similar to those reported earlier with respect to bubble oxygenators. On the basis of these results, we conclude that, for routine short-term perfusion, these new membrane oxygenator models, while marginally different from one another, offer no real advantage over bubble models.

Combined mitral valve and coronary artery surgery.

During the past 10 years, 50 patients underwent combined coronary artery bypass grafting (CABG) and mitral valve replacement (MVR) at our clinic, with additional aortic valve replacement (AVR) in six cases. The early mortality was 8%. During the first half of the study period this mortality was 4/11 patients, but in the second half it was 0/39. All six patients with CABG + MVR + AVR survived the operation. Adverse factors were found to be advanced functional impairment, female sex, concomitant untreated aortic valvulopathy and elevated pulmonary vascular resistance. All 46 patients who survived the operation were followed up for a mean period of 31 months, and during that time there were nine deaths. The survival rate was 54% after 3 years and 40% after 5 years. Most of the patients had improved by at least one functional class. The good results in this series probably were attributable to improvements in surgical procedure (introduction of cold potassium cardioplegia) and in postoperative management (intra-aortic balloon pumping).

The immediate function of sequential aortocoronary vein grafts to closely adjacent myocardial areas.

Blood-flow measurements were performed in 72 patients after sequential vein grafting (Y-grafting) to LAD and diagonal branches. The mean blood flow in the joint graft was 69 ml/min, i.e. significantly more than the 36 ml/min in one branch when the other was occluded. When one branch was occluded for 10 min (11 patients), there was insignificant increase of the flow through the nonoccluded branch. The mean joint graft flow and branch flow increased insignificantly after administration of dipyridamole. Lower blood flow in one branch of the sequential graft than in the joint graft is due to insufficient collateral system. High rate of flow in the joint graft probably reduces the rate of early and late occlusion.

Pancreatitis after cardiac and cardiopulmonary transplantation.

In a review of 176 patients who died after either cardiac or cardiopulmonary transplantation, 15 cases of pancreatitis were identified. The diagnosis was clinically inapparent in 11 of the 15 cases of pancreatitis. A high index of suspicion should therefore be maintained when these patients are cared for. A variety of factors may have contributed to the occurrence of pancreatitis in these patients. These include infection, steroids, azathioprine, low-flow states, extracorporeal circulation, vasopressors, renal failure, and rejection.

The advantage of the thoraco-retroperitoneal approach for aortorenal bypass grafting.

Postoperative angiographic studies after aortorenal saphenous vein bypass grafting have revealed a high incidence of graft dilatation and aneurysms. The aortorenal bypasses in all these series were performed via the transabdominal approach which gives an angle of at least 90 degrees between the graft and aorta. The routine approach in the present study has been the thoraco-retroperitoneal one which has been used since more than 20 years in 189 patients. In 13 of them an aortorenal saphenous vein bypass was performed. The saphenous vein was sutured into the aorta above the orifice of the renal artery giving an acute angle of about 45 degrees. This angle gives much more favourable hemodynamic conditions including less turbulence. All the patients survived the operation and were followed for a mean period of 5 years. Two of the patients were hypertensive because of stenosis of the opposite renal artery. Eight patients are normotensive and three patients are improved. Renal arteriograms performed 4 to 13 years postoperatively in five of the patients showed excellent conditions without any dilatation of the graft. The thoraco-retroperitoneal approach gives a very good access to the entire renal artery and permits an aortorenal bypass with an angle which causes a minimum of turbulence.

Relationship of brain blood flow and oxygen consumption to perfusion flow rate during profoundly hypothermic cardiopulmonary bypass. An experimental study.

A study was made of the relation of brain blood flow and oxygen consumption to changes in perfusion flow rate during cardiopulmonary bypass at 20 degrees C in nine cynomolgus monkeys. Four perfusion flow rates varying from 0.25 to 1.75 L X min-1 X m-2 were randomly instituted, each for a 10 minute period. At the end of each period, brain arteriovenous oxygen content difference was measured and 15 mu radioactive microspheres were injected into the arterial perfusion line. The brain was then removed and section into anatomic regions and radioactivity was counted. Regional and total brain blood flows were calculated, as was whole brain oxygen consumption. Brain perfusion continued in all areas at all perfusion flow rates. Whole brain blood flow decreased (p less than 0.0001) as perfusion flow rate was reduced (45 +/- 6.5, 41 +/- 7.9, and 23 +/- 2.8 ml X min-1 X 100 gm-1 at 1.5, 1.0, and 0.5 L X min-1 X m-2, respectively). The proportion of the total perfusion delivered to the brain increased (p = 0.003) with decreasing perfusion flow rates (5.4% +/- 0.78%, 7.1% +/- 1.24%, and 8.2% +/- 1.11% at 1.5, 1.0, and 0.5 L X min-1 X m-2, respectively). Brain blood flow resistance remained unchanged (p = 0.4) while that of the remaining body increased (p less than 0.0001). There was a greater reduction of blood flow in the cortical white matter (p = 0.01) than in other regions of the brain. Brain oxygen consumption was the same (p = 0.5) at all perfusion flow rates, related to an increasing percent oxygen extraction with decreasing perfusion flow rate (p less than 0.0001). The data indicate that all areas of the brain remain perfused, even at low perfusion flow rates, during profoundly hypothermic cardiopulmonary bypass, and that brain oxygen consumption is maintained in part by increased oxygen extraction and in part by redistribution of the perfusate from the remaining body to the brain.

Early and late efficacy of three types of transvenous atrial leads.

Experience with three transvenous atrial leads, representing different principles, is presented. The types were screw-in (Vitatron Helifix-12), J-lead (Intermedics Lifeline 483-01) and straight-tined (Medtronic 6961). The study comprised insertion of 86 leads (30 Helifix, 40 Lifeline, 16 Medtronic) in 76 patients. Atrial fibrillation occurred during insertion in two patients, and in two others stable electrode positioning in the right atrial appendage was not achieved. Stable position and acceptable intracardiac P-waves were obtained in all the other patients (in 5 after change to another type of lead). Atrial triggered ventricular pacing was used in 34 cases and atrial pacing was used in 38. The P-wave amplitude at insertion was significantly less with Helifix than with Lifeline or Medtronic. The stimulation thresholds (range 0.25-2.5 V) did not differ significantly between the electrodes. Dislodgement of the electrode occurred during the first week in seven cases (5 Lifeline, 2 Helifix), but no late dislodgement occurred. The mean follow-up was 14 months (range 1-31). All three atrial leads offer acceptable function with regard to electro-physiological properties and electrode stability.

Prosthetic valve endocarditis.

Fifty-three (3.6%; actuarially 4.1% at 48 months) of 1465 consecutive in-hospital survivors of valve replacement from 1975 to July 1979 (aortic, mitral, or aortic and mitral, only one untraced) developed prosthetic valve endocarditis (PVE). Incremental risk factors for developing PVE were native valve endocarditis (p less than .0001), black race (p = .0001), mechanical prosthesis (vs bioprosthesis) (p = .005), male sex (p = .04), and longer cardiopulmonary bypass time (p = .09). In general, the hazard function for developing PVE was greatest at 3 weeks after valve replacement. Patients with native valve endocarditis had a tendency to develop PVE early after valve replacement, as did patients in whom mechanical prostheses were used. PVE associated with Staphylococcus epidermidis tended to appear within 6 months of valve replacement, whereas streptococcal PVE tended to appear later after valve replacement. PVE took an atypical form in some patients, but patients with possible PVE (n = 6) had the same findings as those with certain PVE (n = 47). In 11 patients bacteriologic confirmation of PVE was not obtained. The typical prosthetic and periprosthetic characteristics of PVE were present in 30 of the 40 cases in which observations were possible. PVE is a serious condition; 34 (64%) of our 53 patients died. Most deaths occurred within 3 months of the first evidence of PVE. Recovery of some patients is possible with appropriate medical and surgical treatment, but more intense preventive measures are indicated.

Traumatic disruption of the thoracic aorta.

Fourteen cases of injury to the thoracic aorta treated in 1959-1981 are reviewed. Acute rupture was present in nine patients and chronic post-traumatic aneurysm in five. Most of the patients had other, associated injuries, and physical signs of the aortic injury were often scanty. Widening of the mediastinum was the most common roentgenographic finding. All the aortic ruptures were localized to the isthmus. One patient declined surgery. Another died on the operating table just before surgery was started. A third patient died peroperatively from severe bleeding when the aneurysm was dissected free. All of the other 11 patients survived operation without major complications. At follow-up (mean 10 years), ten patients were alive and well and one had died of unrelated cause. The most recent operations were performed with the aid of a TDMAC (Gott) shunt, which makes aortic repair safe and simple. Because aortic trauma often is accompanied by other, severe injuries which make transportation of the patient risky, and so as not to delay operation, the aortic lesions should be repaired at general surgical units. If necessary, a thoracic surgeon should be brought to the hospital.

Extracranial carotid and vertebral artery aneurysms.

Extracranial carotid aneurysms are uncommon, and in the past their management has not always been satisfactory. These aneurysms may be caused by arteriosclerosis, infection or trauma, or they may be congenital. Neurologic symptoms are common. Surgery is recommended for symptomatic aneurysms in patients of all ages. Non-growing aneurysms in old patients can be conservatively managed. Six cases of carotid and one case of vertebral artery aneurysm are reported. The mode of clinical presentation, etiologic factors, angiographic findings and methods of management are discussed.

Intrathoracic tracheal rupture following blunt chest trauma.

Intrathoracic tracheal rupture following closed chest trauma is a potentially lethal injury which can be successfully repaired if the diagnosis is made early. Dyspnoea, mediastinal emphysema and pneumothorax which do not respond to intercostal tube drainage should alert the clinician to the possibility of intrathoracic tracheal rupture. A case is described. A 17-year-old boy sustained two longitudinal lacerations of the membranous portion of the intrathoracic trachea in association with blunt chest trauma. The diagnosis was delayed because of coexisting head injury. The tracheal lacerations were successfully repaired via a right thoracotomy. The principles of management in such injuries are reviewed.

Determinants of early success in repair of aortic coarctation in infants.

Fifty-five infants less than 1 year of age underwent repair of coarctation of the aorta between 1967 and 1981. Sixteen (29%) died while in the hospital, with one death occurring from "pure" coarctation. Of the remaining patients, four among 20 with associated ventricular septal defect (VSD) and 11 among 19 with other major associated cardiac anomalies (p = 0.002) also died. Thirteen (62%) of 21 patients treated by resection and end-to-end anastomosis died in the hospital, while only two (7%) of 30 in whom the subclavian flap repair was used died (p less than 0.0001). Good femoral pulses were present early postoperatively in 29 of 30 patients with the subclavian flap in whom observations were recorded and in nine of 12 patients who received end-to-end anastomosis (p = 0.06). Multivariate analysis showed only the very small size of the patient, the presence of major associated cardiac anomalies other than VSD, and nonuse of the subclavian flap method to be incremental risk factors for hospital death. These data and the reports of others show the subclavian flap technique to be the method of choice for repair of coarctation of the aorta in infants.