Hospital volume is related to clinical and economic outcomes of esophageal resection in Maryland.

BACKGROUND: Previous studies have documented a relationship between hospital volume and perioperative and economic outcomes. Our objective was to determine the effect of hospital volume on outcomes of esophageal resection. METHODS: Statewide database was analyzed for patients who underwent esophageal resection in Maryland (n = 1,136 patients) from 1984 to 1999. Multivariate regression was used to determine the association of hospital volume with in-hospital mortality, length of stay, and charges after adjusting for case mix and time period. RESULTS: Unadjusted in-hospital mortality rates were lower in high volume hospitals (2.7%) than medium (12.7%) and low (16%) volume hospitals (p < 0.001). High hospital volume was associated with (1) fivefold reduction in the risk of death (odds ratio, 0.21; 95% confidence interval, 0.10 to 0.42; p < 0.001); (2) a 6-day (95% confidence interval, 5 to 7 days; p < 0.001) reduction in length of stay; and (3) $11,673 (95% confidence interval, $9,504 to $12,841; p < 0.001) decrease in hospital charges. Conclusions. Hospitals that perform high volumes of esophageal resection have superior clinical and economic outcomes. By referring these patients to high volume centers, we may improve quality and reduce costs.

Aortic paravalvular leaks: alternative suture placement strategy for the left coronary cusp.

Repair of a left coronary cusp aortic paravalvular leak can be achieved by placing stitches through the main pulmonary artery, right pulmonary artery, and left atrium when removal of the previously inserted valve is contraindicated.

Changes in serum myoglobin, total creatine kinase, lactate dehydrogenase and creatine kinase MB levels in runners.

A comparison was made between pre- and post-run serum levels of total creatine kinase (CK), CK-MB isoenzyme, lactate dehydrogenase (LD) and myoglobin (MG) levels in 84 runners in each of three groups; male 5-10 mile run; female 5-10 mile run; and male 15-55 mile run. Levels of CK-MB and MG were quantified using radioimmunoassay, while total CK and LD were measured using spectrophotometric procedures. Post-run levels of all four markers were significantly higher than the pre-run levels (p less than 0.001). Although levels of enzymes and MG correlated with the sex and distance run, the post-run changes did not correlate with age nor with the smoking status of the runners. Elevation of these markers as a result of vigorous exercise in the absence of myocardial infarction requires cautious interpretation of serum enzyme changes in runners.

Intravenous isosorbide dinitrate in the management of acute hypertension following cardiopulmonary bypass.

Twenty-one patients with acute systemic hypertension following cardiopulmonary bypass received isosorbide dinitrate intravenously in order to determine its effectiveness in managing this postoperative problem. Twenty patients underwent coronary artery bypass operation, and 1 patient had a pulmonary valvotomy. Bolus administration (0.25 to 2.5 mg [3.0 to 40.0 micrograms per kilograms]) decreased systemic systolic blood pressure 23% and diastolic blood pressure 25% (both, p less than 0.01). Continuous controlled infusion (0.125 to 0.332 mg per minute [1.5 to 6.0 micrograms/kg/min]) caused a more modest drop in systemic blood pressure, with a 17% reduction in systolic blood pressure and an 11% drop in diastolic blood pressure (both, p less than 0.05). Additional pressure reduction and maintenance therapy were provided by intermittent bolus administration or a continuous infusion. Moderate venodilation (decrease in central venous pressure) accompanied the systemic pressure response. The heart rate was not appreciably altered and, with exception of 1 patient in whom systemic pressures were reduced to 105/60 mm Hg after bolus infusion, the desired level of systolic, diastolic, and mean arterial pressures were readily titrated and maintained in a stable, predictable manner. These observations suggest that intravenously administered isosorbide dinitrate is a practical, safe, and highly effective method of treatment of hypertension following cardiopulmonary bypass.

Transbronchial mucus transfer of bronchogenic carcinoma.

The metastatic transfer of cells from a primary bronchogenic carcinoma to other portions of the lung as a result of mucus embolization and inoculation has been demonstrated. Histologic observations indicate tumor implantation and survival in peripheral bronchioles. In these regions mucosal dysplasia and carcinoma-in-situ changes which characteristically accompany a primary lesion are notably absent. Morphologic changes associated with acute bronchitis and focally denuded bronchial mucosa may be implicated.

Recurrent brain abscess: manifestation of pulmonary arteriovenous fistula and hereditary hemorrhagic telangiectasia.

A unique case of recurrent brain abscess as the primary manifestation of pulmonary arteriovenous fistula is presented. In the absence of hematologic abnormalities and characteristic physical findings, the diagnosis of pulmonary arteriovenous fistula is particularly elusive. Patients with brain abscess must be carefully evaluated for the presence of pulmonary arteriovenous fistula or hereditary hemorrhagic telangiectasia.

Nonpenetrating trauma to the thoracic aorta.

Twenty-seven patients underwent surgical repair for nonpenetrating injuries of the thoracic aorta. Emergency operation was performed in 19 patients with acute aortic injury and there were 12 survivors. Left heart bypass (LHB), external shunts, and simple aortic cross-clamping were methods employed during repair. All operative deaths occurred in the left heart bypass group. Morbidity, hospital stay, operative time, and blood loss all were markedly less in patients repaired with an external shunt or simple cross-clamping. Systemic heparinization related adversely to mortality and morbidity. Eight patients had repair of chronic post-traumatic descending aortic aneurysms. One of these had previous repair elsewhere with paraplegia and subsequent mycotic aneurysm at the graft repair site. He presented to us with massive hemoptysis. Surgical correction in the chronic group was performed using either left heart bypass, external shunt, or simple aortic cross-clamp with graft interposition. The only death occurred in a patient repaired on left heart bypass.

Primary intimal sarcoma of pulmonary valve and trunk with osteogenic sarcomatous elements. Report of a case considered to be pulmonary embolus.

A 49-year-old woman had a six-week history of increasing shortness of breath and fatigue. X-ray films and pulmonary scans showed multiple areas of emboli, especially in the right lung. Treatment with heparin was unsuccessful, and although a repeat scan showed only slight changes, the patient's condition deteriorated. Acute pulmonary edema and ventricular tachycardia preceded her death. Autopsy revealed a primary intimal sarcoma with osteogenic elements arising in the posterior leaflet of the pulmonary valve and obstructing the main pulmonary artery and its right branch.

Selective sputum cultures. A bronchial culture technique using a modified nasotracheal suction catheter with a sterile, inner telescoping cannula.

The contamination of expectorated or catheter-aspirated sputum specimens by pathogenic microorganisms which have colonized the nose and oropharynx remains a formidable obstacle to the accurate interpretation of sputum cultures. This problem is encountered in all forms of acute and chronic bronchopulmonary infection. A standard suctioning technique via a nasotracheal catheter has been modified with a telescoping sterile inner cannula to obtain uncontaminated bronchopulmonary secretions for culture. Bacteriologic results of selective bronchial cultures obtained in 18 patients following major chest surgery have provided important considerations concerning the prophylactic use of antibiotics. The telescoping cannula method is a simple, safe, and practical means of selectively monitoring the bacteriologic flora of the lower respiratory tract.