Placement of a permanent epicardial pacemaker in children using a subcostal approach.

BACKGROUND: Previously described techniques for epicardial pacemakers in children have generally included either a left thoracotomy approach or a subxiphoid incision. METHODS: We have recently used a single left subcostal incision for placement of both the epicardial electrodes and the pacemaker generator. We report our initial experience with this technique in 8 patients. The mean age was 4 years (range, 4 months to 12 years). The smallest patient weighed 4,100 g. RESULTS: The subcostal approach was successful in 7 patients. One patient with a narrow costal margin operated on early in our experience required conversion to a thoracotomy. The pacing thresholds were uniformly excellent in all patients. There have been no associated complications. CONCLUSIONS: Placement of epicardial leads using a left subcostal incision avoids a thoracotomy, is simpler than a subxiphoid approach, and results in acceptable thresholds with minimal morbidity.

Immediate-early gene expression in ovine brain after hypothermic circulatory arrest: effects of aptiganel.

BACKGROUND: Altered gene expression occurs in the brain after global ischemia. We have developed a model to examine the effects of cardiopulmonary bypass and hypothermic circulatory arrest (HCA) on the induction of the immediate-early gene c-fos in the brains of neonatal lambs. We then tested the effects of the noncompetitive N-methyl-D-aspartate antagonist, aptiganel hydrochloride (Cerestat), on c-fos expression and neuronal injury. METHODS: Neonatal lambs (weight, 4 to 6 kg) anesthetized with isoflurane were supported by cardiopulmonary bypass, subjected to 90 or 120 minutes of HCA at 15 degrees C, and rewarmed on bypass to 38 degrees C. One hour after cardiopulmonary bypass was terminated, the brains were perfusion fixed and removed for in situ hybridization and immunohistochemical analysis. Some animals survived 3 days before their brains were removed to examine for neuronal necrosis. One group of lambs (n = 20) received aptiganel (2.5 mg/kg). A second group (n = 25) received saline vehicle only. RESULTS: Increasing duration of HCA induced a corresponding increase in c-fos messenger RNA expression throughout the hippocampal formation and cortex. However, Fos protein synthesis peaked after 90 minutes of HCA and decreased significantly (p < 0.01) after 120 minutes of HCA. Aptiganel administration caused a significant decrease in (p < 0.001) c-fos messenger RNA expression and Fos protein synthesis after 90 minutes of HCA and preserved Fos protein synthesis after 120 minutes of HCA. Neuronal necrosis was observed in the brains of vehicle-treated lambs after 120 minutes of HCA but was significantly decreased (p < 0.05) in the lambs given aptiganel. CONCLUSIONS: These experiments indicate that the transcriptional processes of immediate-early genes remain intact, whereas translational processes are impaired after prolonged HCA. The inability to synthesize Fos proteins after 120 minutes of HCA was associated with neuronal degeneration. Aptiganel preserved translational processes and caused a significant improvement in the neurologic outcome.

Relationship between low estrogen receptor values and other prognostic factors in primary breast tumors.

BACKGROUND: The current study compared the immunocytochemical expression of estrogen (ER) and progesterone (PgR) receptors by malignant breast cells to the hormone receptor concentrations reported from radioligand assays. These values were examined in relation to DNA ploidy and the fraction of cells in S phase. METHODS: ER and PgR concentrations, DNA ploidy, and S-phase fractions were measured by standard techniques with 124 samples of invasive ductal carcinoma. Suspensions of tumor cells were examined by immunocytochemical assay (ICA) for the percentages of ER and PgR positive cells. RESULTS: Twenty-six of the 38 tumors from patients 50 years of age or younger were classified as high S-phase fraction, and 28 tumors had aneuploid levels of DNA. The 20 ER positive tumors each contained less than 100 fmol/mg. Thirty-nine of the 86 tumors from patients older than 50 years were classified as high S phase, and 41 were aneuploid. Sixty-five samples were considered ER positive by radioligand assay. ICA showed that tumors in either age group with less than 40 fmol/mg did not contain ER positive cells. The proportion of samples with PgR levels between 10 and 100 fmol/mg was small, and fewer PgR positive tumors were categorized as negative when examined by ICA for receptor containing cells. The reclassification of the hormone receptor status of a tumor based on ICA appeared to be independent of S-phase and ploidy values. CONCLUSIONS: Tumors that are classified as ER or PgR positive based on accepted cutoff values for radioligand assays may actually be receptor negative because the tumors do not appear to contain receptor positive cells.

Immunocytochemical analysis of hormone receptors with malignant cells separated from human mammary tumors.

The authors compared radioligand assays with immunocytochemistry assays to establish the hormone receptor status of malignant mammary tumors. This study differed from previous work in that immunochemistry assays were used with tumor cell effluents rather than with intact histologic sections. The results showed a 90% qualitative agreement between immunocytochemistry assays and radioligand assays in identifying estrogen receptor (ER)- or progesterone receptor (PgR)-positive and ER- or PgR-negative malignant tumors. However, only 31% of the cells from receptor-positive patients expressed ER, and only 24% of the cells contained PgR. The data showed a 73% agreement between immunocytochemistry and radioligand assays for ER when cases were categorized as strongly positive (> 100 fmol/mg and > 10% stained cells), intermediately positive (3-100 fmol/mg and .1% to 10% stained cells), or negative in both assays. Progesterone receptor values for the three categories showed an agreement between assays of 82%. These observations suggest that immunocytochemical analysis of isolated populations of tumor cells may be a useful means of complimenting radioligand assays in selecting patients for antihormone therapy.

Management of coexistent carotid and coronary artery disease.

Simultaneous coronary artery bypass grafting (CABG) and carotid endarterectomy (CE) were done on 133 patients over an 8-year period. Twenty-seven patients (20%) had previous transient ischemic attacks (TIAs), 12 (9%) had previous strokes, and the remainder (71%) were asymptomatic. All asymptomatic patients had greater than 85% stenosis of the internal carotid artery demonstrated by noninvasive ultrasonography and four-vessel angiography. CE was performed prior to the sternotomy for coronary artery bypass, under the same anesthesia. Nineteen patients had bilateral carotid artery disease. Postoperatively, three patients (2.3%) suffered strokes, an additional three patients (2.3%) suffered transient upper extremity weakness, and one patient from each of these groups died. There were no postoperative strokes or TIAs in patients with bilateral carotid artery disease. Average length of hospital stay was 10 days. Our experience leads us to conclude that the morbidity and mortality of the simultaneous procedure are not affected by bilateral carotid artery disease. In patients with symptomatic coronary artery disease and symptomatic carotid artery disease or asymptomatic carotid artery disease with a high-grade stenosis, we think that simultaneous repair of both lesions should be done.

Effect of a betadine connection shield on central venous catheter sepsis.

The effect on the rate of central venous catheter sepsis of incorporating the catheter hub in a povidone-iodine (Betadine) connection shield was evaluated in a randomized controlled clinical trial involving 47 Silastic catheters inserted in 35 patients solely for the administration of parenteral nutrition. All catheters were tunneled subcutaneously and once inserted were randomized to one of two subsequent management groups. Group 1 (n = 25) were managed in a standard fashion whereas Group 2 catheters (n = 22) in addition were managed by incorporating the catheter hub in a Betadine connection shield (Connection Shield 3; Travenol/Baxter). The catheter lifespans in the two groups were similar (Group 1 mean 10.8 days; range 3-28: Group 2 mean 13.3 days: range 5-31). There was a significant difference in the rates of both clinical sepsis (Group 1, 8 cases; 32%; Group 2, 1 case; 4.5%; p less than 0.05) and bacteriologic sepsis (Group 1, 6 cases; 24%; Group 2, 0 cases; p less than 0.05) in the two groups. Incorporating the catheter hub in a Betadine connection shield confers significant benefit in terms of reducing the incidence of catheter sepsis in patients receiving total parenteral nutrition.

Arm ischemia secondary to giant cell arteritis.

Patients with severe ischemic symptoms that fail to respond to steroid therapy, despite a dramatic and continuous drop in the erythrocyte sedimentation rate, may require arterial bypass surgery to overcome arterial ischemia caused by arteritis. We report the case of a patient with bilateral subclavian artery occlusion secondary to giant cell arteritis who responded well to steroid therapy and arterial reconstructive surgery. The patient has remained well for five years.

Long-term brachial artery catheterization: ischemic complications.

The brachial artery is not used for long-term catheterization and routine hemodynamic monitoring because a high incidence of ischemic complications is anticipated. However, in a review of 157 patients who had 225 percutaneous transbrachial hepatic artery catheters placed for infusion of chemotherapeutic agents, catheters remained in situ from 1 day to 14 months (median 68 days). One hundred seventy-three catheters (77%) were removed electively and 52 catheters (23%) were removed because of complications. Diminution or loss of the radial pulses occurred on insertion of 88 catheters (39.1%) and 16 of these (8%) were removed after 24 hours because ischemic symptoms developed. Subsequently, 25 other catheters (11.1%) were removed because of complications such as paresthesia, eight (3.5%); brachial artery thrombosis, four (1.7%); microembolization, three (1.3%); claudication, two (0.8%); and pseudoaneurysm, one (0.4%). Seven catheters (3.1%) were removed because of a combination of pallor, diminished pulses, and muscle weakness. Hemorrhage from the arteriotomy site necessitated the removal of 11 other catheters (4.9%). Amputation, ischemic ulceration, major neuromuscular sequelae, and peripheral embolization to the head or lower limbs did not occur. This study suggests that long-term brachial artery catheterization is associated with a low incidence of permanent ischemic complications.