[Allowing a patient in a vegetative state to die in hospital under the direction of a nursing-home physician]. / Het laten sterven van een patiënt in een vegetatieve toestand in het ziekenhuis met de verpleeghuisarts als hoofdbehandelaar.

In the case of a 52-year-old man, who was in a vegetative state after resuscitation following an unwitnessed cardiac arrest, the nursing-home physician assumed responsibility for the total treatment in a transfer unit of the hospital. His systematic, multidisciplinary approach enabled direction of the complex situation in which many medical and paramedical personnel were involved. When an airway infection occurred as a complication shortly after responsibility for the patient had been assumed, the nursing-home physician could take a well-considered decision to withdraw medical treatment on the basis of the treatment plan which had been formulated in a short time and contact with the family. In clinical practice it is difficult to determine the most appropriate moment to withdraw all medical therapy, including artificial nutrition and hydration, in order to prevent a hopeless vegetative state. This case illustrates how hospital physicians and nursing-home physicians may cooperate during the 'waiting phase' of the clinical course of a vegetative state. A hopeless vegetative state can be prevented by using these transmural possibilities for cooperation, including an early input of knowledge and experience about the long-term course of a vegetative state.

Regional implementation of the NWC guideline on ST-elevation myocardial infarction: Report from the Task Force Prehospital Triage Zuidoost Brabant (PHT ZoB).

BACKGROUND: The NVVC guideline on ST-elevation myocardial infarction forms the basis for the regional prehospital triage (PHT) project in Zuidoost Brabant. In this project diagnosis and treatment strategies are determined in the ambulance. AIM: To summarise quality assessment and clinical results after one year. METHODS: We evaluated the protocol and patient record form, the patient's call, assignment of tasks, diagnosis, treatment, time intervals, information to hospitals, cooperation and data transmission. Time delays were compared with time delays in a regional dry run before the start of the project and with time delays reported in the literature. RESULTS: Patients still wait over one hour before seeking medical attention. The GP received the majority (65%) of patient calls. In half of all cases (51%), GPs call the ambulance centre only after they have seen the patient. When the patient calls the ambulance centre (35%), information to the GP is either prompt or absent. In 77% of calls to 112 it remains unclear whether the GP was informed at all. The treatment strategy was correct in 97% of cases. Time between symptoms and call decreased in comparison with our local preliminary investigation. Quality assessment after one year shows protocol deviations that are either logical procedural improvements or correctable flaws with no substantial negative influence. CONCLUSION: Short-term clinical results are good, but structured follow-up is needed to reduce mortality in the long term, especially after thrombolysis. A guideline is a snapshot of a dynamic process. The PHT project allows rapid adaptations to be made to new paradigms.

The definition of myocardial infarction during aortocoronary bypass surgery.

In a study of 392 aortocoronary bypass (CABG) patients, we found 16 patients with a postoperative new Q wave, 29 patients with new intraventricular conduction disturbance, 17 patients with cardiogenic shock, and 14 patients with excessive CK-MB activity. Those criteria were considered as diagnostic of perioperative acute myocardial infarction (AMI). Listing the 392 patients in a Venn diagram: five patients had three positive criteria, eight had two, 43 had one, and 336 had none. Ventricular arrhythmia, supraventricular arrhythmia, or ST-T changes occurred in decreasing frequency in patients with a decreasing number of positive criteria. Five patients died postoperatively and in four a postmortem examination was available. Diagnostic criteria partly predicted autopsy findings. We conclude that the diagnostic criteria of perioperative myocardial infarction have a low diagnostic performance.

Risk of operative mortality in surgery for coronary heart disease (a multiple regression analysis of perioperative hemodynamic and electrocardiographic data).

Using multiple regression analysis, we examined perioperative hemodynamic and electrocardiographic variables as predictors of operative mortality in surgery for coronary heart disease. Data were first analyzed as univariates and, if significantly related to mortality, they were subjected to stepwise logistic multivariate regression analysis. The preoperative predictor variables were: heart rate, ventricular arrhythmia and ST-T shift. The intraoperative predictor variables were: ventricular arrhythmia and ST-T shifts; and the postoperative predictor variables were: left ventricular stroke work index, blood pressure, mixed venous oxygen content and intrapulmonary shunt. When only electrocardiographic data were analyzed, the preoperative variables were: ventricular arrhythmia, ST-T shift and anterior wall infarction. The intraoperative variables were: ventricular arrhythmia and ST-T shift. The postoperative electrocardiogram did not give additional information. The common denominator of the relevant hemodynamic and electrocardiographic variables appears to be an accumulation of pre- and perioperative myocardial damage, which leads to operative mortality.

Fontan's operation: an expanded horizon.

The Fontan principle of redirecting systemic venous blood into the pulmonary arteries via a conduit has now gained a much wider application than initially intended. We have applied this type of operation in a series of 15 patients, five of whom had "classical" tricuspid atresia with concordant arterial connections. The other 10 patients showed a variety of congenital malformations, such as double-inlet univentricular heart with discordant arterial connections, double-outlet right ventricle with common atrioventricular canal. Ebstein's anomaly with almost imperforate tricuspid valve, hypoplasia of right ventricular inflow, and a crisscross heart with straddling right atrioventricular valve. Important associated anomalies, such as common atrium and anomalous pulmonary and/or systemic drainage, required particular adaptation of the technique. Thirteen of the 15 patients survived operation and are presently alive. One death occurred in a patient in whom the preoperative diagnosis had to be adjusted during operation because of unexpected total anomalous pulmonary venous connections. The other death occurred in a patient suffering from the "asplenic syndrome." The autopsy in this patient suggested that the large baffle used for atrial septation and ventricular exclusion had obstructed pulmonary venous return. Our experience thus supports the opinion that Fontan's operation has a place in the treatment of otherwise anatomically uncorrectable lesions.

[The subclavian-pulmonary anastomosis (author's transl)]. / L'anastomosi succlavia-polmonare oggi.

A series of 16 patients who underwent Blalock-Taussig anastomosis for severe cyanosis, without hospital deaths, is reported. Based on this recent, limites experience, and on/an extensive review of the literature the Authors analyze objective criteria to identify the ideal palliative systemic-pulmonary shunt. Early results and late sequelae of Blalock-Taussig, Waterston-Cooley and Potts-Smith anastomosis are compared. It is then proposed that the subclavain-pulmonary anastomosis should be considered the palliation of choice of elective and emergency indication to treat severe cyanosis in those patients for whom corrective surgery can not be contemplated.