Subcutaneous phaeohyphomycosis caused by Amesia atrobrunnea in Kuwait.

The recently described genus Amesia encompasses four species but only Amesia atrobrunnea (=Chaetomium atrobrunneum) is known to be pathogenic to humans. Here, we describe a case of subcutaneous phaeohyphomycosis in Kuwait in an apparently immunocompetent patient diagnosed by direct microscopy of the infected tissue and culture. The identity of A. atrobrunnea was established by typical morphological characteristics and by sequencing of internally transcribed spacer (ITS) region and D1/D2 domains of rDNA. To the best of our knowledge, this is the first report documenting etiologic role of this species in causing a locally invasive subcutaneous infection.

Edge effects enhance selfing and seed harvesting efforts in the insect-pollinated Neotropical tree Copaifera langsdorffii (Fabaceae).

Edge effects may affect the mating system of tropical tree species and reduce the genetic diversity and variance effective size of collected seeds at the boundaries of forest fragments because of a reduction in the density of reproductive trees, neighbour size and changes in the behaviour of pollinators. Here, edge effects on the genetic diversity, mating system and pollen pool of the insect-pollinated Neotropical tree Copaifera langsdorffii were investigated using eight microsatellite loci. Open-pollinated seeds were collected from 17 seed trees within continuous savannah woodland (SW) and were compared with seeds from 11 seed trees at the edge of the savannah remnant. Seeds collected from the SW had significantly higher heterozygosity levels (Ho=0.780; He=0.831) than seeds from the edge (Ho=0.702; He=0.800). The multilocus outcrossing rate was significantly higher in the SW (tm=0.859) than in the edge (tm=0.759). Pollen pool differentiation was significant, however, it did not differ between the SW (=0.105) and the edge (=0.135). The variance effective size within the progenies was significantly higher in the SW (Ne=2.65) than at the edge (Ne=2.30). The number of seed trees to retain the reference variance effective size of 500 was 189 at the SW and 217 at the edge. Therefore, it is preferable that seed harvesting for conservation and environmental restoration strategies be conducted in the SW, where genetic diversity and variance effective size within progenies are higher.

A prospective open-label treatment trial of olanzapine monotherapy in children and adolescents with bipolar disorder.

OBJECTIVE: The goal of this study was to assess the effectiveness and tolerability of olanzapine in the treatment of acute mania in children and adolescents. METHODS: This was an 8-week, open-label, prospective study of olanzapine monotherapy (dose range 2.5-20 mg/day) involving 23 bipolar youths (manic, mixed, or hypomanic; 5-14 years old). Weekly assessments were made using the Young Mania Rating Scale (YMRS), Clinical Global Impressions Severity Scale (CGI-S), Brief Psychiatric Rating Scale, and Children's Depression Rating Scale. Adverse events were assessed through self-reports, vital sign and weight monitoring, laboratory analytes, and extrapyramidal symptom rating scales (Barnes Akathisia Scale, Simpson-Angus Scale, and Abnormal Involuntary Movement Scale). RESULTS: Twenty-two of the 23 youths (96%) completed the study. Olanzapine treatment was associated with significant improvement in mean YMRS score (-19.0 +/- 9.2, p < 0.001). Using predefined criteria for improvement of > or = 30% decline in the YMRS and a CGI-S Mania score of < or = 3 at endpoint, the overall response rate was 61%. Overall, olanzapine was well tolerated, and extrapyramidal symptom measures were not significantly different from baseline. Body weight increased significantly over the study (5.0 +/- 2.3 kg, p < 0.001). CONCLUSIONS: Open-label olanzapine treatment was efficacious and well tolerated in the treatment of acute mania in youths with bipolar disorder. Future placebo-controlled, double-blind studies are warranted.

Effects of a videotape information intervention at discharge on diet and exercise compliance after coronary bypass surgery.

BACKGROUND: This study evaluated the relative effects on compliance with recommended lifestyle changes of two experimental videotapes that involved different approaches for preparing coronary artery bypass graft (CABG) patients for the posthospital recovery period. The tapes differed in the extent to which they portrayed the recovery period as a steady, forward progression versus a series of "ups and downs." METHODS: Two hundred sixteen male and female CABG patients were assigned randomly either to view one of the two videotapes before discharge from the hospital or to receive only the standard discharge preparation provided by the hospital. All patients completed measures of anxiety and self-efficacy at discharge, 1 month and 3 months after discharge from the hospital. Patients also completed measures of dietary fat consumption and activity level 1 and 3 months after discharge. RESULTS: Relative to controls, patients who viewed either of the videotapes before hospital release reported higher self-efficacy for adhering to the recommended low-fat diet both at discharge and 1 month after surgery. Viewing either of the videotapes also resulted in significantly less dietary fat intake 1 month after hospital release compared with controls. Patients who viewed the tape that portrayed the recovery period as consisting of ups and downs also reported significantly more frequent moderate exercise at 1 month and more frequent strenuous exercise 3 months after discharge. CONCLUSIONS: The experimental videotapes proved to be an effective method for increasing dietary and exercise compliance during the first 3 months after CABG.

Spontaneous coronary artery dissection in patients with renal transplantation.

We describe two patients with spontaneous coronary artery dissection (SCAD) while on immunosuppressive therapy following renal transplantation. The role of cyclosporine A as a potential etiologic factor in spontaneous coronary artery dissection is discussed. A review of the recent literature on spontaneous coronary artery dissection highlights the changing clinical presentation and management of these patients.

Risks associated with removal of ventricular epicardial pacing wires after cardiac surgery.

BACKGROUND: Epicardial pacing wires are routinely used for the diagnosis and treatment of bradyarrhythmias after cardiac surgery. The frequency of arrhythmias during removal of the wires is unknown, and methods of removal vary among institutions. OBJECTIVES: To describe the frequency of ventricular arrhythmias during removal of epicardial pacing wires from the right ventricle, to determine variables that are predictive of ventricular arrhythmias during wire removal, and to describe patients' perceptions of wire removal. METHODS: A convenience sample of 145 patients who had undergone cardiac surgery was studied during the course of 1 year. Electrocardiographic and vital signs were recorded throughout wire removal. Patients' records were reviewed for variables that could predict the occurrence of arrhythmias during wire removal: laboratory values, history of arrhythmias, medications, medical history, postoperative course, and pain reported by the patient. RESULTS: Sixty-six percent of patients had one premature ventricular contraction or more while the ventricular wires were being removed. Seven percent of patients had nonsustained ventricular tachycardia during wire removal. Patients who had repeat cardiac surgery had significantly more nonsustained ventricular tachycardia than did all other patients (P < .01). Only a history of heart failure (P < .02) was a significant predictor of premature ventricular contractions during wire removal. On a scale of 0 (no pain) to 10 (worst pain), the mean rating of pain intensity reported by patients was 2.39 (SD = 2.77). CONCLUSION: Patients may be at risk for ventricular arrhythmias during removal of epicardial pacing wires. Findings support the need for electrocardiographic monitoring while pacing wires are being removed.

Surgical management of spontaneous left main coronary artery dissection.

Two cases of spontaneous left main coronary artery dissection are reported. This condition is rare and may present as an urgent surgical dilemma. The presentation, diagnosis, and management of primary left main coronary artery dissection are reviewed. Causative factors and underlying pathology are clarified. Prompt diagnosis and surgical intervention with temporary ventricular support is safe and effective.

Atrial fibrillation after cardiac surgery: a major morbid event?

OBJECTIVE: The purpose of the study was to investigate the incidence, predictors, morbidity, and mortality associated with postoperative atrial fibrillation (AF) and its impact on intensive care unit (ICU) and postoperative hospital stay in patients undergoing cardiac surgery in the Department of Veterans Affairs (VA). SUMMARY BACKGROUND DATA: Postoperative AF after open cardiac surgery is rather common. The etiology of this arrhythmia and factors responsible for its genesis are unclear, and its impact on postoperative surgical outcomes remains controversial. The purpose of this special substudy was to elucidate the incidence of postoperative AF and the factors associated with its development, as well as the impact of AF on surgical outcome. METHODS: The study population consisted of 3855 patients who underwent open cardiac surgery between September 1993 and December 1996 at 14 VA Medical Centers. Three hundred twenty-nine additional patients were excluded because of lack of complete data or presence of AF before surgery, and 3794 (98.4%) were male with a mean age of 63.7+/-9.6 years. Operations included coronary artery bypass grafting (CABG) (3126, 81%), CABG + AVR (aortic valve replacement) (228, 5.9%), CABG + MVR (mitral valve replacement) (35, 0.9%), AVR (231, 6%), MVR (41, 1.06%), CABG + others (95, 2.46%), and others (99, 2.5%). The incidence of postoperative AF was 29.6%. Multivariate logistic regression analysis of factors found significant on univariate analysis showed the following predictors of postoperative AF: preoperative patient risk predictors: advancing age (odds ratio [OR] 1.61, 95% confidence interval [CI] 1.48-1.75, p < 0.001), chronic obstructive pulmonary disease (OR 1.37, 95% CI 1.12-1.66, p < 0.001), use of digoxin within 2 weeks before surgery (OR 1.37, 95% CI 1.10-1.70, p < 0.003), low resting pulse rate <80 (OR 1.26, 95% CI 1.06-1.51, p < 0.009), high resting systolic blood pressure >120 (OR 1.19, 95% CI 1.02-1.40, p < 0.026), intraoperative process of care predictors: cardiac venting via right superior pulmonary vein (OR 1.42, 95% CI 1.21-1.67, p < 0.0001), mitral valve repair (OR 2.86, 95% CI 1.72-4.73, p < 0.0001) and replacement (OR 2.33, 95% CI 1.55-3.55, p < 0.0001), no use of topical ice slush (OR 1.29, 95% CI 1.10-1.49, p < 0.0009), and use of inotropic agents for greater than 30 minutes after termination of cardiopulmonary bypass (OR 1.36, 95% CI 1.16-1.59, p < 0.0001). Postoperative median ICU stay (3.6 days AF vs. 2 days no AF, p < 0.001) and hospital stay (10 days AF vs. 7 days no AF, p < 0.001) were higher in AF. Morbid events, hospital mortality, and 6-month mortality were significantly higher in AF (p < 0.001): ICU readmission 13% AF vs. 3.9% no AF, perioperative myocardial infarction 7.41 % AF vs. 3.36% no AF, persistent congestive heart failure 4.57% AF vs. 1.4% no AF, reintubation 10.59% AF vs. 2.47% no AF, stroke 5.26% AF vs. 2.44% no AF, hospital mortality 5.95% AF vs. 2.95% no AF, 6-month mortality 9.36% AF vs. 4.17% no AF. CONCLUSIONS: Atrial fibrillation after cardiac surgery occurs in approximately one third of patients and is associated with an increase in adverse events in all measurable outcomes of care and increases the use of hospital resources and, therefore, the cost of care. Strategies to reduce the incidence of AF after cardiac surgery should favorably affect surgical outcomes and reduce utilization of resources and thus lower cost of care.

Gonococcal endocarditis: assessment by transesophageal echocardiography.

Gonococcal endocarditis is a rare but aggressive infection that has an alarming rate of perivalvular abscess and mortality. We present a case of gonococcal endocarditis with intracardiac abscess and fistula diagnosed by transesophageal echocardiography. Given the often acute nature of gonococcal endocarditis and its propensity toward abscess formation, transesophageal echocardiography should be considered early in the course of this infection.

Characterization and surgical resection of an organized pericardial hematoma assisted by transesophageal echocardiography.

We describe the echocardiographic features of a rare pericardial hematoma causing elevated venous pressure in a patient who had suffered blunt chest trauma in the past. Transesophageal echocardiography demonstrated a large, partially calcified mass in the right cardiophrenic angle impinging on the tricuspid annulus and facilitated intraoperative assessment of surgical resection.

Constrictive pericarditis causing extrinsic mitral stenosis and a left heart mass.

Constrictive pericarditis is a fibrotic process involving both layers of the pericardium and is known to give rise to obstruction to blood flow in the right heart. We report a patient with constrictive pericarditis who had echocardiographic features of mitral stenosis caused by a fibrocalcific mass lesion involving the mitral annulus with infiltration into the base of the posterior mitral leaflet. To our knowledge, this has not been reported in the literature.

Techniques for bronchial anastomosis.

BACKGROUND: Many techniques have been described to optimize the construction of the bronchial anastomosis in lung transplantation. Over the past 60 months we have performed 86 bronchial anastomoses in 70 patients receiving single lung or bilateral single lung transplants. METHODS: No anastomosis was wrapped and no attempt was made at revascularization of bronchial arteries. A continuous nonabsorbable suturing technique was used in all cases. Standard triple-drug immunotherapy with cyclosporine, azathioprine, and prednisone (starting at day 7) was used for each patient. RESULTS: There were no anastomotic leaks, and seven stenoses were identified in five patients (7%). All complications were managed conservatively with stenting, and there were no related deaths. Mean time to stent placement was 109 days. One patient had bilateral stents placed prophylactically during an episode of severe infection for questionable anastomotic viability but without evidence of airway necrosis or obstruction. This patient died of infection at 16 days. Another patient died with stents in place at 71 days. In the four remaining patients, all stents have been removed after a mean of 310 days. These patients were followed up with serial bronchoscopy and were without evidence of recurrent obstruction at 2, 34, 35, and 36 months. Six of seven stenoses occurred in patients with cystic fibrosis. In each patient where stenosis developed the anastomosis was telescoped. Since abandoning the telescoping technique in the remaining 50 anastomoses (14 in patients with cystic fibrosis), no dehiscence or stenosis was encountered. CONCLUSIONS: These data suggest that elaborate techniques aimed at construction of the bronchial anastomosis are not necessary. Moreover, attempts at telescoping may be detrimental. Patients with cystic fibrosis may be a population at higher risk for anastomotic complications. Airway complications can be managed conservatively with good results and little risk to the patient.

Primary pulmonary artery sarcoma: a report of six cases.

Pulmonary artery tumors are rare and a frequently overlooked cause of pulmonary artery occlusion. The presentation is one of progressive pulmonary dysfunction and right ventricular failure. The diagnosis seldom is made preoperatively. We report 6 cases of primary sarcoma of the pulmonary artery identified at operation, which were treated surgically. Resection with or without adjuvant therapy currently offers the only chance for survival. Emphasis must be placed on earlier identification of these tumors.

Anal adenocarcinoma: a comprehensive review.

Adenocarcinoma of the anal canal is a rare form of a rare tumor. It remains less prevalent than both basaloid and keratinizing tumors of the anal canal. Within the category of anal adenocarcinomas, uniformity in histology, biology, or etiology is lacking. This makes subdivision of this rare entity by various parameters necessary. Several etiologic associations have been described, such as chronic fistula-in-ano, anal Crohn's disease, and anal sexual intercourse, raising the issue of cancer prevention and early detection. Various available therapeutic options are also discussed with emphasis on the seemingly promising results of preoperative chemo- and radiation therapy. Because of the rarity and apparent heterogeneity of this tumor, no comparative or analytic epidemiologic studies have been conducted that might resolve these issues. Whether histology differentiates anal adenocarcinoma from anal squamous or cloacogenic tumors in the determination of natural history and allocation to optimal therapy remains unclear. It may be that the gross anatomic location of the tumor alone determines the above and histology is superfluous.

Experience and results with 150 pulmonary thromboendarterectomy operations over a 29-month period.

A program to alleviate chronic, major vessel thromboembolic pulmonary hypertension by pulmonary thromboendarterectomy was initiated at this institution in 1970. Multiple evolutionary changes in the diagnostic evaluation, surgical approach, and postoperative management have been implemented over the series of 323 thromboendarterectomies performed through March 1992. A sequence of five surgeons at the University of California at San Diego have performed these procedures, with the last 150 having been performed by one surgeon. We report here the changes in surgical approach developed over the last 150 cases and the results obtained. The operation involves a median sternotomy incision, the institution of cardiopulmonary bypass, and deep hypothermia with circulatory arrest periods. Incisions are made in both pulmonary arteries into the lower lobe branches. Pulmonary thromboendarterectomy is always bilateral, with removal of both organized thrombus and an endarterectomy plane from all involved vessels. The right atrium is routinely explored for atrial septal defects. Current techniques appear to allow more thorough revascularization and shorter circulatory arrest times. The surgical mortality of 8.7% over this span is below that previously reported from this and other institutions. Among survivors, the hemodynamic and functional results have been excellent. Surgically correctable chronic thromboembolic pulmonary hypertension likely remains underdiagnosed. The diagnostic, surgical, and postoperative management evolution provided by the coordinated team involved at this institution has established that pulmonary thromboendarterectomy can be performed with an acceptable risk and good hemodynamic and symptomatic results.

Relation between upper limit of vulnerability and defibrillation threshold in humans.

BACKGROUND: In the canine model, an upper limit of shock strength exists that can induce ventricular fibrillation during the vulnerable period of the cardiac cycle. This shock strength (the upper limit of vulnerability) closely correlates with the defibrillation threshold and supports the "upper limit of vulnerability" hypothesis of defibrillation. It is not known whether an upper limit of vulnerability exists in humans or whether this limit correlates with the defibrillation threshold. METHODS AND RESULTS: In 13 patients undergoing implantable cardioverter-defibrillator implantation, the shock strengths associated with a 50% probability of reaching the upper limit of vulnerability (ULV50) and a 50% probability of reaching the defibrillation threshold (DFT50) were determined by the up-down algorithm. The ULV50 was determined only for the mid-upslope of the positive T waves and for the mid-downslope of the negative T waves. No major complications occurred during surgery. An upper limit of vulnerability was demonstrated in each patient. The ULV50 was 300 +/- 138 V or 6.8 +/- 5.8 J, which was significantly lower than the DFT50 of 347 +/- 167 V (p = 0.038) or 9.1 +/- 7.3 J (p = 0.013). The correlation between the ULV50 and the DFT50 was significant (r = 0.90, p < 0.001 for voltage; r = 0.93, p < 0.001 for energy). CONCLUSIONS: An upper limit of vulnerability is present in humans. There is a significant correlation between the ULV50 and the DFT50, and the ULV50 is significantly lower than the DFT50.

Cardiovascular effects of acute normovolemic hemodilution in rats with disopyramide-induced myocardial depression.

The effect of myocardial depression on the circulatory response to acute normovolemic hemodilution (hematocrit 23%) with hetastarch was evaluated in 28 anesthetized Sprague-Dawley rats. Cardiac output was recorded using an electromagnetic flow probe. Mild, moderate, and severe myocardial depression were achieved by infusing disopyramide 50, 75, and 85 mg/kg. This resulted in a dose-dependent decrease in cardiac output (r = -0.73, p less than 0.05) and mean arterial pressure (r = -0.65, p less than 0.05), and an increase in left ventricular end-diastolic pressure (r = 0.77, p less than 0.05) and total peripheral resistance (r = 0.46, p less than 0.05). Following hemodilution, cardiac output and mean arterial pressure were significantly lower and total peripheral resistance significantly higher in animals with myocardial depression compared with saline anemic controls. These differences were dose-dependent for cardiac output (r = -0.83, p less than 0.05), mean arterial pressure (r = -0.68, p less than 0.05), and total peripheral resistance (r = 0.51, p less than 0.05). Although control animals were able to significantly increase their cardiac output and stroke volume after hemodilution compared with baseline, animals with severe myocardial depression were unable to do so. This resulted in marked hypotension after hemodilution in controls compared with severely depressed animals. The results suggest a diminished ability of the pharmacologically depressed heart to tolerate acute normovolemic hemodilution.

Effects of antihypertensive drugs on heart and resistance vessels.

STUDY OBJECTIVE - The aim of the study was to examine the effects of antihypertensive drugs on heart and resistance vessels to see whether regression of peripheral vascular hypertrophy accompanies reduction in cardiac mass. DESIGN - Matched groups of spontaneously hypertensive and control rats were treated for 12 weeks with captopril (average dose 65 mg.kg-1.d-1) or hydrochlorothiazide (73 mg.kg-1.d-1) and compared to untreated groups. Perfusion pressure, which has been validated as an index of hypertrophy of resistance vessels, was determined in hind limbs of pithed rats at constant blood flow and maximum vasodilatation. SUBJECTS - Experimental animals were 14 week old male spontaneously hypertensive (SHR) rats (n = 41) and strictly age matched Wistar Kyoto rats (n = 12). SHR rats were assigned at random to three groups: (a) captopril treated (n = 15), (b) hydrochlorothiazide treated (n = 15), (c) control (n = 11). MEASUREMENTS and RESULTS - Mean perfusion pressure was 29.5(SEM 0.4) mm Hg in untreated Wistar Kyoto rats and 37.4(0.5) mm Hg in untreated SHR rats. In comparison with untreated SHR rats, treatment with captopril lowered blood pressure, perfusion pressure [35.2(0.3) v 37.4(0.5) mm Hg, p less than 0.01)], and left ventricular to body weight ratio [2.28(0.03) v 2.63(0.05) mg.g-1, p less than 0.01)]. Treatment with hydrochlorothiazide also lowered blood pressure but had no significant effect on left ventricular weight to body weight ratio [2.54(0.04)]. However, perfusion pressure was reduced to 35.3(0.5) mm Hg, p less than 0.01. CONCLUSIONS - For equal regression of vascular hypertrophy, captopril and hydrochlorothiazide had different effects on regression of left ventricular hypertrophy. Thus left ventricular and vascular structural changes may respond differently to the same drug in the same animal.

The Registry of the International Society for Heart Transplantation.

As of October 1990, the Registry of the International Society for Heart Transplantation has received data on over 14,000 heart and over 1,100 combined heart-lung or lung transplant recipients from over 200 centers worldwide. While the areas of single-lung transplantation and pediatric heart transplantation continue to expand rapidly, further growth in annual numbers of cardiac and pulmonary transplant procedures is now limited by donor supply. Operative mortality and late survival have improved during the past decade, however, infection and rejection continue to be the main causes of death. As the number of long-term survivors continues to increase, chronic rejection remains the major obstacle and results with retransplantation have not been very encouraging.

Preexcitation syndromes: surgical ablation therapy. The Cleveland Clinic experience.

Thirty-four patients with preexcitation syndrome had surgical ablation of the accessory atrioventricular connection. All presented with sustained symptomatic arrhythmias, which had resulted in syncope in seven patients and aborted sudden cardiac death in four. Arrhythmias induced at electrophysiologic evaluation included orthodromic reciprocating tachycardia in 32 patients, antidromic reciprocating tachycardia in five patients, and atrial fibrillation in 29 patients. A single accessory atrioventricular connection was located in 32 patients and two patients had multiple accessory connections. The accessory connection was located with intraoperative mapping in all patients and the pathway was successfully ablated in 32. Eleven patients underwent a transmural approach and 23 patients underwent an epicardial dissection. Cryotherapy was used in 22 patients. After a mean follow-up of 32 months, 28 patients were free from all arrhythmias without drug therapy. Six patients continued to have symptomatic arrhythmias but only one case was suspected to be secondary to unsuccessful ablation of the accessory connection. One patient with heart block induced at the surgical procedure is dependent upon a pacemaker.