An institutional experience with epidural analgesia in children and young adults undergoing cardiac surgery

Background: Allowing spontaneous respiration after cardiac surgery eliminates complications related to mechanical ventilation and optimizes cardiopulmonary interaction. Epidural analgesia has been proposed to promote early extubation after cardiac surgery. Objective: To identify the characteristics of patients with epidural analgesia and safety profiles with respect to the timing of extubation following cardiac surgery. Design and method: A retrospective chart review of patients who underwent cardiac surgery during a 5‐year period. Demographic, procedural, and perioperative variables were analyzed to investigate factors that affect the timing of extubation. Results: A total of 750 records were reviewed. The patients’ median age was 12 months, and 52% were infants (<1 year). Seventy‐five percent of the patients utilized cardiopulmonary bypass. The study population was classified into three groups according to the timing of extubation: 66% were extubated in the operating room or upon arrival at the PICU (Immediate), 15% were extubated within 24 h (mean, 10.8 h; 95% CI, 9.0–12.6) (Early), and 19% were extubated after 24 h (Delayed). For the Immediate and Early groups, multivariate logistic regression identified young age, increased cross‐clamp time, and inotrope score as independent risk factors for the need for mechanical ventilation. Postextubation respiratory acidosis (mean P_aCO₂, 50 mmHg; 95% CI, 49–51) was well tolerated by all patients. There were no neurologic complications related to the epidural technique. Conclusion: Epidural analgesia in children undergoing cardiac surgery provides stable analgesia without complications in our experience.     

Women and Men with Hypercholesterolemia Respond Similarly to an American Heart Association Step 1 Diet

Objective To compare serum lipid level responses of women and men with hypercholesterolemia to an American Heart Association (AHA) step 1 diet.Design Sixty-three women and 99 men with varying degrees of hypercholesterolemia were instructed on an AHA step 1 diet. Subjects were followed up on a biweekly basis with individual visits and group classes for 8 weeks.Setting Outpatient clinic facility of the Metabolic Research Group, University of Kentucky, Lexington.Subjects/samples Through community cholesterol screenings, we recruited 76 women and 108 men aged 30 to 70 years who were within 80% to 130% of their ideal body weight. Serum cholesterol levels were between 5.17 mmol/L and 8.99 mmol/L and serum triglyceride levels when subjects were fasting were less than 5.08 mmol/L. Sixty-three women and 99 men completed the study.Intervention Subjects followed an AHA step 1 diet (30% of energy from fat, 50 to 60% of energy from carbohydrate, 10 to 20% of energy from protein, and less than 300 mg cholesterol per day) for 8 weeks.Main outcome measures Serum lipid levels, nutrient intake, and body weight.Statistical analyses performed Subjects were divided into three groups according to initial serum cholesterol levels (mild=5.17 to 6.17 mmol/L; MODERATE=6.20 to 6.95 mmol/L; SEVERE = 6.98 mmol/L). Within-individual changes in nutrient intakes, body weights, and serum lipid levels were analyzed using dependent t tests. Between-group comparisons were made using analysis of variance (ANOVA). When significant differences were found using ANOVA, differences between groups were evaluated with the Tukey test.Results All subjects tolerated the diet well and average dietary adherence was good, as assessed by a food frequency questionnaire and analysis of 3-day diet records. Serum total cholesterol levels decreased 9.2% overall for women (P<.001) and 7.2% for men (P<.001); serum low-density lipoprotein cholesterol levels decreased 9.2% for women and 9.8% for men; and serum high-density lipoprotein cholesterol levels decreased 3.6% for women and 2.8% for men. Mean serum triglyceride levels decreased significantly for women but not for men. No significant differences were found in the responses of women and men in the corresponding groups. Women and men with higher initial serum cholesterol values showed significantly greater hypocholesterolemic responses to diet than those with lower initial serum cholesterol values.Applications/conclusions The findings of this study confirm the beneficial role of dietary intervention for reducing atherogenic serum lipid levels in women and men. J Am Diet Assoc. 1995; 95:436–441.     

Synthesis of sulfated glycosaminoglycans by human gingival fibroblasts from phenytoin-induced gingival overgrowth in vitro

Abstract – The in vitro synthesis of sulfated glycosaminoglycans (GAGs) was studied in gingival fibroblasts from two patients exhibiting phenytoin(PHT)-induced gingival overgrowth, i.e. pseudopockets, which required surgical excision, from one patient on PHT medication not exhibiting pseudopockets and from two normal controls. The results showed that the newly synthesized GAGs were distributed to the culture medium, to a pericellular pool and to the cell fraction. Gingival fibroblasts from the PHT-induced gingival overgrowth showed a significantly increased incorporation of ³⁵SO₄^2- into GAGs compared to the other strains, and this, increase was mainly confined to the dermatan sulfate fraction. These results are in accordance with our previous biochemical studies where increased amounts of GAGs were found in gingival biopsies from the PHT-induced lesion.     

Intraoral hydrolysis of monofluorophosphate

Abstract – The intraoral hydrolysis of monofluorophosphate (MFP) was compared in nine subjects with natural teeth and in nine edentulous subjects after a 1-min mouthrinse with a 100 ppm MFP solution. Analyses of total F and F- in whole saliva samples collected up to 15 min after the rinse suggested that apatite catalyzed breakdown of MFP mediated by dental enamel contributes significantly to the intraoral hydrolysis of MFP.     

Lipid and carbohydrate metabolism in uraemia

Lipid and carbohydrate metabolism variables were studied in twenty-eight patients with chronic renal failure (mean GFR 7.7 +/- 2.5 ml/min) and uraemic symptoms. 71% of the patients had hypertriglyceridaemia (greater than or equal to 2.2 mmol/l). Total serum cholesterol was normal while VLDL cholesterol was high and alpha-lipoprotein cholesterol was low. The fractional elimination rate of Intralipid was low and inversely correlated to serum triglyceride levels. Intravenous glucose tolerance was reduced with normal or slightly increased fasting blood glucose and insulin values before and during the test. Serum triglycerides were correlated to plasma insulin but not to residual renal function or serum urea levels. The cause of hypertriglyceridaemia and lowering of alpha-Lp cholesterol is not unequivocally clear. Present evidence indicate that retarded catabloism of triglyceride-rich lipoproteins is important but accentuated release of triglyceride-rich lipoproteins may have occurred in a number of cases. The commonly used treatment with beta-blocking agents for hypertension in chronic renal failure may accentuate certain of the metabolic responses in uraemia.     

Reduced High Density Lipoproteins as a Risk Factor after Acute Myocardial Infarction

ABSTRACT. FranzÉn J, Johansson BW, Gustafson A (Department of Internal Medicine, University Hospital, Lund and Section of Cardiology, Department of Internal Medicine, MalmÖ General Hospital, MalmÖ, Sweden). Reduced high density lipoproteins as a risk factor after acute myocardial infarction. In a group of normocholesterolemic, non-diabetic middle-aged males surviving an acute myocardial infarction for 4±2 years (mean ± SD), we have previously described a low apolipoprotein A-1 and a deficient fibrinolytic activity as two major characteristics. In the present study we have followed morbidity and mortality risk factors for five years in these males. Mortality was 40% in a hypertensive group and 16% in a normotensive group. In the normotensive group mortality was related to reinfarction. Furthermore, patients with a poor prognosis in the normotensive group had lower high density lipoprotein (HDL) cholesterol and lower apolipoprotein A-I concentration in plasma than patients with a good prognosis. Unexpectedly, in the hypertensive group death was related to a low (p<0.05) cortisol concentration in urine. It is concluded that a low HDL level may be a bad prognostic sign in males who have sustained an acute myocardial infarction and show no evidence of other risk factors, such as diabetes, hypercholesterolemia or hypertension.     

Within- and Between-Patient Variation of the Signal-Averaged P Wave in Coronary Artery Disease

Objectives: To estimate interobserver, within-patient and between-patient variation of the signal-averaged P wave. To determine whether demographic, clinical, conventional ECG information, and coronary angiographic data are associated with the signal-averaged P wave duration in patients with documented coronary artery disease. Background: A prolonged signal-averaged P wave may indicate the presence of a substrate for atrial tachyarrhythmias and may predict subsequent development of atrial fibrillation. However, information on variation, reproducibility, and determinants of the signal-averaged P wave are sparse. Methods: One hundred ninety-three patients with angiographically documented coronary artery disease underwent two consecutive procedures of signal-averaging of P waves (SAECG1 and SAECG2). Interobserver, within-patient, and between-patient variation of the signal-averaged P wave was estimated (coefficient of variation: SD/mean). Multiple linear regression analysis was applied to identify parameters independently associated with signal-averaged P wave duration (SA-P). Atrial late potentials were considered if SA-P > 140 ms, and logistic regression analysis was applied to identify parameters associated with the presence of atrial late potentials. Results: The interobserver, within-patient, and between-patient coefficients of variation for the signal-averaged P wave duration were 7.5%, 6.0%, and 8.4%, respectively. The signal-averaged P wave duration correlated significantly with standard ECG P wave duration and height of the patient (r = 0.59). Forty-nine percent of the patients had atrial late potentials. P wave duration in the standard ECG correctly classified 73% (140/188) of the patients with respect to atrial late potential positivity or negativity. The sensitivity was 67% and the specificity was 78%. Agreement on the presence or absence of atrial late potentials between two observers was present in 71% (136/193) of the patients, and in 78% (151/193) between SAECG1 and SAECG2. Conclusions: The signal-averaged P wave has limited reproducibility in patients with coronary artery disease, and a normal or abnormal signal-averaged P wave can be predicted from the conventional ECG with high accuracy. It is recommended that the signal-averaged P wave be compared with the standard ECG P wave duration in follow-up studies with the aim of predicting atrial fibrillation.     

COURSE OF RENAL FUNCTION IN IgA GLOMERULONEPHRITIS IN CHILDREN AND ADOLESCENTS

ABSTRACT. The pathophysiology of IgA GN was investigated in different stages of the disease. Seventeen patients who were between 3.5 and 16.5 years of age at the onset were included in the study. Clearance studies were performed repeatedly in 6 patients (in 5 of them over a period extending from the onset to 5-9.5 years) and only once in 9 patients (10-23 years after the onset). Two patients (one with uremia) were only evaluated clinically. C_In, C_PAH and U_NaV were studied during hydropenia (HP) and 3% isotonic saline volume expansion (VE). Shortly after the onset C_In, C_PAH and U_NaV were depressed. Renal function was essentially normal 1 and 2 years after the onset in spite of signs of active disease. A supernormal GFR was found in 7 patients after they had had the condition between 5 and 17 years. After a duration of IgA GN for >9 years 3 of 12 patients had developed hypertension and uremia and 2 had hypertension or labile BP. Three of 10 patients had a normal GFR and BP, but had increased natriuresis during VE. Only 2 of 10 patients were normotensive and had normal renal function. Disturbancies in the renal function are thus frequent in all stages of IgA GN and the changes seem to be related to the duration of the disease. Exaggerated natriuresis may indicate progressive disease.