Left ventricular approach to multiple ventricular septal defects

Multiple muscular ventricular septal defects were closed through an apical left ventriculotomy in 11 patients. The patients were divided into two groups: Group 1, 8 patients who had transposition of the great arteries, and group 2, 3 patients without transposition. There were 4 deaths in Group 1 and non in Group 2. Two of the deaths were caused by a hypoplastic right ventricle, 1 by airway obstruction, and 1 by heart failure and pulmonary edema in a patient who had additional unrecognized muscular defects. An apical left ventriculotomy provides excellent exposure of the septum. The field is not obscured by trabecular bands or papillary muscles. Although 1 patient died because of residual VSDs, this approach, compared with previously described methods, minimizes the risk of unrecognized defects.     

Facilitating effects of pre- and posttrial amphetamine administration on discrimination learning in mice

Two experiments investigated the effects ofd-amphetamine on food-rewarded visual discrimination learning in mice. The findings of Experiment 1 indicate that degree of facilitation learning obtained with posttrial i.p. injections varied with dose: Facilitation was obtained with doses ranging from 0.25 to 2.0 mg/kg, but not with a higher dose (2.5 mg/kg). The findings of Experiment 2 indicate that degree of facilitation varies with time of administration. With two doses (0.5 and 2.0 mg/kg) facilitation was obtained with injections given up to 30 minutes before training or immediately after daily training. No significant effect was obtained with injection given 15 minutes after training. The findings are interpreted as providing further support for the view that amphetamine facilitates learning by affecting time-dependent memory storage processes.This research was supported in part by Research Grant MH-12526 from the National Institute of Mental Health, United States Public Health Service.     

Liver transplantation for malignant tumours in children.

OBJECTIVE: The object of this study was to analyse our results with liver transplantation (LTX) for primitive malignant unresectable liver tumours in children and to discuss the controversial indications, based on our experience. METHODS/PATIENTS: We report on 12 patients, aged 6 months to 14 years, with hepatic malignant tumours: 11 with hepatoblastoma and 1 with fibrolamellar hepatocelullar carcinoma without cirrhosis. LTX was the primary treatment in 10 patients (PRETEXT IV or any grade, if there was extension to the retrohepatic vena cava, 3 hepatic veins or portal vein) and a rescue therapy after recurrence for 1 and for persistence of unresectable macroscopic residuals in 2 patients. One of the patients who underwent a LTX as primary therapy had lung metastases previously resolved with chemotherapy. We used entire liver (n = 5), left lateral segment from cadaveric donor (n = 3), living related donor (n = 3; 2 segments II-III and 1 right lobe) and left lateral segment from split liver (n = 1). All children received chemotherapy prior and post transplantation following the SIOPEL protocol. We analysed procedure tolerance, survival, recurrence rate, disease-free period and risk factors for adverse evolution. RESULTS: All patients overcame LTX and no early graft loss was recorded. Two cases died because of tumour relapse, 1 after primary LTX and 1 after rescue LTX (survival rate of both groups, 90% and 50%). Graft and patient survival rates at 1 year, 3 years, 5 years and 14 years were 91%, 91%, 82% and 82% respectively. The boy who presented with lung metastases developed new ones one year after LTX that were removed and he is currently free of disease. The disease-free period has a probability at 1, 3 and 5 years of 91%, 75% and 75%, respectively. Tumour tissue persistence was the only risk factor for an adverse clinical course in our series. CONCLUSIONS: LTX is a reasonable therapeutic approach for unresectable malignant liver tumours, providing outcomes comparable to those for resectable tumours. Results obtained with LTX are better when it is used as a primary treatment than when used as a rescue procedure. Proper staging and early referral to centres with enough expertise optimise the results. LTX for patients with lung metastases could be a controversial option. Living related-donor transplantation is an excellent alternative to avoid disease progression while on the waiting list for cadaveric donors.     

Protective Effect of Hyaluronidase after Long-Term Aortic Cross-Clamping: Initial Experimental Observations

This work studies the effect of hyaluronidase on myocardium subjected to long-term aortic cross-clamping (three hours) and moderate hypothermia (28°C). Animals receiving hyaluronidase (1,000 U per liter) through the root of the aorta with a procaine-potassium chloride-plasmalyte cardioplegic solution showed better functional, electrical, and morphological response than the untreated animals. These findings, although preliminary, appear to be promising for potential clinical application.     

Drug intake behaviour of immigrants during pregnancy

OBJECTIVE: To assess differences between native Spanish and immigrant pregnant women in behaviour relating to the use of medications during pregnancy. STUDY DESIGN: This cross-sectional study was carried out at the department of obstetrics and gynaecology of an acute-care teaching hospital in the city of Barcelona, Spain. A total of 1103 women who gave birth at the hospital during a 1-year period were enrolled in the study. Each woman was interviewed by a gynaecologist during her stay in hospital after delivery, with special reference to drug use during the pregnancy. Drug exposure was assigned to trimesters, and drugs were divided into therapeutic groups, while the women taking part were divided up by nationality, educational level, parity and age. Data were analysed using bivariate, multivariate, and cluster analyses. RESULTS: Slightly over half (55.7%) of the women were native to Spain and 44.3% were immigrants of other nationalities. About a quarter, or 25.4%, of pregnant patients had not taken any drugs during their pregnancies. The most frequent drugs taken by the others were vitamins, which were used mostly by Spanish women, followed by analgesics, which were mostly taken by non-Spanish western women. The largest group who had taken folic acid was made up of non-Spanish western women, while the Asiatic patients had taken this in the smallest proportion of cases. CONCLUSIONS: Spanish patients and immigrants from other western countries showed a similar behaviour in terms of drug intake during pregnancy, which was different from the behavioural patterns seen in pregnant patients from developing countries.     

Elevated troponin I levels in patients with acute coronary syndrome without ST elevation are associated with increased complexity of the culprit lesion

INTRODUCTION: The prognosis in patients with acute coronary syndrome without persistent ST segment elevation (NSTEACS) differs depending on cardiac troponin levels. Clinical practice guidelines published by the Spanish Society of Cardiology and the ACC/AHA consider patients with NSTEACS and markedly elevated troponin levels as high risk patients. The aim of this study was to identify factors related to markedly elevated troponin I levels in NSTEACS. PATIENTS AND METHOD: We measured troponin I levels in 219 consecutive patients with NSTEACS and normal CK-MB values, and identified 2 groups: patients with markedly elevated troponin levels (more than 10-fold the normal upper limit), and patients with normal or slightly elevated troponin levels (less than a 10-fold increase above the normal limit). We also analyzed clinical and angiographic variables. Logistic regression was used to calculate age- and sex-adjusted associations for the main variables. RESULTS: Forty-one patients (19%) had markedly elevated troponin levels, and 178 (81%) showed normal or slightly elevated troponin I levels. Patients with markedly elevated levels had more frequently prolonged angina, class IIb angina, more severe ECG changes, a higher number of diseased vessels on coronary angiography, and greater severity of the culprit lesion. The culprit stenosis in these patients was more often characterized as ulcerated, showing visible thrombus, and excentric, bifurcated and irregular. Class IIIb angina (odds ratio [OR] = 3.1; CI 95%, 1.1-8.6), bifurcation (OR=6.04; CI 95%, 2.5-14.3), ulceration (OR=3.2; CI 95%, 1.07-9.7) and visible thrombus (OR=2.7; CI 95%, 1.1-6.3) in the culprit lesion were predictive factors associated with markedly elevated levels of troponin I independently of age or sex. CONCLUSIONS: Markedly elevated troponin I levels in patients with NSTEACS are associated with a more severe clinical presentation and increased complexity of the culprit lesion on coronary angiography.     

Determinants of depressive symptoms in narcoleptic patients with and without cataplexy

The present prospective study assesses depressive symptoms in narcoleptic patients with (NC+) and without (NC-) cataplexy (46 women, 40 men) and age- and sex- matched healthy controls. Seventy patients were under treatment with stimulants and/or anticataplectics. All subjects completed the Beck Depression Inventory (BDI), the Zung Self-Rating Depression Scale (SDS), the Global Impression of Severity of Depression (GSD), the Profile of Mood States (POMS) and Epworth Sleepiness Scale. Patients with narcolepsy were more depressed than controls (higher scores in BDI, GSD, SDS, and POMS [in the total score and in all subscale scores]); however, between the NC+ and NC- patient groups, no differences were found. Our study shows that the women and the patients using antidepressants and stimulants (combination) have a higher probability for depressive symptoms independent of the presence of cataplexy. The lack of difference between NC+ and NC- in the level of depression supports the assumption that the major psychosocial burden in narcolepsy is not necessarily associated with the presence of cataplexy.     

Echocardiographic assessment of pulmonary arterial pressure in the follow-up of patients with pulmonary embolism

Background

Echocardiography remains a clinically useful screening test for chronic thromboembolic pulmonary hypertension (CTEPH) in patients with a history of pulmonary embolism (PE). To devise an effective screening strategy, the definition of a high-risk group is necessary.

Methods

We examined a total of 744 patients with acute symptomatic pulmonary embolism (PE) who were enrolled in a Spanish multicenter study. Patients were monitored every 6 months during the first two years, and then once a year thereafter. Transthoracic echocardiography was used to screen patients with a clinical suspicion of CTEPH during follow-up. Pulmonary arterial hypertension was defined as an estimated pulmonary artery systolic pressure (PAP) > 50 mm Hg. The index thromboembolic episode was considered severe if: (a) the patient was immobilized for medical reasons; or (b) systolic blood pressure was less than 90 mm Hg; or (c) troponin T values were above the reference range.

Results

The incidence of PAP > 50 mm Hg at 36 months was 8.3% (95% confidence interval = 4.6%-14.5%). Statistical analysis showed a highly significant association between a severe index thromboembolic episode and the subsequent detection of PAP > 50 mm Hg on echocardiography, with high positive likelihood ratio (2.40) and negative predictive value (> 0.97).

Conclusions

Patients with a severe index thromboembolic episode would constitute a high-risk group for the development of CTEPH. This group of patients should be subjected to a strict follow-up protocol.