Cardiac operations in patients with hematologic malignancies.

OBJECTIVES: Patients with hematologic malignancies are frequently in need of major cardiac operations. Previous reports suggest an increased risk for perioperative complications in these immunodeficient patients. METHODS: Patients diagnosed with any type of hematologic malignancy who underwent open-heart surgery at our institution between 7/1996 and 6/2002 were identified. Their hospital charts were reviewed; demographics, perioperative data and outcomes were recorded. RESULTS: There were 24 patients (20 men, 4 women); mean age was 68+/-13 years (range 31-84 years). Ten patients had chronic lymphocytic leukemia, seven non-Hodgkin lymphomas, three multiple myeloma and one Hodgkin's disease, chronic myelocytic leukemia, hairy cell leukemia and cutaneous T-cell lymphoma each. The mean pre-operative duration of the hematologic disease was 6.6 years. Twenty-two patients underwent coronary artery bypass grafting (with valve replacement in three patients) and two patients had isolated valve replacement. There was one in-hospital death (4.1%). Twelve patients (50%) had a minor or major complication. Seven reoperations were required-five during the same admission (one for mediastinal bleeding, one for an expanding femoral pseudoaneurysm, one for acute cholecystitis and two for IACD/pacer insertion) and two within 30 days (one for deep sternal wound infection and one for leg wound infection). Mean post-operative stay was 8.2+/-5.8 days and mean ICU stay was 1.6+/-1.1 days. There were three late deaths-two were due to progression of the hematologic disease. The 3-year actuarial survival was 83%. CONCLUSIONS: Cardiac operations can be performed with acceptable mortality but significant morbidity rates in patients with hematologic malignancies. Bleeding and infectious complications are most frequently seen and usually lead to reoperations. These findings warrant caution during patient selection.     

Avoidance of Nitrous Oxide for Patients Undergoing Major Surgery: A Randomized Controlled Trial

Background: Nitrous oxide is widely used in anesthesia, often administered at an inspired concentration around 70%. Although nitrous oxide interferes with vitamin B12, folate metabolism, and deoxyribonucleic acid synthesis and prevents the use of high inspired oxygen concentrations, the consequences of these effects are unclear.

Methods: Patients having major surgery expected to last at least 2 h were randomly assigned to nitrous oxide-free (80% oxygen, 20% nitrogen) or nitrous oxide-based (70% N2O, 30% oxygen) anesthesia. Patients and observers were blind to group identity. The primary endpoint was duration of hospital stay. Secondary endpoints included duration of intensive care stay and postoperative complications; the latter included severe nausea and vomiting, and the following major complications: pneumonia, pneumothorax, pulmonary embolism, wound infection, myocardial infarction, venous thromboembolism, stroke, awareness, and death within 30 days of surgery.

Results: Of 3,187 eligible patients, 2,050 consenting patients were recruited. Patients in the nitrous oxide-free group had significantly lower rates of major complications (odds ratio, 0.71; 95% confidence interval, 0.56-0.89; P = 0.003) and severe nausea and vomiting (odds ratio, 0.40; 95% confidence interval, 0.31-0.51; P < 0.001), but median duration of hospital stay did not differ substantially between groups (7.0 vs. 7.1 days; P = 0.06). Among patients admitted to the intensive care unit postoperatively, those in the nitrous oxide-free group were more likely to be discharged from the unit on any given day than those in the nitrous oxide group (hazard ratio, 1.35; 95% confidence interval, 1.05-1.73; P = 0.02).     

Neuroimaging studies of children with serious emotional disturbances: a selective review.

OBJECTIVES: To critically review and integrate, from a developmental perspective, recent magnetic resonance imaging (MRI) studies of 4 childhood psychiatric disorders: schizophrenia, bipolar disorder (BD), attention-deficit hyperactivity disorder (ADHD), and major depressive disorder (MDD). METHOD: We reviewed published reports in refereed journals. We briefly describe the major findings with respect to the brain morphometry, chemistry, and function of children with psychiatric disorders and synthesize the reports in a summary to update clinicians. RESULTS: Some cortical grey matter abnormalities associated with schizophrenia appear to predate the onset of frank psychosis and continue to advance after the onset of psychosis, at least in more severe cases. Pediatric BD is associated with abnormalities in a circuit, thought to be involved in mood regulation, that encompasses the amygdala, striatum, and ventral PFC. Frontostriatal abnormalities are reported consistently in ADHD, potentially reflecting abnormalities in the development of cognitive control. Children with MDD show prefrontal cortical alterations that may differ in familial and nonfamilial subtypes of MDD. CONCLUSIONS: Results from neuroimaging studies of childhood psychopathology reveal abnormalities in the developmental trajectories observed in healthy children. Although MRI has increased our understanding of the pathophysiology of these disorders, routine neuroimaging for children with severe emotional disturbances is not indicated for diagnostic purposes.     

Cefazolin plus ceftazidime versus imipenem/cilastatin monotherapy for treatment of CAPD peritonitis--a randomized controlled trial.

BACKGROUND: Peritonitis is a serious complication of peritoneal dialysis (PD). We studied the efficacy of imipenem/cilastatin monotherapy in the treatment of PD-related peritonitis. METHODS: We performed an open-label, randomized control study comparing imipenem/cilastatin monotherapy (treatment group) versus cefazolin plus ceftazidime (control group) in the treatment of PD peritonitis. The result was further compared to a historic group treated with cefazolin plus netilmycin. Outcome measures were primary response rate at day 10 and complete cure rate. RESULTS: We enrolled 51 patients in the treatment group, 51 in the control group, and identified 96 in the historic group. The primary response rate to the assigned antibiotics was 49.0%, 51.0%, and 49.0% for the treatment, control, and historic groups, respectively (p = 0.97). The primary response rate allowing for change in antibiotic was 82.4%, 90.2%, and 82.3%, respectively, for the three groups (p = 0.41). The complete cure rate was 72.5%, 80.4%, and 82.3%, respectively (p = 0.60). Tenckhoff catheter removal was needed in 6 cases in the treatment group, 6 cases in the control group, and 13 cases in the historic group (p = 0.90). CONCLUSIONS: We concluded that monotherapy of imipenem/cilastatin has similar efficacy compared to the two standard regimens of cefazolin plus ceftazidime or netilmycin in the treatment of PD peritonitis.     

Should balloon angioplasty and stents have any role in operative intervention for lower extremity ischemia?

p < 0.01). Cumulative combined primary patency at 1 year by life-table methods was 82 ± 10% in the staged group and 83 ± 9% in the simultaneous group (p= 0.79). Mean follow-up was 13 ± 6 months. There is a role for balloon angioplasty and stent placement in operative revascularization of ischemic limbs in selected patients: patency was similar to that produced with the staged approach while the length of stay was shorter. Intraoperative balloon angioplasty is safe and effective and stents permit a measure of control in assuring an optimal intraoperative postangioplasty result.     

Ontogeny and cellular expression of MHC and leucocyte antigens in human retina

We have investigated the ontogeny of MHC class I, class II, CD45, and macrophage antigens in wholemounts of normal human fetal retina at 10–25 weeks gestation (WG) using monoclonal antibodies and immunogold histochemistry. MHC class I antigens were expressed on retinal vascular endothelial cells and provided a useful marker of vessel organization from 14–25 WG. Microglial cells expressed immunoreactivity to MHC class I, class II, and CD45 antigens from 10 WG (pre-vascularization) and macrophage S22 (Mac S22) antigen from 14 WG (post-vascularization), although none of the antigens tested were detected on neuronal or macroglial elements. Microglia expressing MHC, CD45, and macrophage antigens occurred in both ramified and rounded forms with no close correlation being observed between morphology and antigenicity. The numbers of immunoreactive cells labeled with each of the four markers increased steadily throughout gestation in all specimens studied. Equivalent numbers of microglia expressed MHC class I, class II, and CD45 antigens in retinae at similar gestational ages; however, our data indicate that microglia expressing Mac S22 antigen comprise approximately 40% or less of the population of MHC and CD45-immunoreactive cells during development. Topographical analyses suggest that MHC class I, class II, and CD45-positive microglia enter the retina from both the peripheral retinal margin and the optic disc from at least 10 WG; Mac S22-positive cells appear in association with the development of the retinal vasculature and enter the retina via the optic disc after 14 WG. © 1995 Wiley-Liss, Inc.