Hypothermic cardiopulmonary bypass and circulatory arrest for operations on the descending thoracic and thoracoabdominal aorta

BACKGROUND: Hypothermic cardiopulmonary bypass with circulatory arrest is an important adjunct for operations on the distal aortic arch, the descending thoracic, and the thoracoabdominal aorta. The safety and efficacy of this technique when compared with other adjuncts (ie, simple aortic clamping, partial cardiopulmonary bypass, regional hypothermia) is not clearly established. METHODS: One hundred and ninety-two patients (age range, 20 to 83 years) with descending thoracic or thoracoabdominal aortic disease had resection and graft replacement of the involved aortic segments using hypothermic cardiopulmonary bypass and intervals of circulatory arrest (mean, 38 minutes). The technique was used when the location and severity of disease precluded placement of clamps on the proximal aorta (31 patients) or (in 161 patients) when extensive thoracic (47) or thoracoabdominal (114) aortic disease was present, and the risk for development of spinal cord ischemic injury was judged to be increased. Lower intercostal and lumbar arteries were attached separately to the aortic graft in 101 of the 161 patients (63%) who had extensive aortic replacement. No other adjuncts for spinal cord protection were used. RESULTS: The 30-day mortality was 6.8% (13 patients). It was 40% (8 of 20) for patients having emergent operations (acute aortic dissection or rupture) and 2.9% (5 of 172) for all others (p < 0.001). The 90-day mortality was 12.5% (24 patients). Paraplegia occurred in 4 and paraparesis in 1 (full recovery) of the 186 operative survivors whose lower limb function could be assessed postoperatively (2.7%). Among the 109 survivors with thoracoabdominal aortic disease, early paraplegia occurred in 1 of 36 with Crawford extent I, 0 of 42 with extent II, and 2 of 31 with extent III disease. One patient (extent II) developed paraplegia on the 9th postoperative day after a hypotensive episode. None of the 47 patients with aortic dissection developed paralysis. Among the 186 operative survivors, renal dialysis was required in 4 patients (2.2%), prolonged inotropic support in 18 (10%), reoperation for bleeding in 9 (5%), mechanical ventilation (> or = 48 hours) in 64 (34%), and tracheostomy in 17 (9%). Four patients (2%) sustained a stroke. CONCLUSIONS: Hypothermic cardiopulmonary bypass with circulatory arrest provides safe and substantial protection against paralysis and renal, cardiac, and visceral organ system failure that equals or exceeds that of other currently used techniques but without the need of other adjuncts.     

Outcome measures of interepisode bipolar patients in a Turkish sample

Background We aimed to study the correlations of several outcome measures in bipolar patients with the clinical features of interepisode period. Methods Bipolar patients who were diagnosed according to DSM-III-R or IV were contacted and asked for a further evaluation. Interepisode bipolar patients (n = 100) were interviewed with the Schedule for Affective Disorders and Schizophrenia (SADS). In addition the Brief Disability Questionnaire (BDQ), the Quality of Life Enjoyment and Satisfaction Questionnaire (Q-LES-Q) and the Global Assessment Scale (GAS) were administered to assess outcome. They were also asked to check the List of Life Events (LLE) for the last six months. Results Our results can be summarised as follows: (1) quality of life was predicted by current subthreshold depressive symptoms; (2) the number of previous depressive episodes, current subthreshold depressive and manic symptoms predicted disability; (3) the number of previous depressive episodes and the duration of hospitalisation as well as current subthreshold depressive and manic symptoms predicted overall functioning; (4) the number and distress level of life events were correlated with suicidal symptoms. Conclusions Our findings suggest that outcome measures were correlated with subsyndromal disorder, the number of previous depressive episodes and the duration of hospitalisation. Accepted: 2 October 2001     

An epilepsy questionnaire study of knowledge and attitudes in Canadian college students

Summary: Purpose: Controversy exists about the relation of societal knowledge and attitudes regarding epilepsy. We conducted a survey to examine knowledge and attitudes, to note gender and occupational influences, and to examine the effect of an informational brochure. Methods: We administered a standardized questionnaire that noted demographics and examined knowledge and attitudes regarding epilepsy and persons with epilepsy, respectively, to a wide variety of Canadian college students. In a separate class we gave every other student a brochure regarding epilepsy and then administered the questionnaire to both the naïve and brochure‐exposed students. Results: Knowledge was patchy and weakest for the approximate prevalence of epilepsy in the population, hereditary epilepsy and several other etiologies, recognition of nonconvulsive seizures as a type of epilepsy, and knowledge of antiepileptic drug–induced teratogenicity. In contrast, attitudes were more uniformly favorable. However, 11 and 14%, respectively, showed negative bias against persons with epilepsy having children and equal opportunity for occupational employment. Women were slightly but significantly more tolerant than men. The brochure‐exposed group showed better knowledge but equivalent attitudes compared with the naïve group. Conclusions: Results compare favorably with surveys in other countries. Although knowledge was patchy, it could be easily improved on with an educational brochure. Attitudes were positive but show some discrepancies from knowledge and a gender effect.     

Ischemic optic neuropathy following spine surgery

Perioperative visual loss (POVL) is a devastating injury that has been reported infrequently after nonocular surgery. The most common cause of POVL is ischemic optic neuropathy (ION). Increasing numbers of cases of ION are being reported after spine surgery, but the etiology of postoperative ION remains poorly understood. After a MEDLINE search of the literature, we reviewed published case reports of ION, specifically those reported after spine surgery performed with the patient in the prone position. Most of the cases involved posterior ION (PION, n = 17), and the remainder anterior (AION, n = 5). Most patients had no or few preoperative vascular disease risk factors. All except one PION and 2 of 5 AION cases reported symptom onset within the first 24 hours after surgery. Visual loss was frequently bilateral (40% of AION, 47% of PION cases). Mean operative time exceeded 450 minutes. The lowest average intraoperative mean arterial blood pressure was 64 mm Hg and the mean lowest intraoperative hematocrit was 27%. The average blood loss was 1.7 L for AION and 5 L for PION patients. PION patients received an average of 8 L of crystalloid solution and 2.2 L of colloid intraoperatively. This compilation of case reports suggests that a combination of prolonged surgery in the prone position, decreased ocular perfusion pressure, blood loss and anemia/hemodilution, and infusion of large quantities of intravenous fluids are some of the potential factors involved in the etiology of postoperative ION. However, levels of blood pressure and anemia intraoperatively were frequently at levels considered acceptable in anesthesia practice. The etiology of postoperative ION remains incompletely understood. Potential strategies to avoid this complication are discussed.     

Primary Peritracheal Schwannoma: Report of a Case

Posterior mediastinal tumors of neurogenic origin commonly arise from the sympathetic or intercostal nerves. However, anterior mediastinal tumors rarely originate from the vagus nerve, and primary neurogenic tumors of the trachea are extremely uncommon. A 19-year-old man was admitted to an emergency department in sudden acute respiratory distress. A tracheostomy was performed and he was transferred to our Ear Nose and Throat Department for further investigation. A bronchoscopic biopsy was taken of a mass occupying the tracheal lumen and intraoperative frozen section examination suggested a schwannoma, so tracheal resection was performed. Although rare, primary tracheal schwannoma should be considered in the differential diagnosis of sudden respiratory distress of unknown origin.     

Communication skills, cultural challenges and individual support: challenges of international medical graduates in a Canadian healthcare environment

Physicians require good communication skills to develop effective patient-physician relationships. Externally funded international medical graduates (IMGs) move directly from their home countries to complete residency training at the University of Ottawa, Canada. They must learn quickly how to work with patients, families and colleagues. A detailed needs assessment was designed to assess IMGs' communication skill needs through focus groups, interviews and surveys with IMGs, program directors, allied healthcare professionals and experts in communication skills. There was a high degree of consensus amongst all participants concerning specific educational needs for communication skills and training issues related to the healthcare system for externally funded IMGs. Specific recommendations include (1) English-language skills; (2) how to get things done in the hospital/healthcare system; (3) opportunities to practise specific skills, e.g. negotiating treatment, (4) adequate support system for IMGs; (5) faculty and staff education on the cultural challenges faced by IMGs.     

National and regional prevalence of self-reported epilepsy in Canada

Summary: Purpose: To assess the point prevalence of self‐described epilepsy in the general population nationally, provincially, and in different groups of interest. Methods: We analyzed data from two national health surveys, the National Population Health Survey (NPHS, N = 49,000) and the Community Health Survey (CHS, N = 130,882). Both surveys captured sociodemographic information, as well as age, sex, education, ethnicity, household income, and labor force status of participants. Epilepsy was ascertained with only one question in both surveys. “Do you have epilepsy diagnosed by a health professional?” (NPHS) and “Do you have epilepsy?” (CHS). Prevalences were age‐adjusted by using national standard populations at the time of each survey. Exact 95% confidence intervals were obtained. Results: In the NPHS, 241 of 49,026 subjects described themselves as having been diagnosed with epilepsy, yielding a weighted point prevalence of 5.2 per 1,000 [95% confidence interval (CI), 4.9–5.4]. In the CHS, 835 of 130,822 subjects described themselves as having epilepsy, yielding a weighted point prevalence of 5.6 per 1,000 (95% CI, 5.1–6.0). Trends in differences in prevalence among some Canadian provinces were observed. Prevalence was statistically significantly higher in groups with the lowest educational level, lowest income, and in those unemployed in the previous year. Prevalence also was higher in nonimmigrants than in immigrants. Conclusions: The overall and group‐specific results are in keeping with those obtained in other developed countries by using different ascertainment methods. We discuss methodologic aspects related to the ascertainment of epilepsy in both surveys, and to the validity and implications of our findings.     

Food fortification with folic acid and twinning among California infants

This study sought to determine whether a change in twinning prevalence was associated with mandatory folic acid fortification. As of January 1998, it became mandatory in the United States that grain products be fortified with folic acid. The effectiveness of this fortification for neural tube defects has been explored, but other possible implications of fortification has not. We computed the prevalence of twinning among more than 2.5 million California births occurring from 1990 to 1999. The prevalence of twin births in California increased over the last decade with increases observed among most maternal race/ethnic, age, and parity groupings. Unadjusted prevalence measures did not reveal substantial increases in twinning prevalence among these groupings after the fortification period relative to the period immediately preceding it. Analyses that simultaneously adjusted for age, parity, race/ethnicity, sexes of twin pair (as a measure of zygosity), year of birth, and fortification period also did not reveal an association between fortification and twinning. Our results do not suggest a change in twinning prevalence associated with folic acid fortification of the US food supply among women delivering in California.