Minimally Invasive Coronary Artery Bypass Grafting: A New Method Using an Anterior Mediastinotomy

The benefit of internal mammary artery (IMA) grafting as a long-lasting intervention for coronary artery disease is well recognized. However, largely because they are less invasive, catheter based alternatives are frequently chosen, particularly to treat single or double vessel disease. To retain the advantages of the IMA graft, and to offset the invasiveness of conventional coronary artery bypass grafting, we developed a new minimally invasive method using an anterior mediastinotomy for treating left anterior descending (LAD) or right coronary artery disease, or both. Feasibility studies using 16 pigs and a human cadaver led to approval by the Institutional Review Board for use of this procedure to treat six patients (four men, two women; mean age, 63.8 ± 13.6 [SD] yrs) who granted informed consent. Pedicle dissection of the IMA, using video assisted thoracoscopy if necessary, was made through a 2-to 3-inch horizontal anterior mediastinotomy. The underlying LAD artery was grafted during femoral vessel cardiopulmonary bypass, with cooling to 30°C, induced ventricular fibrillation, and left ventricular venting if required. Transesophageal echocardiography performed after bypass showed that two patients maintained normal wall motion and four had improvement from the original impairment. One patient suffered a recurrence of angina 4 weeks after the procedure; recatheterization showed an acutely angled IMA, subsequently corrected by balloon angioplasty. The results of follow-up dobutamine echocardiographic stress tests were negative in all patients. With this minimally invasive approach, the procedure should provide the benefits of IMA grafting with shorter hospital stay, more rapid recovery, and less overall cost.     

High risk factors for rehospitalization within six months

Objective. 1. To identify risk factors associated with psychiatric rehospitalization within six months, using global clinical assessments and demographic information and; 2. To determine if risk factors for a hospital in a rural region are similar to those reported for urban hospitals. Method. The setting was a psychiatric unit within a general hospital. All adult admissions for one year were assigned scores on the North Carolina Functional Assessment Scale (NCFAS) and the Global Assessment of Functioning (GAF) scale. Patients were interviewed six months after discharge to determine if they had been rehospitalized and to assign new NCFAS and GAF scores. Results. Significant risk of rehospitalization was predicted by: 1. NCFAS score >90; 2. history of prior hospitalization; 3. nursing home residence; 4. referral from a small community hospital and; 5. non-compliance with outpatient appointments. Conclusions. Global assessments and demographic information collected during an index admission can generate factors to identify patients at risk for rehospitalization within six months. History of prior admissions and non-compliance with outpatient treatment, reported as risk factors in urban settings, were found also to be risk factors in a rural region.He was formerly Assistant Professor, Center for Health Sciences Statistics, East Carolina University School of Medicine.     

Case manager alliance with clients in an older cohort

It was hypothesized that members of an older cohort of seriously mentally ill community mental health clients would develop stronger alliances with intensive case managers. Eighty-six clients participating in a study of case management services completed a measure of working alliance and structured interviews. It was found that older cohort clients, those age 45 or older, showed much stronger alliances with their case managers than younger clients.This research is funded by NIMH/SAMHSA grant R18MH46082.     

Anthropology, nursing and midwifery: a natural alliance?

Anthropology, and its supposed operationalisation within transcultural nursing, is becoming increasingly prominent in educational curricula in the U.K. This increase in interest is driven both by governmental pressure to provide more culturally appropriate care, and an intuitive notion that anthropology, nursing and other related professions such as midwifery have a common basis of mutually overlapping and re-enforcing theory and practice. This paper explores the question of whether there is a natural alliance between anthropology, and the applied aspects of health care disciplines such as nursing and midwifery, by examining some of the concepts underlying each discipline, and the ways in which these concepts are applied in practice. Anthropology is the study of culture, and it is suggested that a more complete understanding of this central concept is essential if it is to be utilised in the applied disciplines encompassed by the practice of nursing and midwifery.     

Intravenous or rectal administration of sedatives in outpatient oral surgery

A number of cross-over studies on sedation in outpatient oral surgery investigated the quality of sedation produced by intravenous or rectal administration of diazepam. The sedation methods were equally efficient with a mean dose of 0.24 mg/kg (range 0.1–0.4) for i.v. administration and 0.53 mg/kg (range 0.5–0.6) for rectal administration. Eighty-five percent of the patients preferred surgery under sedation and local anaesthesia to local anaesthesia alone. The patients preferred the session in which they experienced stronger sedation, regardless of the route of administration.     

In VivoStudies of Adenovirus-Based p53 Gene Therapy for Ovarian Cancer

Objectives.To test the safety, efficacy, and toxicity of gene therapy using wild-type p53-expressing adenovirus (Ad-CMV-p53) in a nude mouse model with intraperitoneal (ip) 2774 human ovarian cancer cell line that contains a p53 mutation.Study design.An initial study of adenovirus tolerance was determined in nude mice by a single ip injection of increasing doses of Ad-CMV-p53. Nude mice were implanted with an LD₁₀₀dose of 1 × 10⁷cells. To study the efficacy and specificity of Ad-CMV-p53 treatment, the mice received treatment with different adenovirus constructs. One group received Ad-CMV-p53 and another group received a control adenovirus construct, Ad-CMV-βgal. To study the treatment response to Ad-CMV-p53, the mice were divided into groups and received various treatment schedules of 1 × 10⁸pfu of Ad-CMV-p53.Results.The mice tolerated Ad-CMV-p53 without adverse effects at doses of 1 × 10⁸pfu. The response to Ad-CMV-p53 showed significant survival duration in each dose regimen, with a survival time greater than that of untreated animals (P= 0.0173). However, no statistically significant survival advantage was observed between Ad-CMV-p53- and Ad-CMV-βgal-treated mice.Conclusions.These studies show that at the adenovirus dose and administration regimen used, there is effective but not specific 2774 tumor growth inhibitionin vivo.Efficient introduction of biologically active genes into tumor cells would greatly facilitate cancer therapy. Thus, although promising, these results caution that much effort will be required to realize the potential for clinical application of adenovirus-based ovarian cancer gene therapy.     

Holographic interferometry forIn Vitro investigation of bioprosthetic valves

Dysfunction of heart valve prostheses—mechanical as well as biological—is a common problem in cardiac surgery. The reasons for the valve failures are still not well understood. Biological valves especially have an unsatisfactory durability; degeneration and calcification very often lead to the failure of the valves. In our opinion, hidden defects present in the valve material prior to implantation of the valves is a plausible explanation for the dysfunction. Hitherto there has been no technique to detect these defects without destructing the specimen. Holographic interferometry proved to be applicable forin vitro evaluation of mechanical heart valve prostheses. In the present paper we describe application of this method to biological valves. Nine porcine bioprostheses and four fresh porcine aortic valves were investigated by means of holographic interferometry. In eight of nine bioprostheses, the results showed irregularities of the leaflet structure which depend on anomalies of the connective tissue of the leaflets of the valves. To make sure that these findings are not due to normal variations of the morphology, the investigations were carried out with fresh and unfixated porcine aortic valves. In the latter, no such anomalies of the structure were detected. The results obtained confirm the above hypothesis on the origin of the later valve dysfunction. Thus, holographic interferometry tests of bioprostheses prior to their implantation prevent the use of potentially dysfunctional valves.Presented at the 35th World Congress, International College of Angiology, Copenhagen, Denmark, July 1993