Transoesophageal echocardiography in cardiac and vascular surgery: implications and observer variability

Transoesophageal echocardiography (TOE) has gained widespreadacceptance among cardiac anaesthetists as a tool to facilitateperi-operative decision-making. This observational study analysesthe impact of TOE and its inter-observer variability on intra-operativepatient management during cardiac and major vascular surgery.From June 1996 to December 1998, standardized reports were obtainedfrom 11 anaesthetists in 1891 adult cardiac and vascular surgerypatients undergoing routine biplane or multiplane TOE. Inter-observervariability and the difference between variables of interestwere tested using the chi-squared test or factorial analysisof variance as appropriate. TOE examinations were performedbefore and after the operation; 1673 (88.5%) patients underwentcardiopulmonary bypass (CPB), and 218 (11.5%) patients had surgerywithout CPB, including 42 (2.2%) coronary revascularizations.In 923 patients (49%), TOE provided additional information thatinfluenced the patient’s therapy. In 968 patients (51%),TOE had only minor or no impact on clinical decision-making.In two patients (0.10%) the scheduled operation was not performed,and in another two patients the TOE examination led to majorcomplications. Observer-dependent variables were: implicationsof TOE for intra-operative decision-making (P<0.0001), estimationof image quality (P<0.0001), pre-operative left ventricularfractional area change (FAC) (P=0.0026), difference betweenpre-operative FAC and post-operative FAC (P=0.033), and requestsfor supervision (P<0.0001). There was no significant differencein the case mix between observers. TOE had an important impacton intra-operative patient management. Inter-observer variabilitywas significant for several variables but not for the frequencyof additional surgical procedures. Br J Anaesth 2001; 86: 497–505     

Health for all in the 21st century?

Approximately two decades ago world health authorities met in Alma-Ata to discuss the unequal distribution of health and other global questions. The meeting produced a declaration that emphasized the role of primary care in the provision of health services. Furthermore, adequate socioeconomic support, such as availability of food security, clean water, appropriate housing, and education, were all considered integral parts of health development. After the meeting, the World Health Organization developed a programme called 'Health for All by 2000', outlining strategies towards maximal health improvements all over the world. Thereafter, individual countries have developed national modifications from this agenda, and global development of health has on average been favourable. In the economically least developed countries, however, progress has been significantly slower than elsewhere. This editorial discusses the problem of inadequate socioeconomic development and increasing global health disparity through an example from Lungwena, a rural area in Sub-Saharan Africa. In the 21st century, poverty reduction is the key strategy towards health improvement in the least developed countries.     

Disturbances in craniofacial morphology in children treated for solid tumors

Because of increased survival rates in childhood cancer, special interest has been focused on the side-effects of the therapy and the quality of life in long-term survivors. Our aim was to investigate craniofacial growth in children who had received different kinds of antineoplastic therapies for solid tumors. A total of 40 children treated in the Turku University Central Hospital were examined and divided into three different groups. Group 1 comprised 18 children treated for intracranial tumors with cranial irradiation (CRI) and chemotherapy (CT) including alkylating agents. Seven children out of 18 in this group received growth hormone (GH) therapy. In Group 2, 11 children with extracranial solid tumors also received multiagent CT including alkylating agents, but no CRI. Group 3 consisted of 11 children treated for Wilm's tumor with CT, which did not include alkylating agents or CRI. A total of 19 linear and four angular variables from the lateral cephalograms of the subjects were measured. Most deviations in craniofacial structures were found in children treated with combined CRI and multiagent CT. All disturbances were seen in the vertical measurements which were reduced when compared to the matched controls. It seems reasonable to assume that impaired growth following combined radio- and chemotherapy, as well as GH treatment, particularly affects cartilage-mediated growth. However, the deviations seen in the present study were fairly minor and did not usually require clinical consideration.     

The effects of knee extensor and flexor muscle training on the timed-up-and-go test in individuals with rheumatoid arthritis

Background and Purpose. Rheumatoid arthritis frequently results in functional impairment. This study investigated the effect of a specific exercise regimen on function. Method. A randomized controlled assessor-blinded (N = 36) compared the effect of knee extensor and f lexor muscle training on pain, the timed up and go (TUG) test and the Health Assessment Questionnaire in subjects with non-acute rheumatoid arthritis. Results. Knee extensor and flexor muscle training increased isokinetic torques at speeds of 60°/sec^?1 and 120°/sec^?1 as measured by an isokinetic dynamometer (p = 0.02–0.003). The experimental group experienced a reduction in pain (p = 0.03), an improvement in TUG time (p = 0.01) and in function as measured by the Health Assessment Questionnaire (p = 0.04). Conclusions. Specific knee muscle training can be administered safely in people with non-acute rheumatoid arthritis, and may produce functional benefits.     

A prospective study of psychosocial adaptation following subarachnoid haemorrhage

Abstract

In this prospective study a series of 89 patients with subarachnoid haemorrhage (SAH), most of whom had a “good” neurological outcome, were interviewed 10 weeks and 12 monts following their SAH about changes in psychosocial functioning since their SAH, and the presence of symptoms, such as excessive fatigue, that can influence psychosocial functioning. Information was also gathered from close relatives whenever possible. Data about a range of “SAH factors”, including site of aneurysm, patient clinical grade, and vasospasm, were also gathered at the time of hospitalisation, and subjects were graded according to the Glasgow Outcome Scale (GOS) at each follow-up assessment. Statistical analyses to see whether these factors were predictive of later psychosocial impairment were carried out. A high proportion of subjects demonstrated some mild to moderate psychosocial impairments at 10 weeks and, although recovery occurred in some areas over the next 8 months, 86% of subjects still suffered from excessive fatigue and 55% from hypersensitivity to noise at the 12-month assessment. Of the subjects who were employed at the time of their SAH and had a good neurological outcome, 59% were either unemployed or were working reduced hours at the 12-month follow-up. Overall the GOS was not sensitive to psychosocial impairment, as 87% of the subjects had a GOS of “1” at both 10 weeks and 12 months. The small number of subjects who demonstrated vasospasm or had a poor neurological grade on discharge from hospital and at follow-up were more likely to report changes in temperament, leisure activities, and social behaviour at follow-up.     

Brain reactive antibodies and the blood-brain barrier: observations in aging rodents and the effects of peripheral kainic acid

This study was initiated to confirm the existence of brain-reactive autoantibodies and to determine if such antibodies have higher affinity for brain regions especially affected in Alzheimer's disease. Serum collected from 90, 300, and 600 day old mice was incubated against brain tissues from these same mice, followed by incubation with fluorescently tagged rabbit antimouse IgG. No antibodies were present in the youngest serum, but considerable antibodies were present at 300 and, especially, at 600 days. Such antibodies were present in the blood vessels, but not in the brains of older animals. These antibodies, applied exogenously, labeled cells equally in all three ages of brains including most cortical and many other neurons, indicating that they are not neurotransmitter specific. In a further study, kainic acid or saline was administered peripherally to 15-month old rats. Kainic acid damaged the blood brain barrier and allowed the CNS entry of brain-reactive antibodies, especially into the subregions of hippocampus most damaged in Alzheimer's.     

Results of surgery for irreversible moderate to severe mitral valve regurgitation secondary to myocardial infarction.

OBJECTIVE: Moderate to severe irreversible mitral regurgitation secondary to myocardial infarction is an independent risk factor for reduced long-term survival. Late effects of correction of mitral incompetence concomitant with coronary artery bypass grafting (CABG) are less well known and the choice of mitral valve procedure is still debated. METHODS: From 1988 to 1998, 93 consecutive patients (mean age 63+/-9 years) were treated for moderate to severe irreversible mitral regurgitation secondary to myocardial infarction; 84 were in NYHA functional class III-IV and 19 were in cardiogenic shock. Thirty-seven patients underwent emergency surgery. Perioperative intraaortic balloon pump (IABP) was necessary in 33 patients. Follow-up ranged from 6 months to 12 years (mean 51 months+/-41). RESULTS: Mitral valve was repaired in 30 patients and replaced in 63. Replacement was preferably performed in patients with major displacement of papillary muscle and in patients with acute papillary muscle rupture. CABG (3.4 distal anastomoses) was performed in all patients and was complete in 92%. Early mortality was 15% (14/93). Multivariable analysis identified need for IABP (P=0.005) and COPD (P=0.02) as risk factors for early death. Emergency surgery had only a trend (P=0.15) for increased mortality; age, low ejection fraction, repair vs. replacement had no influence. Actuarial survival rates at 1, 5 and 10 years were 81, 65 and 56%, respectively. Late survival was similar in patients with replacement or repair (P=0.46). At last follow-up, all but one patient were in NYHA functional class I or II. CONCLUSIONS: Combined mitral valve procedure and myocardial revascularization, as complete as possible, for moderate to severe mitral regurgitation secondary to myocardial infarction achieve satisfactory early and late outcome despite the increased operative mortality. Acute papillary muscle rupture, severe restriction of the mitral valve by major displacement of the papillary muscle are better managed by valve replacement.     

Isolation and characterization of hot particles from Chernobyl fallout in southwestern Finland

Three types of activity composition have been found in airborne hot particles that were transported long distances from the Chernobyl accident. Their characterization is based on the analysis of single particles isolated from Pinus Sylvestris needles. The average activity of the particles was 130 Bq at the time of the accident. The most common type of particle contains the radioactive species 141Ce, 144Ce, 95Zr and 95Nb; the second type includes 103Ru and 106Ru along with the previous isotopes; and the third contains 103Ru and 106Ru only. Cesium-134 and -137 were present only in very small amounts. The activity composition of the Chernobyl reactor core fuel was similar to the composition of the first and second type particle; apparently the core fuel was only partially volatilized. The main bulk composition of the particles is shown to be U. The average aerodynamic size of the identified hot particles is 10 microns. The particles are rectangular or pentagonal in shape.