Long-term results of valve replacement using antibiotic-sterilised homografts in the aortic position

Objective.

Antibiotic-sterilised homograft valves stored at 4 °C have been implanted in the subcoronary position in this unit since 1973. This study was undertaken in order to assess the longterm function of these valves.

Methods.

All 249 patients undergoing homograft aortic valve replacement (AVR) at the Wessex Cardiothoracic Centre between April 1973 and December 1994 were studied. Homograft valve sizes ranged from 15 mm to 28 mm internal diameter, 202 (81.1%) varying between 18 mm and 22 mm. The mean patient follow-up was 12.4 years with a total follow-up of 3096 patient-years. There were six early deaths (2.4%).

Results.

On actuarial analysis, survival was 78.5 ± 2.7% (1SE) at 10 years, 65.7 ± 3.3% at 15 years and 55.0 ± 3.9% at 20 years. The freedom from redo AVR was 87.9 ± 2.4% at 10 years, 71.7 ± 3.8% at 15 years and 49.7 ± 5.6% at 20 years. The freedom from structural degeneration was 85.5 ± 2.5% at 10 years, 63.6 ± 4.0% at 15 years and 41.9 ± 6.4% at 20 years. On multivariate analysis the risk of valve failure was significantly higher in younger patients (P < 0.0001) and in those who underwent aortic root tailoring (P = 0.024). The freedom from endocarditis was 98.4 ± 0.9% at 10 years, 96.2 ± 1.6% at 15 years and 95.1 ± 1.9% at 20 years. Of the 249 patients, 218 had an isolated homograft AVR and were not anticoagulated. In this group there were two possible thromboembolic events.

Conclusion.

As well as the established haemodynamic benefits, this study has shown that homograft AVR with antibiotic-sterilised 4 °C stored homograft valves implanted in the subcoronary position, offers good long-term results.     

The pathogenesis of Dieulafoy's gastric erosion

The solitary gastric erosion of Dieulafoy is rarely recognized but is not an uncommon cause of massive upper gastrointestinal hemorrhage. The English literature has only recently described this lesson in vivo. Its etiology and pathogenesis has remained poorly defined since first described in 1896. We have recently studied a series of nine cases (the largest English literature series), five of which were recognized and diagnosed at operation. Multiple tissue staining techniques were used to study the biopsy specimens for "clues" as to the pathogenesis of this lesion to be a vascular dysplasia that is associated with chronic gastritis and that thrombosis and necrosis of the abnormally tortuous submucosal artery occurs before perforation and exigent bleeding. The total lack of inflammatory reaction at the base of the lesion precludes a diagnosis of "ulceratio simplex" as originally described.     

Congenital pulmonary atresia with ventricular septal defect: angiographic and surgical correlates

Of 181 patients with severe congenital pulmonary atresia and ventricular septal defect or "type IV truncus" (an obsolete term), all but 11% had true central pulmonary arteries. These arteries were demonstrable by large serial biplane angiograms using multiple selective injections into collateral vessels, frequent photographic subtraction, and occasional pulmonary vein-wedge angiograms. These techniques are extremely important for accurate diagnosis and in planning corrective or palliative surgery, which was done in 77% of patients with pulmonary arteries.     

Leisure-time physical activity as an estimate of physical fitness: a validation study

This paper describes a new interview questionnaire for the assessment of leisure-time physical activity (LTPA), and its validation as an alternative estimate of physical fitness. British subjects (77 males, 41 females) provided details of their LTPA over a period of a "typical" 2 weeks, enabling the estimation of the energy expended. Physical fitness was assessed with a battery of measures, the optimal single measure being sub-maximal physical work capacity (PWC). The questionnaire showed LTPA to be stable following test-retest administration (r = 0.86; p less than 0.0001) for total LTPA energy expenditure. Total LTPA was found to be significantly related to PWC (r = 0.48, p less than 0.0001), as were very hard (r = 0.55; p less than 0.0001) and hard LTPA (r = 0.38; p less than 0.0001). Multiple regression analysis with PWC as the dependent variable yielded a multiple correlation of r = 0.87, with significant contributions from very hard and hard LTPA. It is concluded that whilst this questionnaire is both reliable and a valid estimate of physical fitness amongst a population consistent in their leisure-time physical activities, there is scope for its further use within larger populations, allowing for an analysis of the effects of age and gender on the associations so far observed.     

Integration of drug-usage evaluation with a quality assurance program

"If it ain't broke, don't fix it" is a classic quote that is still heard. Although health professionals strive for continuous improvement in the understanding, prevention, and treatment of pathology, they commonly ignore the system for health care delivery. DUE provides an effective mechanism for continuous examination of the system and improvement of patient outcome as it relates to drug therapy. The movement toward integration of DUE and clinical profiles will bring the Medical Center closer to realizing the ultimate goal of total quality care.     

Randomized controlled trial of supported discharge in patients with exacerbations of chronic obstructive pulmonary disease

BACKGROUND: A randomised trial was performed on patients presenting to hospital with an exacerbation of chronic obstructive pulmonary disease (COPD) to compare outcomes in those managed at home with support with those admitted to hospital in the standard manner. METHODS: Over an 18 month period all patients presenting to the Royal Infirmary of Edinburgh on weekdays (n=718) with a diagnosis of an exacerbation of COPD were assessed for inclusion in the trial. Patients with impaired level of consciousness, acute confusion, acute changes on radiography, or an arterial pH of <7.35 or with other serious medical or social reasons for admission were excluded. Patients randomised to home support were discharged with an appropriate treatment package (antibiotics, corticosteroids, nebulised bronchodilators and, if necessary, home oxygen). They were visited by a nurse the following day and thereafter at intervals of 2-3 days until recovery when they were discharged from follow up. Parallel observations were made on patients allocated to normal hospital admission up to the point of discharge. Patients in both groups were assessed at home eight weeks after the initial assessment. RESULTS: Among weekday patients 353 (50%) were considered obligatory admissions, 140 (19%) were admitted because of co-morbidity, 17 (2%) because of poor social circumstances, and 24 (3%) did not consent to the trial. The remaining 184 (26%) were randomised (2:1) either to home support or to a standard hospital admission. The median time to discharge was 7 days for the home support group and 5 days for the admitted group (p<0.01); 25% of the home support group and 34% of the admitted group were readmitted before the final assessment at eight weeks (p>0.05). There were no significant differences between the groups in attendances by GPs and carers or in health status measured eight weeks after the initial assessment. Satisfaction with the service was good. The mean total health service cost per patient was estimated as 877 pounds sterling for the home support group and 1753 pounds sterling for the admitted group. CONCLUSIONS: This study shows that home supported discharge is a well tolerated, safe, and economic alternative to hospital admission for a proportion of patients referred to hospital for admission for an exacerbation of COPD.     

Knowledge and attitudes about otitis media risk: implications for prevention

OBJECTIVES: To investigate maternal knowledge and attitudes about otitis media (OM) risk, to estimate the prevalence of risk factors in the first year of life, and to identify barriers to the reduction of risk factors (eg, formula feeding, day care attendance, and exposure to passive smoke). METHODS: Questionnaires mailed to a systematic sample of 504 Minnesota women >/=18 years old identified through 1994 birth certificates. RESULTS: Eighty percent returned a completed survey. According to maternal report, 29% of infants (age 8 to 13 months) had recurrent OM (>/=3 episodes) and 2% had tympanostomy tubes. Forty-six percent attended day care, 29% had >/=1 smoking parent, and 49% breastfed for 相似文献