Internal mammary artery bypass: thirteen years of experience. Influence of angina and survival in 5125 patients.

Internal mammary artery (IMA) bypass to the anterior descending coronary artery (ADA) was performed in 5125 patients from January 1978 to December 1990. The average age of patients was 68 years; males accounted for 68% (3485 patients) and 82% (4203) were NYHA Class III. Left ventricular function was impaired (ejection fraction < 40%) in 68% (3485 patients). The average number of additional saphenous vein graft (SVG) per patient was 2.2. Operative mortality was 1.8%. Mediastinitis occurred in 51 patients (1.0%). Reoperation for bleeding was necessary in 56 patients (1.1%). Perioperative myocardial infarction was seen in 102 patients (2.0%) and neurological complications occurred in 51 patients (1%). Repeat coronary angiography was performed in 1414 patients (28%) and demonstrated a patency rate of 96% in IMA grafts and 75% in SVG grafts (p < 0.001). Survival at 13 years was 80% from all causes and 90% when non-cardiac deaths were excluded. Recurrence of angina occurred in 768 patients (15%) and reoperation or PTCA was performed in 61 (1.2%). During the same time period, 2345 patients underwent coronary artery bypass utilizing solely SVG. Survival at 13 years was 68% from all causes and 78% when non-cardiac deaths were excluded (p < 0.001). Recurrent angina was present in 727 patients (31%) (< 0.001). This data suggests that long-term probability of cumulative survival and occlusion free survival were significantly greater and the probability of recurrent angina and reoperative CABG and death from cardiac causes were significantly less in the IMA patients and should be the conduit of choice in coronary bypass surgery.     

Choroidal lesions in patients with AIDS.

Seven cases of bilateral, scattered, yellow-white choroidal lesions have been seen in AIDS patients since January 1988. One resulted from presumed extension of cryptococcal meningitis into the optic nerve and choroid. All the remaining six patients had pneumocystis pneumonia at some time during the course of the disease and were receiving aerosolised pentamidine therapy. None died quickly of disseminated Pneumocystis carinii infection, unlike previously reported patients. Mycobacterial infection was also present in five of these six patients. The differential diagnosis of this entity in AIDS patients is discussed.     

The Workup for Bariatric Surgery Does Not Require a Routine Upper Gastrointestinal Series

Background: Morbid obesity is a serious disease that afflicts over five million Americans, threatening their health with such co-morbidities as diabetes, arthritis, pulmonary failure and stroke. Surgery is the only effective therapy, providing long-term control of weight, diabetes, pulmonary failure, and hypertension for as long as 14 years. Because the operation presents a major expense, this study examined whether X-ray examination of the gut could be omitted safely as a cost-saving measure. Methods: The records of 814 consecutive morbidly obese patients who underwent gastric bypass were reviewed to determine: (1) whether these individuals had undergone an upper gastro-intestinal (GI) series, and (2) if these studies influenced therapy or caused cancellation or postponement of surgery. Results: Of the 814 patients, 657 (80.7%) underwent a preoperative GI radiography. Of these examinations, 393 (59.8%) were normal, with the following abnormalities in the remaining 264: hiatal hernia, 164; esophageal reflux, 39; Schatzki's ring, 18; small bowel diverticula, four; renal stones, four; malrotation, three; gall stones, two; pyloric ulcer, one; possible pelvic mass, one; calcified leiomyoma, one; and dysphagial lusoria, one. None of these findings resulted in cancellation or a delay in surgery. Conclusions: The upper GI series can be safely omitted from the routine preoperative evaluation of patients undergoing gastric bypass. At a cost of $741.00 per examination, this change represents significant potential savings. Similar evaluations of other routine preoperative tests may well provide a better basis for the evaluation of these complex patients.     

Sensations during chest tube removal

Nurses prepare patients for chest tube removal, yet little has been written to indicate the sensations to be expected during this routine procedure. The sensations reported by patients and factors that could influence those sensations were examined in this study. The sample consisted of 36 patients after thoracic surgery (24 men and 12 women), all of whom were scheduled to have either a mediastinal or a pleural tube removed. They reported their sensations and the intensity of those sensations (using a 100 mm visual analog scale) within 15 minutes after tube removal. The most frequently reported sensation during chest tube removal was burning, followed by pain and pulling with mean intensities of 64, 62, and 45, respectively. Subjects reported having few sensations after the tube was removed with only five reporting soreness in the chest. The sensations and intensities did not differ for those who did and did not receive analgesia or for those having a pleural tube versus a mediastinal tube removed. The sensations were similar for the old and young subjects with younger subjects reporting higher intensities. Women reported pain more frequently than men, but the intensities of the sensations reported by men and women were not significantly different. The sensations reported during chest tube removal differ from those described in the literature and can be used to prepare patients more appropriately for chest tube removal.     

Cerebrovascular accidents complicating pregnancy and the puerperium

The decreasing incidence of direct causes of maternal death over the past half century has led to a heightened awareness of nonobstetric factors responsible for maternal mortality. For example, cerebrovascular accidents are an important nonobstetric cause of maternal morbidity and mortality. During the 6.5-year period from 1984 to mid-1990, we encountered 15 women in whom pregnancy or the puerperium was complicated by an acute cerebrovascular accident. Six of these women had hemorrhagic strokes and nine had ischemic strokes. During this same time, approximately 90,000 women were delivered at Parkland Memorial Hospital, and thus the incidence of stroke was about one in 6000 pregnancies. Chronic hypertension or preeclampsia was causative in three cases of hemorrhagic stroke. It is important that 20% of the women died as a result of stroke, and of the 12 survivors, 40% have residual neurologic deficits. An aggressive work-up to define the etiology of stroke is necessary in order to implement cause-specific management, with subsequent reduction in morbidity and mortality.     

Acquired immunodeficiency syndrome: a perspective

Infection by the Human T-Lymphotropic Virus Type III (HTLV-III) may lead to the devastating and ultimately fatal disease, acquired immunodeficiency syndrome (AIDS). As the virus is transmitted in similar ways to the hepatitis B virus, concern has developed within the dental profession regarding the possibility of clinicians acquiring AIDS through treatment of infected patients. This paper aims to place the significance of HTLV-III infection to dental practice in perspective.