Assessment of the severity of coronary artery disease at postmortem examination. Are the measurements clinically valid?

OBJECTIVE--To compare the assessment of severity of coronary artery stenosis by the conventional pathology methods with a method designed to resemble quantitative angiography. DESIGN--31 human hearts harvested at necropsy were fixed by perfusion of the aortic root with 10% formol saline at 120 mm Hg for 24 hours. The right coronary and left anterior descending coronary arteries were transversely sliced every 2 mm and the absolute lumen dimensions plotted against the distance from the coronary ostium. Stenosis figures were calculated by comparing the lumen diameter with the lumen diameters in adjacent normal arterial segments in a manner identical to that used in angiographic measurement. The coronary artery segments were then processed histologically. Stenosis was then remeasured by comparing the lumen diameter with the diameter of the vessel within the internal elastic lamina identified by elastic van Gieson staining. RESULTS--Compared with the method that was analogous to angiography, the pathology method used on histological slides overestimated the degree of stenosis by 25-30%. The lack of concordance between the methods was not a function of the severity of the stenosis. CONCLUSION--When they read necropsy reports in which the severity of coronary artery stenosis is assessed cardiologists should be aware of the discrepancy between clinical and pathological methods.     

Clinical office anesthesia: The use of propofol for the induction and maintenance of general anesthesia

Ambulatory surgery has become routine for many plastic surgery procedures. Anesthesia techniques including general anesthesia by inhalation and intravenous infusion and the dissociative technique have all been used successfully for outpatient anesthesia. Propofol (Diprivan), a relatively new agent, has proven to be a safe and effective general anesthesia agent for outpatient surgery. We report on our experience with propofol as an induction agent and continuous drip for general anesthesia maintenance in 100 consecutive outpatient, plastic surgery procedures performed in an office facility. Assessment factors were recovery-room time, nausea and vomiting in the recovery room and at home, hallucinations, patients' recollection of anesthesia experience, and overall patient satisfaction.     

Cobb's collar--a forgotten entity

Cobb's collar or Moormann's ring is a stricture of the bulbar urethra which is largely unrecognised but has considerable relevance urologically as the site of congenital or post-instrumental strictures. The history, anatomy, embryology and surgical importance are reported.     

Immunorecognition of chondrocytes in articular cartilage activated by synovial interleukin 1.

A polyclonal antiserum which recognizes surface epitopes on IL1-activated pig chondrocytes has been used to immunolocalize chondrocytes responding to IL1 produced during co-culture of pig synovium and articular cartilage. Activation of the chondrocytes by the cytokine was restricted to the articular and subarticular region of the cartilage adjacent to the synovium. Chondrocyte activation was also seen when human rheumatoid synovium was co-cultured with the cartilage. The presence of IL1 in some synovial cells was confirmed by immunolocalization using antisera specific for IL1 alpha and IL1 beta.     

Tyramine-Induced cardiac arrhythmias

Five out of 12 physically healthy patients with depression undergoing a tyramine pressor test developed cardiac arrhythmias. These arrhythmias occurred in drug-free patients in three out of 12 infusions following as little as 0.03 mg/kg of tyramine and after moclobemide, a reversible inhibitor of monoamine oxidase-A, in four out of 14 tyramine infusions with as little as 0.04 mg/kg of tyramine. The arrhythmias seen were independent of patient's age and occurred both before and after 30 mmHg elevations in systolic blood pressure. Electrocardiographic abnormalities and arrhythmias seen were a loss of p waves, sinus tachycardia, frequent atrial ectopic beats, atrial premature beats, Wenckebach phenomenon, junctional rhythm, ventricular ectopics, varying QRS configurations, and ventricular bigeminy. Tyramine, both oral and intravenous, caused similar reproducible changes in dogs, though not in rats, mice or guinea pigs. Practical implications are that tyramine pressor testing in humans should be performed cautiously and only with adequate cardiac monitoring and resuscitation facilities at hand. These findings suggest that a normal dietary component can induce serious cardiac arrhythmias, and that a low-tyramine diet may be of value for patients who are susceptible to cardiac arrhythmias.     

A survey of the current methods used in the UK to assess pituitary function.

A national survey of the current methods used by specialists to evaluate pituitary function in the UK was performed by postal questionnaire. Seventy-three respondents, of whom 89% were consultants and 80% clinical endocrinologists, returned the questionnaire. Fifty per cent routinely used the insulin stress test (IST) to evaluate the hypothalamo-pituitary-adrenal (HPA) axis, while 50% routinely used tetracosactrin stimulation, there being little overlap between the two groups. This represents a significant change in clinical practice since the last survey in 1988. In those who used ACTH stimulation there was almost an equal split into those who administered the tetracosactrin intramuscularly (45%) or intravenously (47%). Furthermore, either the peak or 60 min cortisol value was used by 71% when interpreting the result of the test, despite the fact that in previous studies only the 30 min cortisol value has been shown to correlate with the IST result. The IST remains the most frequently used method to assess growth hormone reserve in adult subjects. The thyrotrophin-releasing-hormone and gonadotrophin-releasing-hormone tests are still used routinely by approximately a quarter of clinicians. These results provide data that could be used to develop guide-lines for the use of tests to investigate pituitary function.     

Parental perception of neonatal intensive care in public sector hospitals in South Africa.

BACKGROUND: Little is known about parental experience and decision making with regard to premature infants requiring intensive care in developing countries. We undertook this study to characterise parents' experience of physician counselling and their role in making life-support decisions for very low-birth-weight (VLBW) (birth weight < 1 501 g) infants born in South Africa's public-sector neonatal intensive care units (NICUs). METHODS: Parents of surviving VLBW infants treated in three Johannesburg-area public hospitals and attending follow-up clinics in August 2001 were interviewed regarding their experience of perinatal counselling on outcomes (pain, survival, disability), perception of actual and optimal decision making, and satisfaction with NICU communication. RESULTS: Parents of 51 infants were interviewed. Seventy-five per cent of parents reported antenatal counselling by physicians on at least one perinatal topic (severe disability, pain, death, finances or religious/moral considerations). The majority of parents (> 60%) who received counselling thought that these topics had been discussed adequately. Most parents reported that doctors had the primary decision-making role, either without consulting them (41%) or after consulting them (37%). Joint decision making was rare (14%). Parents wanted more input in life-support decisions than they reported being given. CONCLUSION: Counselling is not consistently provided in public-sector hospitals in Johannesburg. Parents of premature infants want a larger share in NICU decision making than they currently experience. Most parents were satisfied with communication later during their infant's hospitalisation. South Africa presents a unique opportunity to study the use of advanced medical technologies in a nation with marked disparities in access to care.