Determinants of 10-year survival after primary myocardial revascularization.

The first 1000 patients undergoing primary isolated myocardial revascularization each year from 1971 to 1978 were analyzed to elucidate the determinants of long-term survival. Five-year survival was 93.2%, and 10-year survival was 79.3%. Five-year survivals were 96.1%, 94.2%, 92.1%, and 90.8%, respectively, for single, double, triple, and left main disease. Ten-year survivals for the same subsets were 88.6%, 83.0%, 74.9%, and 70.9%. Five-year survivals were 95.3%, 92.4%, 88.0%, and 81.3% for patients with normal, mild, moderate, and severe impairment of the left ventricle. Ten-year survivals for the same subsets were 84.1%, 76.5%, 65.8% and 53.6%. Patients receiving internal mammary artery grafts had 95.6% and 85.8% 5- and 10-year survivals that were superior to 92.0% and 76.2% in patients with only vein grafts. Patients completely revascularized had 95.0% and 82.5% 5- and 10-year survivals, while incompletely revascularized patients had lower (90.5% and 75.2%) 5- and 10-year survivals. Advancing age was the most important factor influencing late survival. Other risk factors in descending order of significance were impaired left ventricular function, no mammary artery graft, smoking, abnormal EKG, three vessel or left main disease, left ventricular end diastolic pressure (LVEDP) greater than 24, hypertension, 1971 to 1974 surgical era, cholesterol greater than 300, incomplete revascularization, and two vessel disease.     

An 11 Year Evolution of Coronary Arterial Surgery (1967-1978)

All patients who underwent isolated myocardial revascularization procedures from 1967-70 (n = 741) were compared with the first 1,000 patients who received similar elective operations each year from 1971 through 1978. Data from these eight years were processed through a computerized cardiovascular information registry. Median age increased from 50 to 56 years, multiple-vessel disease increased from 44 to 89%, and left ventricular asynergy from 41 to 54%. The number of grafts per patient increased from 1.5 to 2.5 and yet morbidity declined in every category except neurologic deficit. Operative mortality was 1.1% from 1967 through 1978 and 0.9% from 1971 through 1978. Graft patency was determined for 475 patients from 1967-70, 553 patients from 1971, 519 from 1972, and 540 from 1973. Patency rates after a mean catheterization interval of 21 months were 77, 77, 84, and 87% respectively. Higher graft patency coincides with introduction of the internal mammary artery graft. Five year follow-up was completed for the 1967-1970 series and 1971, 1972, and 1973 cohorts. Actuarial five year survival was 89.6, 91.6, 93.2, and 91.7%. Five year survival comparisons between 1967-1970 patients and 1971-1973 patients in single-, double-, and triplevessel disease categories show significant extended longevity in the later experience. Abnormal ventricular function and incomplete revascularization adversely influenced longevity (p < 0.05) in all years surveyed. In those series the percentage of asymptomatic patients at five years was 66, 65, 69, and 67%. Lower risk and higher five year survival are attributed to greater technical experience, changing technology, and improved management rather than to selection of lower risk cases.     

Endovascular repair of thoracic aortic lesions with the Zenith TX1 and TX2 thoracic grafts: intermediate-term results

PURPOSE: This prospective study was designed to assess the technical success and outcome after patients with thoracic aortic pathology at high risk for conventional therapy were treated with the Zenith TX1 and TX2 endovascular graft. METHODS: Between 2001 and 2004, patients at high risk for conventional surgical therapy presenting with chronic aortic dissections, thoracic aneurysms, or aortobronchial or aortoesophageal fistulas were treated with a single- or multiple-piece endovascular grafts. Surgical modification of proximal or distal fixation sites was performed when necessary to establish adequate regions for device landing zones. Follow-up studies included radiographic evaluation before discharge and at 1, 6, 12, and 24 months. Aortic morphologic characteristics were determined by using three-dimensional imaging studies and centerline of flow measurements. Statistical analyses were performed with Kaplan Meier analysis to assess survival, factors predictive of poor outcome, and morphologic changes, including sac shrinkage. RESULTS: A total of 100 patients (42% women) were treated, including 81 aneurysms, 15 aortic dissections (with aneurysms), 2 patients with fistulous connections (1 aortobronchial and 1 aortoesophageal), 1 subclavian artery aneurysm, and 1 aortic rupture. Mean follow-up and aneurysm size were 14 months and 62 mm, respectively. Most patients (55%) had undergone prior aortic aneurysm repair. Surgical modifications were required to create adequate implantation sites in 29% patients, including 14 elephant trunk/arch reconstructions, 18 carotid-subclavian bypasses, and 4 visceral vessel bypasses. Iliac conduits were required in 19 patients. Overall mortality was 17%, and aneurysm-related mortality was 14% at 1 year. Sac regression (>5 mm maximum diameter decrease) was observed in 52% and 56% at 12 and 24 months. Growth was noted in one patient (1.6%) at 12 months. Endoleaks were detected in eight patients (8.5%) at 30 days and three patients (6%) at 12 months. Secondary interventions were required in 15 patients. Migration (>10 mm) of the proximal or distal stent was noted in three patients (6%) (two proximal and one distal), none of which required treatment or resulted in an adverse event. CONCLUSIONS: Acceptable intermediate-term outcomes have been achieved in the treatment of high-risk patients in the setting of both favorable and challenging anatomic situations with these devices. The complexity of the patient population, in contrast to endovascular infrarenal repair, attests to the differences in the pathophysiology aortic disease in the anatomic beds.     

Corticosteroids of the peccary (Dicotyles tajacu)

Cortisol and cortisone were tentatively identified as the principal corticosteroids present in the plasma of the male collared peccary (Dicotyles tajacu). On the basis of colorimetric assays the average cortisol concentration was estimated to be 7.5 μg/100 ml of plasma. Cortisol, cortisone, and dehydrocorticosterone were tentatively identified in the extracts of whole adrenal glands from the collared peccary.     

Sexual behavior of assailants during reported rapes

The present study reports on the forced sexual, excretory, and sadistic acts that occur during rape. The main sample consisted of 115 adult, adolescent, and child rape victims that were admitted during a 1-year period to the emergency wards of a large municipal hospital. Forced vaginal intercourse was the most frequent act reported, but many other acts also occurred, ranging from fellatio and cunnilingus to urinating on the victim. It is argued that various social-psychological meanings are attached to forced sexual acts, most notably power, anger, and male camaraderie. Pair/group rape differs from single-assailant rape in the emphasis placed on watching and taking turns. Analyzing the social meanings attached to forced sex makes a contribution to our knowledge about the use of sex to express nonsexual issues.This is a revised version of a paper presented at the American Sociological Association annual meeting, San Francisco, California, September 4, 1978.     

Cannulation of the axillary artery with a side graft reduces morbidity

BACKGROUND: The axillary artery is our preferred arterial cannulation site when the ascending aorta cannot be cannulated. Previously, we cannulated the artery directly; now we use a side graft. The purposes of this study were to (1) investigate cannulation-related morbidity and (2) determine whether use of a side graft reduces it. METHODS: From January 1993 to January 2001, 392 patients underwent 399 axillary artery cannulations. Indications included calcified ascending aorta (129, 32%), ascending aortic aneurysm (115, 29%), type I aortic dissection (85, 21%), cardiac reoperation (70, 18%), and calcified femoral artery (26, 6%). The axillary artery was cannulated directly in 212 (53%) and with a side graft in 187 (47%). Comparisons of cannulation-related morbidity between the direct cannulation and side graft groups were made overall and after both adjusting and matching for propensity score. RESULTS: Cannulation-related morbidity was infrequent, with brachial plexus injury in 7 (1.8%), axillary artery damage in 7 (1.8%), aortic dissection in 3 (0.8%), and arm ischemia in 3 (0.8%). Only 4 of 187 (2.1%) occurred in the side graft group, versus 16 of 212 (7.0%) with direct cannulation (p = 0.03). After propensity adjustment, the odds ratio for reduction of risk of cannulation-related morbidity with use of a side graft was 0.15 (p = 0.002). CONCLUSIONS: Use of the axillary artery as inflow for cardiopulmonary bypass is associated with low morbidity. However, cannulation with a side graft was associated with less cannulation-related morbidity than direct cannulation. Routine use of a side graft is recommended whenever axillary artery cannulation is indicated.