Analysis of surgical versus medical therapy in active complicated native valve infective endocarditis

From 1972 to 1980, 23 patients (Group A) with native valve infective endocarditis underwent surgical intervention, often for multiple indications, during the active stage of the infective process because of progressive class III and IV (New York Heart Association) heart failure (12 patients), persistent severe hypotension (3 patients), uncontrolled infection for over 21 days (11 patients), aortic root abscess (2 patients), and pericarditis (1 patient). Eighty-five patients (Group B) with active native valve endocarditis, matched for severity of illness, were treated medically. Two patients (9%) in Group A and 43 patients (51%) in Group B died during the hospital admission (p < 0.001). Any difference in long-term cumulative survival rate between the 2 groups was largely due to the beneficial impact of surgical management on the hospital mortality. Of 23 patients in Group A, 11 (48%) had an entirely uncomplicated postoperative course. Long-term mortality rates in those with aortic valve endocarditis treated medically (79%) were significantly higher than in those with mitral valve involvement (47%) (p < 0.05). Patients with aortic valve involvement treated surgically had a better hospital (p < 0.005) and long-term (p < 0.005) survival rate than those treated medically. Two groups at risk for postoperative complications were identified; 3 of 11 patients (27%) with uncontrolled infection had an early postoperative recurrence, and 4 of 7 patients (57%) with an aortic root abscess had postoperative prosthetic paravalvular regurgitation.

Surgery therefore effects a substantial reduction in hospital mortality in patients with complicated active infective endocarditis (9% versus 51%), but patients with preoperative prolonged periods of uncontrolled infection or with aortic root abscess are liable to postoperative complications.     

Double outlet right ventricle: clinical and anatomical spectrum.

Thirty-two patients with double outlet right ventricle (DORV) were studied between 1960 and 1976. Associated congenital defects frequently compounded the difficulty of clinical diagnosis. Cardiac catheterisation was performed in 27 patients, and the ventriculograms were studied with particular regard to the relative positions of the great vessels to each other and to the ventricular septal defect. These relationships determine which corrective operation is possible. Correction has been performed in 12 patients with a perioperative mortality of 25%. Although mitral-aortic discontinuity was demonstrated in all cases, consideration of the anatomical spectrum included in the term DORV suggests that discontinuity is not an essential feature. In common with other clinical data and in contrast with necropsy studies, none of our patients was found to show the normal relationship of the great vessels to each other, in which the aorta lies posterior and to the right of the pulmonary artery. The reason for this difference between the clinical and necropsy findings is not apparent. A similar disparity was shown with regard to pulmonary stenosis, which was demonstrated at catheterisation in 68% of the 27 patients (mean gradient 68 +/- 3 mmHg), in contrast with incidences of 18% and 25% in recent necropsy series. Patients in the necropsy studies were frequently neonates or infants, in whom death may have been the result of intractable cardiac failure secondary to excessive pulmonary blood flow. In older patients without pulmonary stenosis and with pulmonary hypertension, frequent observation is imperative so that surgical treatment can be instituted before the development of irreversible pulmonary vascular disease.     

Malignant behavior of myxopapillary ependymoma. Report of three cases

From a series of 66 cases of central nervous system ependymomas, three cases of well differentiated ependymoma of the cauda equina are described. These tumors recurred and spread to produce intracranial deposits. No extraneural lesions were found.     

Residual photosensitivity in mice lacking both rod opsin and cone photoreceptor cyclic nucleotide gated channel 3 alpha subunit

The mammalian retina contains three classes of photoreceptor. In addition to the rods and cones, a subset of retinal ganglion cells that express the putative sensory photopigment melanopsin are intrinsically photosensitive. Functional and anatomical studies suggest that these inner retinal photoreceptors provide light information for a number of non-image-forming light responses including photoentrainment of the circadian clock and the pupil light reflex. Here, we employ a newly developed mouse model bearing lesions of both rod and cone phototransduction cascades (Rho(-/-) Cnga3(-/-)) to further examine the function of these non-rod non-cone photoreceptors. Calcium imaging confirms the presence of inner retinal photoreceptors in Rho(-/-) Cnga3(-/-) mice. Moreover, these animals retain a pupil light reflex, photoentrainment, and light induction of the immediate early gene c-fos in the suprachiasmatic nuclei, consistent with previous findings that pupillary and circadian responses can employ inner retinal photoreceptors. Rho(-/-) Cnga3(-/-) mice also show a light-dependent increase in the number of FOS-positive cells in both the ganglion cell and (particularly) inner nuclear layers of the retina. The average number of cells affected is several times greater than the number of melanopsin-positive cells in the mouse retina, suggesting functional intercellular connections from these inner retinal photoreceptors within the retina. Finally, however, while we show that wild types exhibit an increase in heart rate upon light exposure, this response is absent in Rho(-/-) Cnga3(-/-) mice. Thus, it seems that non-rod non-cone photoreceptors can drive many, but not all, non-image-forming light responses.     

Attitudes and roles of general practitioners in the treatment of schizophrenia compared with community mental health staff and patients

Abstract. Background: Most general practitioners (GPs) are currently treating a small number of patients with schizophrenia; however, little is known about GPs experiences in this area. This paper examines the attitudes and roles of Australian GPs in the treatment of schizophrenia and their relationships with specialist services. Methods: A total of 192 GPs ratings of possible sources and forms of help for patients with schizophrenia were compared with the ratings of 50 mental health services (MHS) staff and 129 patients. Comparisons within the health professionals were also made in relation to diagnostic and treatment confidence, perceived roles, and typical problems encountered. Results: Perceived helpfulness ratings were reasonably consistent across groups. However, patients tended to rank close family members as more helpful. GPs and MHS staff reported complementary roles, with a shared responsibility for early detection and relapse prevention. Treatment compliance, and communication and accessibility to specialist agencies were identified as major problems. Conclusions: GPs fulfil a valuable role in the treatment of schizophrenia, which could be enhanced through improved training. Mental health services need to work more effectively with GPs in treating schizophrenia and acknowledge their complementary roles.     

Qualitative analysis of WMS-III Logical Memory and Visual Reproduction in temporal lobe epilepsy

Clinical observation of performance on the Logical Memory (LM) and Visual Reproduction (VR) subtests from the WMS-III has revealed some variability in retention rates across stories and figures. This paper examined the degree to which this variability occurs in lateralized temporal lobe epilepsy (TLE) in comparison to a matched group from the WMS-III standardization sample, and explored whether analysis of qualitative aspects of LM and VR performance yield additional lateralizing information in TLE. Analysis of LM and VR scaled scores revealed differences between the TLE groups for LM, but not VR scores. All subjects benefited from repetition of LM Story B, with greater improvement in story retention in the Left versus Right TLE group. Variability in VR recall across figures was seen in all groups, with a bimodal distribution of retention rates for each figure and a sizable percentage of each group completely forgetting two or more figures. These results suggest that more careful analysis of individual LM story performance may be useful in some patients with TLE, whereas variability in VR retention across figures is common and should not be over interpreted.