The factor of age has been proposed as the major determinant of survival after correction of total anomalous pulmonary venous connection; consequently, operation may be postponed and the infant's clinical condition deteriorate. This study describes 22 infants who underwent surgical correction of this disorder in the 1st year of life between 1975 and 1978. Twelve were in the 1st month and six in the first 4 days of life. Nine had a type I, six a type II, six a type III and one a type IV lesion. The infants' weights ranged from 2.6 to 6.9 kg (mean 4.0) at the time of operation; this fact emphasizes the retarded growth of these infants.Nineteen of 22 infants (including all 6 infants operated on during the first 4 days of life) survived operation, yielding an 87 percent hospital survival rate. Two late deaths occurred secondary to intimai fibroplasia of the pulmonary veins proximal to the site of atrial anastomosis; this represents a potential problem especially in infants with type III lesions. The strongest determinants of survival were type of lesion, pulmonary venous obstruction and depressed left ventricular function. Age in itself is not a determinant of survival after correction of total anomalous pulmonary venous connection. The timing of corrective surgery should be influenced by the clinical condition of the infant. 相似文献
Recent reports comparing medical versus surgical management of patients with ischemic heart disease highlight the importance of technical quality in the interpretation of surgical results. This review is an attempt to examine current controversies in the conduct of coronary artery bypass with the purpose of suggesting strengths and weaknesses of alternative approaches. Topics include cold cardioplegia versus intermittent aortic occlusion, left ventricular venting, anastomotic technique, optical magnification, “complete revascularization,” sequential versus individual grafting, internal mammary artery versus saphenous vein as conduits and the choice of alternative conduits when saphenous vein is unavailable. 相似文献
That most patients with chronic myelogenous leukemia (CML) have either very low levels or no leukocyte alkaline phosphatase activity (LAP) is an established fact. In view of our new findings7 that normal mature human polymorphonuclear leukocytes (PMN) contain two types of granules, azurophils (1/3) and specifics (2/3), and that alkaline phosphatase is present only in specific granules, we undertook the present studies to determine whether these neoplastic PMN lack a specific granule population or simply lack the enzyme. The cellular buffy coats of five patients with CML (Ph1 plus, LAP minus) were fixed in glutaraldehyde, incubated for peroxidase to identify the azurophil population, and examined by electron microscopy. It was found that the specific granule population was present in all mature PMN. Counts of both azurophil and specific granules per cell were slightly lower than normal but were within an 80%-90% overlap of the normal range. We therefore conclude that the low level of LAP in patients with CML reflects a deficiency of the enzyme rather than a missing granule population. Although the mature PMN appeared relatively normal (with few exceptions), circulating myeloblasts and promyelocytes revealed several abnormalities, the most notable being the presence of large bundles of cytoplasmic microfilaments. The blood of two patients in the terminal phase of disease was reexamined. Most of their cells were immature, with aberrations similar to those in myeloblasts and promyelocytes in the chronic phase of the disorder. In addition, however, we discovered three adnormal populations of mature PMN: (1) PMN containing both populations of granules but lacking peroxidase, (2) PMN lacking specific granules, and (3) PMN lacking azurophil granules. Our findings emphasize the value of electron microscopy and cytochemistry in detecting abnormalities of maturation in the cytoplasm of leukemic PMN. 相似文献
Objectives. This study was undertaken to determine the extent to which cardiovascular specialists are involved with and affected by managed care and to ascertain their attitudes toward it. This survey also served as the follow-up to an initial study on the subject performed by the American College of Cardiology in 1993.
Background. The initial 1993 study was performed to address the lack of any comprehensive examination of the impact of managed care on cardiovascular specialists. In 1995, to reexplore this question and follow up the 1993 findings, the College conducted a survey of its membership in the following areas: 1) physician relationship with managed care plans; 2) number of managed care contracts; 3) breakdown of revenue by payment source; 4) changes in practice in response to managed care; and 5) physician attitudes toward managed care. To the extent feasible, the 1995 questionnaire paralleled the 1993 instrument to facilitate comparisons.
Methods. A questionnaire was mailed to 5,147 practicing College members in the United States, who were categorized by specialty as pediatric cardiologists, adult cardiologists or cardiovascular surgeons. Mailings were sent to 1) all pediatric cardiologists and cardiovascular surgeons; 2) randomly selected adult cardiologists practicing in 10 states with high managed care penetration; and 3) randomly selected adult cardiologists in the nine U.S. census areas who were not practicing in the 10 states with high managed care penetration.
Results. Usable surveys were returned by 1,236 respondents, for an overall response rate of 24%. Involvement with at least one type of managed care organization was reported by 89% of respondents, up from 76% in 1993. Although managed care relationships had increased across physician age, region, practice and specialty, respondents indicated that, on average, well below 50% of their practice revenues stem from managed care contracts. To adapt to the managed care environment, strategic practice changes, such as joining a cardiovascular network, implementing continuous quality improvement systems and adopting clinical pathways, were being instituted by most respondent practices of nine or more physicians. Smaller groups were less active. Most respondents involved with managed care disliked its effects, particularly in clinical matters. Their attitudes toward the assumption of risk, managed fee-for-service arrangements and a private versus single-payer system show that there is no uniformity of opinion regarding the best means to contain costs and promote efficiency.
Conclusions. Managed care has become an established part of cardiovascular specialist practice in the United States. Although this trend is viewed with some disfavor, most respondents are making practice changes to adapt to this new environment.
