Absent right superior vena cava with persistent left superior vena cava: Implications and management

Seven cases of absent right superior vena cava with persistent left superior vena cava and normal situs were diagnosed at Children's Hospital of Pittsburgh. All patients had associated cardiac defects. In two cases the diagnosis was made at autopsy, the first in 1957 in a 26 day old infant with multiple congenital defects and the second in 1965 in a 22 day old infant who had pulmonary atresia with ventricular septal defect and patent ductus arteriosus. Since 1966 absent right superior vena cava has been diagnosed at cardiac catheterization in five children. Three of these children have had surgery, two for subaortic stenosis and one for an atrial septal defect. One has an insignificant atrial septal defect and the fifth has a ventricular septal defect. The electrocardiogram of four reveals a short P-R interval and a leftward frontal plane axis of the P wave, suggesting a low atrial focus. None has had any significant conduction problem. All five children are living and well; the oldest has survived 13 years postoperatively. Certain precautions are necessary should corrective cardiac surgery or transvenous pacemaker insertion be necessary.     

Comparison of wire-guided percutaneous insertion and conventional surgical insertion of intra-aortic balloon pumps in 151 patients

Over a 25-month period, percutaneous wire-guided balloon catheter insertion was attempted in 51 patients, and intra-aortic balloon pump insertion was attempted by conventional surgical method in 100 patients. The success rate in the group undergoing percutaneous insertion was 90.2 percent (46 of 51) and 90 percent in the group undergoing surgical insertion (90 of 100). The indications for intra-aortic balloon counterpulsation were diverse in both groups. The major complication rate in the patient population undergoing percutaneous intra-aortic balloon pump insertion was 15.2 versus 15.6 percent for the surgical group, and there were no cases of leg amputation or aortic dissection in the percutaneous group; however, two cases of leg amputation and one case of aortic dissection resulting in death occurred in the surgical group. The percutaneous intra-aortic balloon pump insertion technique was successfully employed in conjunction with percutaneous transluminal coronary angioplasty in six cases. It is concluded that the wire-guided percutaneous balloon catheter method is a highly successful and rapid means of instituting intra-aortic balloon counterpulsation in a wide variety of clinical situations. However, because of the significant associated complication rate, the decision to institute balloon counterpulsation must weigh the benefit-to-risk ratio, and this procedure must still be evaluated on a case-by-case basis.     

Necrotizing fasciitis

Fourteen patients with necrotizing fasciitis seen over a 5 year period at a public hospital are reviewed. Middleaged men predominated. The disease followed such diverse initiating causes as self-injection with heroin, boil, ischiorectal abscess, perforated occult colonic cancer and trivial abrasions. In a few cases there was no evidence of an initiating lesion. Necrotizing fasciitis affected the arms, legs, trunk and neck. Bacteriologic analysis showed that the disease is usually caused by gram-negative bacilli and hemolytic streptococci, alone or in combination. Morbidity and mortality rates in the present series were influenced by associated clinical conditions such as old age, diabetes mellitus, carcinoma and gram-negative bacteremia.     

Chronic intravascular coagulation associated with chronic myelocytic leukemia. Use of heparin in connection with a surgical procedure.

A women with Philadelphia chromosome-positive chronic myelocytic leukemia lived nearly 12 years from the time of diagnosis. During most of this period she received no therapy, and marked cyclic oscillations in the white blood cell count were documented. The last two years of her illness were marked by a hemorrhagic disorder associated with hypofibrinogenemia, thrombocytopenia, increased plasma fibrinopeptide A concentration and markedly elevated serum levels of fibrin degradation products. The coagulation disorder was rapidly reversible on several occasions with heparin therapy. After treatment with heparin and platelet transfusions, the patient underwent successful resection of a large ovarian cyst with excellent hemostasis during the procedure. Postoperatively, the administration of heparin and platelets was discontinued and a large wound hematoma developed. After resumption of therapy with heparin and platelets, the remainder of her postoperative course was uneventful. The literature on the subject is reviewed and tentative guidelines are offered concerning the management of patients with intravascular coagulation who require diagnostic or therapeutic surgical procedures.     

Alcohol self-administration in monkeys (Macaca radiata): the effects of prior alcohol exposure.

Responding by 4 monkeys was maintained under a fixed ratio 10 (FR 10) schedule for either food, intravenous sucrose or alcohol. The 20 hr sessions were divided so that food was available during hours 1, 6, 11, 16 and alcohol or sucrose during hours 2-5, 7-10, 12-15, and 17-20. All animals failed to maintain responding for isocaloric sucrose but continued to respond for food during those sessions. Responding under alcohol conditions was positively accelerated in 2 animals that were not previously exposed to alcohol, whereas prior exposure to alcohol produced maximal response rates during the first alcohol test session. The effects of alcohol in all monkeys were to suppress responding maintained by food and this suppression could not be produced with programmed infusions of isocaloric sucrose.     

Preoperative versus intraoperative diagnosis of hiatal hernia in bariatric population

BackgroundHiatal hernia is frequently encountered intraoperatively during bariatric surgery. There is scarce research pertaining to the diagnostic accuracy of a preoperative diagnostic modality in comparison to intraoperative diagnosis, along with patient characteristics and related factors contributing to hiatal hernia.ObjectiveTo identify the prevalence and associations of hiatal hernia in the bariatric patient population, we compared the diagnostic accuracy of upper gastrointestinal series and esophagogastroduodenoscopy with the intraoperative findings across various patient characteristics.SettingMetabolic and Bariatric Surgery Accreditation and Quality Improvement Program, Teaching Hospital, New York, USA.MethodsRetrospective study of patients from 2015 to 2018 who met National Institutes of Health criteria for bariatric surgery.ResultsThere were 1094 patients included (135 males, 959 females), with an age range of 18 to 74 years. The diagnostic accuracy was determined by a sensitivity of 64.71% (95% confidence interval [CI] .55–.70), specificity of 74.38% (95% CI .71–.70), positive predictive value of 29.86% (95% CI .24–.30), negative predictive value of 92.59% (95%CI .89–90), likelihood ratio of 2.526, and P value < .0001 for esophagogastroduodenoscopy; a sensitivity of 14.02% (95% CI .08–0), specificity of 98.23% (95% CI .96–.90), positive predictive value of 71.43% (95% CI .50–.80), negative predictive value of 78.35% (95% CI .74–.80), likelihood ratio 7.921, and P value < .0001 were used for upper gastrointestinal series. Hiatal hernia with age <60 years was 17.09% versus 48.44% at >60 years (P < .0001). Hiatal hernia incidence was 17% in Hispanics, 22.5% in Caucasians, and 23.10% in blacks.ConclusionThe prevalence of hiatal hernia is 18.92%. There is strong association between hiatal hernia and age and ethnicity and no association based on sex and body mass index. The diagnostic accuracy of upper gastrointestinal series is very low compared with that of esophagogastroduodenoscopy for hiatal hernia. Preoperative diagnosis of hiatal hernia in the bariatric population is not required based on our study. Not only does it lessen the economic burden, patient wait time, and discomfort of an additional study, but preoperative diagnosis does not change, alter, or aid in the intraoperative management of hiatal hernia considering the suboptimal accuracy of preoperative diagnostics, thus deeming them unwarranted.