Etiology of genital ulcers and prevalence of human immunodeficiency virus coinfection in 10 US cities. The Genital Ulcer Disease Surveillance Group

To determine the etiology of genital ulcers and to assess the prevalence of human immunodeficiency virus (HIV) infection in ulcer patients in 10 US cities, ulcer and serum specimens were collected from approximately 50 ulcer patients at a sexually transmitted disease clinic in each city. Ulcer specimens were tested using a multiplex polymerase chain reaction assay to detect Haemophilus ducreyi, Treponema pallidum, and herpes simplex virus (HSV); sera were tested for antibody to HIV. H. ducreyi was detected in ulcer specimens from patients in Memphis (20% of specimens) and Chicago (12%). T. pallidum was detected in ulcer specimens from every city except Los Angeles (median, 9% of specimens; range, 0%-46%). HSV was detected in >/=50% of specimens from all cities except Memphis (42%). HIV seroprevalence in ulcer patients was 6% (range by city, 0%-18%). These data suggest that chancroid is prevalent in some US cities and that persons with genital ulcers should be a focus of HIV prevention activities.

Long term results of polytetrafluoroethylene in above knee femoropopliteal bypass for critical ischaemia

Ninety-six consecutive above-knee femoropopliteal bypasses, using polytetrafluoroethylene (PTFE) preferentially, were performed for limb-threatening ischaemia. Cumulative primary graft patency was 68 per cent, 49 per cent and 36 per cent and limb salvage 93 per cent, 85 per cent and 75 per cent at 1, 3 and 5 yr respectively. As a result of poor long term survival (51 per cent at 5 yr), and the healing of remedial lesions before graft occlusion, 68 patients (72 per cent) required no further intervention. Eighteen secondary bypasses were undertaken, 12 using ipsilateral saphenous vein. In this group of elderly patients with poor life expectancy, where a limited operation is desirable, the use of PTFE provided excellent limb salvage with low morbidity. Although we can no longer justify our continued use of PTFE in every case of critical ischaemia because of its inferior patency to autogenous vein, we continue to use it preferentially in patients whose lifespan is likely to be short and in cases where a remedial lesion is present.

Exercise echocardiography, angiography, and intracoronary ultrasound after cardiac transplantation

Fifty-one consecutive patients underwent exercise echocardiography, angiography, and intracoronary ultrasound (ICUS) 2.5 years (range from 1 to 6) after cardiac transplantation. The average age of the donor was 29 years (range 13 to 50), and the average age of the recipient was 49 +/- 12 years. In total, 78 studies were performed, as 25 patients had >1 annual evaluation and 2 patients had 3 consecutive annual evaluations. Of the 78 angiographic studies, 40 (26 patients) had evidence of coronary artery disease, defined as a focal stenosis (>20%, n=4) or luminal irregularities (n=36). However, by ICUS all 51 patients had intimal thickening at some point, with 34 patients possessing diffuse disease and 17 focal intimal thickening only. Of the 25 serial studies, 12 progressed by at least 1 Stanford class. The sensitivity of angiography for determination of class III to IV intimal thickening was 64% and the specificity was 76%. On exercise echocardiography, 6 examinations revealed resting wall motions abnormalities, whereas 6 had inducible wall motion abnormalities with exercise. The sensitivity of exercise echocardiography to determine class III to IV intimal thickening was 15%, and the specificity was 85%. In conclusion, exercise echocardiography is an insensitive method for predicting transplant-mediated coronary artery disease, whereas luminal irregularities on angiography may predict the presence of Stanford grade III to IV intimal thickening.

Spinal claudication versus arterial claudication

Ninety-three consecutive treadmill exercise stress test were performed for the assessment of peripheral vascular function. Thirty-one were for atypical claudication-like symptoms including pain on standing, relief on sitting and back pain. Pedal pulses were palpable in 24 patients. Twenty-five patients (81%) had a negative stress test, suggesting a non-vascular aetiology and this finding was subsequently confirmed in 24 of the 25. The final diagnoses were spinal stenosis 13, [CT = 3, myelogram = 5, neurosurgeon opinion = 4, MRI = 1], myositis 2, restless leg syndrome 2 and osteoarthritis 7. Four patients had symptoms due to a combination of peripheral occlusive arterial disease and spinal stenosis; the latter was considered the predominant disorder in all four. Of the original 31 patients with atypical symptoms, spinal stenosis was present in 13 (42%). Atypia- in the common syndrome of intermittent claudication should alert the surgeon to the possibility of spinal canal disorders. Further investigation may identify significant pathology spinal stenosis in particular.

Infantile hypertrophic pyloric stenosis: long-term audit from a general surgical unit

This article describes a 22 year experience of a general surgical unit in the treatment of infantile hypertrophic pyloric stenosis (IHPS). The hospital course of 229 IHPS patients is reviewed. The male:female ratio was 3.6:1, median age 6 weeks (range 2-26 weeks) with a positive family history in 8.3%. The diagnosis of IHPS was established clinically by palpation of a "pyloric tumour" during a pre operative test meal/clinical examination in 92.6%; in the remainder, the diagnosis was made radiologically. Ramstedt's pyloromyotomy was performed within 5 days of admission in 74% of patients and within 10 days of admission in 89%. The median post-operative hospital stay was 10 days (range 3-60 days). Wound morbidity occurred in 10.0% wound infection (7.3%) and wound dehiscence (2.6%). However, wound morbidity was reduced in the second half of the series, partly by greater utililisation of non-absorbable suture in place of chromic catgut for wound closure. Mucosal penetration was suspected in 14.8% of cases. Repeat pyloromyotomy was necessary in 1.3%. One baby died (0.4%)- this was in the early part of the series and was directly attributable to fluid and electrolyte disorder. We conclude that Ramstedt's pyloromyotomy for infantile hypertrophic pyloric stenosis can be performed with acceptable morbidity and minimal mortality in a general surgical unit.

Institutional variation in hemotherapy for solid organ transplantation

BACKGROUND

Solid organ allograft recipients may require large amounts of blood components. The modification of components to make them safer for iatrogenically immunosuppressed transplant patients increases workload demands on blood banks and transfusion services.

STUDY DESIGN AND METHODS

Institutions within the United States and Canada providing hemotherapy as support for transplant recipients were surveyed for their transfusion practices.

RESULTS

Responses from 25 institutions provide the data for this report. In 1991, the mean intraoperative red cell requirements ranged from <1 unit for renal allograft recipients to 17.3 units for liver transplant recipients. The latter group also required the greatest amounts of platelets, fresh-frozen plasma, and cryoprecipitate. More than 75 percent of responding institutions provided either cytomegalovirus-seronegative or white cell-reduced cellular components to pediatric recipients of liver allografts and to both adult and pediatric recipients of heart, lung, and heart-lung allografts. The use of irradiated cellular blood components, although uncommon, was greatest in heart transplant recipients. The use of pretransplantation transfusions for immunomodulation was generally limited to patients awaiting a living-donor renal transplant.

CONCLUSION

Transfusion practices varied among the institutions, but the majority provide cytomegalovirus-safe cellular blood components to heart and lung allograft recipients and to pediatric transplant patients. Gamma-radiated cellular components are not routinely provided to patients undergoing solid organ transplantation. Liver allograft recipients require the greatest amount of hemotherapeutic support.

An exploratory study of the pattern of consent for autopsy in a regional hospital setting

A prospective study of the pattern of responses to requests for autopsy in a general surgical unit was performed. Information on the characteristics of the deceased, of the requestee and of the requester was documented in the case of 66 patients who died while in hospital. Permission to perform autopsy was not requested in 39 out of 66 cases and this was the most frequent contributory factor to the low rate of autopsy. Once a decision to grant or refuse autopsy is made by relatives of the deceased, the decision is unlikely to be reversed. Permission to perform autopsy was more likely to be sought when the deceased was male than when deceased was female. The relatives of patients who had recently undergone surgery were more likely to refuse permission for autopsy than were those of patients who had not had recent surgery.

"How safe is splenectomy?"

The increased risk of sepsis in patients following splenectomy has been well documented. Fear of overwhelming post-splenectomy sepsis (OPSI) has resulted in a generalized trend towards splenic salvage among surgeons. However, splenorrhaphy and attempts at splenic salvage may of themselves predispose to significant morbidity, sometimes more serious than increased susceptibility to infection associated with splenectomy. This study aims to assess the risk of splenectomy and subsequent asplenia. We reviewed 246 patients who underwent splenectomy over a 16 year period. Indications for splenectomy were considered under the following headings: haematological (N = 116), trauma (N = 69), visceral carcinoma (N = 28), incidental (N = 13) and miscellaneous (N = 20). There were 28 deaths in the series, primarily among those in the intra-abdominal carcinoma (13) and multiple trauma (13) groups. Two deaths were recorded among patients undergoing elective splenectomy for benign disease. Thrombo-embolic complications were recorded in nine patients; respiratory tract infection in 36 patients and intra-abdominal abscess in two patients. Two cases of post-splenectomy pneumococcal septicaemia were documented, neither of which was fatal. While not an entirely benign procedure, splenectomy can be performed relatively safely, especially when performed for benign disease in an adult population.

The use of granulocyte colony-stimulating factor in the treatment of fever and neutropenia in a heart transplant patient

We had the opportunity to study the clinical effects of granulocyte colony-stimulating factor in a heart transplant patient with a classic febrile neutropenic episode that was thought to be caused by immunosuppressive therapy. Administration of granulocyte colony-stimulating factor resulted in rapid recovery of his absolute neutrophil count, with resolution of fevers. Endomyocardial biopsy showed no pathologic evidence of worsened rejection. The use of hematopoietic cytokines after the organ allograft requires further study before it can be routinely advocated in this patient population.

Detection of coronary artery disease with upright bicycle exercise echocardiography

This study examined the advantages and limitations of upright bicycle exercise echocardiography in the evaluation of a large series of patients with known or suspected coronary artery disease. The study population consisted of 309 patients (231 men, mean age 57 +/- 11 years) who underwent exercise echocardiography within 8.5 +/- 16.1 days of coronary angiography. All stress electrocardiographic, echocardiographic, and angiographic data were reinterpreted in a blinded manner by the investigators. No patient was excluded because of poor echocardiographic image quality. Wall motion was analyzed at baseline, peak exercise, and immediately after exercise with a 16-segment model, and a regional wall motion score index was calculated at each stage. Abnormalities were ascribed to the distribution of the three coronary arteries and correlated with qualitative angiography. There were 126 patients with wall motion abnormalities at rest and 211 (75%) with coronary artery disease. The stress electrocardiogram (ECG) was negative in 61, positive in 144, and nondiagnostic in 104, yielding a sensitivity of 40% and a specificity of 89%. Echocardiography was normal in 76 of 98 patients without coronary disease (78% specificity) and abnormal in 193 of 211 patients with disease (91% sensitivity). Sensitivity was higher among patients with multivessel disease compared with those with single vessel disease (95% versus 86%, respectively, p = 0.03). Among patients with normal wall motion at rest (n = 183), sensitivity was 83% and specificity was 84%. Of the 104 patients with a nondiagnostic stress ECG, echocardiography correctly identified 95% of those with coronary disease and 75% of those without disease. Among 82 patients with a wall motion abnormality at rest, an additional exercise-induced wall motion abnormality developed in 32 of 46 patients (70%) with multivessel disease and seven of 32 (22%) with single-vessel disease. Overall, echocardiography detected 258 of 392 (66%) individual coronary lesions. Accuracy was higher for lesions in the left anterior descending and right coronary arteries (both 79%) compared with the left circumflex artery (36%, p < 0.001). In conclusion, upright bicycle exercise echocardiography is an accurate technique for the evaluation of patients with known or suspected coronary artery disease and is especially valuable in patients with a nondiagnostic stress ECG. The test provides supplemental information on the extent and location of coronary lesions and is useful in patients with and without prior myocardial infarction.

Polytetrafluoroethylene in above-knee arterial bypass surgery for critical ischemia

Seventy-one consecutive above-knee polytetrafluoroethylene (PTFE) femoropopliteal arterial bypasses performed between 1981 and 1989 for critical ischemia were followed prospectively to determine graft patency and limb salvage. Cumulative graft patency and limb salvage rates were calculated by life table analysis. Graft patency was 80%, 68%, 55%, 39%, and 39%, and limb salvage 97%, 87%, 84%, 77%, and 77% at 1, 2, 3, 4, and 5 years, respectively. Twenty-nine grafts have occluded with re-emergence of critical ischemia in 14, treated by 5 amputations and 9 reconstructions using autogenous saphenous vein (ASV) in 6 and PTFE in 3. These favorable results are not as good in terms of primary patency as those reported with ASV, but good limb salvage, good early patency, ease of use, and preservation of the saphenous vein for use later have encouraged us toward primary use of PTFE in selected patients. This experience strongly questions the wisdom of an "all autogenous" policy for reconstruction at this level.

Duplex imaging of lower limb arterial bypass grafts

A non-invasive programme of post-operative surveillance and intervention where necessary is essential to optimise results with arterial reconstruction. We report our experience with duplex ultrasonography in the follow-up lower limb arterial bypass grafts. One hundred and three duplex studies were performed in 58 patients with 59 lower limb arterial bypass grafts. Grafts were visualised throughout their length and haemodynamic characteristics including peak systolic velocity (PSV) were measured. Angiography was performed on the basis of any significant anatomical or haemodynamic abnormality on duplex. All grafts were visualised throughout their length with ease. Satisfactory visualisation of 86% of anastomoses was achieved. PSV was found to be the most easily reproducible haemodynamic index and the best indicator of graft function. PSV had a median value of 79 cm/sec and a range of 51-117 cm/sec in normal grafts compared to 26 cm/sec (range 19-42 cm/sec) in grafts with stenosis. Twelve pre-occlusive lesions which were not evident clinically, 5 within and 7 outside the graft, have been detected. Eight have been treated by transluminal angioplasty. Two grafts with stenosis and PSVs of less than 25 cm/sec had occluded by the time angiography was performed 2 weeks later. Duplex is an excellent, non-invasive, and repeatable method of screening of grafts at risk of failure, allowing earlier intervention with improved secondary patency.

Restrictive hemodynamic patterns after cardiac transplantation: relationship to histologic signs of rejection

Hemodynamic and echocardiographic data from 33 consecutive patients undergoing cardiac transplantation were correlated with endomyocardial biopsy results to determine whether reversible restrictive hemodynamics accompany histologic evidence of transplant rejection. During the study period 251 biopsy specimens were obtained during periods of no histologic evidence of transplant rejection and 52 episodes of mild, 20 episodes of moderate, and one episode of severe rejection. Right atrial mean pressure increased significantly during episodes of moderate transplant rejection (9.9 +/- 6.2 mm Hg, p less than 0.001) compared with pressures obtained during periods when there was no evidence of rejection (4.6 +/- 3.2 mm Hg), mild rejection (5.8 +/- 3.9 mm Hg), or resolving rejection (4.3 +/- 3.4 mm Hg). Y descent was elevated during moderate rejection (9.6 +/- 4.2 mm Hg, p less than 0.001) compared with pressures during episodes of no rejection (5.6 +/- 2.5 mm Hg), mild rejection (6.6 +/- 2.7 mm Hg), and resolving rejection (5.8 +/- 3.1 mm Hg) and showed a wave morphology consistent with a restrictive hemodynamic pattern. Pulmonary capillary wedge pressure was increased during moderate rejection (14.4 +/- 6.4 mm Hg) when compared with pressures obtained during episodes of no rejection (10.2 +/- 5.8 mm Hg) or resolving rejection (10.2 +/- 5.4 mm Hg) (p less than 0.02). Sensitivity for a right atrial mean pressure of 11 mm Hg indicating moderate rejection was 41% with a specificity of 96%. Sensitivity for Y descent (greater than or equal to 10 mm Hg) was 52% and specificity was 94%.(ABSTRACT TRUNCATED AT 250 WORDS)

Realistic expectations for the patient with intermittent claudication

To determine the natural history of intermittent claudication 112 patients were followed for a minimum of 5 years and a median period of 82 months. Thirty-seven patients (33 per cent) died during the study period. Myocardial infarction (44 per cent) and cerebrovascular disease (28 per cent) were the most common causes of death. Overall mortality rate was 8, 23 and 40 per cent, at 2, 5 and 8 years respectively. Initial ankle-brachial pressure index (ABPI) correlated with subsequent death. With an initial ABPI less than 0.5 death occurred in 20, 50 and 69 per cent at 2, 5 and 7 years respectively, compared with 5, 16 and 24 per cent respectively for those with an initial ABPI greater than or equal to 0.5 (P less than 0.0001). Of the survivors only 21 per cent had worsening claudication and 13 per cent progressed to critical ischaemia. Arterial bypass for limb salvage was required in eight patients and four limbs were lost during the study period. ABPI identifies a subgroup of claudicants with an extremely high risk of death from coronary and/or cerebral pathology. In this subgroup an aggressive approach to the correction of atherosclerotic risk factors, rather than emphasis on the peripheral vascular problem alone, may improve survival.

Abdominal aortic aneurysms: the importance of elective repair

Repair of abdominal aortic aneurysms (AAA) is being performed with a progressively lower mortality and morbidity. We reviewed 111 patients who underwent repair of their AAA. Sixty-two were electively repaired and 49 had emergency surgery. Eight patients had cocomitant non-vascular procedures carried out. Operative mortality was 3.2% and 49% for elective and emergency cases respectively. Postoperative complications occurred in 40% of elective cases and 72% of emergency cases, respiratory complications being the most common, occurring in 25% and 40% of elective and emergency cases respectively. Subsequent graft complications occurred in six patients, five following emergency surgery.

The neonatal duodenal windsock web--a case report and description of a new technique for its operative excision

Duodenal obstruction in the neonate may be caused by an intraluminal diaphram or so-called windsock web. This can present special technical difficulties at operation. This report of a case describes a new technique in the surgical treatment of such a web.

The effect of distal anastomotic site on PTFE graft patency in lower extremity bypass

The site of distal anastomosis of polytetrafluorethylene (PTFE) lower extremity bypass grafts may significantly affect results. We examined patency in 144 cases; 45 femoro-popliteal above knee (AK), 55 femoro-popliteal below the knee (BK) and 44 femoro-distal (D) PTFE bypasses, the groups being comparable with regard to other risk factors studied. Cumulative graft patency at 3 years was 71.3% for AK, 36.7% for BK, 16.4% for D and overall 35%. The site of distal anastomosis is an important determinant, of PTFE lower extremity bypass patency. We have abandoned the use of PTFE for BK and D, but feel that AK PTFE is a suitable alternative to autogenous reversed saphenous vein.

Limb salvage in the elderly

Sixty-eight lower extremity bypass procedures for severe lower limb ischemia were undertaken on 53 patients of 75 years of age and over. The operative mortality was 4.4%. At two years cumulative limb salvage, patient survival, graft patency and survival with an intact limb were 77%, 72%, 44%, and 56%, respectively. Of all patients who died, 66% had an intact limb at the time of death. Based on these results we continue to offer reconstructive surgery to elderly patients.

Exercise echocardiography: detection of coronary artery disease in patients with normal left ventricular wall motion at rest

Most studies investigating the ability of exercise two-dimensional echocardiography to identify patients with coronary artery disease have included patients with left ventricular wall motion abnormalities at rest. This has the effect of increasing sensitivity because patients with only abnormalities at rest are detected. To determine the diagnostic utility of exercise echocardiography in patients with normal wall motion at rest, 64 patients were studied with exercise echocardiography in conjunction with routine treadmill exercise testing before coronary cineangiography. All 24 patients who had no angiographic evidence of coronary artery disease had a negative exercise echocardiogram (100% specificity). Nine of 40 patients with coronary artery disease (defined as greater than or equal to 50% narrowing of at least one major vessel) also had a negative exercise echocardiogram (78% sensitivity). Of the nine patients with a false negative exercise echocardiographic study, six had single vessel disease. Among 25 patients with single vessel disease, exercise echocardiography was significantly more sensitive (p = 0.01) than treadmill exercise testing alone (76 versus 36%, respectively). Among 15 patients with multivessel disease, the two tests demonstrated similar sensitivity (80%). In conclusion, exercise echocardiography is highly specific and moderately sensitive for the detection of coronary artery disease in patients with normal wall motion at rest. Although exercise echocardiography is significantly more sensitive than treadmill exercise electrocardiographic testing alone in patients with single vessel disease, the two tests are similar in their ability to detect coronary artery disease in patients with multivessel disease and normal wall motion at rest.

Risk stratification after acute myocardial infarction by means of exercise two-dimensional echocardiography

To determine whether exercise two-dimensional echocardiography contributes to the prognostic information provided by exercise testing in patients recovering from acute myocardial infarction, 40 patients were prospectively studied by means of pre- and postexercise echocardiography 10 to 21 days after myocardial infarction. Patients were followed for 6 to 10 months or until one of the following clinical end points occurred: death, recurrent myocardial infarction, unstable angina, or coronary artery bypass grafting. Results of treadmill exercise tests were negative in 13 of 20 patients with good clinical outcome (65% specificity) and positive in 11 of 20 patients with poor clinical outcome (55% sensitivity). The resting echocardiogram was abnormal in 37 of 40 patients. The exercise echocardiogram was negative in 19 of 20 patients with good clinical outcome (95% specificity) and positive in 16 of 20 patients with poor clinical outcome (80% sensitivity). We conclude that exercise echocardiography is more sensitive and specific than treadmill exercise testing for predicting the occurrence of subsequent cardiac events after acute myocardial infarction.

Thoracic aortic dissections: magnetic resonance imaging

Six patients with documented dissections of the thoracic aorta (two Type A, four Type B) were examined by magnetic resonance (MR) imaging using a 0.6-Tesla superconductive magnet. Cardiac gating was applied in five cases. Correlation was made with CT and angiography. MR imaging demonstrated the dissection in all six cases and accurately differentiated Type A from Type B dissections. Coronal and sagittal MR sections were advantageous in establishing the relationship of the three arch vessels to the dissection. In addition, cardiac-gated MR was useful in demonstrating mural thrombus and in distinguishing the true from the false lumen based on differences in signal intensity resulting from different flow rates. In five cases, the information obtained by MR was equal to or surpassed that obtained by CT. In the one case of a completely thrombosed dissection, the CT scan was more helpful. MR should become an important imaging modality in the evaluation of aortic dissections.