Nuclear F-actin Cytology in Oral Epithelial Dysplasia and Oral Squamous Cell Carcinoma

Oral cavity cancer has a low 5-y survival rate, but outcomes improve when the disease is detected early. Cytology is a less invasive method to assess oral potentially malignant disorders relative to the gold-standard scalpel biopsy and histopathology. In this report, we aimed to determine the utility of cytological signatures, including nuclear F-actin cell phenotypes, for classifying the entire spectrum of oral epithelial dysplasia and oral squamous cell carcinoma. We enrolled subjects with oral potentially malignant disorders, subjects with previously diagnosed malignant lesions, and healthy volunteers without lesions and obtained brush cytology specimens and matched scalpel biopsies from 486 subjects. Histopathological assessment of the scalpel biopsy specimens classified lesions into 6 categories. Brush cytology specimens were analyzed by machine learning classifiers trained to identify relevant cytological features. Multimodal diagnostic models were developed using cytology results, lesion characteristics, and risk factors. Squamous cells with nuclear F-actin staining were associated with early disease (i.e., lower proportions in benign lesions than in more severe lesions), whereas small round parabasal-like cells and leukocytes were associated with late disease (i.e., higher proportions in severe dysplasia and carcinoma than in less severe lesions). Lesions with the impression of oral lichen planus were unlikely to be either dysplastic or malignant. Cytological features substantially improved upon lesion appearance and risk factors in predicting squamous cell carcinoma. Diagnostic models accurately discriminated early and late disease with AUCs (95% CI) of 0.82 (0.77 to 0.87) and 0.93 (0.88 to 0.97), respectively. The cytological features identified here have the potential to improve screening and surveillance of the entire spectrum of oral potentially malignant disorders in multiple care settings.

Proliferative leukoplakia: Proposed new clinical diagnostic criteria

OBJECTIVE

We aimed to characterize proliferative verrucous leukoplakia (PVL) from a clinical and histopathological standpoint and suggest an updated classification.

SUBJECTS AND METHODS

Records of patients seen at three oral medicine centers with a clinical diagnosis of PVL were reviewed for clinical and histopathological features and malignant transformation (MT).

RESULTS

There were 42 patients (median age: 69 years [range: 36-88]; 35 females). 12.2% were current smokers. Family history of cancer was present in 43.7% of patients. Partial demarcation of lesion margins was present in 31.3% of lesions, followed by verrucous (27.5%), smooth (22.7%) erythematous (22.3%), and fissured (18.3%) appearance. Large and contiguous and multisite and non-contiguous lesions comprised 57.1% (24/42) and 35.7% (15/42) of PVL cases, respectively. 19.1% had prominent erythema (erythroleukoplakia). The most common histopathological diagnosis at first visit was hyperkeratosis without dysplasia (22/42; 56.4%). MT occurred in 71.4% patients after a median of 37 months [range: 1-210] from initial visit; erythroleukoplakia exhibited MT in 100% of cases.

CONCLUSION

The generic term "proliferative leukoplakia (PL)" may be more appropriate than PVL because 18.3% were fissured and 22.7% erythematous. We also propose the term proliferative erythroleukoplakia to more accurately describe the subset of PL with prominent erythema, which had the highest MT rate.

Host-Microbiome Cross-talk in Oral Mucositis

Oral mucositis (OM) is among the most common, painful, and debilitating toxicities of cancer regimen-related treatment, resulting in the formation of ulcers, which are susceptible to increased colonization of microorganisms. Novel discoveries in OM have focused on understanding the host-microbial interactions, because current pathways have shown that major virulence factors from microorganisms have the potential to contribute to the development of OM and may even prolong the existence of already established ulcerations, affecting tissue healing. Additional comprehensive and disciplined clinical investigation is needed to carefully characterize the relationship between the clinical trajectory of OM, the local levels of inflammatory changes (both clinical and molecular), and the ebb and flow of the oral microbiota. Answering such questions will increase our knowledge of the mechanisms engaged by the oral immune system in response to mucositis, facilitating their translation into novel therapeutic approaches. In doing so, directed clinical strategies can be developed that specifically target those times and tissues that are most susceptible to intervention.

World Workshop on Oral Medicine VI: a systematic review of medication-induced salivary gland dysfunction

The aim of this paper was to perform a systematic review of the pathogenesis of medication-induced salivary gland dysfunction (MISGD). Review of the identified papers was based on the standards regarding the methodology for systematic reviews set forth by the World Workshop on Oral Medicine IV and the PRISMA statement. Eligible papers were assessed for both the degree and strength of relevance to the pathogenesis of MISGD as well as on the appropriateness of the study design and sample size. A total of 99 papers were retained for the final analysis. MISGD in human studies was generally reported as xerostomia (the sensation of oral dryness) without measurements of salivary secretion rate. Medications may act on the central nervous system (CNS) and/or at the neuroglandular junction on muscarinic, α-and β-adrenergic receptors and certain peptidergic receptors. The types of medications that were most commonly implicated for inducing salivary gland dysfunction were those acting on the nervous, cardiovascular, genitourinary, musculoskeletal, respiratory, and alimentary systems. Although many medications may affect the salivary flow rate and composition, most of the studies considered only xerostomia. Thus, further human studies are necessary to improve our understanding of the association between MISGD and the underlying pathophysiology.

Comparison of two mouthrinses in relation to salivary flow and perceived dryness

OBJECTIVE

To compare measures of dry mouth following extended use of an alcohol-based mouthrinse (LISTERINE Antiseptic [LA]) and a non-alcohol-based mouthrinse (Crest Pro-Health Rinse [CPH]) on healthy adults with "normal" salivary flow.

METHODS

This single-site, randomized, observer-blinded, parallel study compared unstimulated whole salivary flow and perceived dryness following daily use at weeks 4 and 12 versus baseline. Noninferiority, between-treatment flow comparisons (0.15 mL/min margin), and between-treatment comparisons of the mean Bluestone Mouthfeel Questionnaire (BMQ) visual analog scale scores were made using analysis of covariance.

RESULTS

Measures of dry mouth were comparable between mouthrinses, as demonstrated by both noninferiority of LA versus CPH flow (P < .001) and no significant differences between groups in the BMQ measures at 4 or 12 weeks.

CONCLUSIONS

Extended use of an alcohol-based mouthrinse is no more likely to cause reduction in salivary flow or perceived dryness in individuals with normal salivary flow compared with a non-alcohol-based mouthrinse (CPH).

Report on World Workshops on Oral Medicine (WWOM) IV and V: research themes and citation impact: WWOM VI steering committee

The first World Workshop on Oral Medicine (WWOM) was held in 1988. The portfolio has continued to expand in scope and impact over the past 26 years. Five World Workshops were conducted between 1988 and 2010, focusing on creation of systematic reviews in biomedicine and health care of importance to the international oral medicine community. WWOM VI was conducted in April 2014 and further extended this modeling. This most recent Workshop also fostered creation of the inaugural joint meeting between the American Academy of Oral Medicine and the European Association of Oral Medicine, together with The British Society for Oral Medicine and the Oral Medicine Academy of Australasia. The goal of the WWOM portfolio is to strategically enhance international oral medicine research, education, and clinical practice. To this end, this report summarizes subject areas for WWOM IV (2004) and research recommendations for WWOM V (2010), as well as citation metrics relative to publications from these two conferences. The information is designed to provide research and clinical context for key issues in oral medicine as delineated by the WWOM portfolio over the past 10 years, as well as for projected outcomes of WWOM VI over the next 12 months.

Local drug delivery for oral mucosal diseases: challenges and opportunities

There are few topical formulations used for oral medicine applications most of which have been developed for the management of dermatological conditions. As such, numerous obstacles are faced when utilizing these preparations in the oral cavity, namely enzymatic degradation, taste, limited surface area, poor tissue penetration and accidental swallowing. In this review, we discuss common mucosal diseases such as oral cancer, mucositis, vesiculo-erosive conditions, infections, neuropathic pain and salivary dysfunction, which could benefit from topical delivery systems designed specifically for the oral mucosa, which are capable of sustained release. Each condition requires distinct penetration and drug retention profiles in order to optimize treatment and minimize side effects. Local drug delivery may provide a more targeted and efficient drug-delivery option than systemic delivery for diseases of the oral mucosa. We identify those mucosal diseases currently being treated, the challenges that must be overcome and the potential of novel therapies. Novel biological therapies such as macromolecular biological drugs, peptides and gene therapy may be of value in the treatment of many chronic oral conditions and thus in oral medicine if their delivery can be optimized.

Safety and effectiveness of topical dry mouth products containing olive oil, betaine, and xylitol in reducing xerostomia for polypharmacy-induced dry mouth

Polypharmacy is a common cause of salivary hypofunction, producing symptoms of dry mouth or xerostomia, especially among older populations. As the number of older people continues to increase, polypharmacy-induced salivary hypofunction is becoming an increasing problem. Many over-the-counter products are available for relieving symptoms of dry mouth, but few have been tested in controlled clinical investigations. The purpose of this investigation was to evaluate the safety and efficacy of a group of topical dry mouth products (toothpaste, mouth rinse, mouth spray and gel) containing olive oil, betaine and xylitol. Forty adults were entered into this single-blinded, open-label, cross-over clinical study and 39 completed all the visits. Subjects were randomly assigned at baseline to using the novel topical dry mouth products daily for 1 week, or to maintain their normal dry mouth routine care. After 1 week, they were crossed over to the other dry mouth regimen. The results demonstrated that the use of the novel topical dry mouth products increased significantly unstimulated whole salivary flow rates, reduced complaints of xerostomia and improved xerostomia-associated quality of life. No clinically significant adverse events were observed. These data suggest that the daily use of topical dry mouth products containing olive oil, betaine and xylitol is safe and effective in relieving symptoms of dry mouth in a population with polypharmacy-induced xerostomia.

Eating disorders: a threat for women's health. Oral manifestations in a comprehensive overview

The incidence of eating disorders has progressively increased over the last several years, mainly affecting both the health and quality of life of young women. Such disorders are primarily an outlet for manifest psychic suffering and secondarily, they jeopardize the integrity and function of multiple organ systems resulting in significant morbidity and sometimes, life-threatening outcomes. The complex emerging interplay of etiopathogenetic factors poses many challenges in their prevention and management, which is further complicated by a reluctance by patients with eating disorders to seek medical evaluation and treatment. Recognition of the oral manifestations is important because these signs and symptoms can provide insights about disease progression and parallel general health and psychic status. Oral health care providers may be one of the few providers contacted by this patient population seeking recall prophylaxis or urgent dental care. Thus, improving understanding and knowledge of both general medical aspects of eating disorders and their oral manifestations could be of great impact in elevating the attention of health providers towards this group of very debilitating disorders and, consequently, improving their overall prognosis. In this paper we will review and discuss all these aspects.

Clinical evaluation of chemiluminescent lighting: an adjunct for oral mucosal examinations

OBJECTIVE

The purpose of this study was to describe the utility of oral chemiluminescent lighting (FDA-cleared ViziLite) as an adjunct to standard visual examination (SVE) to enhance visualization of mucosal lesions, particularly those "clinically suspicious" for oral pre-cancer or cancer. Subjects were considered at risk for oral cancer or pre-cancer if they have no a priori knowledge of the presence or absence of an oral lesion at the time of examination.

METHODOLOGY

Five-hundred and one consecutive consenting subjects, over 40 years of age and with a positive tobacco history, received a standard visual examination with conventional incandescent lighting, followed by chemiluminescent lighting. All lesions were recorded, and for lesions detected by both screening modalities, comparisons were made of the subjective parameters of lesion brightness, sharpness, surface texture, and relative size.

RESULTS

A total of 410 epithelial lesions were detected in 270 subjects by standard visual examination, of which 127 were clinically "suspicious" for oral cancer and pre-cancer. Ninety-eight lesions were also visualized by chemiluminescent lighting as "aceto-white" (CL+), in addition to six lesions not previously seen by standard visual examination. Seventy-seven of the CL+ lesions (78.5%) were clinically suspicious; all "suspicious" lesions with an ulcerative component and ulcerated lesions consistent with trauma were CL+. Leukoplakias were significantly more likely to be CL+ than erythroplakias (p < 0.01). Overall, those lesions illuminated by chemiluminescent lighting appeared brighter, sharper, and smaller compared to incandescent illumination.

CONCLUSION

The results of this study suggest that oral chemiluminescent lighting, when used as a screening adjunct following the standard visual oral examination, provides additional visual information. Leukoplakias may be more readily visualized by chemiluminescence. Studies are underway to explore the clinical significance and predictive value of oral chemiluminescent lighting.

The Ami-AliA/AliB permease of Streptococcus pneumoniae is involved in nasopharyngeal colonization but not in invasive disease

The Ami-AliA/AliB oligopeptide permease is an ATP-binding cassette transporter which is found in Streptococcus pneumoniae and which is involved in nutrient uptake. We investigated the role of the three paralogous oligopeptide-binding lipoproteins AmiA, AliA, and AliB by using murine models of pneumococcal colonization and invasive disease. A series of mutants lacking aliA, aliB, and amiA either alone or in combination as double or triple mutations were used. Inoculation of the nasopharynx with a mixture of the obl (oligopeptide-binding lipoprotein-negative) triple-mutant and wild-type (D39) bacteria resulted in significantly smaller numbers of obl bacteria colonizing the nasopharynx. The use of a mixture of individual mutants and wild-type pneumococci revealed that AmiA, AliA, and AliB were all required for successful colonization of the nasopharynx. The obl mutant was more attenuated than the aliB mutant but not the aliA or amiA mutant. Therefore, there is some redundancy in the Ami-AliA/AliB complex in terms of nasopharyngeal colonization, with AliA and AmiA being able to compensate for the removal of AliB. Animals with invasive disease caused by these mutants had survival times, bacterial loads, and inflammatory cytokine production levels similar to those of animals infected with wild-type pneumococci. Our results show that although the Ami-AliA/AliB complex is not required for virulence during pneumococcal pneumonia, it does play a role in colonization of the nasopharynx.

ZmpB, a novel virulence factor of Streptococcus pneumoniae that induces tumor necrosis factor alpha production in the respiratory tract

Inflammation is a prominent feature of Streptococcus pneumoniae infection in both humans and animal models. Indeed, an intense host immune response to infection is thought to contribute significantly to the pathology of pneumococcal pneumonia and meningitis. Previously, induction of the inflammatory response following infection with S. pneumoniae has been attributed to certain cell wall constituents and the toxin pneumolysin. Here we present data implicating a putative zinc metalloprotease, ZmpB, as having a role in inflammation. Null mutations were created in the zmpB gene of the virulent serotype 2 strain D39 and analyzed in a murine model of infection. Isogenic mutants were attenuated in pneumonia and septicemia models of infection, as determined by levels of bacteremia and murine survival. Mutants were not attenuated in colonization of murine airways or lung tissue. Examination of cytokine profiles within the lung tissue revealed significantly lower levels of the proinflammatory cytokine tumor necrosis factor alpha following challenge with the Delta zmpB mutant (Delta 739). These data identify ZmpB as a novel virulence factor capable of inducing inflammation in the lower respiratory tract. The possibility that ZmpB was involved in inhibition of complement activity was examined, but the data indicated that ZmpB does not have a significant effect on this important host defense. The regulation of ZmpB by a two-component system (TCS09) located immediately upstream of the zmpB gene was examined. TCS09 was not required for the expression of zmpB during exponential growth in vitro.

Rare venous connection causes severe cyanosis after the Fontan operation

We describe a rare case of cyanosis following the Fontan operation secondary to right-to-left shunting through a pulmonary vein connected to both the left atrium and the hepatic veins. This is a hazardous anomaly in a Fontan candidate and should be considered in those with unexpected postoperative desaturation.

Outcome following heart transplantation in Maori and Polynesian patients: a comparison with European New Zealanders

AIM

To compare demographic, clinical and outcome data of Maori and Polynesian with New Zealand European heart transplant patients.

METHODS

A retrospective analysis was made of data from the 104 patients who underwent heart transplantation at Green Lane Hospital over a period of twelve years, of whom 79 were European, 23 Maori/Polynesian, and two Asian. Clinical characteristics, blood group, HLA matching and outcomes of recipients were compared.

RESULTS

There was no significant difference in age and gender between the two groups. Maori and Polynesian patients were heavier, had a greater body mass index and were more likely to have rheumatic heart disease than their European counterparts. Maori/Polynesian patients were predominantly blood group A, whilst European patients were mainly group O. The waiting time for a donor heart was similar in both groups. There was no significant difference in number of rejection episodes and survival.

CONCLUSIONS

Green Lane Hospital has the largest international experience of heart transplantation in Maori and Polynesian patients. Although there are some differences in clinical profile, outcome in terms of rejection episodes and survival is similar in the two groups.

Stage one norwood procedure results: The green lane experience

AIMS

This study examined the presentation outcome, morbidity and mortality of infants who have undergone the stage one Norwood procedure for single ventricle reconstruction.

METHODS

A retrospective review was done on the first 20 patients to undergo this procedure at Green Lane Hospital, Auckland, New Zealand. Seven patients were diagnosed antenatally. Fetal cardiology records in the same time period were reviewed.

RESULTS

Twelve of the 20 patients (60%) have survived, and all of these patients have undergone their bi-directional Glenn procedure with no mortality. Eight patients died, with five of the deaths occurring in the perioperative period. Initial surgical mortality was 75%, decreasing to 25% since 1998. Antenatal diagnosis has not improved surgical outcome to date.

CONCLUSION

With advances in surgical technique and pre- and postoperative care, neonates born with single ventricle anatomy have an acceptable surgical option. Babies who survive the Norwood operation have a good chance of surviving the later stages of the cardiac reconstruction process, and they have a reasonable outlook in the intermediate term.

Transposition of the great arteries: operative outcome in the current era

AIMS

To assess the operative outcome, cardiac and neurodevelopmental sequelae in infants with transposition of the great arteries (TGA) undergoing the arterial switch operation (ASO).

METHOD

Cross-sectional review of the 48 consecutive patients operated on in the calendar years 1995 and 1996 was undertaken to obtain recent cardiac, growth and neurodevelopmental parameters, and the mortality results were compared to the entire cohort of infants who underwent the ASO for definitive repair of TGA and double outlet right ventricle at Greenlane hospital between 1984 and 1998.

RESULTS

Between January 1995 and December 1996, 48 patients underwent the ASO. 96% were alive, and 88% alive and free from reoperation or significant neurological sequelae at a mean followup interval of sixteen months. Six (13%) had important residual cardiac lesions, of which supra valvular pulmonary stenosis was the most common. Growth parameters at follow-up were normal, as was the neurodevelopmental progress of all but two survivors (96%).

CONCLUSION

In the current era, the ASO is a relatively safe procedure with excellent cardiac and neurodevelopmental outcome in the majority of infants.

Lifesaving oral cancer screening

Each year 605 New York State residents, on average, die from oral and pharyngeal cancer. Disappointingly, the mortality rate has not changed significantly in more than 25 years. Early detection and risk factor prevention are the two best public health tools to reduce mortality. Dental care workers must play an increasingly important leadership role in the fight against oral cancer. A technique for an annual oral cancer screening is described in this article.

The failing Fontan with atrial flutter: a successful surgical option

Two successful cases of eliminated atrial flutter and improved clinical status for Fontan patients are presented. An operation combining introduction of an extracardiac conduit for the Fontan connection, to direct all systemic venous blood away from the atrium, and atrial pathway division and cryoablation, is a useful surgical option for failing Fontan patients.

Subclinical aortic perforation with the infant double-button patent ductus arteriosus occluder

Modification of the double-button (Sideris) patent ductus arteriosus (PDA) occluder has resulted in a single-strut aortic component rather than the conventional cross-strut design. We report the use of this infant PDA occluder for transcatheter closure in three patients with PDA measuring 2 mm, 3.7 mm, and 4 mm. Subclinical aortic perforation with a small aortic aneurysm developed in two patients 1 year after occluder implantation. The third patient had developed a small aortic aneurysm without perforation at 3-month follow-up. All three patients had a residual shunt and underwent successful PDA surgical closure with aortic aneurysmal repair. Single-strut umbrella designs are not recommended for PDA transcatheter closure.

Blunt chest trauma and the heart

The Green Lane Hospital experience of patients presenting with cardiac damage as a result of chest trauma has been reviewed following the recent referral of a patient with tricuspid regurgitation due to trauma. A retrospective search of surgical records was made over the preceding 28 years which yielded a further nine patients. Our group has experienced a number of unusual causes of non-fatal cardiac trauma that have followed accidents. In nine out of ten cases closed chest injury resulted in damage to the heart. In some, diagnosis had been delayed for years. Echocardiography is a very useful diagnostic tool. Surgery was undertaken in all cases.

Long-term survival and valve-related complications in young women with cardiac valve replacements

BACKGROUND

The type of cardiac valve replacement associated with the lowest health risks for young women who may undergo pregnancies is unknown. We investigated which valve type was associated with greatest patient and valve survival and the effect of pregnancy on valve loss.

METHODS AND RESULTS

In this retrospective study, all women 12 to 35 years old who underwent valve replacements between 1972 and 1992 at Greenlane Hospital were identified, and follow-up was available in 93%. The 232 women were followed up for 1499 patient-years. Ten-year survival of women with mechanical (n=178), bioprosthetic (n=73), and homograft (n=72) valves was 70% (95% CI, 59% to 83%), 84% (95% CI, 72% to 99%), and 96% (95% CI, 91% to 100%), P=0.002. After adjustment for confounding variables, the relative risk (RR) of death with mechanical compared with bioprosthetic valves was 2.17 (95% CI, 0.78 to 5.88). Thromboembolic events occurred in 45% of women with mechanical valves within 5 years, compared with 13% with bioprosthetic valves, P=0.0001. Valve loss at 10 years was higher in bioprosthetic valves [82% (95% CI, 62% to 92%)] than in mechanical [29% (95% CI, 17% to 39%)] or homograft [28% (95% CI, 12% to 41%)] valves, P=0.0001. Pregnancy was not associated with increased bioprosthetic (RR, 0.96; 95% CI, 0.68 to 1. 35), homograft (RR, 0.65; 95% CI, 0.37 to 1.13), or mechanical (RR, 0.54; 95% CI, 0.27 to 1.08) valve loss.

CONCLUSIONS

Although 10-year valve survival was greater with mechanical than bioprosthetic valves, mechanical valves may be associated with reduced patient survival in young women. Thromboembolic complications, often with long-term sequelae, were common with mechanical valves. Pregnancy did not increase structural deterioration or reduce survival of bioprosthetic valves.

Coronary revascularisation in young adults

OBJECTIVE

To evaluate the long-term outcome of coronary artery bypass surgery (CABG) in patients < 40 years old and to determine factors predictive of adverse outcomes.

METHODS

Retrospective review of data on 220 patients who underwent isolated CABG at Green Lane Hospital, New Zealand from 1970 to 1992.

RESULTS

The actuarial survival after surgery was 91, 74 and 50% at 5, 10 and 15 years, respectively. Recurrence of ischaemic symptoms occurred at a median time of 72 months, and only 20% of patients remained asymptomatic 10 years after CABG. Univariate analysis of potentially adverse surgical factors showed that patients who had prolonged bypass time (> or = 100 min, P < 0.007) had increased late mortality. There were two distinct operative eras with respect to the use of IMA conduits (4% pre 1985, 87% post 1984) The relationship between IMA conduits use and survival was significant on time independent analysis (P < 0.02), but was not using the log-rank test. Preoperative clinical characteristics associated with increased late mortality were impaired left ventricular function (end-systolic volume (ESV) > or = 80 ml, P = 0.008; ejection fraction < 40%, P = 0.0005), and lack of aspirin use either pre- or post-operatively (P < 0.0001). Multivariate analysis indicated that reduced ejection fraction (P = 0.04) and prolonged bypass time (P = 0.05) was associated with an increased risk of late death. Aspirin therapy (P = 0.001) was associated with decreased late mortality. Cumulative events rate of reintervention and mortality was reduced in female patients (P = 0.0009). At review, 45% of patients had total cholesterol > 6.5 mmol/l.

CONCLUSION

To avoid the early recurrence of symptoms, the need for reintervention and late mortality, young patients should receive IMA conduits, cardioplegia as myocardial protection, aspirin and therapy to modify/ameliorate their risk factors including dyslipidaemia, diabetes and left ventricular dysfunction.

Risk factors in heart transplantation. A statistical study of New Zealand cases

The first heart transplantation in New Zealand was performed on December 2, 1987. This study covers all forty-five transplantations that were performed in New Zealand at Green Lane Hospital from that time through January 1994. Eleven patients from that group have died. The 30 day and 1, 2 and 4 year survival rates were found to be 91.1, 86.7, 80.0 and 75.6%, respectively. The mean waiting period of the patients for heart transplantation was 61.9 days. Only pulmonary vascular resistance was a statistically significant risk factor for early death after cardiac transplantation. Ischemic time was not a significant risk factor in this study.

Late outcome after coronary artery bypass graft surgery in patients < 40 years old

BACKGROUND

Randomized trials confirm the long-term efficacy of coronary artery bypass graft surgery (CABG), although there are no randomized data in patients < 40 years old. Because these patients have been reported to have an early recurrence of symptoms, the long-term postoperative outcome was examined.

METHODS AND RESULTS

The long-term outcome of patients (n = 221) < 40 years old undergoing CABG at Green Lane Hospital, New Zealand, from 1970 to 1992 was determined. The 30-day mortality rate was 1.8% for initial and 9.5% for redo CABG. The median times to angina or myocardial infarction (recurrent ischemic event), further intervention, and death were 6.0, 9.6, and 14.2 years, respectively. Factors associated with increased late mortality on univariate analysis included end-systolic volume (ESV) > or = 80 mL (P = .004; 10-year mortality 19% versus 39% ESV > or = 80 mL), no internal mammary conduit (P = .01), no lipid-modifying therapy (P = .005), and no postoperative aspirin use (P = .0002); the latter was also associated with increased recurrent ischemic events (P = .04) or increased reintervention (P = .02). On stepwise logistic regression analysis, factors associated with increased late mortality were increasing ESV (P = .004), no internal mammary artery conduit (P = .009), diabetes (P = .04), and no postoperative aspirin (P = .02); the latter was also associated with increased recurrent ischemic events (P = .02). Hypercholesterolemia (> or = 6.5 mmol/L) was present in 65% of patients at presentation and 45% at follow-up.

CONCLUSIONS

To attempt to prevent recurrent ischemia or late death, patients < 40 years old who require CABG should receive internal mammary conduits, aspirin, lipid-modifying therapy, therapy to inhibit ventricular dilatation, and strict diabetes management.

Good long-term outcome following surgical repair of post-infarction ventricular septal defect

BACKGROUND

A post-infarction ventricular septal defect (VSD) is a serious complication of a myocardial infarction with 90% of patients dying by two months, in published series. Urgent surgical repair improves the prognosis.

AIMS

To assess the Green Lane Hospital experience over a ten year period, especially with regard to hospital mortality and long-term follow up.

METHODS

A retrospective case note review of all 35 consecutive patients undergoing post-infarct VSD repair from 1981 to 1990. Long-term follow up was obtained in all but one patient (97%).

RESULTS

Twenty-one male and 14 female patients presented with a mean age of 67 years (range 51-75). All were in NYHA class 3 or 4, 14 (40%) were in cardiogenic shock. Following urgent surgical repair, 30 day mortality was 31% (11 patients). A further three patients died at two, 33 and 39 months; one patient was lost to follow up. At a mean follow up of 61 months (range 16-111), 15 patients were in NYHA class 1 or 2, five in NYHA class 3 or 4. For the whole group (n = 35) the actuarial survival was 66% at one year, 62% at three years and 58% at nine years.

CONCLUSION

Post-infarct VSD surgery is of major prognostic benefit with patients obtaining a good long-term outcome.

End-systolic volume and long-term survival after coronary artery bypass graft surgery in patients with impaired left ventricular function

BACKGROUND

Left ventricular function is the main predictor of long-term survival in patients with coronary artery disease. In patients with impaired left ventricular function after myocardial infarction, end-systolic volume is a better predictor than the global ejection fraction. We analyzed long-term follow-up of patients with impaired left ventricular function undergoing coronary artery bypass graft surgery to evaluate preoperative predictors of survival.

METHODS AND RESULTS

Consecutive patients with ejection fractions < or = 40% (n = 193) who had undergone surgical revascularization were followed to assess the predictive value of preoperative baseline characteristics and catheterization findings for long-term survival. Patients were followed for 133 +/- 30.7 months. At the time of surgery, patient age was 56 +/- 7.9 years and 169 patients (87.6%) had a history of previous myocardial infarction. Thirty-one patients (16%) were female. The ejection fraction was 32 +/- 7%, and the end-systolic volume was 147.4 +/- 52.6 mL. One hundred sixty-four patients (84.9%) had three-vessel disease, and 44 (22.8%) had a left main stenosis with > 50% diameter loss. Follow-up was complete in 99%. Fourteen patients died (7.3%) within the first 30 days after surgery. Twelve-month actuarial survival was 86%, 4-year survival was 80%, and 10-year survival was 40%. Predictors of poor long-term survival on multivariate analysis were end-systolic volume index (chi 2 = 14.02, P = .002), number of previous myocardial infarctions (chi 2 = 6.47, P = .001), preoperative stenosis score (chi 2 = 4.97, P = .02), and age at the time of surgery (chi 2 = 4.45, P = .03).

CONCLUSIONS

End-systolic volume index is the major predictor of survival after coronary artery bypass graft surgery in patients with impaired left ventricular function. Strategies to prevent ventricular dilatation, such as angiotensin-converting enzyme inhibitors, may improve the long-term outcome in these patients.

Waiting lists for coronary artery surgery: can they be better organised?

AIM

To determine whether a numerical ranking system can provide an equitable basis for prioritising patients awaiting coronary artery bypass grafting.

METHODS

A review of the current coronary surgery waiting list was undertaken using a newly developed scoring system. The factors included in the score were age, symptoms, results of exercise testing, coronary anatomy, employment status and perceived surgical risk. This score was compared with a Canadian consensus system. Rankings were then compared with the clinical priorities given by clinicians when the patients were placed on the waiting list.

RESULTS

There was excellent correlation between the two priority ranking systems using only those items included in the Canadian system (r = 0.9179). However, correlation between the Canadian system and the full Green Lane Hospital (GLH) scoring system was weaker (r = 0.6869). The Canadian system assigned higher surgical priorities than Auckland clinicians. Comparison between the GLH system and clinical priority gradings (O, urgent out of hospital), (A) and (B) showed considerable scatter. Waiting times for these three categories considered acceptable by the Canadian consensus group were two to six weeks for priority (O), six weeks to three months for priority (A) and three to six months for priority (B). The mean times on the waiting list for the 260 patients still awaiting surgery at GLH were two months for (O), 11 months for (A) and 22 months for (B).

CONCLUSIONS

The Canadian and expanded GLH ranking systems are no more than aids to establishing priorities. They cannot replace clinical judgement because the importance of individual scoring items is heavily influenced by the ranking of other items. Waiting times for surgery are now grossly excessive despite the use of criteria for entry to the waiting list which are very conservative by international standards. There is no equitable or clinically acceptable way to modify priorities to reduce waiting times, and institution of a booking system is impractical.

Coronary artery surgery in the elderly: long-term follow-up

BACKGROUND

There has been controversy concerning the indications for coronary artery surgery in the elderly, particularly in countries where health resources are restricted.

AIMS

To assess the results of coronary artery bypass grafting (CABG) in a large group of elderly subjects with regard to initial risks and long term follow-up.

METHODS

Ninety-six consecutive patients aged 70 years or older underwent isolated CABG between January 1981 and December 1985. Long term follow-up was obtained in 94 (98%).

RESULTS

The mean age was 71.6 years (70-78) and mean duration of follow-up 73 months. Seventy (73%) were male. In 80 cases the myocardial score was > 10. In 22 of 90 who had left ventricular angiography the ejection fraction was < 50%. Hospital survival was 96% and the five year survival 77%. It was not influenced by gender, myocardial score, ejection fraction or age at the time of operation. The status of survivors was reviewed in 1991. Of the 55 long term survivors 35 (64%) were free of angina. Eight (15%) and ten (18%) were in the Canadian Cardiovascular Society Angina classes 1 and 2 respectively. Seventeen patients (31%) had symptoms of heart failure with 14 (25%) in NYHA class 2 and 3 (5%) in class 3. Eight patients (15%) had survived a cerebrovascular event during follow-up. There were 35 late deaths (37%). Sixteen of these were cardiac, 18 due to other causes and one unknown.

Aortic valve replacement in the elderly

Aortic valve replacement is an established mode of therapy that enhances and prolongs life in patients with significant aortic valve disease. This is true for the elderly, but with a higher reported mortality and morbidity than in younger patients. One hundred and eighty-three elderly patients aged 70 years and over were considered suitable candidates for isolated aortic valve replacement (n = 97) or aortic valve replacement combined with coronary artery bypass surgery (n = 86) in the decade 1980-89. The mean age at surgery was 73.2 years (70-80). The hospital mortality and morbidity of this group were compared to 340 consecutive patients aged 60-69 who underwent similar surgery over the same period. There was no significant difference in hospital mortality: 4.4% for elderly patients and 4.1% for those aged 60-69. Measures of hospital morbidity were similar except for the perioperative stroke rate, which was 4.4% in the elderly patients and 1.5% in the younger group (p < 0.05). Detailed long term follow up was obtained in 75 of the 76 elderly patients who underwent aortic valve replacement or aortic valve replacement combined with coronary artery bypass surgery in the first five year period. Hospital survival was 99% (one hospital death). The overall five year actuarial survival was 81% and greater than the age and sexmatched general population (73%). Of the 44 patients alive at the time of review, 35 (80%) were free of angina and 32 (73%) had no significant symptoms of heart failure. Additionally, these patients were questioned about their quality of life.(ABSTRACT TRUNCATED AT 250 WORDS)

The role of dipyridamole in addition to low dose aspirin in the prevention of occlusion of coronary artery bypass grafts

One hundred and one subjects were randomised to receive either aspirin 100 mg or aspirin 100 mg + dipyridamole 300 mg daily before undergoing coronary bypass surgery. The drugs were commenced at least 36 hours before operation and patients were followed for one year. There were three perioperative deaths and 37 withdrawals, of which 14 were drug related (aspirin four, aspirin + dipyridamole ten). Cineangiocardiograms at nine weeks and one year showed vein graft patency rates of 93% and 87% for subjects treated with aspirin alone; and 90% and 89% in those who received aspirin+dipyridamole. During the follow-up period 14% of 232 coronary lesions in the aspirin treated group advanced by more than two grades compared with 15% of 315 lesions in the aspirin+dipyridamole group. The study did not establish superiority of one regimen over another in terms of graft patency or progress of lesions in native vessels. However, low dose aspirin was better tolerated than combination therapy.

Progress of patients with pulmonary atresia after systemic to pulmonary arterial shunts

Between February 1980 and June 1987, 42 shunts were placed in 39 infants with pulmonary atresia: 33 were modified Blalock-Taussig shunts with polytetrafluoroethylene (PTFE) and 9 were classic Blalock-Taussig shunts. There were four hospital deaths not related to the shunts. The remaining 35 patients were followed up for 1.6 months to 6.3 years (mean, 24.7 +/- 18 months). Repeat cineangiocardiographic studies revealed stenosis or distortion of the pulmonary arteries related to the site of the shunt in 11/22 patients (50%) with PTFE shunts and in 1/6 (17%) with classic Blalock-Taussig shunts; the stenosis was severe in only 1 patient. Mean increase in the pulmonary arterial index in the group with classic Blalock-Taussig shunts was 117 +/- 52 mm2/m2 (not significant) and in the group with PTFE shunts, 158 +/- 21 mm2/m2 (p less than 0.001). Late shunt occlusion occurred in 1 patient 23 months postoperatively. Thereafter, shunt patency rate remained at 94% +/- 6%. At the end of 1 year 81% +/- 7% of patients were judged to have adequate palliation, but between 2 and 3 years, only 60% +/- 10%. Univariate analysis showed that after 2 years the ranking order for successful palliation was classic Blalock-Taussig, 5-mm PTFE, and 4-mm PTFE shunts, but differences did not achieve statistical significance.

Fatal cerebral haemorrhage after tiger snake (Notechis scutatus) envenomation

OBJECTIVE

This case report illustrates the threat to life posed by tiger snake venom-induced coagulopathy, the importance of first-aid, precautions with antivenom administration, the dose of antivenom and the necessity to monitor the coagulation status.

CASE SUMMARY

An 11-year-old child was envenomated several times by a tiger snake (Notechis scutatus). Despite administration of three ampoules (9000 units) of tiger snake antivenom, fatal cerebral haemorrhage occurred. Inadequate first-aid had been applied. The bite site was covered with a loose bandage instead of a pressure-immobilisation bandage. In hospital, facilities to monitor coagulation status were unavailable.

CONCLUSIONS

More public education is required in first-aid management of snake envenomation. Frequent monitoring of coagulation status is necessary to optimise antivenom and coagulation factor therapy.

Assessment and follow-up of patients with ventricular septal defect and elevated pulmonary vascular resistance

Cardiac catheterization was undertaken in 87 patients (for a total of 89 studies) with ventricular septal defects, including 58 patients with moderate or severe elevation of pulmonary arteriolar resistance. When resting resistance was less than or equal to 7.9 U . m2, it always decreased with isoproterenol and no postoperative problems were experienced with pulmonary vascular obstructive disease. In 36 patients resting resistance measured greater than or equal to 8 U . m2. In 17 of these patients it decreased to less than 7 U . m2 with isoproterenol. Fifteen patients were operated on and postoperative problems with pulmonary vascular disease were experienced only in the single patient whose repair broke down. Surgery was undertaken in 4 of 19 patients in whom resistance did not decrease to less than 7 U . m2 with isoproterenol and advanced pulmonary vascular disease was evident in the 3 patients with follow-up observation. Correlation between measured resistance and other hemodynamic parameters was only fair. A pulmonary to systemic resistance ratio greater than or equal to 0.75 always indicated high absolute resistance but resistance ratios less than 0.75 were found quite frequently in the group with limited response to isoproterenol. These data argue that a reliable estimate of resistance, less than 7 U . m2, with a vasodilator predicts a good postoperative response regardless of measurements at rest or other hemodynamic parameters. Although observations on postoperative progress of patients with resistance greater than 7 U . m2 with a vasodilator are limited, a good postoperative course is unlikely unless resistance can be lowered to a level close to 7 U . m2.

Early and late results of re-operation for coronary artery disease: a 13-year experience

A second coronary artery bypass grafting procedure was performed for recurrent angina in 119 patients between 1970 and mid-1983. Angiographic findings were assessed and computerized using the Brandt myocardial scoring system. The myocardial score was similar prior to the first and second operations. Graft failure was the most common indication for re-operation, either alone (48%) or in combination with progression of coronary artery disease (29%) or incomplete revascularization (10%). Progression of coronary artery disease alone was an indication in 9% and previous incomplete revascularization alone in 4%. The completeness of revascularization at the end of operation was analysed using a new index, the myocardial score/graft coverage rate. This showed that revascularization was less complete at the second operation than at the first (P less than 0.0001). The hospital mortality at re-operation was 2.5% and the peri-operative myocardial infarction rate was 9.2%. The follow-up period was 54 months (range 10-160 months). Actuarial survival was 94% at 5 years and 74% at 10 years. The average onset of recurrent angina was earlier after the second operation than after the first (P = 0.001). Using a cumulative actuarial curve, survival at 8 years was 85%, a further 6% of patients had undergone a third or fourth operation, and a further 25% were in NYHA Classes III or IV. Therefore 54% achieved a good or excellent result. It was concluded that re-operation is a worthwhile procedure.

Multivariate analysis of the long-term results of coronary artery bypass grafting performed during 1976 and 1977

The results of 492 consecutive coronary artery bypass grafting operations performed for angina in the 2-year period from 1976 to 1977 were evaluated 77 months after surgery. Follow-up was complete in 99%. In 80% of patients angina severity was New York Heart Association functional classes III or IV. An ejection fraction of less than 50% and left ventricular end-diastolic pressure of more than 15 mm Hg were each present in one-third of patients. Thirteen patients (2.6%) died in hospital and 70 (14%) died later during the follow-up period. Twenty-six reoperations were performed for recurrent angina (5.3%). Angina was initially relieved by operation in 97% of patients, but only 57% were alive and free of angina 6 years after their operation. Despite this, 91% of patients at last follow-up were in functional class I or II and 94% thought their symptoms were better than preoperatively. The mean postoperative time of onset of angina, estimated independently by family physicians and patients, was 33 months. The significant preoperative predictors of late death were a low left ventricular ejection fraction, previous myocardial infarction, prior cardiac surgery, increased cardiothoracic ratio and the number of coronary arteries with significant narrowing.

Prosthetic repair of coarctation of the aorta with particular reference to Dacron onlay patch grafts and late aneurysm formation

Prosthetic material was used in the repair of coarctation of the aorta in 72 patients followed for 8 months to 24 years after operation. False aneurysms occurred late postoperatively in 1 of 17 instances when a tube graft was used to replace the resected aorta and in 1 of 2 patients when the graft bypassed the obstructed area. A Dacron onlay patch graft (DOPG) was used in 52 patients as the primary method of repair, to revise a previous repair or as an adjunct to another procedure at the time of initial operation. True or false late aneurysm occurred between 6 and 18 years postoperatively in 5 of the 38 patients in whom a DOPG was used for primary repair of the coarctation or to revise an earlier repair, an actuarial incidence of 38% at 14 years. Diagnosis of aneurysm formation late postoperatively depends on awareness of this complication and careful assessment of lateral as well as posteroanterior chest radiographs. DOPG should be avoided whenever possible.

Arrhythmia prophylaxis after aorta-coronary bypass. The effect of minidose propranolol

After aorta-coronary bypass grafting, 164 consecutive patients were randomized to receive propranolol 5 mg every 6 hours orally (n = 82) or to serve as control subjects (n = 82). All patients were receiving beta blockers preoperatively. There were no significant differences between the two groups. The incidence of sustained supraventricular (nonsinus) tachyarrhythmias was 23% in the control group and 9.8% in the treated group (p = 0.02). The incidence of ventricular arrhythmias was 15% in the control group and 2.4% in the treated group (p = 0.005). The overall difference in clinically important arrhythmias was 38% in the control group and 12.2% in the treated group (p = 0.0002). We conclude that low-dose oral propranolol in patients who were receiving beta blockers preoperatively is effective in reducing the incidence of clinically important arrhythmias occurring after aorta-coronary bypass grafting.

Serum myoglobin concentration as an index of myocardial damage after cardiac surgery

We assessed serum myoglobin concentration as an index of myocardial damage after cardiothoracic surgery in a dog model and man. Experimentally, we compared 12 dogs subject to left thoracotomy either with or without coronary artery ligation to cause an infarct. Serial blood sampling for 24 hours after surgery showed that the times taken for the myoglobin peak concentrations to appear distinguished the two groups without overlap. These times were 2.4 +/- 0.4 hours after surgery without ligation compared with 9.8 +/- 0.8 hours in the ligated group (P less than 0.001). Clinically, serial sampling was performed over 48 hours in 20 patients having undergone cardiac surgery involving cardiopulmonary bypass. A further 80 patients were investigated for 12 hours. Myoglobin was compared with the activities of creatine kinase, 2-hydroxybutyrate dehydrogenase and glutamate-oxaloacetate transaminase in relation to electrocardiographic criteria of myocardial damage. A myoglobin peak greater than 800 micrograms/1 appearing later than 6 hours after starting bypass was found in those patients suffering myocardial damage. The appearance times and activities of the enzymes tested were widely scattered and difficult to interpret. We conclude that blood samples taken at approximately 3 and 6 hours after starting bypass should suffice to characterise both peak myoglobin and its time of appearance which together form a sensitive index of myocardial damage. However, this conclusion is limited by the low incidence of myocardial damage (3%) in this group of patients.