Internal mammary arteriography without selective cannulation using a new balloon occlusion catheter

Internal mammary artery (IMA) angiography can be difficult and time-consuming. We evaluated a custom designed balloon-tipped catheter, a Berman catheter (Arrow International, Reading, PA) modified by creating an end-hole to allow passage of a wire through the central lumen, for imaging the IMA without selective cannulation. We compared ease of use, procedure time, and image quality of the new catheter with the standard selective catheter technique. Thirty-six patients with IMA grafts were randomly assigned to imaging with either the study catheter or a standard catheter. Image quality, graded from poor to excellent, time to catheter placement in the subclavian artery (TIME 1), time to initial IMA angiography (TIME 2), and the difference between these two (TIME 3) were recorded. TIME 3 defined the time required to find and seat the catheter at the IMA site. The image quality was good or excellent in all but one patient. This one patient, randomized to the standard catheter technique, had poor image quality with the selective catheter. However, exchange for the study catheter resulted in excellent image quality. There was no difference in TIME 1 (P = 0.57) or TIME 2 (P = 0.55) between the two techniques. There was a significant difference in TIME 3 (P = 0.05) favoring the study catheter. There were no complication using either technique and the total contrast volume used was not significantly different between the two techniques (P = 0.32). We conclude that a new catheter technique for imaging the IMA without selective cannulation is safe, fast, easy to use, and may offer particular advantage in patients whose internal mammary artery is difficult to access.

Closure of multiple pressure sores with split total thigh flap

Pressure sores remain a pervasive and recurrent problem in the chronically bedridden and immobilized insensate patient populations, such as those with spinal cord injury. Various musculocutaneous flaps based on muscles of the buttock and thigh are routinely used to close primary, uncomplicated ulcers. The gluteus maximus, tensor fascia lata, and posterior thigh muscles, for example, can be used to close the majority of primary defects. In the case of extensive and recurrent ulceration, however, particularly when the hip joint or proximal femur is infected or marked heterotopic ossification is present, these conventional flaps are inadequate. The total thigh flap offers a solution to some of these problems by providing a large volume of tissue as a unit to cover the defects, particularly in cases in which other reconstructive options have been exhausted. We describe a modification in the total thigh flap procedure by splitting the flap according to its vascularity to achieve closure of multiple pressure ulcers in a one-stage procedure.

Brachial plexus injury caused by impalement

Open injuries of the brachial plexus are rare. One such case, that of a 68-year-old impaled on a fence spike, is presented here. Certain principles to guide evaluation and treatment are discussed. Concomitant injury to the pleura or to vascular structures requires immediate attention; the extent and type of plexus damage may be determined from physical findings and the nature of injury. The results of plexus reconstruction are variable and routine exploration may be detrimental. The Brooks classification is reviewed.

Postprandial blood pressure decrease in well elderly persons

To learn if postprandial reduction in blood pressure occurs in active, very well elderly persons, we identified 16 such subjects over the age of 75 years, free of cardiovascular disease, taking no drug affecting blood pressure control. Each underwent measurement of seated and standing blood pressure and heart rate before and after a standard breakfast and before and after a volume of water (control). Eight young persons underwent the measurements before and after the meal. The elderly but not the young showed a significant fall in systolic and diastolic pressures after the meal, with heart rate increases in some subjects clearly inadequate for the decline in systemic pressure. No symptoms were seen. But postprandial decrease in blood pressure may in some less robust elderly persons be a factor in syncope and falls. This change may also confuse the monitoring of antihypertensive treatment in older outpatients.

Cardiopulmonary effects of the head-down tilt position in elderly postoperative patients: a prospective study

We studied the use of the head-down tilt position (Trendelenburg) in elderly postoperative patients in the intensive care unit to determine its effect upon cardiac and pulmonary function. Twenty-two patients (mean age 68.4 years) were placed in a 12 degrees head-down tilt position for 15 minutes. No deterioration was shown in any measured cardiac parameter; mean arterial pressure, cardiac index, and right and left ventricular stroke work increased significantly (P less than .05). Further, there were no observed changes in arterial or venous oxygenation, or in venous admixture. Because of the uncertain effect of the head-down tilt position upon cerebral blood flow, the routine use of this position is not recommended for the treatment of hypotension or during cardiopulmonary resuscitation. The results of this study, however, show that the cardiopulmonary effects are well tolerated if the position is required, as during central venous access procedures.

Control of catecholamine-induced tachycardia with alinidine in the anesthetized dog

Sinus tachycardia is a common complication of beta-adrenergic agonist therapy. A new selective bradycardic agent, N-allyl-clonidine, or alinidine, has been found effective against sinus tachycardia caused by a variety of stimuli. To determine whether it would also control catecholamine-induced sinus tachycardia, the effects of alinidine in two groups of anesthetized dogs treated with either dobutamine, 10 microg/ kg/min, or isoproterenol, 0.1 microg/kg/min, were studied. In both groups, alinidine significantly reduced the heart rate (P < .0001 in the dobutamine group, and P < .005 in the isoproterenol-infused dogs). The other hemodynamic effects of dobutamine were not adversely affected by alinidine, while the isoproterenol-infused dogs had a further afterload reduction when treated with alinidine. It is concluded that alinidine is effective against catecholamine-induced sinus tachycardia, possibly through mechanisms not related to beta-adrenergic receptors.

Venous hypercarbia in canine hemorrhagic shock

The venous-arterial PCO2 gradient may increase in certain low-flow states, such as CPR and canine endotoxemia. To determine whether venous hypercarbia also occurs in hemorrhagic shock, we studied 12 anesthetized, mechanically ventilated dogs. We performed laparotomies on the animals, inserting catheters into their renal, superior mesenteric, and external iliac veins. Flow in the corresponding arteries were determined using electromagnetic flow probes. The dogs were randomized into a control group (n = 6), and a hemorrhagic shock group (n = 6) which was bled to a mean arterial pressure of 45 to 50 mm Hg and maintained at this pressure for the 6-h study. The results demonstrated a significant (p less than .05) increase in lactate and venous-arterial PCO2 gradient systemically and in all three regional beds. A significant decrease of venous blood pH accompanied these changes which are consistent with our previous findings in low-flow, canine endotoxemia. We conclude that venous hypercarbia is a nonspecific phenomenon, common to low-flow states. The increased CO2 represents both an increased CO2 production and a decreased removal, secondary to low-flow.

Thrombocytopenia following peritonitis in surgical patients. A prospective study

Thrombocytopenia is commonly found in patients with serious infection. To investigate this phenomenon, 14 consecutive patients (68 +/- 10 years) who underwent laparotomy for bowel perforation and culture-proven peritonitis were prospectively studied. Ten noninfected laparotomy patients served as a control group. None of the 10 control patients developed thrombocytopenia. Of the infected group, 12 of 14 patients (85%) developed thrombocytopenia (less than 100,000/mm3). One patient (9%) developed disseminated intravascular coagulation (DIC). Of the remaining 11 patients with thrombocytopenia, platelet counts fell from preoperative level of 350,000 +/- 166,000 to 54,000 +/- 30,000 (p less than 0.001) and reached this nadir 4.3 +/- 2 days after surgery. There was no statistically significant difference in prothrombin time, partial thromboplastin time, or fibrinogen levels before versus after operation in this group. Bleeding times in seven patients were 5.5 +/- 2 minutes, and bone marrow examination in five patients with platelet counts of less than 50,000/mm3 revealed normal or increased megakaryocytes. No patient in this group bled, had medications held, or received platelet transfusions. Platelet counts increased greater than 100,000/mm3 at a mean of 8.9 +/- 4.1 days after operation. It is concluded that thrombocytopenia is common following surgery for intra-abdominal infection, is not usually associated with DIC, clinical bleeding, or coagulation abnormalities, does not commonly result from bone marrow suppression, and is transient and does not require routine platelet transfusions.

Recurrent Salmonella typhimurium bacteremia associated with the acquired immunodeficiency syndrome

Seven Haitian and one white patient with the acquired immunodeficiency syndrome and Salmonella typhimurium bacteremia were identified over a 28-month period. In three patients bacteremia developed concurrently with an opportunistic infection associated with the acquired immunodeficiency syndrome. The remaining five patients had their initial episodes of bacteremia 3 to 11 months before the diagnosis of the acquired immunodeficiency syndrome. These five patients had signs suggestive of the syndrome, plus evidence of disordered cellular immune function (lymphopenia, anergy, decreased T-helper cells, decreased proliferative responses, and a deficiency in mononuclear-cell alpha interferon production). Salmonella typhimurium bacteremia in the appropriate clinical setting may be an opportunistic pathogen associated with the acquired immunodeficiency syndrome.

Cirrhotic hyperglobulinemia: increased rates of immunoglobulin synthesis by circulating lymphoid cells

We have measured immunoglobulin (Ig) synthesis by circulating lymphoid cells of 20 patients with cirrhotic hyperglobulinemia (CH) and 20 age-matched controls. We used specific anti-Ig antisera to precipitate Ig synthesized from [14C] amino acid precursors in 13 controls and employed an electroimmunoassay of the "rocket" type to measure Ig elaborated by cultured cells in 4 patient-control pairs. In addition, we studied 3 patient-control pairs by absorption of elaborated Ig onto an anti-Ig-coated solid phase, bromoacetylcellulose. The synthetic index (SI; the ratio of Ig synthesis by a CH patient and a control) was elevated in every case. Mean SI by coprecipitation was 7.2 +/- 5.4 (mean +/- SD), by rocket" 7.3 +/- 3.0 for IgG and 2.2 +/- 0.8 for IgA, and by immunoabsorption 13.8 +/- 8.4 for IgG. Three cirrhotic nonhyperglobulinemic patient-control pairs showed a mean SI of 1.0 +/- 0.1. CH and control populations showed equal numbers of membrane Ig-positive B lymphocytes by immunofluorescence. We conclude that (1) peripheral blood lymphoid cells are appropriate for study of differences in Ig synthetic capacity among individuals; (2) CH is associated with increased in vitro Ig synthesis; and (3) CH lymphocytes may be an appropriate cell population for the study of control mechanisms in Ig synthesis.

Computer simulation model of an x-ray department

A computer simulation model has been designed to predict the effects of changes in the work load and resources of an x-ray department. The model has been used to produce histograms of patient waiting times and to show the effect on these of introducing changes in the speed of processing films and in the numbers of cubicles and radiographers available. The predicted benefit of using a faster film processor has been confirmed in practice.