Massive hemoptysis in patients with cystic fibrosis: three case reports and a protocol for clinical management

The clinical management of massive hemoptysis in patients with cystic fibrosis proceeds according to the following paradigm. The site of bleeding is identified by bronchoscopy, ideally under general anesthesia. Then selective bronchial arteriography is performed. If collaterals to the spinal cord are visualized, arterial embolization is abandoned and pulmonary resection is undertaken within the limits of pulmonary function.     

Delayed postoperative cardiac tamponade: diagnosis and management

Symptoms and signs of decreased cardiac output associated with an elevated venous pressure should alert one to the possibility of delayed cardiac tamponade. Enlargement of the cardiothoracic ratio shown by serial roentgenograms and demonstration of significant pericardial effusion by echocardiogram or radionuclide angiocardiography support the diagnosis. Erratic response of the prothrombin time to administration of warfarin and abnormal results of liver function test are additional clues to its diagnosis. Right heart catheterization documents the presence of tamponade and excludes other diagnostic considerations. Operative decompression of the pericardial space can be accomplished by pericardicentesis, subxiphoid pericardiotomy, median sternotomy, or thoracotomy. Hemodynamic observations following the relief of tamponade assure that an adequate therapeutic procedure has been performed.     

Coarctation of the Aorta in Infants and Children: 25 Years of Experience

Repair of coarctation of the aorta was performed in 334 patients ranging from less than a year to 16 years of age at Children's Hospital of Pittsburgh from 1953 to 1977. Resection and end-to-end anastomosis were performed in 310, interposition grafts in 7, and other procedures in 17. There were 41 operative deaths among the 95 infants less than 1 year old (43% mortality); all of these infants had associated cardiac anomalies. Only 1 operative death occurred in patients older than a year (0.4% mortality). No hospital deaths occurred in patients with isolated coarctation of the aorta. Eleven late deaths were due to associated anomalies (7) and unrelated or unknown causes (4). Postoperatively, hemorrhage occurred in 7, paradoxical or persistent hypertension in 128, postcoarctectomy syndrome in 32, neurological problems in 14, pulmonary complications in 53, and infections in 12 patients. Restenosis occurred in 26 patients (8%); only 10 have required reoperation. Residual hypertension was present in 28 of 264 patients (11%). Mortality from coarctation resection remains high in infants, but is minimal in children older than 1 year. Based on minimizing the risk of restenosis and residual hypertension, elective repair of coarctation is recommended when the patient is about 6 years of age.     

Cardiopulmonary Dynamics during Arteriovenous Perfusion: Cardiac Output,Pulmonary Arterial Resistance,and Right Ventricular Stroke Work

The effects of arteriovenous perfusion on myocardial performance, pulmonary circulatory dynamics, and organ preservation were studied in dogs in order to evaluate the applicability of arteriovenous extracorporeal membrane oxygenation for partial respiratory support. Studies were made on normally oxygenated dogs, on dogs made hypoxic by oxygen deprivation and ventilatory depression, and on dogs with pulmonary injury and moderate pulmonary hypertension induced by injection of oleic acid into the right ventricle. The latter two groups were included to assess the changes that occur in cardiopulmonary dynamics in the presence of hypoxia and pulmonary hypertension. A micro-channel membrane oxygenator was employed to provide partial respiratory support to the group of animals with pulmonary injury. The results indicate that no deleterious hemodynamic changes occurred in any of the groups of animals with arteriovenous flow for periods of up to 5 hours at rates corresponding to 20 to 35% of the total cardiac output. Adequate systemic oxygenation was provided by the microchannel oxygenator at these rates of arteriovenous perfusion.     

Anomalous origin of the right coronary artery from the pulmonary artery.

Three patients with anomalous origin of the right coronary artery from the pulmonary artery are presented together with a review of the 14 patients with this anomaly previously reported. One of the current patients is the youngest to be diagnosed before operation and the youngest to undergo corrective operation. Although the lesion is usually asymptomatic, it may contribute to sudden death. The only suggestive physical finding is a continuous murmur with diastolic accentuation, which is present only in some patients. There are no diagnostic electrocardiographic or chest roentgenographic changes. Diagnosis is made best by selective left coronary arteriography showing retrograde filling of the right coronary artery from collateral vessels. Operative repair should consist either of direct reimplantation of the proximal right coronary artery into the aortic root or of saphenous vein bypass graft to the coronary artery with ligation of its origin. Operation is recommended when the lesion is recognized.     

Asynchronous rejection of heart and lungs following cardiopulmonary transplantation

Eighteen patients have received 19 combined heart-lung allografts since March, 1982. During the maturation of our program of heart-lung transplantation, we have learned that isolated rejection of the lung can occur frequently and that exclusive dependence on the cardiac biopsy can be misleading. Of the 18 patients who received allografts, 10 are the basis for this report. The other patients were excluded because of death from excessive bleeding (1), inadequate lung preservation (2), an inability to differentiate rejection from infection (3), or an absence of rejection of either the heart or the lungs (2). Rejection of the lung was suggested, in the absence of clinical evidence of infection, by the radiographic appearance of a diffuse pulmonary infiltrate. It was confirmed by a prompt response to augmentation of maintenance immunosuppression with an intravenous pulse of methylprednisolone. The presence or absence of cardiac rejection was determined by the standard endomyocardial biopsy. Direct biopsy of the involved lung through a thoracotomy was performed in 4 patients so that a definitive histological diagnosis of rejection would reinforce the anticipated clinical diagnosis. The clinical course in 6 of the 10 patients plus the results of the open lung biopsy in 3 of them suggest that isolated rejection of the lung developed in the absence of cardiac findings. Patients responded within 12 to 24 hours to augmented immunosuppression with a dramatic improvement in the abnormal chest radiograph. In all 10 patients, either isolated lung or synchronous heart and lung rejection episodes were confined to the first six weeks after operation unless a severe alteration in the immunosuppression was made (2 patients).(ABSTRACT TRUNCATED AT 250 WORDS)     

Surgical management of univentricular heart with subaortic obstruction

In children with a univentricular heart and a rudimentary subaortic chamber, surgical relief of subaortic obstruction caused by a restrictive bulboventricular foramen is associated with high morbidity and mortality. A 6-year-old child with a univentricular heart of the left ventricular type, a rudimentary subaortic chamber, and atresia of the left-sided atrioventricular valve had pulmonary artery banding in infancy. Severe subaortic obstruction subsequently developed. At operation, the pulmonary artery was transected and the stump was anastomosed directly to the posterior aspect of the ascending aorta, diverting left ventricular blood into the aorta through the pulmonary valve. The distal pulmonary artery was anastomosed side-to-side to the ascending aorta to provide pulmonary blood flow. Cardiac catheterization fifteen months after the operation demonstrated an excellent hemodynamic result. When the pulmonary artery is adequate in size, a bypass operation by way of an anastomosis between the ascending aorta and the pulmonary artery is a relatively safe and effective means of relieving the ventricular outflow obstruction caused by a restrictive bulboventricular foramen.     

Primary hyperparathyroidism. Preoperative evaluation and correlation with surgical findings

The clinical and operative findings in 101 patients with the diagnosis of primary hyperparathyroidism are reviewed, with particular emphasis on the current methods of preoperative evaluation.Of these patients seventy-two (72 per cent) underwent neck exploration. The twenty-nine patients who did not have an operation either refused operative treatment or were not granted an operation because of medical reasons (multiple system disease in elderly patients). Fourteen of the surgical patients (20 per cent) required re-exploration. Two patients had negative neck explorations.Preoperative evaluation included routine serum calcium (X3), serum phosphorus, and alkaline phosphatase determinations, and appropriate radiologic evaluation. Urinary cyclic AMP levels were helpful in differentiating primary hyperparathyroidism from nonparathyroid hypercalcemia.Phosphorus clearance studies were helpful as were twenty-four hour urinary calcium determinations. Parathyroid scans and arteriography were not helpful diagnostically and intravenous toluidine blue was of no benefit intraoperatively.Eleven patients had selective neck vein catheterizations for parathyroid hormone immunoassays with 63 per cent localization.Of seventy patients with positive surgical findings, eleven had chief cell hyperplasia, six had adenomatous hyperplasia, and fifty-three had adenoma(s).     

Experimental retained antrum. Diagnostic technics and histopathologic correlations

Retained gastric antrum was evaluated in six dogs, and diagnostic methods correlated with histopathology. Secretin and calcium infusion did not significantly alter circulating gastrin levels. 99 mTc scanning was uniformly positive and did not depend on the presence of parietal cells. The failure to consistently develop hypergastrinemia and the absence of gastrin cell hyperplasia suggest that factors other than gastrin may be implicated in the recurrent ulceration seen with retained antrum.     

Serial coagulation studies in patients undergoing Mustard procedure

Following the Mustard procedure for operative correction of transposition of the great arteries, the incidence of serious hemorrhage in our original series was nearly 40%. Coagulation studies were performed serially in the next 4 patients undergoing the operation in an attempt to elucidate the etiology. Preexisting coagulation defects were present in all, but none had evidence of intravascular coagulation. Multiple clotting factors and platelets were decreased in the immediate postoperative period with gradual improvement in two weeks.In a patient with thrombocytopenia or deficient coagulation factors, preoperative phlebotomies may elevate these values to normal levels. When complete correction of the coagulation system has been achieved by this maneuver, a normal amount of postoperative bleeding has occurred in our patients.     

Principal component analysis of coagulation assays in severely injured children

Background

Trauma-induced coagulopathy is common and associated with poor outcome in injured children. Our aim is to identify patterns of coagulation dysregulation after injury and associate these phenotypes with relevant clinical outcomes.

Chloroquine improves the response to ischemic muscle injury and increases HMGB1 after arterial ligation

Objective

We have previously shown that exogenous administration of the nuclear protein high mobility group box 1 (HMGB1) improves angiogenesis after tissue ischemia. Antagonizing HMGB1 prolongs muscle necrosis and deters regeneration. In this study, we evaluated HMGB1 expression in peripheral arterial disease (PAD) and the mechanisms that promote its release in a murine model of hindlimb ischemia. Specifically, we investigated how chloroquine (CQ), a commonly employed disease-modifying antirheumatic drug, promotes HMGB1 release from muscle. We hypothesized that CQ could increase HMGB1 locally and systemically, allowing it to mediate recovery from ischemic injury.

Esophageal function after injection sclerotherapy: pathogenesis of esophageal stricture

Injection sclerotherapy effectively controls hemorrhage from esophageal varices. Treatment must be repeated at intervals to obliterate varices. Long-term sequelae of such treatment are unknown but may include stricture formation. To assess the impact of repeated sclerotherapy on esophageal function, this prospective study measured lower esophageal sphincter pressure, reflux, and motility in patients before and after treatment. Injection sclerotherapy had no effect on lower esophageal sphincter pressure. Reflux was common before treatment and became even more prevalent after treatment, with reflux occurring in 60 percent of postsclerotherapy patients. Striking disturbances in esophageal motility were observed after treatment. Injection sclerotherapy induces a chemical esophagitis that impairs esophageal motility. Delayed acid clearance in the presence of reflux results in superimposed acid esophagitis. Esophageal strictures may thus be produced. We advise a standard antireflux medical regimen in our sclerotherapy patients.     

Bacterial presence in aortic thrombus at elective aneurysm resection: Is it clinically significant?

Infected thrombus in an abdominal aortic aneurysm represents a potential source of subsequent aortic graft sepsis. Previous reports have documented a 10 to 15 percent incidence of positive results of culture of the contents of an abdominal aortic aneurysm and have recommended prolonged postoperative organism-specific antibiotic therapy when a positive culture is encountered. In our study, we cultured the intraluminal thrombus during elective aneurysm repair in 64 patients with abdominal aortic aneurysms and found bacterial growth in 9 (14 percent of all patients). Eight of the nine patients received no antibiotic therapy other than the routine prophylaxis regimen, and no evidence of either early or late prosthetic graft sepsis occurred (mean follow-up 25 months). We conclude that a positive result of culture may not imply clinical infection at the time of operation and that prolonged postoperative organism-specific antibiotic therapy does not appear necessary in the patient with an asymptomatic aneurysm and no overt evidence of infection of the aneurysm at the time of operation.     

The effect of occlusive dressings on collagen synthesis and re-epithelialization in superficial wounds

The effects on superficial wounds in domestic pigs of (1) two different occlusive dressings, (2) non-occlusive wet to dry gauze dressings, and (3) air exposure were compared. Collagen synthesis and re-epithelialization were increased in the wounds treated with occlusive dressings. Re-epithelialization was increased beneath both the oxygen-impermeable and the oxygen-permeable dressing. When they were removed the wet to dry gauze dressing and one of the occlusive dressings often damaged the new epidermis.