123rc/medical_text huggingface dataset:
Mediastinal tracheostomy using a pectoralis major myocutaneous flap after resection of carcinoma of the esophagus involving the proximal part of the trachea. An operative procedure of mediastinal tracheostomy using a pectoralis major myocutaneous flap is presented. In this procedure, the terminal portion of the trachea penetrates through the center of a pectoralis major myocutaneous flap and the tracheal wall is completely wrapped with the muscular portion of the flap. Between 1981 and 1988, eight patients with carcinoma in the cervicothoracic segment of the esophagus underwent mediastinal tracheostomy after laryngoesophagectomy and extended resection of the proximal part of the trachea through sternal manubrectomy, because of invasion into the trachea. In five of eight patients, a pectoralis major myocutaneous flap was used to construct a tracheal stoma. A skin flap only, or both a skin flap and a muscle flap, was used in the other three. In four of eight patients, tracheal necrosis occurred, and rupture of the brachiocephalic artery occurred in one patient when the tracheal stoma had been constructed using both a skin flap and a muscle flap. However, neither skin breakdown nor bleeding from the major vessels occurred when using the myocutaneous flap. Therefore, it is concluded that the construction of the tracheal stoma using a pectoralis major myocutaneous flap is recommended for mediastinal tracheostomy after laryngoesophagectomy with extended resection of the proximal part of the trachea.
Selective dopamine DA1 stimulation with fenoldopam in cirrhotic patients with ascites: a systemic, splanchnic and renal hemodynamic study. We studied the effects of fenoldopam, a selective dopamine DA1 agonist on systemic and splanchnic hemodynamics, renal blood flow and sodium excretion in 12 patients with alcoholic cirrhosis and ascites. Hepatic, azygos and renal veins were catheterized before and after intravenous administration of fenoldopam, 0.05 micrograms/kg/min for 1 hr and increased to 0.1 micrograms/kg/min for another hour. Mean arterial pressure progressively decreased (from 83 +/- 7 to a minimum of 77 +/- 8 mm Hg 100 min after starting the infusion) but returned to baseline level at 120 min. Plasma norepinephrine and renin activity increased (respectively from 567 +/- 297 to 919 +/- 375 pg/ml, p less than 0.05, and from 17 +/- 14 to 23 +/- 15 ng/ml/hr, p less than 0.05). Renal blood flow, urine output or sodium excretion did not change. Sodium output decreased at 1 hr from 6.9 mumol/min to 4.0 mumol/min, p less than 0.05. Both hepatic venous pressure gradient and azygos blood flow significantly increased by 21%. We conclude that the acute administration of fenoldopam did not improve renal hemodynamics or function in patients with cirrhosis and ascites. In addition, dopamine DA1 agonism caused further increases in norepinephrine concentration and plasma renin activity. Portal pressure also increased, probably because of an increase in mesenteric blood flow. These results question the renal benefit and raise concern about the use of dopamine agonists in patients with cirrhosis and ascites.
The role of attitudes, beliefs, and personal characteristics of Italian physicians in the surgical treatment of early breast cancer. The influence of Italian physicians' attitudes, beliefs, and personal characteristics on medical decision making is examined in the case of surgical treatment of early breast cancer. Responses to a mail survey of 657 physicians from different specialties were analyzed comparing doctors recommending a radical procedure (9%) to those preferring a conservative procedure for younger patients only (25%), and those considering conservative surgery the treatment of choice regardless of patients' age (66%). The findings suggest that the likelihood of physicians' preferring a conservative procedure is influenced by their specialty and the extent to which they feel that a patient should have a role in the treatment decision more than by differences in the beliefs of treatment outcomes. Only preferences of the small group indicating radical surgery as the sole admissible treatment can be accounted for by ignorance or distrust of results of recent trials. These findings suggest that other than scientific factors guide many doctors in their decision making; they may help to explain why the diffusion of research results into clinical practice is often disappointingly slow.
Brain death and organ donation in a neurosurgical unit: audit of recent practice OBJECTIVE--To assess the potential for increasing the yield of donors by comparing the current pattern of brain death and organ donation in a neurosurgical unit with that reported in 1981 and with a recent national audit. DESIGN--Retrospective review of all deaths for 1986, 1987, and 1988 and prospective data for 1989. SETTING--A regional neurosurgical unit serving 2.7 million population. RESULTS--Of 553 deaths, 35% (191) patients died while on a ventilator and 17% (92) after discontinuation of ventilation. Medical contraindications to donation were found in 23% (32) of 141 patients tested for brain death, in 38% (19) of 50 patients who died while being ventilated who were not tested, and in 12% (11) of 92 patients no longer being ventilated. Consent for donation was sought in 88% (96) of 109 medically suitable brain dead patients and granted in 70% (67) of these. Half those with permission for multiorgan donation had only the kidneys removed. CONCLUSIONS--More organs may be lost owing to transplant team logistics than by failure to seek consent from relatives of brain dead patients. The estimated size of the pool of potential donors depends on what types of patients might be considered. Ensuring that all who die while being ventilated are tested for brain death and considering the potential for donation before withdrawing ventilation could yield more donors. Ventilating more patients who are hopelessly brain damaged to secure more donors raises ethical and economic issues.
Fatal disseminated mycobacterial infection following intravesical bacillus Calmette-Guerin. We describe a fatal case of disseminated mycobacteriosis after intravesical bacillus Calmette-Guerin immunotherapy. We summarize the prior safety record of this therapeutic modality, discuss local and systemic pathophysiological mechanisms by which dissemination might have occurred, and review the reported clinical experience with antituberculous chemotherapy for significant bacillus Calmette-Guerin infection. Finally, we offer suggestions for prophylaxis of certain patients with a history of exposure to intravesical bacillus Calmette-Guerin.
Gastric adaptive relaxation and symptoms after vagotomy. Gastric adaptive relaxation is reported to be impaired after vagotomy. This abnormality has been implicated in the pathogenesis of postvagotomy symptoms, but no association has previously been demonstrated between the two. Gastric adaptive relaxation was measured in 15 healthy volunteers and 33 patients more than 1 year after highly selective vagotomy or truncal vagotomy and drainage. Seventeen patients were asymptomatic. The remainder were symptomatic including seven patients with persistent diarrhoea. Fasted subjects were intubated with a Ryle's tube containing a pressure microtransducer within a flaccid (800 ml) plastic bag. Gastric corpus-fundus pressure was recorded during distension of the bag with air (15 ml/s) over 30 s. Pressure indices were derived from the areas under the pressure curves. Median (range) pressure indices were: healthy volunteers 12.7 (7.5-17.1) cmH2O, highly selective vagotomy 14.0 (9.8-15.9) cmH2O (n.s.), truncal vagotomy and drainage 14.5 (8.6-26.8) cmH2O (P = 0.04). All patients with diarrhoea had abnormally high pressure indices (P less than 0.001). Pressure indices in all other patient groups were within the normal range. We conclude that gastric adaptive relaxation remains abnormal in patients with postvagotomy diarrhoea but not in those who are asymptomatic or who have other symptoms.
Plasma concentrations of bupivacaine and two of its metabolites during continuous interscalene brachial plexus block. An interscalene brachial plexus block was performed via a catheter with 20-28 ml of 0.75% bupivacaine plus adrenaline for surgery of the shoulder region in 12 patients. Constant infusion of 0.25% bupivacaine 0.25 mg kg-1 h-1 was continued for 24 h. During surgery light general anaesthesia, without analgesics, was maintained. Plasma concentrations of total and unbound (free fraction) bupivacaine, desbutylbupivacaine (DBB), 4-hydroxybupivacaine (4-OHB) and alpha 1-acid glycoprotein (AAG) were measured at predetermined intervals during the continuous block. The greatest mean plasma concentrations of bupivacaine were measured at 30 min (1.63 (SD 0.55) micrograms ml-1) and 60 min (1.38 (0.48) micrograms ml-1). There was a small but statistically significant increase in the plasma concentration of bupivacaine between 12 and 24 h of infusion. The mean unbound concentration of bupivacaine in plasma decreased from 0.044 (0.015) microgram ml-1 (3.6 (1.1)% of total bupivacaine concentration) at 3 h to 0.023 (0.011) micrograms ml-1 (2.1 (1.0)%) at 24 h. The AAG concentration in plasma increased by 38% in 24 h. The metabolites DBB and 4-OHB were detectable in plasma from 30 min, with a gradual increase during infusion. At 24 h the mean concentrations of DBB and 4-OHB were 0.33 (0.22) micrograms ml-1 and 0.13 (0.04) micrograms ml-1, respectively. There were no toxic reactions during the blocks.
The comportmental learning disabilities of early frontal lobe damage. Two adult patients are described who suffered bilateral prefrontal damage early in life and who subsequently came to psychiatric attention because of severely aberrant behaviour. A battery of developmental psychology paradigms (not previously used to assess neurologically impaired individuals) showed that social and moral development of these 2 patients was arrested at an immature stage. In comparison with other types of brain damage which disrupt cognitive development, frontal damage acquired early in life appears to provide the neurological substrate for a special type of learning disability in the realms of insight, foresight, social judgement, empathy, and complex reasoning.
Lower extremity percutaneous transluminal angioplasty: multifactorial analysis of morbidity and mortality. We analyzed the outcome of 202 percutaneous transluminal angioplasty (PTA) procedures performed between 1983 and 1989 to quantitate procedural risks and define factors associated with suboptimal results or immediate clinical failure. Premorbid factors studied included age, sex, treatment of single versus multiple lesions, stenoses versus occlusions, premorbid status of the limb (claudication vs limb threat), and most distal level of PTA. Adverse outcomes included complications (hematoma, acute occlusion, or thrombosis of PTA site, distal embolization, failure to dilate or cross, arterial dissection, rupture, and significant systemic derangement), major amputations (below knee and above knee), and deaths. There were 66 complications (32.7%), 22 amputations (10.9%), and 12 deaths (5.9%) in our series. Logistic regression analysis revealed that the major predictive variable for the occurrence of a complication (p = 0.002), and the only predictive variable for the outcomes of amputation and death (p = 0.0001 and p = 0.0139, respectively), was the premorbid clinical status of the limb. Lower extremity PTA is not an intrinsically benign procedure and is associated with a significant risk of complication, amputation, and procedure-associated death. These adverse outcomes cluster in patients with limb threat. Therefore it may be reasonable to restrict the use of PTA to patients with claudication and strictly selected cases of limb threat.
Secretory carcinoma of the breast. Most studies of secretory carcinoma of the breast have been single case reports or separate analyses of the problem in either children or adults. We studied 10 female patients, aged 5 to 87 years. Most patients presented with a palpable mass, often near the areola. Five of six tumors were estrogen receptor negative; three analyzed for progesterone receptor were positive. Histologic patterns present in varying proportions were "classic" secretory carcinoma with microacini, abundant secretion with papillary features, and with prominent solid and papillary apocrine features. The tumors had strong reactivity for alpha-lactalbumin, S100, and carcinoembryonic antigen (polyclonal) and were negative for gross cystic disease fluid protein and anti-carcinoembryonic antigen (monoclonal). Six patients had mastectomy; four had local excision; none had axillary nodal metastases initially. With follow-up of 3 to 72 months (mean, 47 months; median, 48 months), two patients treated by local excision had local recurrences, one patient had axillary nodal metastases. All patients are alive. Comparison of patients under and over 30 years of age revealed one important difference: younger patients had a longer interval between detection and biopsy-30 vs 2 months. Treatment recommendations are initial wide excision or quadrantectomy with low axillary dissection in most cases and, in premenarchal patients, strong effort to preserve the breast bud without jeopardizing local control.
Efficacy of transesophageal echocardiography as a perioperative monitor in patients undergoing cardiovascular surgery. Analysis of 149 consecutive studies. To evaluate the usefulness of transesophageal echocardiography as a perioperative monitor in patients undergoing cardiovascular surgery, 149 consecutive patients were studied since 1985. Left ventricular function was assessed by measurement of left ventricular dimension and ejection fraction in patients with valvular disease. This monitoring was useful in detecting the changes in left ventricular performance in patients with volume overload and in managing patients in the early postoperative period. Cardiac tamponade was clearly demonstrated before changes in electrocardiogram and hemodynamic data. In 27 patients, transesophageal color Doppler echocardiography was used to confirm that there was no residual regurgitation immediately after valvular reconstructive surgery. Transesophageal color Doppler echocardiography was also useful in detecting the entry of false lumen before surgery in 7 patients with dissecting aortic aneurysm. There were no unsuccessful introductions, no traumatic or thermal injuries, 18 patients (12.1%) with hoarseness and 5 patients (3.4%) with transient arrhythmia. In conclusion, transesophageal echocardiography provides a good imaging window to the heart and great vessels perioperatively. This expedient, safe informative imaging method can be used more routinely in patients during surgery.
Long-term results after atrial correction of complete transposition of the great arteries. This study presents the late results for the first 104 consecutive patients surviving and atrial repair for transposition of the great arteries (TGA) between January 1971 and December 1978 (group 1). Mean follow-up was 12 years (range, 0.1 to 17.7 years). The actuarial survival rate at 18 years was 84.2% (70% confidence limits, 79% to 88%) for simple TGA and 93.7% (70% confidence limits, 84% to 97%) for complex TGA. Nine of the 11 deaths were sudden. Two (2.6%) of the 78 late survivors operated on for simple TGA are in New York Heart Association functional class III or IV versus 4 (26.7%) of the 15 survivors with complex TGA; the other patients are doing very well. To better assess long-term results, we report the findings for randomly obtained electrocardiograms, Holter monitor recordings, radionuclide angiographic studies, and cardiac catheterizations performed in 1987 in a larger group of 159 long-term survivors of atrial repair operated on at Ospedale Riuniti di Bergamo from January 1971 to December 1984 (group 2), which includes all of group 1. The findings confirm that the arterial switch repair is the procedure of choice for complex TGA and that there is a major incidence (approximately 10%) of systemic right ventricular dysfunction and rhythm disturbances after the atrial repair. On the other hand, our late survival rate at 18 years of 84% for simple TGA with 97.5% of the patients in functional class I is a result that should be kept in mind, especially in institutions where the arterial switch is a relatively new approach and presumably is a higher risk to cause early death.
In-hospital symptoms of psychological stress as predictors of long-term outcome after acute myocardial infarction in men. The impact of high levels of psychological stress symptoms in the hospital after an acute myocardial infarction (AMI) was examined over 5 years among 461 men who took part in a trial of psychological stress monitoring and intervention. Psychological stress was assessed using the 20-item General Health Questionnaire (GHQ) 1 to 2 days before hospital discharge. Once discharged, patients in the treatment group responded to the GHQ by telephone on a monthly basis and, when they reported high levels of stress symptoms (GHQ greater than or equal to 5), received visits from nurses to help them deal with their life problems. Control patients received routine medical care after discharge. Post-hoc subgroup analyses based on life-table methods showed that, for patients receiving routine care after discharge, high stress (GHQ greater than or equal to 5) was associated with a close to threefold increase in risk of cardiac mortality over 5 years (p = 0.0003) and an approximately 1.5-fold increase in risk of reinfarction over the same period (p = 0.09). In contrast, highly stressed patients who took part in the 1-year program of stress monitoring and intervention did not experience any significant long-term increase in risk. Although program impact was significant in terms of reduction of both cardiac mortality (p = 0.006) and AMI recurrences (p = 0.004) among highly stressed patients, there was little evidence of impact among patients with low levels of stress in the hospital.
Tracheal extubation in children: halothane versus isoflurane, anesthetized versus awake. The authors compared the incidence of respiratory complications and arterial hemoglobin desaturation during emergence from anesthesia in children whose tracheas were extubated while they were anesthetized or after they were awake and to whom halothane or isoflurane had been administered. One hundred children 1-4 yr of age undergoing minor urologic surgery were studied. After a standard induction technique, patients were randomized to receive either isoflurane or halothane. In 50 patients tracheal extubation was performed while they were breathing 2 MAC of either halothane or isoflurane in 100% oxygen. The remaining 50 patients received 2 MAC (volatile agent plus nitrous oxide) during the operation, but tracheal extubation was delayed until they were awake. A blinded observer recorded the incidence of respiratory complications and continuously measured hemoglobin saturation for 15 min after extubation. When tracheal extubation occurred in deeply anesthetized patients, no differences were found between the two volatile agents. When tracheal extubation of awake patients was performed, the use of isoflurane was associated with more episodes of coughing and airway obstruction than was halothane (P less than 0.05). Awake tracheal extubation following either agent was associated with significantly more episodes of hemoglobin desaturation than was tracheal extubation while anesthetized.
Sarcoid reaction mimicking intrathoracic dissemination of testicular cancer. The close observation of patients treated for testicular cancer led to the suspicion of intrathoracic and/or mediastinal metastases on radiologic examination in a number of patients without other evidence of relapse. This report presents two patients with combined seminomatous and nonseminomatous germ cell tumors with isolated sarcoid reactions of hilar and interlobular lymph nodes, detected concomitant with diagnosis and 12 months after diagnosis, respectively. Histologic examination appears to be imperative in these cases to avoid unnecessary chemotherapy.
Magnetic resonance imaging of vertebral osteoblastoma: a report of two cases. Two patients with vertebral osteoblastoma evaluated with computed tomography and magnetic resonance imaging are presented. A literature review revealed that cases of osteoblastoma originating within the vertebral body are exceedingly rare.
Covalent binding of oxidative biotransformation intermediates is associated with halothane hepatotoxicity in guinea pigs. In vivo covalent binding of halothane biotransformation-reactive intermediates to hepatic protein and lipid was examined in association with the subsequent development of hepatic necrosis in the guinea pig. Oxidative halothane biotransformation was inhibited by the use of deuterated halothane, whereas reductive metabolism was enhanced by low inspired oxygen concentrations. Male outbred Hartley guinea pigs (n = 8) were exposed to either 1% (v/v) halothane or deuterated halothane--with a fractional inspired O2 concentration (FIO2) of 0.40 or 0.10--for 4 h. Livers removed from half of the animals immediately after anesthesia were evaluated for organic fluorine bound to protein and lipid. The remaining animals were evaluated for a hepatotoxic response up to 96 h after exposure. Only guinea pigs that received 1% halothane at an FIO2 of 0.40 had centrilobular necrosis develop with significantly increased plasma alanine aminotransferase activities. All other treatment conditions significantly reduced oxidative halothane biotransformation, as indicated by decreased plasma trifluoroacetic acid concentrations. These reductions were associated with a significant decrease in organic fluorine bound to hepatic proteins. An FIO2 of 0.10 during halothane anesthesia significantly enhanced reductive biotransformation, as indicated by plasma fluoride ion concentrations. This was associated with a significant increase in organic fluoride bound to hepatic lipids. Centrilobular necrosis did not develop under these conditions. Thus, covalent binding to subcellular proteins by the trifluoroacetyl acid chloride intermediate generated by oxidative halothane biotransformation is implicated as a mechanism of centrilobular necrosis in guinea pigs. Binding to lipids by reductive pathway generated free radicals does not appear to be involved in production of the lesion.