bluuebunny/crossref_metadata_2025 huggingface dataset:
Extracorporeal membrane oxygenation life support: a new approach
Authors: Horton SB , Horton AM , Mullaly RJ , Butt WW , Mee Rbb
Published: November 2007

The use of extracorporeal life support (ECLS) is considered in children who (1) have an acute life-threatening heart or lung disease, (2) are normal before the illness and are likely to be normal if they survive, and (3) have an 80% chance of death. Our use of a constrained vortex pump (CVP) offers a number of potential advantages compared to a roller pump. The circuit is designed to provide the capability of changing over to a new circuit while maintaining full support and is primed to match the biochemistry of the patient as closely as possible. Since May 1989 at the Royal Children's Hospital, Melbourne, Australia, we have provided ECLS to 30 neonates (20 of whom survived) and 22 children (eight of whom survived). ECLS is a useful technique for supporting patients who are unable to be adequately ventilated or oxygenated or who have an inadequate cardiac output.
Magnetic resonance imaging and P300 (event-related auditory evoked potentials) in the assessment of postoperative cerebral injury following coronary artery bypass graft surgery
Authors: Toner Istra , Hamid Shahnaz K , Peden Carol J , Taylor Kenneth M , Smith Peter LC , Newman Stanton P , Phil D.
Published: November 2007

Cerebral injury following coronary artery bypass grafting (CABG) surgery was investigated with magnetic resonance imaging (MRI) and P300, a long-latency endogenous evoked potential associated with psychological processing of stimulus information. Twelve patients were studied before and after surgery. Prior to surgery, MRI abnormalities were found in all but one patient. After surgery, five patients had new abnormalities, mainly deep white-matter lesions (DWML). Postoperative P300 latency was significantly increased in six patients. P300 topographical distribution showed a shift from predominantly posterior cerebral regions to frontal regions in most patients. Postoperative P300 and MRI deficits were found in three of the five patients. One of the patients with marked MRI change (DWML in caudate nucleus) did not show P300 deficit.
Desmopressin (DDAVP), tranexamic acid and haemostasis
Authors: Lethagen Stefan
Published: November 2007

Desmopressin is a widely used haemostatic drug. In contrast to vasopressin, it has no pressor activity. The effect is immediate, with two to six-fold increases in the plasma concentrations of coagulation factor VIII, von Willebrand factor and tissue plasminogen activator, and of platelet adhesiveness. Desmopressin is used in patients with mild haemophilia A, von Willebrand's disease, congenital platelet dysfunction or acquired platelet dysfunction due to uraemia or such drugs as aspirin. Tranexamic acid is an antifibrinolytic agent effective against menorrhagia, epistaxis and bleeding after conization or oral surgery; its haemostatic effect in connection with major surgery is presently being evaluated.
Effect of prostacyclin PGl2 on cardiopulmonary bypass- induced lung injury
Authors: Fessatidis I. Th. , Brannan J.J. , Taylor K.M. , Kanellaki-Kyparissi M. , Abdulla A.K. , Olsen E.C.J.
Published: November 2007

Lung injury produced by cardiopulmonary bypass (CPB) is clinically characterized as postperfusion pulmonary dysfunction syndrome. The roles of humoral factors, altered perfusion modes and the occurrence of diffuse microembolism have been subjects of a number of studies. This paper presents the effectiveness of a platelet inhibiting drug, PGl2, in preventing occlusive microaggregates in the pulmonary circulation.

In a series of experimental dog studies using a PGI2 dosage protocol of 10 ng/kg/minute for 30 minutes prior to the onset of CPB followed by 20 mg/kg/minute during CPB, the following effects have been observed:

1) Preservation of platelet numbers during CPB (p<0.01 versus controls; n = 16).

2) Significant reduction in platelet aggregation during CPB (p <0.01; n = 16).

3) Insignificant hypotensive effect at normal levels of peripheral vascular resistance (n = 16).

4) Occlusive fibrin, leucocytes and small platelet-based microaggregates obstructing pulmonary arterioles in six of the seven control dogs but in none of the dogs receiving PGl 2 infusion.

5) No evidence of perivascular or intra-alveolar oedema, interstitial inflammatory cell infiltrates or haemorrhage was seen in either group of dogs.

The controversy existing in relation to the possible therapeutic role of PGl2 and, in particular, its ability to prevent occlusive microaggregates in the arterioles and capillaries of vital organs should encourage further clinical studies of PGl2 and its derivatives during cardiac surgery.
A simple, safe and economical method for administration of continuous warm blood cardioplegia
Authors: V Rao Parachuri , Forsyth Andrew T , Johnson Jonathan M
Published: November 2007

We describe a simplified technique for the delivery of continuous warm blood cardioplegia, which is safe, simple, and inexpensive.
Risk factors for renal dysfunction after coronary surgery: the role of cardiopulmonary bypass technique
Authors: Ranucci Marco , Pavesi Marco , Mazza Ermanno , Bertucci Carla , Frigiola Alessandro , Menicanti Lorenzo , Ditta A. , Boncilli A. , Conti Daniela
Published: November 2007

We studied 316 patients undergoing cardiopulmonary bypass for coronary artery surgery in order to determine perioperative risk factors for postoperative renal dysfunction

A preliminary univariate analysis was performed by χ2 analysis for categorical data and Mann-Whitney U-test for continuous variables to detect significant correlations between each risk factor and the occurrence of moderate or severe renal dysfunction. Subsequently, a multiple logistic regression was applied to the three risk factors identified as predictive for severe renal dysfunction. Low cardiac output syndrome and need for banked blood transfusions combined with a low haematocrit value during cardiopulmonary bypass increase the probability of severe renal dysfunction in the postoperative course.
Determination and comparison of heat exchange efficiency of four commercially available blood cardioplegia sets
Authors: Hundley David S , Vertrees Roger A , Brownstein Louis , Clancy Michael , Garwood Alexander P , DeiRossi Anthony J
Published: November 2007

An in vitro comparison of the heat exchange properties of the Electromedics D1081A, Sarns MP-4 'Conducer Coil' 165720, Bentley HE-1 00 and the Shiley BCD Plus 4:1 blood cardioplegia sets was performed. The efficiency was calculated for each heat exchanger and post-heat exchange blood path temperatures were compared.

The calculated efficiency for each heat exchanger is as follows: Electromedics D1081A at 18 I/minute coil water flow (0.95); Sarns MP-4 165720 at 9 I/minute coil water flow (0.93); Bentley HE-100 at 10 I/minute coil water flow (0.91); Shiley BCD Plus at 15 I/minute coil water flow (0.90).

Blood path, precoil temperatures for each unit were compared statistically with no differences found ( p > 0.05). Blood side, postcoil temperatures were then compared. The average postcoil blood path temperature of the Electromedics D1081A was 1.6° ± 0.1 °C, of the Sarns MP-4 165720 it was 2.1 ± 0.1°C, of the Bentley HE-100 it was 2.7° ± 0.3°C, and the Shiley BCD Plus 3.0° ± 0.4°C.

The results of this experiment indicate that the average postcoil temperature of the Electromedics D1081 A was lower than the Sarns MP-4 165720 ( p < 0.05) which was lower than that of the Bentley HE-100 ( p < 0.05) and Shiley BCD Plus ( p < 0.05). No statistical difference was found between the average postcoil temperature of the Bentley HE-1 00 and the Shiley BDC Plus.
Clinical evaluation of the Medtronic Maxima Plus membrane oxygenator
Authors: Fried David W , DeBenedetto Benjamin N , Zombolas Theodore L , Leo Joseph J
Published: November 2007

The purpose of this study was to clinically evaluate the degree of improvement, if any, in the oxygen transfer performance of the recently released Medtronic Maxima Plus membrane oxygenator. The outside diameter of the hollow fibres was reduced, increasing the membrane surface area from 2.0 m2 to 2.3 m2 without altering the polycarbonate housing.

Maximum extrapolated oxygen transfer of the Maxima Plus (444 ml O2/minute) was increased 23.68% when compared to the Maxima (359 ml O2/minute). When expressed per metre squared of membrane surface area, the Maxima Plus had an increase of 13.5 ml O2/m2/Minute (7.24%) over the Maxima. Pressure drop across the Maxima Plus was within 3.5 mmHg of the Maxima over the range of clinical blood flows indicating that the fibre bundle packing density was not significantly altered. Oxygen transfer consistency, expressed as a function of the standard deviation of oxygenator performance index values, was not significantly different for the two oxygenators.

We concluded that the improvement in total oxygen transfer was due to an increase in membrane surface area as well as enhanced transfer efficiency per metre squared. We believe that the improved oxygen transfer performance was accomplished without impacting significantly upon the other attributes of the oxygenator (e.g., pressure drop, consistency, priming volume).
Cardiopulmonary bypass with adequate flow and perfusion pressures prevents endotoxaemia and pathologic cytokine production
Authors: Quigley RL , Caplan MS , Perkins JA , Arentzen CE , Alexander JC , Kuehn BE , Hoff WJ , Wallock ME
Published: November 2007

Endotoxin and cytokine inflammatory mediators comprise the afferent and efferent limbs of the 'acute phase response'. During cardiopulmonary bypass (CPB) there may be gut translocation of endotoxin and contact activation of lymphocytes. It has been hypothesized that the haemodynamic instability encountered following CPB is caused by the 'acute phase response'. In this study we attempted to quantify the acute phase response in patients undergoing open-heart surgery and determine the influence of these cytokines on perioperative morbidity. Four perioperative blood samples were drawn from 20 consecutive patients undergoing coronary artery bypass grafting (CABG). These samples were assayed for endotoxin and four cytokines. In all cases the cardiac index was maintained > 2.4 l/min/m 2 during nonpulsatile normothermic bypass (37°C) and > 1.8 l/min/m 2 during nonpulsatile hypothermic bypass (28°C), and the perfusion pressure > 60 mmHg.

Endotoxin was not detected in any of the test samples despite positive nonpatient controls. Interleukin 6 (IL-6) and tumour necrosis factor (TNF) were not detected despite an assay sensitivity of 80 and 10 pg/ml, respectively. TNF was detectable with an assay sensitivity of 0.5 pg/ml although there were no significant differences within the group. Interleukin 1 (IL-1) was detected (range = 0.98 - 9.09 ng/ml) in patients and again there were no trends within the group. The platelet activating factor (PAF) values peaked at crossclamp release (1.3 ng/ml versus a baseline of 0.2 ng/ml); however, there was no significant difference within the study.

The perioperative rise in PAF suggests that of all the mediators assayed this cytokine has the lowest synthesis threshold in response to stress, related to nonpulsatile CPB, and is unrelated to endotoxaemia (as detected by the limulus amoebocyte lysate (LAL) assay). Despite recent reports outlining the incidence of endotoxaemia, cytokine activation and the benefits of anti inflammatory therapy during CPB, our data suggest that maintenance of high flow and perfusion pressures during nonpulsatile CPB reduces the incidence of any 'acute phase response' of clinical significance.
The haemostatic effectiveness of autologous platelet rich plasma sequestered after heparin administration and institution of cardiopulmonary bypass
Authors: Quigley RL , Perkins JA , Caprini JA , Haney El , Switzer SS , Wallock ME , Hoff WJ , Kuehn BE , Arentzen CE , Alexander JC
Published: November 2007

Preoperative harvesting and postoperative reinfusion of autologous platelet rich plasma (PRP) has been reported to decrease blood loss as well as the requirement for homologous blood transfusion following cardiopulmonary bypass (CPB). We have developed a technique of intraoperative PRP sequestration which occurs during the initial period of CPB after the patient's circulation is supported and heparin has been given (PRP+). This process does not require any additional hardware, personnel or expense and it is performed without difficulty or complication.

To evaluate the effect of PRP+ sequestration and reinfusion on blood loss and homologous blood requirement after CPB, we randomly assigned 126 consecutive patients undergoing elective open heart surgery into the experimental group 1 (PRP+) (n = 64) or the control (no platelet pheresis) group 2 (n = 52). A third group (n = 10) were not included in the randomization. Patients in group 3 had PRP prepared by conventional techniques (PRPc) prior to heparin administration and given to the patient after protamine infusion.

Aggregation and activation studies were performed on the PRP+, PRPc, and blood bank platelets (BBP). Per cent aggregation of PRP in response to ADP was superior to that of BBP. There were no significant differences in ADP induced aggregation between PRP+ and PRPc. There was no significant difference in platelet activation (CD62) or number between the three groups. Patients infused with PRP+ showed significantly increased aggregation to ADP when compared with untreated patients 120 minutes after return to the ICW. Furthermore, more homologous haemostatic components (platelets/fresh frozen plasma) were required in the control group.

We have demonstrated that collection of autologous PRP+ after administration of heparin does not interfere with its haemostatic effectiveness compared with PRPc prepared before the initiation of bypass. Moreover, this can be performed universally in haemodynamically unstable patients without any additional costs.
The effects of congenital heart disease and cardiac surgery on I iver blood flow in children
Authors: Mitchell Ian M , Pollock James CS , Jamieson Morgan PG
Published: November 2007

Children with congenital heart disease may have some degree of hepatic impairment, with further impairment developing shortly after surgical correction of the cardiac defect. The redistribution of organ blood flow that occurs during cardiopulmonary bypass implicates ischaemia as one of the principal causes of injury.

The aim of this study was to measure liver blood flow in children with congenital heart disease and to determine both the effects of cardiopulmonary bypass and the consequences of corrective surgery. Indocyanine green clearance and auricular densitometry, were used in 31 children. In 83% we demonstrated a reduced liver blood flow, with a mean percentage disappearance rate (PDR) of 12.9% (SEM ± 1.2). This finding was unrelated to the patient's age, the type of congenital heart defect or the presence or absence of cyanosis.

During cardiopulmonary bypass, hepatic perfusion was further reduced in 77% of children, by an average of 67%, out of proportion with the iatrogenic reduction in total body flow. Six hours after surgery, liver blood flow had increased significantly above preoperative levels (p< 0.001; t-test) to approximately normal values with a mean PDR of 20.4% (SEM ± 1.5).
Regional cerebral oxygenation during cardiopulmonary bypass
Authors: Baris Ronald R , Israel Andrew L , Amory David W , Benni Paul
Published: November 2007

A significant number of patients suffer transient neuropsychological dysfunction after coronary artery bypass graft (CABG) surgery. Recent studies have implicated reduced levels of O2 supply/demand ratio during the rewarming phase of cardiopulmonary bypass (CPB). Using a near infrared spectroscopy (NIRS) system that permits continuous noninvasive monitoring of regional cerebral O2 saturation (rSO2), we investigated rSO2 during CPB.

Following Institution Review Board approval and informed consent, 10 patients undergoing elective CABG were studied. Nonpulsatile CPB with a membrane oxygenator, haemodilution and alpha-stat pH management was used. The NIRS system consisting of two low-power laser diode sources (780 nm and 810 nm) with a photodetector placed on the frontal cortex was used to measure continuously haemoglobin, oxyhaemoglobin and cerebral blood volume. Continuous rSO2 measurements were obtained before, during moderate hypothermia, and during the rewarming phase of CPB. A rSO2 < 50% was defined as abnormal.

Onset of rSO2 < 50% was at 32°C, and the highest incidence occurred during the late stages of rewarming (35-37°C). On rewarming from hypothermic CPB, 70% of our patients sustained a rSO2 < 50% for an average total duration of 9.3 minutes, primarily at the end of the rewarming period. This suggests a transient global imbalance in cerebral O2 supply and demand in a large percentage of patients during the rewarming phase of CPB. However, it has not been determined how long a rSO2 < 50% can be permitted before neuropsychological dysfunction is induced. Additional studies correlating psychometric testing with rSO2 measurements should prove useful in detecting episodes of impaired cerebral oxygenation, and help define rewarming protocols.
Potential for reduction in morbidity and cost with total leucocyte control for cardiac surgery
Authors: Ortolano Girolamo A
Published: November 2007

The economics of health care in the USA and abroad has caused a shift in the focus on therapeutic interventions that transcend issues of safety and clinical efficacy. Now, cost justification is emerging as a major consideration to influence clinical practice. This brief review of the medical literature attempts to identify leucocyte-mediated adverse reactions that develop in open-heart surgery, quantify the costs incurred to manage such reactions and infer the savings that may accrue by controlling the burden of leucocytes presented to the open-heart surgical patient using commercially available leucocyte reducing filtration technology.
The relationship between systemic oxygen uptake and del ivery during moderate hypothermic cardiopulmonary bypass: critical values and effects of vasodilation by hydralazine
Authors: Cavaliere F. , Gennari A. , Martinelli L. , Zamparelli R. , Schiavello R.
Published: November 2007

The relationship between oxygen delivery (DO2) and uptake (VO2) has been studied during moderately hypothermic cardiopulmonary bypass (CPB) in 15 patients undergoing myocardial revascularization. As soon as nasopharyngeal temperature was lowered to 32°C, blood flow was decreased from 2.4 to 2.0 l/min/m 2. Arterial and mixed venous blood gas analyses were performed five and eight minutes later and DO2 and VO2 were calculated; VO2 stabilized in five minutes after changing blood flow and neither DO2 nor VO2 values changed three minutes later (DO 2: 217 ± 19 versus 215 ± 17 ml/min/m2; VO2: 63 ± 12 versus 66 ± 14 ml/min/m2). Blood flow then was increased to 2.3 l/min/m2 and DO2 and VO2 were determined again, five minutes later; they both increased significantly, to 243 ± 20 and 74 ± 13 ml/min/m 2, respectively. However, a further blood flow increase to 2.6 l/min/m 2 which caused DO2 to increase to 277 ± 24 ml/min/m 2, did not affect VO2 which was unchanged five minutes later (76 ± 13 ml/min/m2); VO2 dependence on DO2 values higher than 243 ± 20 ml/min/m2 was consequently ruled out. Ten patients, having a mean arterial pressure higher than 80 mmHg, were eventually vasodilated with hydralazine, 0.1 mg/kg intravenously, and DO2 and VO2 were determined after five and ten minutes. As blood flow did not change, DO2 was unaffected while a slight increase in VO2 mean values was observed which was not statistically significant (prior to hydralazine: 78 ± 15 ml/min/m2; five minutes later: 82 ± 17 ml/min/m2; 10 minutes later: 76 ± 18 ml/min/m2).

In conclusion, during hypothermic CPB at 32°C, VO2 plateau ranges between 48 and 102 mi/min/m 2 (mean ± 2 SD) in 95% of patients, corresponding to 66 and 141 ml/min/m 2 at 37°C; this finding closely matches other literature reports. Consequently, lower VO2 values suggest inadequate oxygen supply to tissues. Critical DO2 at 32°C is lower than 283 ml/min/m2 in 97.5% of patients. Finally, arterial vasoconstriction does not seem to play a significant role in tissue hypoperfusion.
Clinical performance of a high-efficiency rapid flow leucocyte removal filter for leucocyte depletion of heparinized cardiopulmonary bypass perfusate
Authors: Gu YJ , deVries AJ , Boonstra PW , van Oeveren W.
Published: November 2007

The method of leucocyte depletion has been recently introduced to the field of cardiopulmonary bypass to reduce leucocyte-mediated organ dysfunction. In this study, we evaluated the efficacy and biocompatibility of the Pall RC400 filters for leucocyte depletion of heparinized cardiopulmonary bypass (CPB) perfusate taken from the heart-lung machine during routine cardiac surgery. For each filter, 700 ml blood were used as filtrate. Filtration was divided into the following groups to study the effect of loading pressure on the efficacy of the filters: under gravity pressure as a control (n = 8), under 100 mmHg (n = 8), 200 mmHg (n = 8), and 300 mmHg loading pressure (n = 8) driven by a roller pump. In addition, heparinized predonation blood taken at the beginning of CPB (n = 8) was filtered under gravity in comparison with the perfusate taken at the end of CPB. The results showed that the average leucocyte removal rate by an RC400 filter for 700 ml of blood was 96.8%. There was no significant difference of leucocyte removal rate between filtration under gravity and under loading pressure up to 300 mmHg. This allows clinical filtration at a speed up to 500 ml/min. The platelet removal rate was significantly higher in blood taken at the beginning of CPB than in blood taken at the end of CPB. Complement split product, C5a, increased only slightly during filtration indicating that this filter, made from polyester, has a good blood compatible characteristic. We conclude that the Pall RC400 leucocyte removal filter is suitable and safe to be used for leucocyte filtration of heparinized CPB perfusate during cardiac surgery.
The effect of low-dose epsilon-aminocaproic acid on patients following coronary artery bypass surgery
Authors: Montesano Ralph M , Gustafson Patricia A , Palanzo David A , Manley Norman J , Sadr Farrokh S
Published: November 2007

The effect of low-dose epsilon-aminocaproic acid (EACA) on the postoperative course of 46 patients was studied. Patients undergoing coronary artery bypass grafting were randomly selected in two groups. Group 1 (20 patients) received 5 g EACA upon initiation of cardiopulmonary bypass (CPB). Group 2 (26 patients) received no antifibrinolytic drugs prior to CPB. Neither group received antifibrinolytic drugs after CPB. There was no significant difference between the two groups' blood usage on CPB: 0.65 units in Group 1 and 0.60 units in Group 2. After CPB, blood usage significantly differed: 2.2 ± 1.7 (SD) units in Group 1 and 3.9 ± 3.0 units in Group 2 (p = 0.033). Significant difference was also demonstrated in postoperative blood loss in the first 24 hours: 1610 ± 531 ml in Group 1 versus 2025 ± 804 ml in Group 2 (p = 0.043). Pre-CPB administration of low-dose EACA significantly decreases blood loss and blood usage in the postoperative period.
Differences in blood activation related to roller/centrifugal pumps and heparin coated/uncoated surfaces in a cardiopulmonary bypass model circuit
Authors: Moen O. , Fosse E. , Bråten J. , Andersson C. , Høgåsen K. , Mollnes TE , Venge P. , Kierulf P.
Published: November 2007

An in vitro model cardiopulmonary bypass (CPB) circuit consisting ot tubing, oxygenator and venous reservoirs with either a roller or a centrifugal pump, and with either heparin-coated (Carmeda Bioactive Surface, CBAS) or uncoated surfaces, was studied with respect to 'blood activation', using small- scale-based blood volume (450 + 500 ml). Sixteen circuits were tested in each pump group, eight with and eight without heparin-coated surfaces, by circulating heparinized fresh human blood for 72 hours at 30°C. Blood plasma, sampled at defined intervals, was analysed for haemolysis (lactate dehydrogenase and potassium), complement activation (C3bc and C5b-9 (TCC)), complement lytic inhibitors (vitronectin and clusterin), coagulation activation (fibrinopeptide A), granulocyte (lactoferrin and myeloperoxidase) and platelet (β-thromboglobulin) activation and contaminating endotoxin. The heparin coating significantly reduced the concentrations of C3bc, TCC, fibrinopeptide A, lactoferrin, myeloperoxidase and β-thromboglobulin. The two pump types did not differ with respect to these parameters, but the roller pump caused significantly higher increases in plasma LDH and potassium and significantly greater reductions in clusterin and vitronectin than the centrifugal pump. Endotoxin concentration was low at the start and after 24 hours in all groups. These results confirm that heparin-coated CPB surfaces reduce blood activation, and suggest that centrifugal pumps cause less haemolysis and less reduction in lytic complement inhibitors than roller pumps.
Massive arterial air embolism during cardiopulmonary bypass: antegrade blood cardioplegia delivered by the pump — an accident waiting to happen
Authors: Jones NC , Howell CW
Published: November 2007

Of the many possible causes of air embolism occurring in patients undergoing cardiopulmonary bypass (CPB), human error due to the perfusionist or the surgeon accounts for the vast majority. This case, however, presents a previously unreported, but recognized, cause of air embolism, due to a technical problem encountered during the administration of blood cardioplegia. The nature of some of the older CPB pumps allows the administration of cardioplegia at a time when the main CPB pump is not rotating. A situation may then arise whereby air may be entrained and delivered to the patient. The management of massive air embolism is discussed, and recommendations are made to prevent such an occurrence happening in the future.
Effects of cardiopulmonary bypass on systemic vascular resistance
Authors: Kam Pca , Hines L. , O'Connor E.
Published: November 2007

During cardiopulmonary bypass (CPB), complex neuroendocrine responses occur and result in haemodynamic changes. Systemic vascular resistance (SVR) before, during, and after CPB was documented in patients undergoing coronary artery bypass surgery. Whilst the overall effect was an increased SVR, transient profound decreases in SVR at the commencement of CPB, during the rewarming phase, and immediately on weaning off CPB were demonstrated.
Clinical outcome after coronary surgery with heparin-coated extracorporeal circuits for cardiopulmonary bypass
Authors: Baufreton Christophe , Le Besnerais Paul , Jansen Piet , Mazzucotelli Jean Philippe , Wildevuur Charles RH , Loisance Daniel Y
Published: November 2007

In this prospective randomized trial, we studied whether heparin-coated extracorporeal circuits (ECC), known to reduce complement activation, could improve the clinical outcome of 200 patients undergoing coronary artery surgery. Patients have been divided into two groups (heparin-coated ECC and uncoated ECC groups) which were similar in terms of age, gender, left ventricle function, preoperative aspirin use and consequent intraoperative aprotinin use, number of grafts, duration of aortic cross-clamping and cardiopulmonary bypass.

Univariate analysis showed that heparin coating did not reduce significantly postoperative bleeding (640 ± 311 versus 682 ± 342 ml with uncoated ECC) nor the need for transfusion (19% of patients versus 25% with uncoated ECC). Adverse events, including all mortality and morbidity noticed during the five first postoperative days, occurred in 20 patients of the uncoated ECC group and in eight patients of the heparin-coated ECC group (p = 0.013). The most frequent complications were supraventricular arrhythmias that occurred in 13 patients of the uncoated ECC group and in four patients of the heparin-coated ECC group (p = 0.02). Multivariate analysis by stepwise logistic regression showed that only heparin coating of the ECC was shown as a significant predictive factor of adverse events reduction (p = 0.01; odds ratio = 0.34). These data suggest that heparin coating reduced postoperative complications in patients undergoing coronary artery surgery.
The role of limited, symptom-directed autopsies in terminal malignant disease
Authors: Carter RL
Published: November 2007

Results are presented from a series of 63 limited, symptom-directed autopsies carried out on patients dying with advanced malignant disease. Three main clinical features were studied: pain in the head and neck, dysphagia and intestinal obstruction. The applications and limitations of this procedure are critically discussed. It is concluded that the limited, symptom-directed autopsy can clarify selected clinical features with a local, structural basis. The information gained can be exploited in subsequent clinical practice.
Quality before quantity - a note of caution
Authors: Twycross Robert G
Published: November 2007

Whether seeking cure or comfort, the aims of medicine from the cradle to the grave are all concerned with improving the patient's quality of life. Generally, the hope is also to prolong survival. Thus, unless qualified, the concept that quality is preferable to quantity is of dubious validity. Measuring the absolute or subjective quality of a person's life is not possible. Assessing selected aspects is, however, essential if objective advice is to be given to patients concerning the benefits, burdens and risks of a range of treatment options. It is important that 'quality of life' and 'meaning of life' are not confused in the practitioner's mind. A low quality of life should not be equated with 'meaninglessness' or 'worthlessness'.
We don't need to be God after all
Authors: Earnshaw-Smith Elisabeth
Published: November 2007

This paper sets out to show how some of the stress and frustrations experienced by all health care professionals may arise out of our problem-orientated training and clinical practice. It suggests how we can find and use a new, positive and therefore balancing focus in our work. This new focus serves to sustain and encourage the clinician, it invests patients and families with value and the potential for personal growth through painful experiences, and it identifies rewarding opportunities seldom recognised in the crisis situation which envelops both professional and patient. Facets of an apparently negative situation are thereby found to be positive and enabling when re-examined and re-defined. Change in our focus can produce for our patients and those around them deeper changes and more long-standing benefits than we have previously noticed. Work which we have thought was concerned with illness and sometimes death can be seen to be bringing into being a new quality of life.
Can doctors accurately predict the life expectancy of patients with terminal cancer?
Authors: Heyse-Moore LH , Johnson-Bell VE
Published: November 2007

The prognosis of 50 consecutive patients admitted to a hospice was over-estimated by the referring doctor in 88% of cases. Great caution should be excercised when making estimates of prognosis.
Palliative hospice care in Australia
Authors: Cavenagh JD , Gunz FW
Published: November 2007

Palliative hospice care in Australia is developing as a result of increasing professional interest, fertilized by community and overseas influences. The modern approach in palliative care has been most potent in states without older established terminal care institutions, allowing more freedom and greater pace of development. Little research has been done to date, but teaching responsibilities are being taken seriously by organizations involved. Although it is only in its infancy, palliative care in Australia is establishing a foundation considered to be strong, and enthusiastic responses to future problems will be seen.
Nutritional problems and care of patients with far-advanced disease
Authors: Taylor Mary B , Moran Brendan J , Jackson Alan A
Published: November 2007

Nutritional problems in far-advanced disease have complex and interrelated causes. This is particularly true with cancer patients, who may have systemic disease producing multiple physical and psychological effects and who require complex treatment. Some solutions can be found which, if tailored to the individual patient, can improve the quality of life for both relatives and patients.
Quality of life in advanced cancer: the benefits of asking the patient
Authors: Fowlie Midge , Berkeley John , Dingwall-Fordyce Ianthe
Published: November 2007

Following a review of the literature on quality of life indicators a comparative study of patients in a continuing care unit and a general medical ward showed that patients' needs and concerns are highly individualistic. The MacAdam assessment of suffering was found to be a useful diagnostic and therapeutic tool, particularly in the areas relating to a patient's mood or spirits.
Problems of terminal care in elderly patients
Authors: Blackburn AM
Published: November 2007

The care given to 27 elderly men dying in a geriatric ward was examined and compared with terminal care directed to younger patients dying with cancer. Important practical differences were highlighted:

1) Difficulties in communication with elderly dying patients are frequently encountered and require heightened powers of observation of nonverbal information and empathy.

2) There is often little time for staff to provide effective terminal care for elderly patients. The diagnosis of dying is frequently made by exclusion, after failure of standard medical treatment. It is more difficult in the absence of neoplasia and requires a more holistic approach to patient care.

3) A significant proportion of elderly patients who die in hospital do not have family or friends to visit them and may require additional attention and support.
Sodium naproxen: continuous subcutaneous infusion in neoplastic pain control
Authors: Toscani Franco , Barosi Katia , Scazzina Maurizio , Camerini Sandro
Published: November 2007

Fourteen patients who had been taking naproxen orally (as a single analgesic or in association with morphine, according to the therapeutic drug sequence proposed by WHO) were changed to a subcutaneous continuous infusion of sodium naproxen alone (10 cases) or associated with morphine (4 cases), administered via a portable micro-pump because of the impossibility of taking it orally. All the patients had pain from advanced cancer.

The patients were all monitored with daily checks on the severity and duration of pain, numbers of hours slept, drug use and symptom appearance. Follow-up was continued until death. The same level of analgesia achieved by oral administration was maintained for all patients. In two cases, the presence of a high sodium naproxen and morphine concentration in the same syringe produced a precipitate of morphine which caused an obstruction of the butterfly needle. The administration of sodium naproxen not combined with other drugs in the pump proved a valuable technique, well accepted by the subjects. Its effectiveness appears comparable to oral administration of naproxen.
Pressure sores: prevention and management — a nursing perspective
Authors: Gilchrist Brian , Corner Jessica
Published: November 2007

The nursing perspective of pressure sores is wide. It is necessary to understand the cause in order to reduce risk factors and to learn the principles underlying the methods of creating the ideal environment for wound healing.
Review article : Weakness in terminal illness
Authors: Lichter Ivan
Published: November 2007

Causes of weakness are considered and attention is drawn to those that may be capable of amelioration. The mechanisms of cancer cachexia are reviewed. The role of reduced food intake, negative energy balance and metabolic changes occurring in cancer patients is examined.
The issue of opioid availability for cancer pain relief
Authors: Stjernswärd Jan , Teoh Noreen
Published: November 2007

Access to appropriate drugs is essential for implementing existing knowledge in cancer pain relief. However, the opioids needed for the control of pain are not available in most countries.
Place of death of cancer patients in Israel: the experience of a 'home-care programme'
Authors: Loven David , Goldberg Efrat , Hart Yaakov , Klein Baruch
Published: November 2007

This is an analysis of the eventual place of death of 58 patients with advanced cancer, all of whom died over the course of one year following treatment at home by a home-care programme in an Israeli community. Seventeen (29%) died in their homes, 23 (40%) died in general hospitals and 18 (31 %) died in chronic hospitals. The correlation between place of death and the following factors was examined: the relationship between each patient and his primary care person (PCP), length of treatment by the home-care programme, age, sex, ethnic origin, degree of mobility at commencement of home care and principal symptoms. Only the degree of family relationship of the PCP showed significant correlation with the actual place of death of patients, whether at home or in hospital ( p=0.03). None of the patients with a PCP of second-degree relationship died at home. The authors conclude that when the PCP is closely related to the patient and is accompanied by a home-care team trained to offer comprehensive assistance, two-thirds of the patients in an Israeli community could be spared chronic hospitalization and almost half of these could also eventually die at home.
Hospice care: Jewish reservations considered in a comparative ethical study
Authors: Byrne Peter , Dunstan GR , Jakobovits The Lord , Jayaweera Raja LA , Marshall John , Philipp Elliot E , Saunders Dame Cicely , Seller Mary J
Published: November 2007

Hospice care, the origin and growth of which are described, now has its own regimen and philosophy of care. Elements in this were believed to be contrary to Rabbinic prescriptions for the care of the dying, particularly the duty to sustain hope. A philosophical study shows that the practice and Rabbinic principles are not necessarily contradictory. Beliefs about life, death and dying in Eastern religions, and in Christianity, are outlined to show that these too are compatible with the goals and methods of hospice care.
The stability of diamorphine alone and in combination with anti-emetics in plastic syringes
Authors: Allwood MC
Published: November 2007

The compatibility and stability of diamorphine alone and in combination with haloperidol or cyclizine was investigated. The concentration of each drug was monitored during storage in plastic syringes at ambienttemperature. Diamorphine hydrochloride alone could be assigned a shelf life of approximately 18 days. The compatibility and stability of diamorphine was not greatly influenced by the presence of haloperidol, while the addition of cyclizine reduced the stability of the opiate, a shelf life of approximately 10 days being indicated. Concentrations of diamoprhine hydrochloride greater than 20mg/ml cannot be combined with high cyclizine concentrations due to precipitation.
USA hospice care in the 1990s
Authors: Magno Josefina B
Published: November 2007

The rapid growth of palliative care in the USA has been markedly slowed by restrictions and changes in funding. Despite this, a census in 1989 showed that nearly 200 000 patients were being cared for by hospice programmes employing nearly 20 000 staff in paid positions. Programmes have had to adapt to altered funding requirements. The greatest remaining problem is physicians' ignorance of the specialty of hospice/palliative medicine. The ignorance can be overcome by establishing palliative care as a medical subspecialty (as in the UK) and introducing it into the curricula of medical schools.
Review articles : Alcohol and palliative care
Authors: Kerr Derek
Published: November 2007

Alcohol is one of nature's most ancient medicines. Its uses and effects are reviewed along with its place in palliative care, particularly its role as a euphoriant, sedative, analgesic and appetite stimulant.
Treatment of diarrhoea due to enterocolic fistula with octreotide in a terminal cancer patient
Authors: Mercadante Sebastiano
Published: November 2007

A patient is described whose output from an enterocutaneous fistula was greatly reduced using octreotide, a somatostatin analogue.
Symptoms of lung cancer
Authors: Krech Ruth L , Davis Jeff , Walsh Declan , Curtis Elizabeth B
Published: November 2007

Lung cancer is the most common cancer and kills more people than any other malignancy. We describe the symptoms experienced in persons with lung cancer. Data on 100 consecutive patients were collected prospectively using a standard assessment tool. The median number of symptoms was nine. The most common and severe symptoms were pain (86), dyspnoea (70) and anorexia (68). There were no differences between males and females. Males aged 64 and under had higher incidences of easy fatigue, taste changes and sleep problems. Men over 64 had higher incidences of cough and >10% weight loss. Although there was a general increase in the number of symptoms as the performance status worsened, those with the poorest performance status reported the fewest symptoms. Since there is little effective treatment for most lung cancers, clinical management, research and resources should be directed by, and targeted to, palliative care.
Pneumothorax following insertion of subcutaneous needle
Authors: Ingham JM , Cooney NJ
Published: November 2007

Two cases of pneumothorax following the insertion of subcutaneous butterfly needles for the administration of regular bolus injections of morphine are reported. Recommendations to prevent this rare complication are put forward.
Characteristics of clients referred to home, hospice and hospital palliative care services in Western Australia
Authors: Bradshaw Pamela J
Published: November 2007

Perth, in Western Australia, has three major palliative care services: a home care service, a freestanding hospice and a purpose-built palliative care unit in a teaching hospital. A retrospective study of patients referred to these services over a six-month period was carried out to find how they were used. The records of 176 clients were compared, which showed that there were some differences between the client groups referred to each of the services. Those referred to the inpatient services were older ( F = 0.0031), less likely to have a carer available (χ2 = 18.62, p < 0.5) and needed more nursing care. Lung cancer accounted for more male admissions (29%) to all services, while breast and lung cancer were more common among women, with a mixed pattern of referral. Lack of private insurance did not seem to influence the choice of service. Overall the clients of the inpatient services were older, had more nursing needs and were less likely to have someone to care for them, characteristics which health services facing an ageing population need to consider.
Eliciting the current problems of the patient with cancer - a flow diagram
Authors: Maguire Peter , Faulkner Ann , Regnard Claud
Published: November 2007

The assessment of a patient is an integral part of clinical management. It should be conducted in a way which maximizes the likelihood of patients disclosing all their main problems, whether physical, social or psychological in nature. Unfortunately, professional carers can be uncertain of their ability to do this. This flow diagram leads the carer through key points in the assessment interview.
Review article : Hormone treatments in the common 'hormone-dependent' carcinomas
Authors: Wood Bridget C
Published: November 2007

Current understanding of the mechanisms of action of hormonal therapies in carcinomas of the breast, prostate, endometrium and ovary is briefly reviewed. The range of available hormonal therapies for each disease is considered together with response rates, toxicity and any evidence for survival benefit. Practical guidelines for the palliative use of hormonal therapies are suggested.
An audit of morphine prescribing in a specialist cancer hospital
Authors: Turner Rose , Clark Judith , Root Timothy , Hardy Janet
Published: November 2007

The object of this study was to assess the quantity and quality of morphine prescribing in a specialist cancer hospital. An audit of prescription charts of all patients was performed using palliative care unit recommendations as the standard. The major weaknesses identified in morphine prescription were a lack of provision of breakthrough doses, the use of 'as required' (prn) oral morphine in the absence of regular oral morphine, and the lack of reference in the unit guidelines to co-prescription of aperients, antiemetics and night sedation. These deficiencies were targeted in an education programme and the survey was repeated to complete the audit cycle. Although some improvement in prescribing practice was shown, persistent problems have illustrated the need for an ongoing hospital-wide education programme.
The spiritual component of palliative care
Authors: Grey Alison
Published: November 2007

This article discusses the concept of spirituality within palliative care. It considers aspects of religion and creativity in relation to spirituality, which may be inter-related as well as being significant in their own right. The nurse's role within the interdisciplinary team is explored. The expertise required as well as the emotional effect on nurses offering spiritual support is described.
Comparison of piroxicam and acetylsalicylic acid for pain in head and neck cancers: a double-blind study
Authors: Saxena Abha , Andley Manoj , Gnanasekaran N.
Published: November 2007

This double-blind, placebo controlled study compared the analgesic efficacy of piroxicam with acetylsalicylic acid (ASA) in patients having continuous pain with advanced head and neck cancers. They were randomly divided into two groups of 25 patients each; 36 of these 50 patients completed the study. After four days of treatment, there was a significant reduction in a modified numerical rating scale (NRS) of pain in the piroxicam group as well as in the ASA group. There was a concomitant increase in the hours of sleep in the piroxicam group and in the ASA group. The decrease in NRS and the increase in sleeping hours was not statistically significantly different between the two groups. Patients receiving piroxicam had a low incidence of upper gastrointestinal side-effects compared with those receiving ASA. The results of this study suggest that piroxicam can be used as first line treatment in place of ASA in patients with head and neck cancers suffering from moderate to severe pain. The advantages are less frequent dosing, better patient compliance and few side-effects.
The assessment of need for bereavement follow-up in palliative and hospice care
Authors: Payne SA , Relf M.
Published: November 2007

This paper describes a postal survey of palliative care services and teams which were identified in the 1992 Directory of Hospice Services in the UK and Ireland. Its aims were to investigate how units assess the need for bereavement follow-up, and to determine the nature and extent of services provided for bereaved adults. We sent out 397 questionnaires, of which 187 were returned, a response rate of 47%. Results indicate that 156 respondents (84%) provided follow-up and a further 13 (7%) were planning bereavement services. Only 48 (25%) units undertook formal standardized risk assessment procedures to allocate appropriate services; in 41 units (85%) this was done by a nurse. Of the remaining 125 units, 58 (46%) reported basing their decisions on clinical impressions. Content analysis of the formal assessment instruments revealed 39 subcategories, which were broadly grouped into three areas: circumstantial factors at or near to the time of death, personal factors and social factors. Recommendations are made for further study.