Biomedical subjects
Publications and source records attributed to L Thulin.
Self-monitoring of anti-vitamin K treatment by patients with heart valve prostheses is a good alternative to hospital control. Self-monitoring at home allows patients more freedom and opportunity to take greater responsibility for their treatment. Experience from over a years' complication-free treatment of 12 patients is reported in the article.
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OBJECTIVE: To assess risk factors for mortality in cardiac surgical adult patients as part of a study to develop a European System for Cardiac Operative Risk Evaluation (EuroSCORE). METHODS: From September to November 1995, information on risk factors and mortality was collected for 19030 consecutive adult patients undergoing cardiac surgery under cardiopulmonary bypass in 128 surgical centres in eight European states. Data were collected for 68 preoperative and 29 operative risk factors proven or believed to influence hospital mortality. The relationship between risk factors and outcome was assessed by univariate and logistic regression analysis. RESULTS: Mean age (+/- standard deviation) was 62.5+/-10.7 (range 17-94 years) and 28% were female. Mean body mass index was 26.3+/-3.9. The incidence of common risk factors was as follows: hypertension 43.6%, diabetes 16.7%, extracardiac arteriopathy 2.9%, chronic renal failure 3.5%, chronic pulmonary disease 3.9%, previous cardiac surgery 7.3% and impaired left ventricular function 31.4%. Isolated coronary surgery accounted for 63.6% of all procedures, and 29.8% of patients had valve operations. Overall hospital mortality was 4.8%. Coronary surgery mortality was 3.4% In the absence of any identifiable risk factors, mortality was 0.4% for coronary surgery, 1% for mitral valve surgery, 1.1% for aortic valve surgery and 0% for atrial septal defect repair. The following risk factors were associated with increased mortality: age (P = 0.001), female gender (P = 0.001), serum creatinine (P = 0.001), extracardiac arteriopathy (P = 0.001), chronic airway disease (P = 0.006), severe neurological dysfunction (P = 0.001), previous cardiac surgery (P = 0.001), recent myocardial infarction (P = 0.001), left ventricular ejection fraction (P = 0.001), chronic congestive cardiac failure (P = 0.001), pulmonary hypertension (P = 0.001), active endocarditis (P = 0.001), unstable angina (P = 0.001), procedure urgency (P = 0.001), critical preoperative condition (P = 0.001) ventricular septal rupture (P = 0.002), noncoronary surgery (P = 0.001), thoracic aortic surgery (P = 0.001). CONCLUSION: A number of risk factors contribute to cardiac surgical mortality in Europe. This information can be used to develop a risk stratification system for the prediction of hospital mortality and the assessment of quality of care.
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Fifteen patients with severe pain due to malignancy were treated by continuous epidural morphine infusions. A disposable external pump was used. Patients were treated in a hospital setting or at home for a total of 906 days. Pain intensity was estimated by VAS. The pumps functioned well. Bacterial growth was found in 0.6% of the balloon reservoirs used, while the epidural filters were free from growth. There were no clinical infections. It appears that this delivery system is safe, practical and suitable for use in the home environment.
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Somatostatin is a peptide that has anticholeretic properties in the dog. The purpose of the present work was to investigate if somatostatin is an anticholeretic agent in humans also. The effects of intravenous infusion of somatostatin on hepatic bile flow and biliary electrolytes and secretion of biliary lipids were studied in 7 patients with complete biliary drainage who had been operated on for choledocholithiasis. Somatostatin, 250 microgram/h, was found to decrease the hepatic bile secretion by approximately 30%. The peptide also reduced the outputs of bile acids, cholesterol, and phospholipids and the outputs of sodium, potassium, and chloride. The concentrations of the biliary lipids were not significantly changed. Somatostatin inhibited the erythritol clearance in the 2 patients studied by approximately 25%. The present study thus provides evidence that somatostatin inhibits bile formation in humans. It appears as if the reduction in bile production is mainly due to decreased canalicular bile flow. It is possible that this effect of somatostatin is attributable to inhibition of bile acid synthesis or of transport-secretion of bile acids, or both.
The microvascular circulation in the heart, lung and thymus was studied by fluorometry in 32 haemorrhagically shocked rats. Exsanguination to a blood pressure of 35 mmHg for 180 min did not result in any reduction of this circulation in the heart or lung, but in the thymus it was reduced by 52%. Retransfusion of shed blood caused no change in cardiac microcirculation, whereas the microcirculation in the thymus was increased by 59%. In the lungs a heterogeneous fluorescence pattern was observed after retransfusion, with large dark areas alternating with normal fluorescent ones and even some small intensively fluorescent areas. After retransfusion, maldistribution of blood flow seems to be a phenomenon of haemorrhagic shock in the lungs.
Malignant cardiac tumours located on heart valves are very rare. We report on a myxofibrosarcoma originally presented as a cardiac myxoma (CM), partly with chondroid differentiation, located on the posterior leaflet of the mitral valve. The tumor recurred twice, the first time disguised as a CM with only minor components of myxofibrosarcoma, and finally metastazised as a myxofibrosarcoma. Patient survival (40 months from first surgery) was surprisingly long and this may well reflect both the effectiveness of the combined radiation and cytostatic treatment and the histopathological features of the tumor.
Fluorescein flowmetry (FF) implies the measurement of a relative capillary blood flow, expressed as an index--that is, the ratio between the maximum fluorescence, obtained during the first circulatory passage of sodium fluorescein (Na-F), and the rise time, defined as the time interval between 10% and 90% of the maximum fluorescence. The aim of this study was to develop FF to be used during endoscopy for the evaluation of ventricular and duodenal mucosal blood flow. FF was applied during gastroduodenoscopy in 38 patients with normal mucosa, as verified by histopathologic examination. The blood flow index did not differ significantly for the mucosa of the fundus, corpus, and antrum. However, when compared with the duodenal mucosa, the blood flow index of the ventricular mucosa was almost twice as high (P less than 0.01). This, in turn, was due to a significantly higher maximum fluorescence in the ventricular mucosa (P less than 0.01), indicating a denser capillary network than in the duodenal mucosa. Since FF is a reliable method, easy to perform and without complications, it is suitable whenever mucosal blood flow warrants measurement during endoscopy.
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Prophylactic somatostatin (Stillamin, Serono) was given i.v. to 26 patients for 24 hours (250 micrograms/h) in order to reduce the incidence and severity of hyperamylasemia and pancreatitis following endoscopic retrograde cholangiopancreatography (ERCP). Patients who during the preceding year had been subjected to ERCP served as historical controls. The incidence of hyperamylasemia following ERCP was 58% and 57% in somatostatin-treated patients and controls, respectively. There was no significant difference between the serum amylase levels in the controls and in patients given prophylactic somatostatin. No patient developed clinically overt pancreatitis. It is concluded that prophylactic somatostatin does not reduce the incidence or severity of hyperamylasemia following ERCP.
Nine patients with bleeding oesophageal varices, who had not responded to aggressive conservative treatment, underwent emergency transabdominal oesophageal transection and reanastomosis using a mechanical stapling instrument. According to the classification of Child, 2 were graded as Class A, 4 as Class B, and 3 as Class C. Successful control of haemorrhage was achieved in all patients. Three patients died 15-33 days postoperatively. Causes were hepatic failure, sepsis and circulatory insufficiency. Recurrent variceal bleeding occurred in one patient after 15 and 23 months. One patient bled from the oesophageal wall were a clips had slipped after 17 months. One patient required postoperative dilatation due to oesophageal stricture. There was no anastomotic leakage and no cases of hepatic encephalopathy. One patient died after 26 months from an intercurrent disease. The remaining 5 patients are alive and free from symptoms related to varices 6, 20, 24, 25 and 32 months postoperatively. When other measures prove ineffective, transection with the EEA instrument can be recommended to control exsanguinating haemorrhage from oesophageal varices. It seems to be a useful additional procedure to those already in use. For definite assessment and conclusion, however, more experience from additional operations must be gained and longer follow-up is required.
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In sixteen patients subjected to intestinal surgery, the transport of sodium fluorescein (Na-F) was measured between the mucosal and serosal-muscular layers. Experiments were carried out in intestinal anastomosis by fluorescein flowmetry (FF). The blood-flow index of the mucosal layer was about twice the serosal-muscularis, per unit tissue volume. The temporal changes in fluorescence pattern from the two layers showed that more than 90% of Na-F, eliminated from the mucosal layer, was transported to the serosal-muscular layers. In six patients, in whom Na-F was instilled intraluminarily, fluorescence was seen on the outside of the intestine after 3 min. However, when the circulation was stopped before Na-F was instilled, no fluorescence was seen, this suggests that the transport was not only due to diffusion but also to convection. The results suggest that functional serially-coupled exchange vessels may exist within the intestinal wall, and that Na-F is transported both by convection and diffusion.