Aortic root anomalies of the neck presenting in adults. Review of the literature with three case reports.
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Adult↗
Biomedical subjects
T D Brow
Publications and source records attributed to T D Brow.
Continuing controversy in the management of concomitant coronary and carotid disease: an overview.
OBJECTIVES: To perform an analytical overview of the risk factors, pathogenesis of stroke and the strategies for the management of concomitant coronary artery disease and carotid artery stenosis (CAS). Four strategies were analysed; CABG in the presence of CAS, combined (CE+CABG), reverse (CABG+CE<3 months) and prior staged (CE+CABG<3 months). METHODS: A literature search formed the basis of a reference database. Outcome was assessed by the 30-day permanent stroke and mortality rate for the different approaches. Accrued rates of permanent stroke and mortality rate were expressed in terms of mean stroke and mortality rate (MSR, MMR). Data was analysed comparatively and expressed in terms of P value, odds ratio and confidence limits. RESULTS: 33 different risk factors for stroke at CABG were identified. Significant factors included: ascending aortic atheroma, emergency procedures, impaired left ventricular function, cardioplegia and peripheral vascular disease. Risk of stroke at CABG increased with higher grade CAS (50 vs. 80%, P=0.009). Pathogenesis of stroke at CABG is multifactorial; the role of flow limiting CAS is controversial and other mechanisms are implicated. Analysis of the four strategies revealed that in the Prior Stage (n=573) the MSR was 1.5% and MMR 5.9%, in the Unprotected CABG+CAS series the MSR was 3.8% (n=840) and MMR (n=596) 4.4%, in the Reverse stage series (n=83) the MSR was 2.4%, and MMR 4.8%. For Combined procedures (n=3,295) the MSR was 3.9% and MMR 4.5%. Comparative analysis indicated a significant reduction in stroke for Prior vs. Combined (1.5 vs. 3.9%, P=0.007, odds 0.39, CI 0.2-0.77) with a higher mortality (5.9 vs. 4.5%, P=0.1, odds 1.41, Cl 0.96-2.06, NS). The stroke rate in the Prior stage also remained significantly lower compared to the Unprotected CABG group both mixed (P=0.015) and asymptomatic CAS (P=0.047). When total risks (MSR+MMR), were analysed, similar results were found between the groups; Prior 7.4%, Reverse stage 7.2%, Combined 8.4%, Unprotected CABG+ >50% CAS 11.5%. CONCLUSIONS: Stroke at CABG is due to multiple risk factors, one of which is high-grade carotid stenosis. Pathophysiology of stroke, although multifactorial, supports embolism rather than flow limitation as the primary mechanism. Lack of randomised trials has made it impossible to draw firm conclusions regarding the best management strategy. There was no significant difference in the overall stroke and mortality risk between the various strategies, however, subgroup analysis suggests that, when carefully selected, patients do better by staging the operations. In our opinion patients without severe cardiac disease should be considered for Prior staging and the rest for Combined procedure. The role of reverse staging needs further evaluation.
Carotid Stenosis↗
Chronic leg pain - problem solved.
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Chronic Disease↗
The significance of creatine kinase in cardiac patients with acute limb ischaemia.
OBJECTIVE: The value of creatine kinase (CK) and aspartate transaminase (AST) has not been previously evaluated following cardiac surgery in the diagnosis of acute limb ischaemia. Our objective was to assess the value of CK and AST with reference to the diagnosis of limb ischaemia, effect on renal function and prognosis following cardiac surgery. DESIGN: all patients entering ICU had daily CK and AST measurements over a two -year period. A retrospective study of patients with CK values >5,000 U/L was performed. SETTING: adult intensive care unit of a secondary and tertiary referral centre for cardiothoracic surgery with on site facilities for vascular surgery. PATIENT: twenty-seven patients had CK values greater than 5,000 U/L. A further random sample of 35 patients, with no limb ischaemia were used to give medians for CK and AST following cardiac surgery. INTERVENTIONS: twelve of twenty-seven (44%) patients were noted to have acutely ischaemic limbs; 6 of these (CK>16,000 U/L) underwent surgical intervention. MEASURES: serum levels of CK, Peak CK, AST, Peak AST and CK/AST ratios. Related to procedure and outcome in terms of mortality and morbidity including, acute limb ischaemia defined on clinical grounds and renal failure defined as creatinine >200 pmoles/L. RESULTS: The median values for CK and AST immediately following uncomplicated cardiac surgery were 135 (IQR 36-383) and 43 (IQR 26-58) respectively. Median CK for the patients (CK>5,000) without clinical ischaemia was 7,440 U/L compared to the group with ischaemia 17,472 U/L (p<0.05). Renal failure developed in 48% of all patients. Eight of the 9 patients with CK>15,000 developed renal failure compared to 5 of the 13 with CK 5,000-15,000 U/L (p<0.01). 30% of patients underwent haemofiltration; of these, 87% died. For patients with ischaemia peak CK and creatinine correlated. (r = 0.83, p<0.05) Day of peak CK and peak AST correlated (r = 0.92, p<0.01). Logged values of CK with log values of AST showed a highly significant relationship (beta = 1.16, p<0.001). The overall mortality was 33%. CONCLUSIONS: PATIENTs who develop limb ischaemia following cardiac surgery have a high morbidity and mortality. A CK of 17,000 U/L (5667-46539) is indicative of serious limb ischaemia. Renal failure is likely to develop in patients with CK>15,000 U/L. AST may become a useful additional marker of limb ischaemia.
Acute Disease↗
Toward a rational management of concomitant carotid and coronary artery disease.
BACKGROUND: Patients with angina undergoing carotid endarterectomy have a high perioperative mortality. Our aim was to assess the outcome of carotid endarterectomy in patients with concomitant coronary artery disease, in particular, to examine the timing of carotid endarterectomy and CABG. METHODS: A retrospective study was performed at a tertiary and secondary referral centre for cardiovascular disease. Over a five-year period 71 carotid endarterectomies and 6,590 coronary artery bypasses were performed. Significant (>70%) internal carotid stenoses were found in 35 (0.5%) patients due for CABG. Of these, 23 patients underwent Combined procedures (Carotid and CABG), 9 Reverse staged (CABG then Carotid), and 3 Prior staged carotid endarterectomies (Carotid then CABG). 36 other carotid endarterectomies were in patients evaluated cardiologically, but did not require CABG (Isolated group). Risk factors, 30 day perioperative outcome including hospital inpatient stay and early follow-up are reported. RESULTS: The Combined group 30-day perioperative mortality rate was 4.3% and permanent stroke rate 8.6%. There were no major complications in Reverse or Prior staged cases. Isolated group mortality was 2.7% with no strokes. Risk factors were more prevalent in the combined group; 56% previous myocardial infarction, 39% hypertension, 35% a history of raised cholesterol and 46% intermittent claudication. All cases were followed up for a mean of 18.4 months, with no carotid stroke related events. Overall hospital stay for staged patients was a mean 19.3 days (SE=2.4) days compared to mean 9.8 days for combined patients (SE=0.97, p<0.001). CONCLUSIONS: Patients with combined cardiac and carotid disease benefit from assessment of both systems in order to stage CABG and carotid endarterectomy. Risk factors were more prevalent in the combined group; a combined procedure offered a median difference of 8 days less hospital inpatient stay compared to the staged cases. Our experience suggests that carefully planned management of concomitant coronary and carotid disease can achieve better results.
Aged↗
Psychophysiological evidence for a state theory of hypnosis and susceptibility.
Psychophysiological evidence is presented of altered cerebral organisation under hypnosis. Bilateral electrodermal activity was examined to tones presented simultaneously with the induction of hypnosis. Susceptibility was monitored throughout. Two control conditions were devised, one for division of attention and another for relaxation. In addition there was a familiarisation session which permitted groups to be equated for rates of habituation. Both faster and slower habituation were found under hypnosis but the direction of change related to susceptibility; Susceptible subjects showed a reduction in orienting responses and Unsusceptible subjects an increase in responses. Susceptible subjects also had lower tonic levels of activity and fewer nonspecific responses during the induction prior to the tones. Neither relaxation nor listening to a story altered habituation systematically. Under hypnosis there was a reversal in lateral asymmetries in orienting response amplitudes in Susceptible subjects suggesting a shift in hemispheric influences from left to right.
Adult↗