Biomedical subjects
Publications and source records attributed to C F Hughes.
The case of a 73-year-old man in whom squamous cell carcinoma developed in a median sternotomy scar 12 months after coronary artery bypass grafting is presented. A brief review of the literature is included. The etiology of scar carcinoma is discussed and an outline of management given.
Mitral valve replacement combined with coronary artery bypass grafting has been reported as being associated with a higher mortality than either mitral valve replacement or coronary artery bypass grafting alone. Cause of mitral valve disease and severity of mitral regurgitation have been reported as related to mortality. To study the correlation of the cause of mitral valve disease and severity of mitral regurgitation to hospital mortality and long-term survival, we analyzed the results of 135 patients undergoing mitral valve replacement and coronary artery bypass grafting between June 1974 and August 1989. The hospital mortality was 11.8% (16/135). Fifteen preoperative and operative variables were tested for correlation with hospital or late mortality using univariate tests and multivariate regression. Advanced age (greater than 60 years), New York Heart Association functional class, and wall motion score were independently associated with hospital mortality (p less than 0.05). The cause of mitral valve disease and severity of mitral regurgitation were not related to hospital mortality or long-term survival (p greater than 0.05). The follow-up rate was 96.6% for the hospital survivors (115/119). Mean follow-up was 52.6 +/- 4.1 months. There were 35 late deaths. Survival was 91.9%, 89.9%, 78%, and 49.9% at 1, 2, 5, and 10 postoperative years, respectively. Preoperative New York Heart Association functional class and use of catecholamines during the postoperative intensive care period were independently related to late survival (p less than 0.05).(ABSTRACT TRUNCATED AT 250 WORDS)
The clinical characteristics, perioperative complications and medium term outcome were analysed for patients undergoing emergency coronary artery bypass surgery (CABG) following failed coronary angioplasty (PTCA). Seven hundred and twenty PTCAs were performed from June 1981 to June 1989, of which 30 (4.2%) resulted in CABG within four hours of PTCA. The perioperative course and follow-up were compared to 30 patients undergoing elective CABG, matched retrospectively for age, sex, month of operation and number of grafts. The emergency group had a tendency to more post operative bleeding, but no increased incidence of early reoperation for bleeding, and had a high incidence of periprocedural Q wave infarction (20% vs 3%, p less than 0.05). The emergency group had shorter bypass time and decreased use of the internal mammary artery (7% vs 50%, p less than 0.05). There was one in-hospital death in the emergency group. At medium term follow-up (3.4 +/- 2.4 years, range two months to eight years) there was one late death in each group, and seven patients in each group had return of angina or congestive heart failure. Twenty-one patients in the emergency group and 22 patients in the elective group were asymptomatic on no cardiac medications. We conclude that patients with failed PTCA requiring emergency CABG are more likely than an elective group to have post operative bleeding but no increased risk of early reoperation, and have a higher incidence of perioperative Q wave infarction.(ABSTRACT TRUNCATED AT 250 WORDS)
Bronchogenic cysts are congenital lesions of the respiratory tract. Although usually benign, they have the potential to develop complications and can pose a dilemma in diagnosis and treatment. Twenty patients who presented to the Cardiothoracic Surgical Unit at Royal Prince Alfred Hospital over a 10 year period are reported. Symptoms were common (75%) but serious complications were rare (5%). Most cysts were excised completely at thoracotomy with minimal morbidity. The correct diagnosis was established pre-operatively in less than half of the patients. Therefore excision is recommended to confirm the diagnosis, to exclude malignancy and to minimize possible complications.
Primary malignant germ cell tumours of the mediastinum are rare and are associated with poor survival when treated with surgery alone or with surgery when chemotherapy has failed. Recent improvements in combination chemotherapy have given some prospect of cure. A patient treated with primary surgical excision and postoperative chemotherapy, who remains free of disease 24 months after completion of treatment is reported here.
An adult male patient with duplication cyst of the cervical oesophagus is reported. Benign tumours of the oesophagus are rare and amongst them the congenital cysts form a small group. Only four cases of duplication of the cervical oesophagus have been reported in the literature, all initially presenting in children. Patients usually present with pressure symptoms due to rapid enlargement of the cyst secondary to bleeding or infection. Diagnosis previously has been suggested by barium swallow and oesophagoscopy. Computed tomography (CT) clearly demonstrated the oesophageal duplication. This report describes the first patient to present with a cervical duplication of the oesophagus in adulthood and only the second in whom CT has been used to establish the diagnosis. Surgical excision is recommended in all patients with duplication cysts of the cervical oesophagus.
The case of a patient in whom two separate episodes of infective endocarditis were treated by excision of the infected vegetation ("vegetectomy") is reported. In carefully selected patients, early conservative operation may preserve the native valve and avoid the hazards of anticoagulative medication and prosthetic endocarditis in habitual drug abusers.
The anatomic and clinical features of 47 patients who were 18 years of age or older at the time of total intracardiac repair for tetralogy of Fallot are reviewed. Twenty (43%) patients had had previous palliative surgery. Of 14 pulmonary-systemic shunts, 9 (64%) remained patent. The location of the ventricular septal defect was infracristal in 90% of patients. The predominant right ventricular outflow tract obstruction was at the infundibulum in 30%; another 64% of patients had combined valvular and infundibular obstruction. Total intracardiac repair was achieved; hospital mortality was 8.5%. Morbidity was minor, and hemorrhage was a significant problem in only 2 patients. Thirty-five patients have been followed from 11 months to 15 years after surgery. There were 4 late deaths; the actuarial 10-year survival rate was 82%.
A theory of inhibition and psychosomatic disease suggests that the failure to confide traumatic events is stressful and associated with long-term health problems. We investigated the short-term autonomic correlates of disclosing personal and traumatic experiences among two samples of healthy undergraduates. In Experiment 1, subjects talked into a tape recorder about extremely stressful events that had occurred in their lives, as well as what they planned to do following the experiment. Skin conductance, blood pressure, and heart rate were continuously measured. Based on judges' ratings of subjects' depth of disclosure, subjects were classified as high or low disclosers. Talking about traumatic events was associated with decreased behavioral inhibition, as measured by lower skin conductance levels among high disclosers. Disclosing traumatic material was also associated with increased cardiovascular activity. In Experiment 2, subjects both talked aloud and thought about a traumatic event and about plans for the day. Half of the subjects were alone in an experimental cubicle and talked into a tape recorder; the remaining subjects talked to a silent "confessor" who sat behind a curtain. Among high disclosers, both talking and thinking about traumatic events produced lower skin conductance levels than did thinking or talking about plans for the day. The presence of a confessor inhibited subjects' talking. Implications for understanding the nature of confession and the development of an inhibitory model for psychosomatic processes are discussed.
A study to analyse the effects of left ventricular diastolic pressure on coronary pressure-flow relations during physiological vasodilatation was carried out in 14 anaesthetised dogs. The left circumflex artery was perfused at controlled pressures via an extracorporeal circuit and vasodilatation induced by 15 s occlusion of coronary flow. The relation between end diastolic coronary perfusion pressure and flow at peak hyperaemia was linear above 40 mmHg (group 1, n = 7) and became curvilinear at perfusion pressures below 40 mmHg (group 2, n = 7). At a mean left ventricular end diastolic pressure of 8.6(0.8) mmHg the mean zero flow intercept (Pint) in group 1 was 22.5(2.3) mmHg. Graded increases in left ventricular end diastolic pressure by infusion of blood resulted in a parallel rightward shift of the vasodilated pressure-flow relation (Pint = 1.06 X LVEDP + 13.8 mmHg, r = 0.87). The curvilinear relations at low perfusion pressures in group 2 had lower zero flow intercept pressures (Pint = 4.8(0.7) mmHg at left ventricular end diastolic pressure 6.6(1.5) mmHg). As with group 1, graded increases in left ventricular end diastolic pressure caused a rightward shift of the pressure-flow relation, with a direct relation between left ventricular end diastolic pressure and zero flow intercept (Pint = 0.93 X LVEDP + 3.9 mmHg, r = 0.89). Diastolic coronary pressure-flow relations during physiological vasodilatation are essentially linear at perfusion pressures greater than 40 mmHg but are appreciably curved at lower pressures. Increases in left ventricular end diastolic pressure cause a parallel rightward shift of the linear region of the pressure-flow relation.(ABSTRACT TRUNCATED AT 250 WORDS)
A fourth case of pharyngeal injury after an attempt to open a bottle of 'home brew' is presented. For the first time the potential barotrauma causing this injury is recognized. The principles of diagnosis, investigation and treatment are described. Early surgical intervention will minimize contamination and allow adequate drainage of the contaminated space. Early institution of antibiotics will minimize local and generalized toxic phenomena. Alternate routes of alimentation allow local healing and rapid recovery of the patient.
Between 1974 and 1981, 20 patients had surgical treatment for bullous emphysema. There were 15 males and five females with a mean age of 40 years. The majority of patients had symptomatic respiratory disease, were smokers and had a past history of lung disease. In all cases bullae were visible on chest X-ray, the primary diagnostic investigation, and simple spirometry was used to assess lung function pre- and postoperatively. Cyst resection was performed in 14 cases (two bi-laterally) and pleurodesis was added in six of these cases. Lobectomy was performed in four patients and in two a pedunculated cyst was simply ligated and excised. There were no deaths and morbidity was acceptably low. Vital capacity (VC), Forced expiratory volume in 1 s (FEV1) and FEV1:VC ratio were all significantly improved with surgery though the correlation of subjective and objective results was variable. Surgery is appropriate for symptomatic patients with bullae visible on chest X-ray and asymptomatic patients with rapidly enlarging bullae occupying more than 30% of a hemithorax.
Carcinoid tumours of the mediastinum are very rare. They are frequently malignant and run a quite different course from that of the more benign thymomas. We report a 70 year old man with an anterior mediastinal tumour which was initially diagnosed as a thymoma but which was subsequently shown to be a carcinoid tumour. Surgical extirpation was greatly enhanced by pre-operative angiography and arterial embolisation of the tumour. Early and aggressive diagnostic attempts, pre-operative angiography, with or without arterial embolisation, and complete surgical excision offer the best hope of a cure for these malignant tumours.
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Eleven patients were given varying doses of cardioplegic solution contaminated with Enterobacter cloacae. Five patients died. Early bleeding, necessitating reoperation, occurred in eight patients and a total of 126 units of blood and 203 units of platelets were given (range 2 to 19 and 15 to 47 units, respectively). Mycotic aneurysms developed in four patients, rupturing between the ninth and eleventh postoperative day. Only one of these patients survived. Other complications included adult respiratory distress syndrome (three patients), renal failure (four patients), sternal infections (six patients), and organic brain syndrome (five patients). Although some factors of gram-negative septicemia were identified in retrospect, others were masked by the clinical setting in which it occurred. We recommend that each dose of cardioplegic solution be prepared on an individual basis and used immediately. We also recommend that "sternal blood" be cultured on all patients. The subtle features of "gram-negative septicemia" necessitate urgent investigation and treatment. The combination of low white cell count, high cardiac output, and low peripheral vascular resistance should be assumed to indicate septicemia until proved otherwise. A full coagulation screen including platelet function and fibrin degradation products should be performed in any and all patients with these findings. Mycotic aneurysms mandate urgent reoperation with interposition of a saphenous vein segment of these patients are to survive.
The left anterior descending coronary artery was ligated in 58 open-chest anaesthetised dogs; 23 were controls, 15 were given intravenous propranolol 1 mg . kg-1 before and at 6 h intervals after coronary ligation, nine had bilateral cervical vagal nerve stimulation (VS) before and for 4 to 6 h after coronary ligation, and 11 had both VS and propranolol. None of the 20 dogs undergoing VS developed ventricular fibrillation within the first hour after coronary ligation compared to nine of the remaining 38 (P less than 0.05). Compared to controls, myocardial creatine kinase (CK) depletion in the epicardial layer of the infarct centre measured 24 h after coronary ligation was significantly less in the groups treated separately with vagal nerve stimulation and propranolol. Myocardial blood flow (MBF) measured at 15 min after coronary ligation was reduced to the normal myocardium by the interventions, but was unchanged at the infarct centre. Severely ischaemic myocardium (MBF less than or equal to 20% of normal) was better protected by the interventions than was moderately ischaemic myocardium. At 15 min after coronary ligation, the heart rate--blood pressure product (RPP) was reduced compared with controls by propranolol (18% reduction, P less than 0.05), reduced more by vagal stimulation (by 37%, P less than 0.001) and still more by vagal stimulation with propranolol (by 43%, P less than 0.001). Preservation of CK in myocardium with MBF less than or equal to 20% of normal was improved by VS and propranolol given separately roughly in proportion to reduction in RPP, but further reduction in RPP by VS and propranolol together did not improve CK levels further. We conclude that there may be an optimum level of indices of oxygen demand for preservation of very ischaemic myocardium in experimental infarction.