Biomedical subjects
Publications and source records attributed to K G Davidson.
A 67-year-old woman had aortic and mitral annulus calcification resulting in severe stenosis and incompetence of the valves. Mitral annulus calcification produces specific echocardiographic abnormalities which may forewarn of technical difficulties during surgery.
Between January 1977 and December 1986, 1606 Bjørk-Shiley tilting disc prostheses (BS) and 1346 Carpentier Edwards porcine prostheses (CE) were implanted in 1300 and 1156 patients, respectively, at the same institution. During the time of implantation, both valves have developed: the BS through standard disc and convexo-concave to monostrut, and the CE valves from standard to supra-annular. Newer valve types were used where applicable as they became available. Preoperative status in respect of age and cardiac rhythm were similar. There were significantly more females (64% BS: 54% CE, P less than 0.001); worse NYHA grade (74% Grade 111 and IV-BS: 56% 111 and IV-CE, P less than 0.001) more closed heart surgery (26% BS: 18% CE, P less than 0.001) and more previous open heart surgery (11.6% BS: 8.9% CE, P less than 0.001) in the BS group. All BS patients were anticoagulated and 49% of mitral CE patients and 7% of aortic CE patients were anticoagulated. There was no significant difference between the two groups in hospital mortality (BS 7.2%: CE 6.3%), late mortality (BS 2.5%/patient year: CE 3.2%/patient year) overall incidence of systemic embolism (BS 1.3%/patient year: CE 1.4/patient year), prosthetic valve endocarditis (BS 0.7%/patient year: CE 0.9%/patient year), valve failure (BS 0.5%/patient year: CE 0.9%/patient year) or peri-prosthetic leak (BS 1.2%/patient year: CE 1.3%/patient year). The incidence of systemic embolism in the aortic position was lower with the BS prosthesis (BS 0.2%/patient year: CE 1.2%/patient year, P less than 0.02).(ABSTRACT TRUNCATED AT 250 WORDS)
A case is reported in which blunt chest injury caused an intimal tear in the left anterior descending coronary artery. Despite few external signs of injury the patient sustained a myocardial infarction resulting in life threatening arrhythmias and considerable left ventricular dysfunction.
Serum testosterone concentrations were measured preoperatively in 39 men undergoing thoracotomy for histologically proved bronchial carcinoma, in 10 patients with pulmonary opacities that transpired to be non-malignant (benign group) and in 23 men were undergoing minor elective surgical procedures (control group). Thirteen of the 39 patients with known bronchial carcinoma were considered to have had curative surgery and 26 a palliative procedure when operative and pathological findings were taken into consideration. Low serum testosterone concentrations (less than 12 nmol/l) were detected in four patients in the curative group, in 22 in the palliative group (chi 2 test: p less than 0.001), three in the benign group, and in two patients in the control group. A low serum testosterone concentration in patients with bronchial carcinoma may be an indicator of metastatic disease and sequential serum testosterone estimations may prove useful in the follow up of patients thought to have undergone curative surgery.
Between January 1977 and December 1982, 986 Björk-Shiley and 744 Carpentier-Edwards valves were implanted in 774 and 620 patients, respectively, at the same institution. All Björk-Shiley patients and 57% of patients with a Carpentier-Edwards valve in the mitral position received long-term anticoagulation. Mean follow-up was 3.2 years (range 0 to 8.8) in the Björk-Shiley patients and 3.5 years (range 0 to 8.2) in the Carpentier-Edwards group. There was no significant difference between the two groups in hospital mortality (Björk-Shiley 7.6%; Carpentier-Edwards 6.0%), overall incidence of embolism (Björk-Shiley 1.4 per 100 patient-years; Carpentier-Edwards 1.6% py), endocarditis (Björk-Shiley 0.6% py; Carpentier-Edwards 0.8% py), periporsthetic leak (Björk-Shiley 1.6% py; Carpentier-Edwards 1.4% py), anticoagulant-related complications (Björk-Shiley 0.3% py; Carpentier-Edwards 0.1% py), valve failure (Björk-Shiley 0.78% py; Carpentier-Edwards 0.68% py), reoperation for complication (Björk-Shiley 1.68% py; Carpentier-Edwards 1.22% py), and late mortality (Björk-Shiley 3.1% py; Carpentier-Edwards 3.0% py). Actuarial freedom from valve-related events was similar in the two groups. In the aortic position, freedom from embolism was significantly better in the Björk-Shiley group than the Carpentier-Edwards group (Björk-Shiley 99% at 3 and 5 years; Carpentier-Edwards 96% and 92% at 3 and 5 years; p = 0.023). In the mitral position, the overall incidence of reoperation was higher in the Björk-Shiley group (1.78% py) than in the Carpentier-Edwards group (0.48% py) (p = 0.004). Actuarial analysis shows this difference to be confined to the first 6 years of follow-up. The commonest indication for reoperation was valve failure in both groups. However, when analysis is confined to this indication, the difference between the reoperation incidence in the mitral position becomes insignificant (Björk-Shiley 0.85% py; Carpentier-Edwards 0.29% py; p = 0.085). This study confirms the satisfactory performance of both the Carpentier-Edwards and Björk-Shiley valves in the short and middle term and indicates no clear-cut advantage for either prosthesis.
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Lung tumours of non small cell pathology were cultured by clonogenic assay in several media. Culture was successful in spleen conditioned medium, but only 57% grew and low plating efficiencies (PE) meant that only 23% of the original number produced significant drug results. Comparison of rat erythrocyte lysate (REL) medium with serum free defined medium (HITES) and HITES + 10% FBS demonstrated clear enhancement of PE in REL although growth was 100% successful in all these media. Ninety-three percent of samples tested against drugs in REL produced significant results. A later comparison of REL with McCoy's 5A + rbc +/- hydrocortisone produced relatively poor culture success for these 3 media and equivocal growth patterns. Low PE was attributed to age of rats used for rbc. Vindesine and cis-platinum cytotoxicity in spleen conditioned medium were 61% and 15% sensitivity respectively. These do not concur with clinical experience but the figures for overt resistance, at 39% and 69%, correspond with expected non-responders to these regimes. Drug testing in REL produced figures correlating more closely with clinical performance at 45% sensitivity to platinum and 36% of patients sensitive to both drugs, but the vindesine sensitivity at 55% is again discrepant with performance of this drug as a single agent.
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A 63-year-old man was admitted to the Cardiothoracic Department of Glasgow Royal Infirmary for surgical treatment of a left suprahilar opacity. A left pneumonectomy was required to deal with an extensive upper lobe tumor. Histopathological examination, in addition to a moderately well-differentiated squamous cell carcinoma, revealed the presence of a band-like infiltrate of plasma cells and lymphoplasmacytoid cells at the main bronchial resection margin. Immunohistochemical studies confirmed this to be an extramedullary plasmacytoma by showing IgA and kappa positive monotypic cells. No paraprotein was detected in the serum. The value of immunohistochemistry in the differential diagnosis has been emphasized.
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Sixty-six patients with lung cancer underwent mediastinal staging with gallium scanning, CT scanning and mediastinal exploration at mediastinoscopy and/or thoracotomy. Histological findings at time of mediastinal exploration were correlated with the results of the non-invasive staging scans. Gallium scanning had an accuracy of 78.8 per cent and CT scanning had an accuracy of 77.3 per cent. There was no evidence of increased test accuracy by performing both scans in the same individual. Either scanning technique may be utilised as a simple non-invasive mediastinal staging procedure, and where negative it is appropriate to proceed directly to thoracotomy.
The indications for intra-aortic balloon pumping vary widely from country to country and from one cardiac surgical unit to another. Its use in Glasgow from 1976 to 1983 in 63 patients has been reviewed. Six of the patients (9.5%) had the intra-aortic balloon inserted before cardiac surgery, 43 (68.2%) at the time of surgery, and 14 (22.2%) in the postoperative period. Of the 63 patients, 11 could not be weaned from cardiopulmonary bypass despite intra-aortic balloon pumping, and died in the operating room. A further 35 patients had intra-aortic balloon pumping but died in the immediate postoperative period. Seventeen patients (27%) survived from six weeks to 3.3 years after receiving the support of intra-aortic balloon pumping. There was major morbidity in 11 patients (17%), all of whom developed degrees of ischaemia due to ileofemoral arterial obstruction in the leg in which the balloon was inserted. The conservative use of the method in this centre is reflected in the high mortality of these patients.
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Over the past 9 years, ten patients have presented to the Thoracic Unit, Glasgow Royal Infirmary, with 12 empyemas secondary to intra-abdominal sepsis. In eight patients, the presenting signs and symptoms were wrongly attributed to primary intra-thoracic pathology. All were subsequently found to have intra-abdominal sepsis. The presence of empyema after recent abdominal surgery or abdominal pain strongly suggests a diagnosis of ipsilateral subphrenic abscess. Adequate surgical drainage is essential. In our experience, limited thoracotomy with subdiaphragmatic extension offers the best access to both pleural and subphrenic spaces and provides the greatest chance of eradicating infection on both sides of the diaphragm.
Fifteen patients with extravalvular aortic root infection and associated infective endocarditis underwent urgent operation for this condition at Glasgow Royal Infirmary between 1977 and 1983. Four patients (26.7%) subsequently died between 1 and 68 months after operation. All patients underwent aortic valve replacement, with debridement or suture closure of abscess cavities as indicated. Three patients also required insertion of permanent pacing systems for complete heart block. Three other patients required further surgical intervention. Aortic valve rereplacement was done on two occasions in 1 patient and repair of a periprosthetic leak in the second patient; the third required one additional procedure to close an aorto-right atrial fistula postoperatively. Ten out of 11 survivors are in New York Heart Association Class I, and the remaining patient is in Class II. Aggressive surgical therapy without the need for complicated reconstructive procedures of the aortic root is effective in the management of extravalvular aortic root infections.
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