Bruce Ferguson

After more than a decade of experimental and clinical research into the basic mechanisms underlying atrial fibrillation, we were able to develop a surgical procedure that appears to cure the arrhythmia. This surgical procedure has been used in 100 patients in our institution and in a total of approximately 130 patients by surgeons in other institutions. The surgical results have been excellent, which indicates the sophisticated electrophysiologic mapping systems are unnecessary and that the results are not surgeon-specific.

The present study examined the response of children to a stressor condition. Urine samples were collected from 38 children between ages 10 and 12 preceding a class presentation and again one week later, when no unusual event was occurring. Cognitive tasks and a state anxiety inventory were administered on both occasions. Personality and stressor situation inventories (hypothesized antecedent factors) were completed. Bidirectional changes in catecholamine levels were demonstrated (adrenalin: 55% of the children showed an increase, 29% a decrease; noradrenalin: 47% increase, 40% decrease; 3-methoxy-4-hydroxyphenethylene glycol: 40% increase, 42% decrease). Distinct differences in gender distribution and cognitive performance were demonstrated for the increase and decrease subgroups. It was suggested that both increases and decreases in catecholamine levels represent responses to the stressor situation, with an increase representing an adaptive response and a decrease representing a less adaptive response.

Ischemic heart disease remains the most common cause of death in developed countries. Significant advances have been made in the treatment of coronary artery disease (CAD), resulting in several options for medical, percutaneous and surgical therapies. The goals of treatment must be rigorously upheld when considering the optimal therapy for each patient with CAD, which include anginal relief, improved quality

Infections are the most common noncardiac complication after cardiac surgery, but their incidence across a broad range of operations, as well as the management factors that shape infection risk, remain unknown. This study sought to prospectively examine the frequency of post-operative infections and associated mortality, and modifiable management practices predictive of infections within 65 days from cardiac surgery. This study enrolled 5,158 patients and analyzed independently adjudicated infections using a competing risk model (with death as the competing event). Nearly 5% of patients experienced major infections. Baseline characteristics associated with increased infection risk included chronic lung disease (hazard ratio [HR]: 1.66; 95% confidence interval [CI]: 1.21 to 2.26), heart failure (HR: 1.47; 95% CI: 1.11 to 1.95), and longer surgery (HR: 1.31; 95% CI: 1.21 to 1.41). Practices associated with reduced infection risk included prophylaxis with second-generation cephalosporins (HR: 0.70; 95% CI: 0.52 to 0.94), whereas post-operative antibiotic duration >48 h (HR: 1.92; 95% CI: 1.28 to 2.88), stress hyperglycemia (HR: 1.32; 95% CI: 1.01 to 1.73); intubation time of 24 to 48 h (HR: 1.49; 95% CI: 1.04 to 2.14); and ventilation…

... Nelson, HE (1980). Analysis of spelling errors in normal and dyslexic children. In U. Frith (Ed.), Cognitive processes in spelling (pp. ... Neuropsychological significance of phonetically accurate and phonetically inaccurate spelling errors in younger and older retarded spellers. ...

Fractional flow reserve-guided coronary artery bypass grafting is emerging in cardiac surgery, in which the nature (anatomic and functional characteristics) of the target vessel epicardial coronary artery stenosis is important in graft site selection. The nature of the stenosis might determine a different physiologic response to bypass grafting. We report our recent experience using near infrared fluorescence complex angiography and perfusion analysis to identify the nature of stenoses in the target vessel by imaging the physiologic response to grafting. In 167 patients who underwent consecutive multivessel coronary artery bypass grafting cases (63% off-pump coronary artery bypass grafting) with traditional anatomy-based revascularization, we imaged and analyzed 359 grafts (53% arterial). This platform provides angiographic data of both the target vessel epicardial coronary artery and graft simultaneously (to assess the imaged competitive flow); and because a change in fluorescence intensity is proportional to the change in blood flow and perfusion, the quantified change (if any) in regional myocardial perfusion surrounding the grafted target vessel epicardial coronary artery. The patient outcomes in our series were excellent. All 359 grafts were widely patent by angiography, and 24% of the arterial and 22% of the saphenous vein grafts showed no regional myocardial perfusion change in response to bypass grafting. In 165 in situ internal mammary artery grafts to the left anterior descending artery (>70% stenosis), 40 had no change in regional myocardial perfusion, and 32 of the 40 had competitive flow imaged. An important number of angiographically patent bypass grafts demonstrated no change in regional myocardial perfusion, suggesting anatomic, but nonfunctional, stenoses in those target vessel epicardial coronary arteries. In in situ arterial grafts, imaged competitive flow is associated with nonfunctional stenoses in the target vessel epicardial coronary artery. Imaging these physiologic responses to target vessel revascularization might be useful in the emerging fractional flow reserve-guided era.

Valvular endocarditis occurring in patients with dialysis-dependent renal failure increases the risk of mortality following valve surgery, but few specific data are available to guide surgical selection. The study aim was to develop a simple risk scoring system to identify high-risk dialysis patients undergoing valve surgery for endocarditis. Using STS data from between January 1994 and December 2003, a total of 1,862 valvular procedures was recorded in dialysis patients with endocarditis. Isolated mitral procedures were performed in 718 patients, isolated aortic in 656, double valves in 386, isolated tricuspid in 55, and triple valves in 47. Logistic regression analysis was performed relating baseline variables to hospital mortality. Points were assigned to each significant risk factor by rounding regression coefficients to integers. An estimate of risk was obtained for each patient by averaging the predicted mortality among all patients having the same number of total points. In the logistic regression, significant variables (all p < 0.001) and effect estimates (odds ratios; points) were: cardiogenic shock or salvage status (2.77; 3), double valve (2.37; 3), age > or = 60 years (2.02; 2), isolated mitral valve (1.89; 2), body surface area > 2.1 m2 (1.86; 2), arrhythmia (1.56; 1), active endocarditis (1.54; 1), and female gender (1.53; 1), with a C-statistic of 0.705. Mortality increased exponentially as a function of points, with operative mortality exceeding 70% at 10 points. The risk of mortality for dialysis patients having valve surgery for endocarditis is high, yet depends on a variety of factors. The proposed risk scoring system successfully discriminates between higher and lower risk patients, and could contribute to better decision making.

Advances in critical care medicine have allowed for improved care of patients requiring prolonged intensive care unit length of stay (prICULOS) after cardiac operations, yet little is known regarding their eventual outcomes. The purpose of this study was to examine short- and long-term outcomes in patients undergoing cardiac operations with prICULOS. All cases of coronary artery bypass grafting (CABG), aortic valve, mitral valve, and combined CABG/valve surgical procedures performed at a single institution from July 2002 to July 2007 were identified. All-cause mortality in patients discharged alive from the hospital was determined until December 2007 through linkage with the Social Security Death Index. Patients who experienced intraoperative death or those with missing or invalid social security numbers were excluded. The definition of prICULOS was total ICULOS greater than 7 days. A total of 3,478 patients met inclusion criteria. One hundred thirty-seven of three thousand four hundred seventy-eight patients (3.9%) experienced prICULOS. These patients were more likely to be older than 70 years (55.5% versus 30.5%; p<0.0001) and to have had recent myocardial infarction (28.5% versus 20.1%; p=0.02), previous cardiac operation (18.3% versus 6.9%; p<0.0001), and emergent status (9.5% versus 1.6%; p<0.0001). They experienced greater in-hospital mortality (37.2% versus 1.7%; p<0.0001) and those who were discharged alive had worse long-term survival (log-rank, p<0.0001). After risk adjustment, prICULOS emerged as a significant predictor of in-hospital death (odds ratio [OR] 20.9; 95% confidence interval [CI], 12.9-33.7) and decreased long-term survival (hazard ratio [HR] 2.9; 95% CI, 2.0-4.3). Patients with prICULOS after cardiac operations have worse overall outcomes. These data may be used to inform these patients and their families of realistic expectations regarding their clinical course.

Cardiovascular disease is the leading cause of morbidity and mortality in patients on hemodialysis. To our knowledge, no studies have examined long-term outcomes of hemodialysis patients following coronary artery bypass grafting (CABG) in a predominately rural, low-income, and racially dichotomous population. Long-term survival of hemodialysis patients undergoing non-emergent, isolated CABG was compared with non-hemodialysis patients. Survival probabilities were computed using the Kaplan-Meier product limit method and stratified by hemodialysis. Hazard ratios (HR) and 95% confidence intervals (95%CI) were computed using a Cox regression model. Hemodialysis patients (n=220) had shorter long-term survival than non-hemodialysis patients (median survival=3.3 versus 14 years, p<0.0001). The survival difference remained statistically significant after adjusting for clinically relevant variables (HR=5.2, 95%CI=4.4-6.2). Hemodialysis patients had significantly shorter long-term survival ...

Intraoperative assessment of graft anastomoses is commonly performed after off-pump coronary artery bypass grafting (OPCAB). The SPY imaging system allows intraoperative graft assessment. We document correlation between intraoperative SPY images and wall motion abnormality by transesophageal echocardiogram (TEE) during OPCAB. A 79-year-old female underwent OPCAB. Intraoperative graft patency assessment was performed with the SPY and left ventricular wall motion was assessed by TEE. SPY imaging demonstrated poor flow trough the distal vein graft anastomosis to the posterior descending artery, which correlated with a new posterior wall motion hypokinesis. After graft revision, SPY imaging demonstrated good distal flow and the TEE demonstrated normalization of the left ventricular posterior wall motion. SPY technology allows the surgeon to accurately assess graft patency intraoperatively and allows immediate correction of a technical problem.

The current study: (1) examined the relation between therapeutic alliance and changes in adolescent externalizing behavior in Multisystemic Therapy; (2) tested whether maternal depression mediates this relation; and (3) determined whether mothers' and clinicians' perceptions of the alliance differentially predicted outcomes. Alliance was rated near the end of the first month of treatment. At pre-, mid- and posttreatment, maternal depression and adolescents' externalizing behavior were assessed via mother reports, and by clinicians at pre- and posttreatment only. Mediational analyses showed that therapist-rated alliance was related to improvements in maternal depression, which, in turn, was associated with reductions in adolescent externalizing behavior as rated by mothers. There was no association between mothers' and therapists' perceptions of the therapeutic alliance.

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