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OBJECTIVE: The aim of our study was to evaluate the role of magnetic resonance cholangiography (MRC) in the diagnosis of biliary tract complications (BC) after orthotopic liver transplantation (OLT). MATERIALS AND METHODS: Among 21 OLT patients who underwent routine follow-up MRC using a breath-hold T2-weighted turbo spin-echo sequence with half-Fourier acquisition (HASTE), 5 had an elevated serum alkaline phosphatase level. Diagnostic confirmation was obtained with endoscopic retrograde cholangiography (ERC) (n = 11), surgery (n = 3), or clinical and laboratory follow-up of at least 1 year (n = 8). RESULTS: In 13 patients, no abnormality of the biliary tract was detected using MRC. In 8 patients, anastomotic strictures were diagnosed, 7 of which were confirmed at surgery or using ERC. One patient with normal findings at MRC and abnormal liver function test results was found to have a stricture at ERC. All patients with normal MRC and liver function tests had 1 year of uneventful follow-up and were considered true-negative cases. We found that MRC had 87.5% sensitivity, 92.3% specificity, 87.5% positive predictive value, 92.3% negative predictive value, and 90.4% accuracy for the diagnosis of BC. CONCLUSION: MRC is a valuable examination to detect BC after OLT. It provides useful information for planning interventional procedures.

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PURPOSE: The purpose of this study is to determine whether the routine use of intraoperative surface aortic ultrasonography decreases the stroke rate in coronary artery bypass graft surgery (CABG). METHODS: One hundred ninety-five consecutive patients undergoing CABG between July 1, 1992, and June 30, 1993 (study group), were evaluated by intraoperative surface aortic ultrasonography. Based on information obtained, changes in the operative technique were made in an effort to decrease the incidence of embolic stroke from unsuspected atherosclerotic disease of the ascending aorta. The outcome of these patients was compared with that of 164 consecutive patients who underwent CABG between July 1, 1991, and June 30, 1992 (control group), in whom the ascending aorta was assessed by inspection and palpation only. RESULTS: Significant disease was detected in three (2.0%) of 164 patients in the control group. Modifications in their operative technique consisted of hypothermic fibrillatory arrest with no cross-clamping of the aorta and left ventricular venting in two patients and single cross-clamping in one patient. There were five strokes overall in this group (3.0%), and six patients died (3.6%), one in whom the stroke contributed directly to the cause of death. In the study group the ultrasonic findings were normal to mild in 168 patients, moderate in 20 patients, and severe in seven patients. These results led to a modification of the technique in 19 patients, (10%): hypothermic fibrillatory arrest with no cross-clamping of the aorta and left ventricular venting in 14 patients, modification in the aortic cannulation site or single cross-clamping in three patients, and modification in placement of proximal anastomoses or all arterial grafts in two patients. No strokes occurred in this group (p < 0.02, Fisher's exact test). Five patients died, for an operative mortality rate of 2.6%. CONCLUSION: These data indicate that intraoperative ultrasonography of the ascending aorta with simple modifications in operative technique reduces the stroke rate in CABG.

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During the double-blind, multicenter trials of the synthetic surfactant Exosurf Neonatal, we measured pulmonary mechanics at 28 days of age in 30 surfactant- or placebo-treated infants. In the 20 surfactant-treated and 10 air-treated infants studied, there were no differences in lung compliance or resistance at 28 days of age. These observations suggest that improvements in pulmonary function reported early in the neonatal course after the administration of exogenous surfactant are not detectable at 28 days of age.

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To determine whether a single prophylactic dose of synthetic surfactant would reduce mortality and morbidity rates, we performed a randomized, controlled trial of Exosurf Neonatal at 19 hospitals in the United States. The Exosurf preparation (5 ml/kg) was instilled into the endotracheal tube of premature infants weighing 700 to 1100 gm during mechanical ventilation, as soon as practical after birth. Control infants were treated with air (5 ml/kg). Dose administration was performed in secrecy by clinicians who did not reveal for 2 years what they had instilled. A total of 222 infants received air and 224 received the synthetic surfactant; 36 infants with congenital pneumonia or malformations were excluded from the primary efficacy analysis. By the age of 28 days, there were 44 deaths in the air group and 27 deaths in the surfactant group (p = 0.022). By the age of 1 year after term there were 61 deaths in the air group and 35 deaths in the surfactant group (p = 0.002). Although there was no reduction in the incidence of respiratory distress syndrome, a significant reduction in the number of deaths attributed to respiratory distress syndrome, a significant reduction in the incidence of pulmonary air leaks, and significantly lower requirements for oxygen and mean airway pressure indicated that lung disease was less severe in the Exosurf-treated infants. There were no significant differences in the incidence of complications such as bronchopulmonary dysplasia, intraventricular hemorrhage, patent ductus arteriosus, necrotizing enterocolitis, and infection. The results indicate that a single prophylactic dose of Exosurf, in high-risk premature infants treated soon after birth, reduces the number of deaths from respiratory distress syndrome and the overall mortality rate.

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Thirty-eight patients undergoing a cardiac operation randomly received either tranexamic acid, a potent inhibitor of plasminogen, or placebo in an effort to determine whether prophylactic antifibrinolytic therapy reduces chest tube drainage. Twelve-hour blood loss was 750 +/- 314 (standard deviation) ml in the placebo group and 496 +/- 228 ml in the drug group (p = 0.0057). Fibrin split products were present more frequently in patients in the placebo group (17 of 20 compared with four of 18 in the drug group; p = 0.0002). Tranexamic acid markedly decreased plasminogen availability (112 +/- 104 units in the placebo group versus 36 +/- 18 units in the drug group, p = 0.0058). Plasma fibrinogen concentrations were similar in the placebo and drug groups. Patients in the placebo group received more fresh-frozen plasma and more mediastinal shed blood than those in the drug group. No coagulation-related complication occurred in the group receiving tranexamic acid. We conclude that prophylactic tranexamic acid can be administered safely to inhibit fibrinolysis during cardiac operations, decrease postoperative bleeding, and possibly decrease the frequency of blood product transfusion.

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A two-stage epidemiologic survey was carried out on a probability sample of the population aged 4 through 16 years in Puerto Rico. The survey used the Child Behavior Checklist as a screening instrument, and prevalence rates were estimated on the basis of clinical diagnoses and other measures provided by child psychiatrists during the second stage. Maladjustment was operationally defined through the use of combined measures, including DSM-III diagnosis and a scale of functional impairment. Data were provided on the demographic correlates of maladjustment and on the comorbidity of DSM-III diagnostic domains. The prevalence rates obtained vis-à-vis the availability of mental health services on the island reflected a major public health problem.

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The correlation of transcutaneous bilirubin measurements with serum bilirubin concentrations is not good enough to allow for accurate prediction of the serum values. To impose the jaundice meter's potential clinical usefulness, we evaluated 344 paired jaundice meter-serum bilirubin measurements in 125 infants, using new guidelines from the marketing company which were designed to identify which infants require serum bilirubin determinations rather than to predict the actual bilirubin values. Use of the new guidelines correctly assessed the need for serum determinations in most infants, but false positives and, more importantly, false negatives (missed high serum values) did occur.

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