Inhaled iloprost controls pulmonary hypertension after cardiopulmonary bypass

PURPOSE: Severe pulmonary hypertension (PH) is a major cause of right ventricular (RV) dysfunction. Various iv vasodilator modalities have been used with limited results because of lack of pulmonary selectivity. The aim of the present controlled study was to evaluate the efficacy of inhaled iloprost, a synthetic prostacyclin analogue, in patients with elevated pulmonary vascular resistance (PVR) immediately after separation from cardiopulmonary bypass (CPB). METHODS: Twelve patients with persistent PH after discontinuation of CPB were included in the study. In all patients standard hemodynamic monitoring was used. Inhaled iloprost was administered via nebulized aerosol at a cumulative dose of 0.2 micro g*kg(-1) for a total duration of 20 min. Complete sets of hemodynamic measurements were performed before inhalation (baseline), during and after cessation of the inhalation period. Echocardiographic monitoring of RV function was also used. RESULTS: Inhaled iloprost induced a reduction in the transpulmonary gradient at the end of the inhalation period in comparison to baseline (9.33 +/- 3.83 mmHg vs 17.09 +/- 6.41 mmHg, P < 0.05). The mean pulmonary artery pressure to systemic artery pressure ratio decreased over this period (0.28 +/- 0.08 vs 0.45 +/- 0.17, P < 0.05). A statistically significant decrease of the PVR to systemic vascular resistance ratio was also observed (0.15 +/- 0.05 vs 0.21 +/- 0.05, P < 0.05). Improved indices of RV function were observed in echocardiographic monitoring. CONCLUSION: Inhaled iloprost appears to be a selective pulmonary vasodilator and may be effective in the initial treatment of PH and the improvement of RV performance in the perioperative setting.     

Case-control study between extrapleural pneumonectomy and radical pleurectomy/decortication for pathological N2 malignant pleural mesothelioma.

OBJECTIVE: To compare the outcomes of extrapleural pneumonectomy (EPP) and radical pleurectomy/decortication (P/D) for N2 malignant pleural mesothelioma (MM). PATIENTS AND METHODS: In a retrospective case-control study we analysed the results of the 57 patients [49 male and 8 female, median age 59 (range 14-70) years] who underwent radical surgery for MM found to have pathological N2 disease over a 7-year-period. EPP was performed on 45 and P/D on 12 patients. Prognostic factors, postoperative course, pathological data and postoperative survival were analysed. RESULTS: Those in the P/D group were significantly older (median age 62 vs 58 years, p=0.03) than in the EPP group. There was no difference in postoperative hospital stay (p=0.1) nor T stage (p=0.7) between the groups. There were no significant differences in the proportion of patients undergoing some adjuvant therapy in each group (p=0.2). Mean survival from diagnosis was 15 months in the EPP group and 16 months for those who underwent P/D (p=0.4). CONCLUSIONS: Preservation of the lung during radical surgery for N2 MM does not compromise survival even in an older group population. We therefore now have ceased to perform EPP in cases of N2 disease and we make every effort to accurately stage patients with mediastinoscopy to identify them.     

Recurrent venous thrombosis following free flap surgery: The role of heparin-induced thrombocytopenia

Complications following free tissue transfer have been well established in the literature. Common and rare causes of free flap failure must be addressed by the treating surgeon when microvascular patency is threatened. With the evolution and prevalence of microsurgery, ‘rare’ causes of free flap failure will become increasingly frequent. A high index of suspicion must be established in patients with multiple failed operative interventions. A case of recurrent free flap failure secondary to heparin-induced thrombocytopenia is presented in a patient with a history of squamous cell carcinoma of the floor of the mouth, and a long-standing history of alcohol and tobacco consumption.     

Evaluation of the effects of elastic compression in patients with postphlebitic limbs by laser-Doppler flowmetry

Laser-Doppler flowmetry has been used to study the skin microcirculation in 20 normal limbs and 80 limbs of patients with venous hypertension and leg ulceration due to deep venous reflux. It was found that limbs with venous hypertension had a high skin resting blood flow (BRF) and an impaired veno-arteriolar reflex (VR). There was a marked improvement in both BRF and VR after elastic compression for three weeks and an association between this improvement and the rate of healing of the leg ulcers. The results indicate that elastic compression may affect the microcirculation even though it does not alter the venous pressure measurements when the elastic stockings are removed.     

Treatment of chronic sialadenitis by intraductal penicillin or saline.

PURPOSE: We sought to describe the treatment of chronic sialadenitis by intraductal penicillin or saline. PATIENTS AND METHODS: The study group consisted of 32 males and 23 females with chronic submandibular sialadenitis aged 12 to 65 years and 16 males and 11 females with chronic parotitis aged 8 to 65 years who were treated by intraductal instillation of penicillin or saline. RESULTS: In the patients with submandibular sialadenitis, 44 patients treated with penicillin and 11 treated with saline became symptom free; symptoms recurred in 3 treated with penicillin, of whom 2 became symptom free after further instillations and 1 after removal of a sialolith at the ductal orifice; and follow-up of 22 patients verified that 18 treated with penicillin and 4 with saline had been symptom free for 1 to 15 years and 1 to 3 years, respectively. In the patients with parotitis, 18 patients treated with penicillin, 8 treated with saline, and 1 treated with both became symptom free; symptoms recurred in 1 treated with penicillin and 1 with saline, both of whom became symptom free after further instillations; and follow-up of 15 patients verified that 11 treated with penicillin, 3 with saline, and 1 with both had been symptom free for 1 to 14 years, 2 to 12 years, and 3 years, respectively. CONCLUSION: The intraductal instillation of penicillin or saline is a simple and surprisingly successful technique for the treatment of chronic sialadenitis.     

Objective noninvasive evaluation of venous surgical results

The hemodynamic effect of conventional surgery for varicose veins has been evaluated with a new method of air-plethysmography. The functional venous volume of the leg, venous reflux, and calf muscle pump-ejecting capacity have been measured in 42 legs with primary varicose veins. The patients were studied clinically, with Doppler ultrasound, duplex scanning, and phlebography preoperatively. Doppler ultrasound was repeated postoperatively. Air-plethysmography was performed one day before surgery and 8 to 10 days after surgery. A decrease of the functional venous volume of 16% has been observed (p less than 0.001). The abolition of venous reflux has been shown in all the patients. An improvement in the calf muscle pump-ejecting capacity has also been shown, with a 30% increase of the ejection fraction of the calf muscle pump and with a 43% decrease of the residual volume fraction after 10 tiptoe movements (p less than 0.001). The results indicate that this new method of air-plethysmography apart from its diagnostic value offers a new and unique technique for a noninvasive, objective, and quantitative evaluation of the results of established and experimental venous surgery.     

Prolactin,growth hormone and insulin-like growth factor-l in newborn children of smoking mothers*

OBJECTIVE Since maternal smoking causes fetal circulatory abnormalities, as well as disturbances of the maternal endocrine equilibrium, we measured the PRL, hGH and insulin-like growth factor-l (IGF-I) concentrations in the cord and venous blood of neonates of smoking mothers to determine whether or not the tobacco smoke affects the endocrine status of the neonate. DESIGN The above hormones were measured in the cord blood of the newborns of both smoking and non-smoking mothers. Also, PRL and hGH were determined at 24 and 72 hours after birth in newborns of both groups. PATIENTS Fifty-three newborns of smoking and 47 newborns of non-smoking mothers were investigated. Seventeen of the newborns of the smoking and 21 of the nonsmoking mothers were preterm. The remainder were full-term. MEASUREMENTS PRL was measured with a solid-phase immunoradiometric assay, hGH with a solid-phase two-site immunoradiometric assay and IGF-I with a solid-phase radioimmunoassay after extraction with acid-etha-nol. RESULTS The median value of PRL in the 17 preterm newborns of smoking mothers was 4941 mU/l (range 1322-7230), whereas in the 21 preterm newborns of nonsmoking mothers it was 2013 mU/l (range 243-4740) (P = 0 0002). The median hGH value in the above subjects was 1020 mU/l (range 35 2-208 4) and 59 8 mU/l (range 11 6-134-2), respectively (P = 0 0039). The median IGF-I was 580 7 U/l (range 253 2-4851 1) and 530 6 U/l (range 239 6-3591 5), respectively (P = 0 429). In the 36 full-term newborns of smoking mothers the median PRL value was 5171 mU/l (range 2074-7530), whereas in the 26 full-term newborns of non-smoking mothers it was 5081 (range 244-6540) (P = 0 048). The median hGH was 69 6 mU/l (range 42 3-280 0) and 32 2 mU/l (range 6 2-200 0), respectively (P = 0 0031). Also, the median IGF-I value was 926 3 U/l (range 348 5-5344 7) and 462 1 U/l (range 250 2-1578 7), respectively (P = 00024). On the 3rd day the PRL in the preterm neonates of both smoking and non-smoking mothers showed the same 16-5% drop, and thus the difference between the groups was maintained. A similar reduction in the hormone levels was observed in the full term neonates. CONCLUSIONS The findings indicate that the maternal tobacco-smoking causes disturbances of the endocrine status of the fetus, as shown by the increased levels of PRL, hGH and IGF-I, which are more pronounced between 30 and 37 weeks of gestation than at term.