Whole-body inflammation in trauma patients. An autopsy study

In a review of autopsy specimens and reports in 35 trauma cases, we found signs of generalized inflammation and tissue damage with increases in organ weights in organs not primarily injured. These abnormalities occurred independent of the time of death and were also found in patients who died of brain injury alone. The most pronounced signs of inflammation and increases in organ weights were found when the adult respiratory distress syndrome, hypovolemic shock, or multiple organ failure were the causes of death. These findings are similar to those found in several organs of rabbits after four hours of complement activation in combination with 20 minutes of hypoxia. Therefore, the autopsy findings in this series of trauma patients might represent the morphologic features of adult respiratory distress syndrome and multiple organ failure in an early, preclinical stage.     

Resorbable suture support for ventricular aneurysmectomy

The edge of tissue left after ventricular aneurysmectomy requires very careful placement and tying of the sutures. The use of Teflon felt as a support appears to redistribute the pressure and thus prevent the sutures from cutting through the vulnerable tissue. In many cases, Teflon felt reinforcement is preferred to direct unsupported closure because of perioperative of immediately postoperative bleeding complications. However, the unavoidable full immobilization of the sutured area, the possible risk of foreign body infection, and the extensive adhesions and calcification in the long term compelled us to search for a better alternative, combining the convenience of both methods and limiting the risks. PDS (polydioxine) resorbable pledgets and strips, provided by Ethicon GmbH, were used as a suture support during the past 2 years for closure of 29 ventricular aneurysmectomies and four ischemic ventricular septal defects, all except one in combination with coronary bypass grafting. The PDS material was easy and efficient to apply and caused no complications during and after the operation. In one case, we had the opportunity to review the supported scar during a second operation for new coronary grafts after 18 months. The formerly feared "linear scar petrification," usual after use of Teflon felt, was absent. The scar was free from difficult adhesions. Our initial experience suggests the further extensive use of this resorbable material as a support for various sutures at risk.     

Serum adipokines and low density lipoprotein subfraction profile in hypopituitary patients with growth hormone deficiency

The aim was to evaluate the concentrations of lipid subfractions in relation to adipokines and metabolic parameters in adult growth hormone (GH)-deficient hypopituitary patients on conventional replacement therapy. The study included 21 GH deficient-hypopituitary patients (age: 36.0 ± 15.1 years, male/female: 7/14) on conventional replacement therapy other than GH and 20 comparable controls (age: 37.3 ± 14.0 years, male/female: 6/14). Lipid subfractions (Lipoprint system), serum adipokine (leptin, adiponectin, resistin) concentrations, body composition, a surrogate marker for insulin resistance (HOMA) and conventional lipid profile were evaluated. No statistically significant difference was found with respect to HOMA, adipokine concentrations and anthropometric parameters between patients and controls except for significantly increased waist-to-hip ratio in hypopituitary group. Total and LDL cholesterol concentrations were significantly higher in the patients. LDL particle size (268.88 ± 3.16 vs. 271.31 ± 3.11 ?, P = 0.151) and small-dense LDL subfraction did not differ significantly. According to logistic regression analysis, triglyceride concentrations ≥1.69 mmol/L was the sole parameter significantly and independently predicted small (<268 ?) LDL particle size (P = 0.019) in the whole group. Increased triglyceride concentrations affect LDL particle size in GH-deficient hypopituitary patients. Small dense LDL seems not directly contribute to atherogenic potential in hypopituitarism.     

Mast cell corticotropin-releasing factor subtype 2 suppresses mast cell degranulation and limits the severity of anaphylaxis and stress-induced intestinal permeability

1. Download : Download high-res image (382KB)
2. Download : Download full-size image

     

Cardiac events after combined surgery for coronary and carotid artery disease

Objective: To evaluate serious cardiac events after combined (either single or two stage) coronary artery surgery (CAS) and carotid endarterectomy (CEA) for concomitant coronary and carotid artery disease. Methods: We have analyzed our 15 year experience (January 1981–September 1996) with 201 consecutive patients operated on using both approaches. Group A consisted of 48 patients with the single-stage procedure, while in group B (153 patients), two stage procedure was carried out, either as carotid endarterectomy (CEA), followed by coronary artery bypass surgery (CAS) (group B₁⁻ 103 patients), or as CAS followed by CEA (group B₂⁻ 50 patients). Five patients from B₁ group died after the CEA procedure, but were included, despite the fact they never reached the second stage. Left main coronary artery disease was found in 41 patients (20.4%), poor left ventricular function in 49 (24.4%) previous MI in 133 (66.2%), while 136 (67.7%) were in NYHA functional class III or IV. Bilateral carotid involvement was present in 61 patients (30.3%). Unstable angina was more prevalent in groups A and B₂ (P<0.0001), NYHA class III/IV in group A (versus B₁, P=0.001 and versus B₂, P=0.02), low ejection fraction in groups A and B₂ (P<0.0001), bilateral carotid stenosis in group B₁ (versus A, P=0.003 and versus B₂, P<0.0001), and ulcerated plaque in group B₁ (P<0.0001). These differences dictated the surgical strategy, which resulted in different protocols for clinical and operative management. Results: Early mortality for the entire group was 5.5% (11/201) 6.2% in group A, 7.8% in group B₁ and 0% in group B₂, respectively; (P>0.05). Serious morbidity occurred in 7.5% of patients (8.3% in group A, 7.8% in group B₁ and 6% in group B₂, respectively; P>0.05). Univariate analysis revealed only bilateral carotid stenosis to influence early outcome (P=0.04). Conclusion: Patients with concomitant coronary and carotid artery disease have relatively good immediate operative results, providing all existing lesions are corrected. Despite it did not reach the statistical significance, cardiac events were less frequent in groups A and B₂ indicating possible protective effect of prior CAS in patients with concomitant disease.     

Renal angiomyolipoma with malignant transformation, simultaneous occurrence with malignity and other complex clinical situations

Renal angiomyolipoma is a benign kidney tumor, which is characterized by the presence of mature or immature fat tissue, thick-walled blood vessels, and smooth muscles. However, there is a rare possibility of transformation to a malignancy. This transformation could be toward sarcoma. And also angiomyolipoma could be associated with renal adenocarcinoma in the same kidney. The aim of this study is to show the association of angiomyolipoma with complex clinical situations such as malign transformation, simultaneous occurrence with adenocarcinoma, bilateral tumors with tuberous sclerosis or Wunderlich Syndrome. Findings of clinical presentation, pathological evaluation, urography, ultrasonography, and computerized tomography of 19 patients who were diagnosed angiomyolipoma in our clinic during 1994–2003 were examined retrospectively. Our records indicated that radical nephrectomy was performed in three cases of angiomyolipoma in which the differential diagnosis from adenocarcinoma could not be made and in another case of angiomyolipoma, which was associated with adenocarcinoma. Simple nephrectomy was performed in four symptomatic angiomyolipoma cases with tumor size larger than 4 cm and partial nephrectomy in another case. In one case, renal angiomyolipoma was associated with adenocarcinoma in the same kidney. In one case, post-operative recurrence of angiomyolipoma developed 7 months after nephrectomy. This patient was diagnosed low-grade leiomyosarcoma. Angiomyolipoma is regarded as a benign tumor of the kidney; however, it may also show aggressive behaviors and rarely transform to sarcoma. It may also exist in the same kidney along with adenocarcinoma or sarcoma.     

Partial Left Ventriculectomy and Limited Heart Transplantation Availability

BACKGROUND AND AIM: Partial left ventriculectomy, a novel cardiac volume reduction operation, is applied in countries without a developed heart transplantation program. We sought to determine its impact in our population of patients. METHODS: Partial left ventriculectomy was performed in 38 patients during the last 4 years. Basic inclusion criteria were nonischemic dilated cardiomyopathy and poor response to medical therapy for heart failure. Hemodynamic evaluation was carried out before and after operation. A modified surgical technique of mitral valve repair and ventricle suturing was applied. RESULTS: Thirty-day, 6-month, and 2-year survival rates were 82% +/- 7%, 65% +/- 8%, and 61% +/- 9%, respectively. Duration of heart failure symptoms was the only predictor of survival (p = 0.042). A high proportion of noncardiac causes of death was noted. Functional capacity in surviving patients improved at every successive measurement up to 1 year postoperatively. CONCLUSIONS: The introduction of partial left ventriculectomy in a country with limited heart transplantation availability had a great impact on the management of end-stage heart failure and may represent the only surgical option for some patients. The average cost per patient was substantially lower when compared to heart transplantation.