Arterial line filtration during cardiopulmonary bypass. Neurologic, neuropsychologic, and hematologic studies

One hundred patients who underwent elective cardiac operations were randomized into two groups. Group 1 had a 20 micron nylon screen filter in the arterial line. In Group 2 no filter was used in the arterial line. Neurologic and neuropsychologic examination of the patients was performed with seven psychometric tests of the Wechsler Memory Scale and the Wechsler Adult Intelligence Scale. These tests were conducted before and a mean of 10 days after the operation. Platelet counts and hemoglobin and total protein levels were measured at the onset and at the end of cardiopulmonary bypass. Two patients died during their hospital stay. Neurologic damage with focal signs was found in the postoperative examination in six patients (three in each group). Twenty-eight patients (28.5%) exhibited signs of mild cerebral dysfunction as assessed by the presence of archaic (primitive) reflexes. Fifteen were in Group 1 and 13 in Group 2 (no significant difference). Sixty patients (61%) had decrements greater than one standard deviation in at least one of the three tests that showed most decreased postoperative scores. There were 32 in Group 1 and 28 in Group 2 (no significant difference). When each test was analyzed individually, there were no significant differences between the two groups. Platelet counts decreased, during cardiopulmonary bypass, a mean of 33% in Group 1 and 34.5% in Group 2 (no significant difference). Both hemoglobin and total protein levels remained virtually unchanged. These results indicate that the addition of a small-pore filter in the arterial line does not prevent the neurologic and neuropsychologic disturbances frequently encountered after cardiopulmonary bypass. The filter itself does not appear to have a direct effect on the blood components. Routine use of an arterial line filter remains questionable.     

Nocardiosis pulmonar en pacientes con EPOC: características y factores pronósticos

Introduction

Pulmonary nocardiosis (PN) is a severe infection with a high morbidity and mortality that mainly affects immunocompromised patients. In recent years, an increase in PN cases has been detected among patients with chronic obstructive pulmonary disease (COPD). The factors that are associated with its presence and determine its prognosis remain unknown.

Methods

Retrospective study of COPD patients diagnosed with PN over the period from 1997-2009 at the Hospital de la Santa Creu i Sant Pau, in Barcelona (Spain). Demographic, clinical, microbiological and evolution data were evaluated in all cases

Results

Thirty patients were identified with PN and COPD. Mean age (standard deviation) was 76 (7) years and the mean FEV₁ was 40 (14)%. Chronic respiratory failure was observed in 56,7% patients and 51,7% had received systemic corticosteroid therapy previous to the PN diagnosis. The most common symptoms were cough and dyspnea (90%). Alveolar infiltrates were observed in 60% of the cases. The most frequently isolated Nocardia species was N. cyriacigeorgica (68%). The one-month mortality rate was 17%, while the one-year mortality rate was 33%. The factors associated with mortality within the first year included previous systemic corticosteroid treatment, less than three months of specific antibiotic therapy and active associated neoplasm.

Conclusions

PN affects patients with moderate-severe COPD and has high short- and mid-term mortality rates. Previous corticosteroid treatment, specific antibiotic therapy for less than 3 months and active neoplasia were factors associated with mortality.     

Robotic versus laparoscopic adrenalectomy: a comparative study in a high-volume center

Background

Minimally invasive surgery has become more popular in recent years. The da Vinci^® robot is one of the new technologies the use of which has gained popularity in a host of different specialties. Originally used in cardiac surgery, marked increases in utilization have been seen in urology, gynecology, and thoracic surgery. Use in general surgical procedures has now become more common. The objective benefits of the robot are unclear compared to those of laparoscopy in many procedures. The aim of this study was to assess the benefits and disadvantages of robot-assisted laparoscopic surgery for adrenalectomy in a high-volume center compared to routine laparoscopic techniques.

Methods

We conducted a retrospective study including consecutive patients who underwent minimally invasive adrenalectomy in a tertiary referral center at the University of Alabama Birmingham. Demographic, clinical, histopathological, and surgical variables were recorded. Patients were divided in two groups: laparoscopic adrenalectomy (LA) and robot-assisted adrenalectomy (RA). Groups were compared using the χ² test for categorical variables and Student’s t-test for continuous variables. Significance was considered p < 0.05.

Results

Sixty patients were included, with 30 patients in each group. There were no significant differences between groups with respect to demographic variables except there were more pheochromocytoma patients in the LA group than in the RA group (13/30 vs. 5/30, respectively; p = 0.02). This study demonstrated increased operative time in the robotic group (190 ± 33 min) versus the laparoscopic group (160 ± 41 min) (p = 0.003). There was a trend for less blood loss in RA versus LA (30 ± 5 ml vs. 55 ± 74 ml; p = 0.07). There was no mortality. Morbidity and length of hospital stay were similar for both groups.

Conclusions

Robotic adrenalectomy is as safe and technically feasible as laparoscopic adrenalectomy. Subjective benefits for the surgeon with robot-assisted surgery include three-dimensional operative view, ergonomically comfortable position, and elimination of the surgeon’s tremor. The operating time is significantly longer but patient outcomes are similar to those of the laparoscopic technique.     

Hereditary gastric cancer. Genetics and clinical management

Recently, germline mutations in the E-cadherin/CDH1 gene have been identified in families with an autosomal-dominant inherited predisposition to gastric cancer of the diffuse type. Criteria to define familial gastric cancer syndromes have been proposed and include review of the histopathology and pedigree analysis of any family with an aggregation of gastric cancer cases. Of families with two or more cases of diffuse gastric cancer in first- or second-degree relatives < 50 years of age or three or more cases at any age, up to half may be attributable to inherited germline mutations in the E-cadherin/CDH1 gene. Cumulative lifetime risk of developing gastric cancer in CDH1 mutation carriers is 70%, women from these families also have increased risk for developing lobular breast cancer. Prophylactic gastrectomies have been performed in several unaffected CDH1 mutation carriers; despite normal endoscopic examinations and negative gastric biopsy specimens, pathologic foci of early gastric cancer were found in all surgical specimens. Based on these results, guidelines for genetic testing, counseling and management of individuals with hereditary diffuse gastric cancer have been proposed. Raised awareness among the physician community regarding this syndrome may allow for increased detection and prevention of gastric and breast cancers in these high-risk individuals.