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Objective: To examine the feasibility of the modified gasless trans-subclavian approach endoscopic thyroidectomy for lateral neck dissection (LND) in papillary thyroid carcinoma (PTC). Methods: The clinical data of 31 patients with PTC who underwent modified gasless trans-subclavian approach endoscopic LND in the Department of Head and Neck Surgery, Run Run Shaw Hospital, from January to October 2022 were retrospectively analyzed. There were 2 males and 29 females, aged (32.6±8.3) years (range: 17 to 55 years). The maximum diameter of the primary thyroid lesion (M(IQR)) was 1.06 (1.16) cm (range: 0.53 to 2.44 cm), and the maximum diameter of the metastatic lymph node was (1.04±0.37) cm (range: 0.44 to 1.88 cm). Operation time, postoperative hospital stay, number of lymph nodes dissected, and postoperative complications were recorded. Outpatient follow-up was conducted until November 30, 2022. Results: All operations were successfully completed with the endoscopy approach without conversion to open surgery. The operation time was 160 (20) minutes (range: 100 to 215 minutes), and the postoperative hospital stay was 4 (2) days (range: 2 to 14 days). The number of lymph nodes obtained by dissection in the central and lateral compartment of the neck was 11 (12) (range: 0 to 37) and 34.7±14.8 (range: 15 to 69), respectively. Temporary hypoparathyroidism occurred in 4 cases and all recovered within 1 month after the operation. One case suffered from recurrent laryngeal nerve injury (continuing followed up to assess whether it is a temporary injury). The complication of LND included 1 case of chylous leakage that was recovered with conservative treatment, 1 case of Horner syndrome returned to normal 3 months after surgery. During follow-up, there was no residual tumor or recurrence. Conclusion: The modified gasless trans-subclavian approach endoscopic LND for PTC is feasible, with a thorough dissection and concealed incision.
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Carcinoma Papilar , Neoplasias de la Tiroides , Masculino , Femenino , Humanos , Cáncer Papilar Tiroideo/cirugía , Disección del Cuello , Neoplasias de la Tiroides/cirugía , Neoplasias de la Tiroides/patología , Estudios Retrospectivos , Carcinoma Papilar/cirugía , Endoscopía , TiroidectomíaRESUMEN
Objective: To examine the safety and feasibility of gasless submental-transoral combined appoach endoscopic thyroidectomy for papillary thyroid carcinoma (PTC). Methods: A retrospective analysis of the clinical data of 41 patients with PTC who underwent the gasless submental-transoral combined appoach endoscopic thyroidectomy at the Department of Head and Neck Surgery, Sir Run Run Shaw Hospital, Zhejiang University School of Medicine from November 2020 to April 2021. There were 5 males and 36 females with the age of (35.0±8.7) years (range: 19 to 58 years). A horizontal incision with a length of 2.0 cm is made under the chin as an observation hole, a 10 mm Trocar and a self-developed retractor are inserted, and two 5 mm longitudinal incisions are made on the labial side in the vestibule of the oral cavity as an operation hole, each inserting a 5 mm Trocar, the operation direction is from the cranial side to the caudal side. The sensation of the lower lip and chin was measured on the first day and one month postoperative. The operation time, hospital stay, the number of lymph nodes dissected and postoperative complications were recorded. Results: Surgical procedures in all cases were successfully completed under endoscopic approach without transfering to open surgery. The operation time was (99±34) minutes (range: 50 to 180 minutes) and the postoperative hospital stay was (3.4±2.2) days (range: 2 to 16 days). The maximum diameter of PTC was (7.6±5.8) mm (range: 2 to 30 mm), and the number of lymph nodes of the central compartment dissection was 6(5) (M(IQR)) (range: 1 to 25). The duration of follow-up is 1 month after operation, and the follow-up method is adopted in outpatient clinic. Postoperation complications included 2 cases of transient hypoparathyroidism, One case of recurrent laryngeal nerve injury (continue to follow up to assess whether it is a temporary injury). Postoperative minor chyle leak, seroma, and local redness and swelling in 1 case each were cured after conservative treatment. 1 case of transient minor numbness of the lower lip was observed. No permanent hypoparathyroidism, postoperative bleeding and numbness of the chin was observed. Conclusion: The gasless submental-transoral combined appoach endoscopic thyroidectomy is a feasible approach in selected PTC patients and has clinical application value.
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Neoplasias de la Tiroides , Tiroidectomía , Adulto , Endoscopía , Femenino , Humanos , Masculino , Persona de Mediana Edad , Disección del Cuello , Estudios Retrospectivos , Cáncer Papilar Tiroideo/cirugía , Neoplasias de la Tiroides/cirugía , Adulto JovenRESUMEN
OBJECTIVE: To assess the cost-effectiveness of mifepristone and misoprostol (MifeMiso) compared with misoprostol only for the medical management of a missed miscarriage. DESIGN: Within-trial economic evaluation and model-based analysis to set the findings in the context of the wider economic evidence for a range of comparators. Incremental costs and outcomes were calculated using nonparametric bootstrapping and reported using cost-effectiveness acceptability curves. Analyses were performed from the perspective of the UK's National Health Service (NHS). SETTING: Twenty-eight UK NHS early pregnancy units. SAMPLE: A cohort of 711 women aged 16-39 years with ultrasound evidence of a missed miscarriage. METHODS: Treatment with mifepristone and misoprostol or with matched placebo and misoprostol tablets. MAIN OUTCOME MEASURES: Cost per additional successfully managed miscarriage and quality-adjusted life years (QALYs). RESULTS: For the within-trial analysis, MifeMiso intervention resulted in an absolute effect difference of 6.6% (95% CI 0.7-12.5%) per successfully managed miscarriage and a QALYs difference of 0.04% (95% CI -0.01 to 0.1%). The average cost per successfully managed miscarriage was lower in the MifeMiso arm than in the placebo and misoprostol arm, with a cost saving of £182 (95% CI £26-£338). Hence, the MifeMiso intervention dominated the use of misoprostol alone. The model-based analysis showed that the MifeMiso intervention is preferable, compared with expectant management, and this is the current medical management strategy. However, the model-based evidence suggests that the intervention is a less effective but less costly strategy than surgical management. CONCLUSIONS: The within-trial analysis found that based on cost-effectiveness grounds, the MifeMiso intervention is likely to be recommended by decision makers for the medical management of women presenting with a missed miscarriage. TWEETABLE ABSTRACT: The combination of mifepristone and misoprostol is more effective and less costly than misoprostol alone for the management of missed miscarriages.
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Abortivos/administración & dosificación , Aborto Retenido/tratamiento farmacológico , Mifepristona/administración & dosificación , Misoprostol/administración & dosificación , Abortivos/economía , Aborto Retenido/economía , Adolescente , Adulto , Análisis Costo-Beneficio , Método Doble Ciego , Quimioterapia Combinada , Femenino , Humanos , Mifepristona/economía , Misoprostol/economía , Embarazo , Adulto JovenRESUMEN
During the period from late 2019 to early 2020, we performed a foodborne virus detection from shellfish collected in Singapore at retail level. Multiple human enteric viruses were included as our targets including human noroviruses (NoVs) GI and GII, hepatitis A virus, hepatitis E virus and rotavirus. Out of the 60 shellfish samples, 23 (38·3%) were detected to be positive by reverse transcription-quantitative polymerase chain reaction (RT-qPCR) with human enteric viruses. Six samples were selected to proceed with virome capture sequencing with positive control samples spiked with serially diluted NoV GII clinical samples in oyster extract. As a result, the natural sample with comparable Ct values (34·0-35·0) of the spiked sample as detected by RT-qPCR generated much lower read counts (>7-log2 cumulative sum scaling difference) and genome coverage (406 nt. vs 3715 nt.), suggesting that the RT-qPCR positive signals detected from the shellfish samples collected at the retail market were likely from degraded RNA derived from inactive virus particles.
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Norovirus , Ostreidae , Animales , Contaminación de Alimentos/análisis , Humanos , Norovirus/genética , ARN Viral/genética , Reacción en Cadena de la Polimerasa de Transcriptasa Inversa , Mariscos , Singapur , ViromaRESUMEN
Study question: What is the chance of clinical pregnancy when fallopian tube catheterization is used for proximal tubal obstruction? Summary answer: The pooled clinical pregnancy rate of tubal catheterization after proximal tubal obstruction is 27% (95% CI 25-30%). What is known already: Restoring fallopian tube patency by performing tubal catheterization has fallen out of favour since the increased availability of IVF. Our study is the first systematic review and meta-analysis to investigate reproductive outcomes following tubal catheterization for proximal tubal obstruction. Study design, size, duration: We undertook a systematic review and meta-analysis of 27 observational studies consisting of 1720 patients undergoing tubal catheterization for proximal tubal obstruction, who attempted to conceive naturally after the procedure. Participants/materials, setting, methods: Systematic literature searches were performed in MEDLINE, EMBASE and the Cochrane Central Register of Controlled Trials. A total of 2195 titles and abstracts were reviewed. Only studies that reported outcomes when tubal catheterization was performed with no other tubal surgery were included. Twenty-seven cohort studies matched the inclusion criteria for the meta-analysis. Main results and the role of chance: The meta-analysis showed a pooled clinical pregnancy rate of 27% (95% CI 25-30%) after the use of tubal catheterization for unilateral or bilateral proximal tubal obstruction (27 studies, 1556 patients). In women with bilateral obstruction (14 studies, 617 patients), the clinical pregnancy rate was 27% (95% CI 23-32%). Our meta-analysis demonstrated that the pooled cumulative clinical pregnancy rates were 22.3% (95% CI 17.8-27.8%) at 6 months, 25.8% (95% CI 21.1-31.5%) at 9 months, 26.4% (95% CI 23.0-30.2%) at 12 months, 26.0% (95% CI 22.8-29.7%) at 18 months, 27.0% (95% CI 24.0-30.5%) at 24 months, 27.9% (95% CI 24.9-31.3%) at 36 months and 28.5% (95% CI 25.5-31.8%) at 48 months. The pooled live birth rate (14 studies, 551 patients) was 22% (95% CI 18-26%). The pooled ectopic pregnancy rate (27 studies, 1556 patients) was 4% (95% CI 3-5%). The included studies scored satisfactorily on the Newcastle-Ottawa quality assessment scale. Limitations, reasons for caution: The pooled clinical pregnancy rate after tubal catheterization was found to be almost comparable to that after IVF. However, included studies were small, non-comparative series with significant clinical heterogeneity in population characteristics, follow-up and surgical equipment, technique and experience. Wider implications of the findings: These findings suggest fallopian tube catheterization as an alternative strategy to IVF in patients presenting with proximal tubal obstruction. Further research should focus on comparing different surgical techniques of fallopian tube catheterization with IVF and provide cumulative reproductive outcomes over long-term follow-up. Study funding/competing interest(s): No funding was required and the authors have no competing interests to declare. Registration number: N/A.
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Enfermedades de las Trompas Uterinas/cirugía , Infertilidad Femenina/cirugía , Índice de Embarazo , Adulto , Cateterismo/métodos , Femenino , Humanos , Embarazo , Resultado del TratamientoRESUMEN
In this study, the efficacies of short hairpin RNAs (shRNAs) targeting different regions of West Nile virus (WNV) strain Sarafend genome were investigated. Short hairpin RNAs targeting Capsid, NS2B and NS4B genes were cloned into pSilencer 3.1-H1 neo and designated as pshCapsid, pshNS2B and pshNS4B, respectively. Vero cells that were positively transfected were selected for creating stable cell lines expressing shRNAs constitutively. These cells were subjected to West Nile virus at multiplicity of infection (M.O.I.) of 10. The cells stably transfected with pshCapsid gave the best silencing effect among the three stable cell lines (transfected with pshCapsid, pshNS2B and pshNS4B) at both 12- and 24 h p.i. When compared to the non-transfected WNV-infected cells, pshCapsid stably transfected cells showed more than 4 log(10) unit reduction in viral transcripts and greater than 3 log(10) unit reduction in virus production. Cells stably transfected with pshNS2B did not exhibit as strong an inhibition when compared to the pshCapsid stably transfected cells having only 2 log(10) unit reduction in virus titre. The pshNS4B-stably transfected cells did not suppress WNV replication. Hence, from this study, pshCapsid has the potential to be developed into effective antiviral strategy for WNV infection.
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Vectores Genéticos , Interferencia de ARN , ARN Interferente Pequeño/farmacología , ARN Viral/metabolismo , Replicación Viral/efectos de los fármacos , Virus del Nilo Occidental/fisiología , Animales , Chlorocebus aethiops , ARN Interferente Pequeño/genética , ARN Interferente Pequeño/metabolismo , ARN Viral/genética , Transfección , Células Vero , Proteínas Virales/genética , Proteínas Virales/metabolismo , Virión/metabolismo , Virus del Nilo Occidental/genética , Virus del Nilo Occidental/metabolismoRESUMEN
Dengue virus (DV) is a flavivirus and its urban transmission is maintained largely by its mosquito vectors and vertebrate host, often human. In this study, investigation was carried out on the involvement of domain III of the envelope (E) glycosylated protein of dengue virus serotypes 1 and 2 (DV-1 and DV-2 DIII) in binding to host cell surfaces, thus mediating virus entry. Domain III protein of flavivirus can also serve as an attractive target in inhibiting virus entry. The respective DV DIII proteins were expressed as soluble recombinant fusion proteins before purification through enzymatic cleavage and affinity purification. The purified recombinant DV-1 and DV-2 DIII proteins both demonstrated the ability to inhibit the entry of DV-1 and DV-2 into HepG2 cells and C6/36 mosquito cells. As such, the DV DIII protein is indeed important for the interaction with cellular receptors in both human and mosquito cells. In addition, this protein induced antibodies that completely neutralized homologous dengue serotypes although not with the same efficiency among the heterologous serotypes. This observation may be of importance when formulating a generic vaccine that is effective against all dengue virus serotypes.
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Virus del Dengue/fisiología , Proteínas del Envoltorio Viral/fisiología , Internalización del Virus , Animales , Línea Celular , Culicidae/citología , Culicidae/virología , Virus del Dengue/metabolismo , Virus del Dengue/patogenicidad , Humanos , Ratones , Ratones Endogámicos BALB C , Estructura Terciaria de Proteína , Proteínas del Envoltorio Viral/metabolismoRESUMEN
RNA interference is one of the effective emerging anti-viral strategies to inhibit virus infection in cells. In this study, a small interfering RNA expressing vector (pSilencer-NS5) targeting the NS5 gene of West Nile virus (WNV) was employed to target and destroy WNV transcripts. Real-time PCR revealed drastic reduction in WNV RNA transcripts in pSilencer-NS5-transfected Vero cells. The virus infectious titre was also significantly reduced by 90% as determined by plaque assays. The resulting decrease in virus replication was shown to be specific since both scrambled and nucleotide(s) mismatch siRNA against WNV NS5 gene did not have any effect on WNV productive yields. Furthermore, Western immunoblot analysis on the expression of viral NS5 and envelope (E) proteins showed significant down-regulation on the expression of viral NS5 and envelope (E) proteins in virus-infected cells that were pre-transfected with pSilencer-NS5. These data clearly supported the notion that the expression of vector-based siRNA against WNV NS5 gene is able to exert its silencing effect on WNV-infected cells without inducing cytotoxicity, hence holding promise in therapeutic treatment of this important emerging infectious disease.
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Interferencia de ARN , ARN Interferente Pequeño/metabolismo , Proteínas no Estructurales Virales/biosíntesis , Replicación Viral , Virus del Nilo Occidental/fisiología , Animales , Chlorocebus aethiops , Citoplasma/química , Expresión Génica , Vectores Genéticos , Microscopía Electrónica de Transmisión , Microscopía Fluorescente , Estabilidad del ARN , ARN Mensajero/genética , ARN Mensajero/metabolismo , ARN Interferente Pequeño/genética , ARN Viral/genética , ARN Viral/metabolismo , Reacción en Cadena de la Polimerasa de Transcriptasa Inversa , Células Vero , Proteínas del Envoltorio Viral/biosíntesis , Proteínas no Estructurales Virales/genética , Replicación Viral/genética , Virus del Nilo Occidental/genéticaRESUMEN
Maintenance of cell architecture and positioning of organelles are major functions of the cytoskeleton. On the other hand, induction of heat shock proteins (HSPs) and reorganization of the cytoskeleton are the most significant changes in heat-shocked mammalian cells. We examine the alterations in HSP70 and its constitutively expressed cognate, HSC70, as well as the cytoskeleton and organelles in 9L rat brain tumor cells upon heat shock. We employed fluorescence microscopy and scanning electron microscopy to follow these changes. Levels of HSP70s were quantified by Western blotting. Accumulation of HSC70 was more transient and the protein translocated to and subsequently exited from the nucleus more rapidly than HSP70. Changes in actin microfilaments include the nuclear localization of actin fraction and disappearance of cytoplasmic microfilament bundles, while the cortical actin microfilaments were almost unaffected. Furthermore, microtubules retracted slightly from the cell periphery but remained largely unchanged. In contrast, the intermediate filaments collapsed into the perinuclear region. The mitochondria converted from filamentous into granular forms and clustered in a region overlapping with the collapsed intermediate filaments. All of the above alterations are reversible and largely reverted after 8 h of recovery. The effect on Golgi organization was very transient and the apparatus assumed a normal appearance within 4 h after the heat treatment. The ER, on the other hand, was totally unaffected by the heat treatment. These observations help correlate the sequential events following a stress like heat shock and suggest possible physiological functions of these essential constituents of a cell under stress.
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Citoesqueleto/fisiología , Proteínas HSP70 de Choque Térmico/metabolismo , Animales , Proteínas Portadoras/metabolismo , Núcleo Celular/metabolismo , Tamaño de la Célula , Retículo Endoplásmico/fisiología , Aparato de Golgi/fisiología , Proteínas del Choque Térmico HSC70 , Respuesta al Choque Térmico , Mitocondrias/fisiología , Orgánulos/fisiología , Ratas , Células Tumorales CultivadasRESUMEN
STUDY OBJECTIVES: With the improvements in video-assisted thoracoscopic surgery, more older patients and patients with respiratory impairments are undergoing bulla ablation using new and costly technology. We evaluated the cost-effective technique of thoracoscopic endoloop ligation of bullae in patients with bullous emphysema. PATIENTS: From March 1992 through January 1996, 79 advanced age (mean age, 64 years) and oxygen dependency patients underwent thoracoscopic procedure using endoloop ligation for treatment of bullous emphysema. Clinical data were collected from chart review. Only patients with radiographically confirmed diagnosis of bullous emphysema were included in this evaluation. Thoracoscopic endoloop ligation of bulla was carried out under general anesthesia with double-lumen endotracheal tube and single-lung ventilation. RESULTS: Sixty-five patients (82%) exhibited subjective improvement in their symptom status at 3-month follow-up (from grade 2 or 3 to grade 1 or 2) according to the Modified Medical Research Council dyspnea scale. The mean duration of chest drainage was 6 days (range, 4 to 16 days). Average hospital stay was 9.5 days (range, 5 to 26 days). There was no postoperative death. A comparison of preoperative and postoperative functional evaluation was available in only 16 patients who showed an increase in FEV1 (from 0.85 to 1.02 L) and a decline in residual volume after operation. Complications include persistent airleak over 10 days in seven patients (8.9%), wound infection in three patients, and localized empyema in two patients. There was no recurrence after a mean follow-up of 21 months. CONCLUSION: These encouraging results have shown that thoracoscopic endoloop ligation of bulla has proved to be a safe, reliable, and cost-effective technique for bullous emphysema. With careful preoperative evaluation and meticulous postoperative care, many patients could be rehabilitated by endoloop litigation of the bullae.
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Endoscopía , Enfisema Pulmonar/cirugía , Análisis Costo-Beneficio , Endoscopía/economía , Volumen Espiratorio Forzado , Humanos , Ligadura , Enfisema Pulmonar/economía , Enfisema Pulmonar/fisiopatología , Espirometría , Toracoscopía , Resultado del TratamientoRESUMEN
Hypothermic circulatory arrest is commonly used to facilitate repair of complex congenital heart defects and aortic lesions and for complex neurosurgical procedures. However, extended periods of circulatory arrest may impair cerebral metabolism and cause ischemic injury. Retrograde cerebral perfusion has been applied recently in aortic surgery to protect the brain. From January 1991 to December 1993, 29 patients underwent emergency operations to repair acute type A aortic dissection with the aid of hypothermic circulatory arrest. Six patients received hypothermic circulatory arrest without retrograde cerebral perfusion with a rectal temperature of 16.4 degrees +/- 0.9 degrees C (mean +/- standard error of the mean, group 1). Retrograde cerebral perfusion during hypothermic circulatory arrest was performed in 15 patients with a rectal temperature of 15.9 degrees +/- 0.5 degrees C (group 2) and in eight patients with a rectal temperature of 21.7 degrees +/- 0.8 degrees C (group 3). The hypothermic circulatory arrest times were 25 +/- 4, 42 +/- 4, and 63 +/- 6 minutes, respectively (p < 0.05). The cardiopulmonary bypass times were 173 +/- 5, 184 +/- 7, and 143 +/- 6 minutes, respectively (p < 0.05). All patients survived the operation and regained consciousness with no neurologic defects. Follow-up (mean 23.2, 14.5, and 5.1 months, respectively) was complete in all patients except one. This patient, from group 2, was killed in a road traffic accident 12 months after the operation. Our experience suggests that retrograde cerebral perfusion can effectively protect the brain from ischemic injury and extend the safe period of hypothermic circulatory arrest. With the aid of retrograde cerebral perfusion, prolonged circulatory arrest can probably be performed safely with moderate hypothermia.
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Aneurisma de la Aorta/cirugía , Disección Aórtica/cirugía , Isquemia Encefálica/prevención & control , Paro Cardíaco Inducido , Perfusión , Adulto , Anciano , Anciano de 80 o más Años , Puente Cardiopulmonar , Femenino , Humanos , Masculino , Persona de Mediana Edad , Perfusión/métodos , Factores de TiempoRESUMEN
Low cardiac output after open heart operations in neonates and infants carries a high mortality. Delayed sternal closure may be life-saving but may prolong hospital stay and increase costs. To circumvent these issues, we shaped homograft bone and interposed it between the sternal edges to allow primary wound closure in 2 pediatric patients. Midterm results are satisfactory.
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Trasplante Óseo/métodos , Procedimientos Quirúrgicos Cardíacos/métodos , Stents , Esternón/cirugía , Preescolar , Femenino , Cardiopatías Congénitas/cirugía , Humanos , Lactante , Recién Nacido , Trasplante HomólogoRESUMEN
BACKGROUND: Minimally invasive surgical approaches have been applied recently in the management of valvular heart disease. In this report, we reviewed our preliminary experience of minimally invasive aortic valve replacement. METHODS: Eighteen patients were operated on by means of an "I" ministernotomy, and 16 patients were operated on by means of a full median sternotomy during the same period. There was no difference between these two groups in term of age, sex, and preoperative left ventricular ejection fraction. In patients of the ministernotomy group, the operations were approached through an "I" median sternal split, from the second to the fifth intercostal space, 8 to 10 cm in length, with transverse division. Cardiopulmonary bypass was established through aorto-right atrial cannulation with aortic cross-clamping and antegrade or retrograde delivery of blood cardioplegia. RESULTS: Under direct vision, aortic valve replacement was performed successfully in patients of both groups. The duration of cardiopulmonary bypass time and aortic cross-clamp time was significantly longer in the ministernotomy group than in the full sternotomy group. However, the length of incision, duration of endotracheal intubation, intensive care unit stay, pain score, postoperative length of stay, and return to normal activity interval were significantly shorter and lower in patients of the ministernotomy group than in those of the full sternotomy group. All patients recovered from the operation rapidly. Follow-up was complete in all patients with no late complications. Echocardiographic examination showed good function of aortic prostheses. CONCLUSIONS: Our experience demonstrates that the "I" ministernotomy provides good exposure, reduced wound pain, enhanced recovery, shortened hospital stay, and good cosmetic healing. It may be a good alternative for surgical correction of aortic valve lesions.
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Válvula Aórtica/cirugía , Implantación de Prótesis de Válvulas Cardíacas , Esternón/cirugía , Adulto , Anciano , Puente Cardiopulmonar , Femenino , Humanos , Tiempo de Internación , Masculino , Persona de Mediana Edad , Procedimientos Quirúrgicos Mínimamente Invasivos , Complicaciones PosoperatoriasRESUMEN
The internal mammary artery (IMA) has become the conduct of choice for coronary artery bypass grafting. However, the IMA graft can exhibit vasoconstriction during the perioperative period. Experiments were designed to determine the role of cyclooxygenase products in human IMA during hypoxia. Rings of IMA, with and without endothelium, were suspended in organ baths containing physiologic salt solution. Rings were contracted with norepinephrine and then exposed to hypoxia for 15 minutes. In segments with endothelium, hypoxia induced a transient relaxation followed by contraction. This contraction was associated with a significantly increased production of thromboxane B2, the stable metabolite of thromboxane A2 (n = 10; from 120.7 +/- 3.5 pg/mg wet tissue before hypoxia to 175.8 +/- 5.2 pg/mg during hypoxia; p < 0.05). This hypoxic contraction could be attenuated by indomethacin. However, thromboxane B2 could not be detected in samples from organ baths containing IMA segments without endothelium before or during hypoxia. This study demonstrated that endothelium of human IMA grafts releases thromboxane A2 basally and that production is augmented by hypoxia, which acts to constrict the underlying vascular smooth muscle, increase vascular tone, and promote ischemic events such as vasospasm and thrombosis, particularly in hypoxemic patients.
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Endotelinas/biosíntesis , Endotelio Vascular/metabolismo , Arterias Mamarias/metabolismo , Tromboxano A2/biosíntesis , Humanos , Técnicas In Vitro , Arterias Mamarias/fisiología , VasoconstricciónRESUMEN
Coronary artery endothelium exhibits functional impairment after ischemia and reperfusion. Canine left anterior descending coronary arteries were exposed to ischemia (60 minutes) followed by reperfusion (60 minutes) through a left internal mammary artery graft. In organ chamber experiments, control (left circumflex coronary artery) and reperfused (left anterior descending coronary artery) arterial segments were contracted with prostaglandin F2 alpha and exposed to hypoxia (oxygen tension = 35 +/- 5 mm Hg). Reperfused coronary rings with endothelium exhibited contractions to hypoxia that were significantly greater than contractions in control rings with endothelium (+78% +/- 8% and +14% +/- 5%, respectively; p < 0.05). This phenomenon could be blocked by NG-monomethyl-L-arginine. Electron microscopic studies showed platelet adhesion and aggregation, denudation of the endothelium and disruption of the intercellular junctions, edematous subendothelial matrix, and vesiculation of the smooth muscle cells in reperfused LAD. Swelling, vacuole formation, and loss of neurofilament occurred in the nerve fibers accompanying the vessels. These phenomena were not observed in control vessels. This study demonstrates that early after coronary artery bypass grafting, hypoxia can induce coronary vasospasm mediated by an L-arginine-dependent metabolic pathway in the endothelium. The ultrastructural changes in the coronary endothelium include platelet adhesion, aggregation, and platelet-induced contraction of coronary smooth muscle. The endothelium-dependent hypoxic coronary vasospasm and ultrastructural changes in the coronary endothelium may play an important role in the pathogenesis of myocardial ischemia and infarction after coronary artery bypass grafting.
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Puente de Arteria Coronaria/efectos adversos , Vasos Coronarios/patología , Endotelio Vascular/patología , Músculo Liso Vascular/patología , Revascularización Miocárdica , Agregación Plaquetaria/efectos de los fármacos , Daño por Reperfusión/patología , Enfermedad Aguda , Animales , Arginina/análogos & derivados , Arginina/farmacología , Hipoxia de la Célula/efectos de los fármacos , Vasos Coronarios/efectos de los fármacos , Dinoprost/farmacología , Perros , Endotelio Vascular/efectos de los fármacos , Femenino , Masculino , Microscopía Electrónica de Rastreo , Microscopía Electrónica de Transmisión de Rastreo , Modelos Biológicos , Músculo Liso Vascular/efectos de los fármacos , Músculo Liso Vascular/fisiopatología , Contracción Miocárdica/efectos de los fármacos , Óxido Nítrico/antagonistas & inhibidores , Adhesividad Plaquetaria/efectos de los fármacos , Daño por Reperfusión/etiología , omega-N-MetilargininaRESUMEN
Perforation of the thoracic esophagus can be fatal unless diagnosed promptly and treated effectively. The high mortality with delayed treatment is due principally to an inability to effectively close the perforation and prevent leakage. From 1982 to 1988, 7 consecutive patients (aged 16 to 73 years) were treated after a delayed diagnosis (26 hours to 25 days) of thoracic esophageal perforation. In all patients, the perforation was closed after debridement with total exclusion of the esophagus (T-tube cervical esophagostomy plus absorbable ligatures applied to the esophagogastric junction and the cervical esophagus distal to the esophagostomy). Radical decortication and wide mediastinal and pleural drainage were also done. Nutritional supply was given through a feeding gastrostomy. Antibiotics were administered according to the results of cultures. All patients survived. Continuity of the esophagus was established by removal of the T tube and spontaneous absorption of the ligatures. Endoscopy and esophagography performed 4 weeks after the initial operation showed a well-healed esophagus without stenosis or leakage in all patients. No secondary thoracotomy or esophageal reconstruction was necessary. No dysphagia was noted during follow-up (range, 12 to 50 months; mean follow-up, 23 months). We conclude that primary closure of the perforation and total esophageal exclusion with the use of absorbable ligatures and T-tube esophagostomy can provide a one-stage operation with good results for repair of thoracic esophageal perforation diagnosed late.
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Perforación del Esófago/cirugía , Esofagostomía/métodos , Adolescente , Adulto , Anciano , Perforación del Esófago/diagnóstico por imagen , Perforación del Esófago/patología , Unión Esofagogástrica/cirugía , Esofagoscopía , Esofagostomía/instrumentación , Esófago/diagnóstico por imagen , Esófago/patología , Femenino , Estudios de Seguimiento , Humanos , Intubación/instrumentación , Ligadura , Masculino , Persona de Mediana Edad , Radiografía , Estudios Retrospectivos , Tórax , Factores de TiempoRESUMEN
During a 5-year period, we treated 14 cases of traumatic asphyxia. There were 12 male and 2 female patients ranging in age from 2 to 32 years. Most suffered crushing injuries at work or were run over by motor vehicles. Mild to severe cervicofacial cyanosis and petechiae developed in all patients. A fear response was reported by 12 of the patients. Subconjunctival hemorrhage was also found in 12 patients. Nine patients had tachypnea and 7 complained of dyspnea. Most of the patients suffered some associated injuries including 8 head injuries, 7 pulmonary contusions, and 6 cases of blunt abdominal trauma. Less-associated injuries were rib fractures, brachial and radial nerve injuries, hemothorax, and pneumothorax. The hospital stay ranged from 4 to 28 days (mean, 14 days) and follow-up from 10 to 60 months (mean, 32 months). Treatment for traumatic asphyxia included measurement of arterial blood gases, oxygen supplementation, and intubation with mechanical ventilation. The patients' recovery conditions were relative to the severity of injury and the associated injuries.
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Asfixia/terapia , Traumatismo Múltiple/complicaciones , Heridas no Penetrantes/complicaciones , Adolescente , Adulto , Asfixia/etiología , Asfixia/fisiopatología , Niño , Preescolar , Femenino , Humanos , Tiempo de Internación , Masculino , Traumatismo Múltiple/fisiopatología , Estudios Retrospectivos , Heridas no Penetrantes/fisiopatologíaRESUMEN
BACKGROUND: Minimally invasive cardiac surgical techniques recently have been applied in the management of a variety of intracardiac lesions. METHODS: Fourteen patients (6 boys and 8 girls; age, 8.9 +/- 5.5 years; body weight, 29.0 +/- 13.5 kg) were operated on using minimally invasive cardiac surgical techniques for the closure of a ventricular septal defect (subarterial in 11 patients and perimembranous in 3 patients). The operations were performed through a left anterior minithoracotomy and were guided by video-assisted endoscopic techniques under femorofemoral cardiopulmonary bypass. The myocardium was protected by continuous coronary perfusion with hypothermic fibrillatory arrest. The right ventricular outflow tract was entered after pericardiotomy was performed. RESULTS: Closure of the defect (directly in 4 patients and by patch in 10 patients) was performed successfully in all patients. A right ventricular outflow tract obstruction and ruptured sinus of Valsalva aneurysm also were repaired in 1 patient each. The duration of cardiopulmonary bypass was 41 +/- 10 minutes (range, 28 to 100 minutes) and the total operative time was 2.2 +/- 0.8 hours (range, 1.3 to 3.5 hours). All the patients recovered rapidly from their operation and had an uneventful postoperative course. Follow-up (mean, 6.2 months; range, 6 to 9 months) was complete in all patients. There were no late deaths. Transthoracic echocardiographic examination showed no residual shunt and no aortic regurgitation in all patients. CONCLUSIONS: Our experience demonstrates that minimally invasive cardiac surgical techniques are technically feasible and an alternative option for the repair of a ventricular septal defect.
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Procedimientos Quirúrgicos Cardíacos/métodos , Endoscopía/métodos , Defectos del Tabique Interventricular/cirugía , Puente Cardiopulmonar , Niño , Ecocardiografía , Femenino , Humanos , Masculino , Factores de Tiempo , Resultado del TratamientoRESUMEN
Prosthetic rings are customarily used for mitral annuloplasty to plicate and reinforce the annulus and keep the annulus from further dilating. From July 1984 to March 1992, mitral annular plication using polytetrafluoroethylene (PTFE) graft material was performed on 73 patients (age range, 15 to 69 years; mean, 35.7 years) with mitral regurgitation. The cause of the mitral regurgitation was rheumatic in 50.7% and degenerative in 36.9% of the patients. After other repair procedures on the mitral valve apparatus had been performed, a PTFE graft (3 mm) was tailored to the length of the free edge of the anterior leaflet and then inserted at the posterior part of the mitral annulus between the commissures. The operative mortality was 2.7%. Follow-up ranged from 0.7 to 8.5 years (mean, 5.6 years). Postoperative echocardiography confirmed that 94.2% of the survivors had either no or only mild mitral regurgitation with a large mitral valve area (2.7 +/- 0.3 cm2) and almost no pressure gradient across the mitral valve or left ventricular outflow tract. Two patients successfully underwent redo PTFE mitral annuloplasty. Two patients died, one 15 and the other 20 months later, due to myocardial failure, with no mitral regurgitation. The event-free survival rate was 90% +/- 4% at 8 years. We conclude that PTFE mitral annuloplasty is an effective procedure that yields good long-term results.
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Insuficiencia de la Válvula Mitral/cirugía , Válvula Mitral/cirugía , Politetrafluoroetileno , Adolescente , Adulto , Anciano , Prótesis Vascular , Femenino , Estudios de Seguimiento , Humanos , Masculino , Persona de Mediana Edad , Insuficiencia de la Válvula Mitral/mortalidad , Cardiopatía Reumática/cirugía , Tasa de SupervivenciaRESUMEN
Thrombotic obstruction, a rare but often fatal complication of cardiac valve prostheses, appears to occur more frequently in tilting-disc valves than in other valve designs. Its diagnosis and surgical treatment remain a challenge. Ten consecutive patients who had thrombosis of a tilting-disc valve prosthesis were treated in Chang Gung Memorial Hospital from November 1982 to August 1990. Preoperative clinical features, including exertional dyspnea, new murmur, and absence of a metallic click from the prosthetic valve, occurred in all of the patients. Symptoms were present for 1 week or more before reoperation in 70% of the patients; nevertheless, many patients were referred only after acute exacerbation of heart failure and development of pulmonary edema. Echocardiography confirmed prosthetic valve malfunction in 90% of the patients. One unconfirmed case was later documented by cardiac catheterization. Anticoagulant therapy was in the therapeutic range for only half of the patients at the time of admission. Prompt reoperation was performed for thrombectomy (8 patients, all survived) or valve replacement (2 patients, one death). Long-term outcome was satisfactory in all survivors with a mean follow-up of 31.6 months. These findings emphasize the importance of considering the diagnosis of thrombosis in patients with mechanical heart valve prostheses who are first seen with nonspecific symptoms and minor changes of their physical findings. The diagnosis could be easily made by echocardiography. Thrombectomy is an easy, fast, and safe procedure, especially for these critically ill patients.