RESUMEN
Endometriosis is a chronic condition causing menstrual pain, irregular bleeding and infertility among women. Although usually in the pelvis, it can manifest in atypical places. We describe a 39-year old woman with a previous endometriosis diagnosis who presented three times on the second menstrual day with dyspnea and chest pain. Imaging showed right-sided pneumothorax on all three occasions. Thoraco-scopy revealed endometriosis-like lesions. Histology was suggestive of endometriosis. After treatment with chemical pleurodesis and hormonal suppression she has remained symptom-free. Diagnosis should be obtained by concomitant thoraco- and laparoscopy with biopsies to verify the disease and give a basis for appropriate treatment.
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Endometriosis , Neumotórax , Adulto , Endometriosis/complicaciones , Endometriosis/diagnóstico , Femenino , Humanos , Pulmón/diagnóstico por imagen , Menstruación , Neumotórax/diagnóstico por imagen , Neumotórax/etiologíaRESUMEN
BACKGROUND: Extracorporeal membrane oxygenation (ECMO) treatment is generally offered in large tertiary cardiothoracic referral centres. Here we present the indications and outcome of venovenous-ECMO (VV-ECMO) treatment in a low-volume, geographically isolated single-centre in Iceland, a country of 350 000 inhabitants. Our hypothesis was that patient survival in such a centre can be similar to that at high-volume centres. METHODS: A retrospective study that included all patients treated with VV-ECMO in Iceland from 1991-2016 (n = 17). Information on demographics, indications and in-hospital survival was collected from patient charts and APACHE II and Murray scores were calculated. Information on long-term survival was collected from a centralized registry. RESULTS: Seventeen patients were treated with VV-ECMO (nine males, median age 33 years, range 14-74), the indication for 16 patients was severe acute respiratory distress syndrome, most often following pneumonia (n = 6), H1N1-infection (n = 3) or drowning (n = 2). Median APACHE-II and Murray-scores were 20 and 3.5, respectively, and median duration of VV-ECMO treatment was 9 days (range 2-40 days). In total 11 patients (64,7%) survived the treatment, with 10 patients (58,8%) surviving hospital discharge, all of who were still alive at long-term follow-up, with a median follow-up time of 9 years (August 15th, 2017). CONCLUSION: Venovenous-ECMO service can be provided in a low-volume and geographically isolated centre, like Iceland, with short- and long-term outcomes comparable to larger centres.
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Procedimientos Quirúrgicos Cardíacos/estadística & datos numéricos , Oxigenación por Membrana Extracorpórea/estadística & datos numéricos , Procedimientos Quirúrgicos Torácicos/estadística & datos numéricos , APACHE , Adolescente , Adulto , Anciano , Procedimientos Quirúrgicos Cardíacos/métodos , Ahogamiento , Femenino , Estudios de Seguimiento , Mortalidad Hospitalaria , Humanos , Islandia , Masculino , Persona de Mediana Edad , Neumonía/complicaciones , Sistema de Registros , Síndrome de Dificultad Respiratoria/terapia , Estudios Retrospectivos , Análisis de Supervivencia , Procedimientos Quirúrgicos Torácicos/métodos , Adulto JovenRESUMEN
In the recent decade uniform treatment guidelines for non-small cell lung cancer (NSCLC) have been introduced in Sweden. The objective of this study was to examine time trends and differences in treatment intensity for NSCLC between county clinical centres in Central Sweden. A second aim was to investigate whether any differences in treatment of NSCLC were associated with differences in survival. 4345 patients with a diagnosis of NSCLC between 1995 and 2003 were identified in the population-based Lung Cancer Register of Central Sweden. Multivariate logistic regression was used to estimate odds ratios to analyse the likelihood of receiving different treatment modalities for NSCLC. Cox proportional hazard models estimating relative hazard ratios were used to identify factors related to death (by any cause). Of all patients, 33.4% received no treatment, and 17.5% underwent surgery. Between 1995 and 2003, the proportion of patients receiving chemotherapy rose from 14.6% to 55%. There were pronounced differences between county centres in treatment policies, especially concerning surgery and radiotherapy. The likelihood of receiving treatment for NSCLC was highest at county centre A where both surgical treatment and chemotherapy were given more often. Compared to this reference county, the risk of death was between 20% and 40% higher in the other counties after adjusting for age, stage, gender, time period, smoking status and histopathological type. When analyses were adjusted for treatment, county of residence was no longer a prognostic factor. Despite common guidelines there were marked differences in treatment activity between the counties. Treatment activity was associated with survival. Survival benefits may follow improvement in compliance to guidelines.
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Carcinoma de Pulmón de Células no Pequeñas/epidemiología , Carcinoma de Pulmón de Células no Pequeñas/terapia , Neoplasias Pulmonares/epidemiología , Neoplasias Pulmonares/terapia , Adulto , Anciano , Anciano de 80 o más Años , Femenino , Humanos , Funciones de Verosimilitud , Masculino , Oncología Médica/métodos , Persona de Mediana Edad , Análisis de Regresión , Factores de Riesgo , Suecia , Resultado del TratamientoRESUMEN
OBJECTIVES: The Impella recovery axial-flow system is a mechanical assist system for use in acute heart failure. This retrospective study reports the use of the device at three cardiothoracic units in Sweden. DESIGN: Fifty patients (35 men, mean age 55.8 years, range 26 to 84 years) underwent implantation of 26 ImpellaLP 2.5/5.0 (support-time 0.1 to 14 days), 16 ImpellaLD (support-time 1 to 7 days) and 8 ImpellaRD (support-time 0.1 to 8 days) between 2003 and 2007. Implantation was performed because of postcardiotomy heart failure (surgical group, n=33) or for various states of heart failure in cardiological patients (non-surgical group, n=17). The intention for the treatments was mainly to use the pump as a "bridge-to-recovery". RESULTS: Early mortality in the surgical and non-surgical groups was 45% and 23%, respectively. Complications included infection, 36% and right ventricular failure, 28%. Cardiac output and cardiac power output postoperatively were significantly higher among survivors than non-survivors. CONCLUSIONS: The Impella recovery axial-flow system facilitates treatment in acute heart failure. Early intervention in patients with acute heart failure and optimized hemodynamics in the post-implantation period seem to be of importance for long-term survival. Insufficient early response to therapy should urge to consider further treatment options.
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Insuficiencia Cardíaca/terapia , Corazón Auxiliar , Enfermedad Aguda , Adulto , Anciano , Anciano de 80 o más Años , Procedimientos Quirúrgicos Cardíacos/efectos adversos , Diseño de Equipo , Femenino , Insuficiencia Cardíaca/etiología , Insuficiencia Cardíaca/mortalidad , Insuficiencia Cardíaca/fisiopatología , Corazón Auxiliar/efectos adversos , Hemodinámica , Mortalidad Hospitalaria , Humanos , Masculino , Persona de Mediana Edad , Recuperación de la Función , Estudios Retrospectivos , Factores de Riesgo , Suecia/epidemiología , Factores de Tiempo , Resultado del TratamientoRESUMEN
Tuberculosis is a rare cause of acute respiratory distress syndrome (ARDS) and mortality rates are high in tuberculosis patients that need treatment with mechanical ventilation. Experience of the use of extracorporeal membrane oxygenation (ECMO) in such circumstances is scarce. We report the case of an 18 year old man where prolonged therapy (50 days) with extracorporeal membrane oxygenation (ECMO) allowed extensive lung damage from miliary tuberculosis to heal. The case reflects how challenging the diagnosis of tuberculosis may be and how difficult it is to reach adequate blood levels of anti-tuberculosis drugs while on ECMO. It's also an example of how indications for ECMO have been expanding the last years and that long term ECMO therapy is possible without serious complications.
RESUMEN
BACKGROUND: Perfusion strategies during aortic surgery usually comprise hypothermic circulatory arrest (HCA), often combined with selective antegrade cerebral perfusion (SACP) or retrograde cerebral perfusion. Cerebral blood flow (CBF) is a fundamental parameter for which the optimal level has not been clearly defined. We sought to determine the CBF at a pump flow level of 6 mL/kg/min, previously shown likely to provide adequate SACP at 20°C in pigs. METHODS: Repeated positron emission tomography (PET) scans were used to quantify the CBF and glucose metabolism throughout HCA and SACP including cooling and rewarming. Eight pigs on cardiopulmonary bypass were assigned to either HCA alone (n = 4) or HCA+SACP (n = 4). The CBF was measured by repeated [15O]water PET scans from baseline to rewarming. The cerebral glucose metabolism was examined by [18F]fluorodeoxyglucose PET scans after rewarming to 37°C. RESULTS: Cooling to 20°C decreased the cortical CBF from 0.31 ± 0.06 at baseline to 0.10 ± 0.02 mL/cm3/min (p = 0.008). The CBF was maintained stable by SACP of 6 mL/kg/min during 45 minutes. After rewarming to 37°C, the mean CBF increased to 0.24 ± 0.07 mL/cm3/min, without significant differences between the groups at any time-point exclusive of the HCA period. The net cortical uptake (Ki) of [18F]fluorodeoxyglucose after rewarming showed no significant difference between the groups. CONCLUSIONS: Cooling autoregulated the CBF to 0.10 mL/cm3/min, and 45 minutes of SACP at 6 mL/kg/min maintained the CBF in the present model. Cerebral glucose metabolism after rewarming was similar in the study groups.
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Encéfalo/diagnóstico por imagen , Circulación Cerebrovascular/fisiología , Paro Circulatorio Inducido por Hipotermia Profunda/métodos , Perfusión/métodos , Tomografía de Emisión de Positrones/métodos , Complicaciones Posoperatorias/prevención & control , Flujo Sanguíneo Regional , Animales , Aorta Torácica/cirugía , Encéfalo/irrigación sanguínea , Encéfalo/metabolismo , Modelos Animales de Enfermedad , Glucosa/metabolismo , Complicaciones Posoperatorias/diagnóstico , Reproducibilidad de los Resultados , Porcinos , Procedimientos Quirúrgicos Vasculares/efectos adversosRESUMEN
OBJECTIVES: Acute type A aortic dissection is a life-threatening disease associated with significant morbidity and mortality. Treatment is challenging and requires emergency surgery. This study presents for the first time the short- and long-term outcome of acute type A aortic dissection repairs in Iceland. MATERIALS AND METHODS: A retrospective review of 45 patients (mean age 60.7 ± 13.9 years, 68.9% male) treated for type A aortic dissection at Landspitali University Hospital between 1992 and 2014. Data was gathered from medical records about known risk factors, presenting symptoms, type of procedure, complications and operative mortality. RESULTS: Out of 45 operations the majority (73.3%) was performed in the second half of the study period. Nearly all patients presented with chest pain and 46.7% were in shock on arrival. Malperfusion syndrome was apparent in 26.7% of cases. A variety of operative methods were used, including hypothermic circulatory arrest in 31.1% of the cases and one-third of patients needed aortic root replacement. Reoperation rate for postoperative bleeding was 29.3% and perioperative stroke occurred in 14.6% of patients. The 30-day mortality rate was 22.2% (10 patients) and 5- and 10-year survival was 71.4 ± 8.2% and 65.4 ± 9.4%, respectively. CONCLUSIONS: The short-term outcomes of surgical repair for acute type A aortic dissection in Iceland is comparable to neighbouring countries, including 30-day mortality and long-term survival. Complications, however, are common, especially reoperations for bleeding. 1Department of Cardiothoracic Surgery, Landspitali University Hospital, 2Faculty of Medicine, University of Iceland. KEY WORDS: Aortic dissection type A, aortic aneurysm, open heart surgery, complications, operative mortality, survival. Correspondence: Arnar Geirsson, arnarge@landspitali.is.
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Aneurisma de la Aorta/cirugía , Disección Aórtica/cirugía , Implantación de Prótesis Vascular , Enfermedad Aguda , Disección Aórtica/diagnóstico por imagen , Disección Aórtica/mortalidad , Aneurisma de la Aorta/diagnóstico por imagen , Aneurisma de la Aorta/mortalidad , Implantación de Prótesis Vascular/efectos adversos , Implantación de Prótesis Vascular/mortalidad , Femenino , Hospitales Universitarios , Humanos , Islandia , Masculino , Registros Médicos , Persona de Mediana Edad , Hemorragia Posoperatoria/etiología , Hemorragia Posoperatoria/mortalidad , Hemorragia Posoperatoria/cirugía , Reoperación , Estudios Retrospectivos , Factores de Riesgo , Accidente Cerebrovascular/etiología , Accidente Cerebrovascular/mortalidad , Análisis de Supervivencia , Factores de Tiempo , Resultado del TratamientoRESUMEN
BACKGROUND: Surgical resection is currently standard treatment in early stage lung cancer. The aim of the present study was to identify stage-related factors and patient characteristics influencing survival after complete resection. METHODS: We identified 395 patients with non-small cell lung cancer who had undergone potentially radical operation during 1987 to 1999 at one thoracic surgery institution in central Sweden. Factors independently related to survival were identified in a multivariate analysis. Survival was analyzed in low-, medium-, and high-risk groups based on a risk score calculated from relative hazards for identified risk factors. RESULTS: Overall 5-year survival among the 395 patients was 51%. The strongest factor predicting prognosis was positive lymph nodes at operation. Higher age, earlier period for operation, impaired lung function, current smoking, and major operative complication were all related to poorer prognosis. Patients with tumor stage Ia had a 5-year survival of 69%, compared to 73% in patients in the low-risk group. CONCLUSIONS: Tumor stage is the best prognostic indicator after radical operation. Inclusion of other tumor- and patient-related variables did not add prognostic information of clinical relevance beyond that provided by tumor stage alone.
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Carcinoma de Pulmón de Células no Pequeñas/mortalidad , Neoplasias Pulmonares/mortalidad , Adenocarcinoma/mortalidad , Adenocarcinoma/patología , Adenocarcinoma/cirugía , Anciano , Carcinoma de Pulmón de Células no Pequeñas/patología , Carcinoma de Pulmón de Células no Pequeñas/cirugía , Carcinoma de Células Escamosas/mortalidad , Carcinoma de Células Escamosas/patología , Carcinoma de Células Escamosas/cirugía , Femenino , Humanos , Neoplasias Pulmonares/patología , Neoplasias Pulmonares/cirugía , Metástasis Linfática , Masculino , Mediastinoscopía , Persona de Mediana Edad , Análisis Multivariante , Estadificación de Neoplasias , Pronóstico , Factores de RiesgoRESUMEN
OBJECTIVES: Superior venous outflow obstruction affects cerebral perfusion negatively by reducing cerebral perfusion pressure (CPP). We present a randomized study designed to compare two alternative strategies to preserve the CPP during superior vena cava (SVC) congestion and cardiopulmonary bypass (CPB). METHODS: Fourteen pigs on bi-caval CPB were subjected to 75% occlusion of the SVC flow. CPP was restored either by vasopressor treatment (VP, n = 7) or by partial relief (PR) of the congestion (n = 7). The cerebral effects of the interventions were studied for 60 min with intracranial pressure (ICP) monitoring, cerebral blood flow measurement, the near-infrared light spectroscopy tissue oxygen saturation index (StO2), arterial and venous blood gas analyses and serial measurements of the glial cell damage marker protein S100ß. RESULTS: Both strategies restored the CPP to baseline levels and no signs of severe ischaemia were observed. In the PR group, the venous and ICPs were normalized in response to the intervention, while in the VP group those parameters remained elevated throughout the experiment. The haemoglobin oxygen saturation in the sagittal sinus (SsagO2) was increased by both VP and PR, while significant improvement in the StO2 was observed only in the PR group. The S100ß concentrations were similar in the two groups. CONCLUSIONS: Experimental SVC obstruction during CPB may reduce the CPP, resulting in impaired cerebral perfusion. Both vasopressor treatment and improved venous drainage can, in the short term, individually restore the CPP during these circumstances.
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Puente Cardiopulmonar/métodos , Síndrome de la Vena Cava Superior/tratamiento farmacológico , Vasoconstrictores/farmacología , Animales , Presión Venosa Central/efectos de los fármacos , Presión Venosa Central/fisiología , Circulación Cerebrovascular/efectos de los fármacos , Circulación Cerebrovascular/fisiología , Presión Intracraneal/efectos de los fármacos , Presión Intracraneal/fisiología , Norepinefrina/farmacología , Oxígeno/sangre , Distribución Aleatoria , Subunidad beta de la Proteína de Unión al Calcio S100/sangre , Espectroscopía Infrarroja Corta , Síndrome de la Vena Cava Superior/fisiopatología , PorcinosRESUMEN
INTRODUCTION: Non-small cell lung cancer (NSCLC) is characterized by a multitude of genetic aberrations with unknown clinical impact. In this study, we aimed to identify gene copy number changes that correlate with clinical outcome in NSCLC. To maximize the chance to identify clinically relevant events, we applied a strategy involving two prognostically extreme patient groups. METHODS: Short-term (<20 month; n = 53) and long-term survivors (>58 month; n = 47) were selected from a clinically well-characterized NSCLC patient cohort with available fresh frozen tumor specimens. The samples were analyzed using high-resolution single-nucleotide polymorphism array technology to assess gene copy number variations and array-based gene expression profiling. The molecular data were combined with information on clinical parameters. RESULTS: Genetic aberrations were strongly associated with tumor histology. In adenocarcinoma (n = 50), gene copy number gains on chromosome 8q21-q24.3 (177 genes) were more frequent in long-term than in short-term survivors. In squamous cell carcinoma (n = 28), gains on chromosome 14q23.1-24.3 (133 genes) were associated with shorter survival, whereas losses in a neighboring region, 14q31.1-32.33 (110 genes), correlated with favorable outcome. In accordance with copy number gains and losses, messenger RNA expression levels of corresponding genes were increased or decreased, respectively. CONCLUSION: Comprehensive tumor profiling permits the integration of genomic, histologic, and clinical data. We identified gene copy number gains and losses, with corresponding changes in messenger RNA levels that were associated with prognosis in adenocarcinoma and squamous cell carcinoma of the lung.
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Carcinoma de Pulmón de Células no Pequeñas/genética , Carcinoma de Pulmón de Células no Pequeñas/mortalidad , Carcinoma de Pulmón de Células no Pequeñas/patología , Aberraciones Cromosómicas , Cromosomas Humanos/genética , Dosificación de Gen , Adenocarcinoma/genética , Adenocarcinoma/mortalidad , Adenocarcinoma/patología , Adulto , Anciano , Anciano de 80 o más Años , Carcinoma de Células Grandes/genética , Carcinoma de Células Grandes/mortalidad , Carcinoma de Células Grandes/patología , Carcinoma de Células Escamosas/genética , Carcinoma de Células Escamosas/mortalidad , Carcinoma de Células Escamosas/patología , ADN de Neoplasias/genética , Femenino , Perfilación de la Expresión Génica , Regulación Neoplásica de la Expresión Génica , Humanos , Neoplasias Pulmonares/genética , Neoplasias Pulmonares/mortalidad , Neoplasias Pulmonares/patología , Masculino , Análisis por Micromatrices , Persona de Mediana Edad , Estadificación de Neoplasias , Polimorfismo de Nucleótido Simple , Pronóstico , Reacción en Cadena en Tiempo Real de la Polimerasa , Tasa de Supervivencia , SobrevivientesRESUMEN
To investigate the effects on cerebral perfusion by experimental venous congestion of the superior vena cava (SVC) during bicaval cardiopulmonary bypass (CPB) at 34 °C, pigs were subjected to SVC obstruction at levels of 75%, 50%, 25% and 0% of baseline SVC flow at two arterial flow levels (low, LQ, high, HQ). The cerebral perfusion was examined with near-infrared spectroscopy (NIRS), cerebral microdialysis and blood gas analysis. SVC obstruction caused significant decreases in the NIRS tissue oxygenation index (TOI) and in SVC oxygen saturations (P<0.05, both groups), while the mixed venous saturation was decreased only in the LQ group. Sagittal sinus venous saturations were measured in the HQ group and found significantly reduced in response to venous congestion (P<0.05). No microdialysis changes were seen at the group level, however, individual ischemic patterns in terms of concomitant venous desaturation, decreased TOI and increased lactate/pyruvate occurred in both groups. The total venous drainage remained stabile throughout the experiment, indicating increased flow in the inferior vena cava cannula. The results indicate that SVC congestion may impair cerebral perfusion especially in the case of compromised arterial flow during CPB. Reduced SVC cannula flow may pass undetected during bicaval CPB, if SVC flow is not specifically monitored.
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Isquemia Encefálica/etiología , Puente Cardiopulmonar/efectos adversos , Circulación Cerebrovascular , Monitoreo Intraoperatorio , Síndrome de la Vena Cava Superior/complicaciones , Animales , Biomarcadores/sangre , Análisis de los Gases de la Sangre , Glucemia/metabolismo , Isquemia Encefálica/sangre , Isquemia Encefálica/fisiopatología , Presión Venosa Central , Modelos Animales de Enfermedad , Glicerol/sangre , Hipotermia Inducida , Ácido Láctico/sangre , Microdiálisis , Monitoreo Intraoperatorio/métodos , Oxígeno/sangre , Ácido Pirúvico/sangre , Flujo Sanguíneo Regional , Espectroscopía Infrarroja Corta , Síndrome de la Vena Cava Superior/sangre , Síndrome de la Vena Cava Superior/fisiopatología , Porcinos , Vena Cava Inferior/fisiopatologíaRESUMEN
Hypothermic arrest and selective antegrade cerebral perfusion (SACP) is widely used during aortic arch surgery. The microdialysis technique monitors biomarkers of cellular metabolism and cellular integrity over time. In this study, the cerebral changes during hypothermic circulatory arrest (HCA) at 20 degrees C and HCA with SACP at two different temperatures, 20 and 28 degrees C, were monitored. Twenty-three pigs were divided into three groups. A microdialysis probe was fixated into the forebrain. Circulatory arrest started at a brain and body temperature of 20 degrees C or 28 degrees C. Arrest with/without cerebral perfusion (flow 10 ml/kg, max carotid artery pressure 70 mmHg) lasted for 80 min followed by reperfusion and rewarming during 40 min and an observation period of 120 min. The microdialysis markers were registered at six time-points. The lactate/pyruvate ratio (L/P ratio) and the lactate/glucose ratio (L/G ratio) increased significantly (P<0.05), during arrest, in the HCA group. The largest increase of glycerol was found in the group with tepid cerebral perfusion (28 degrees C) and the HCA group (P<0.05). This study supports the use of SACP over arrest. It also suggests that cerebral metabolism and cellular membrane integrity may be better preserved with SACP at 20 degrees C compared to 28 degrees C.
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Temperatura Corporal , Circulación Cerebrovascular , Paro Circulatorio Inducido por Hipotermia Profunda , Microdiálisis , Perfusión/métodos , Prosencéfalo/metabolismo , Animales , Biomarcadores/líquido cefalorraquídeo , Puente Cardiopulmonar , Paro Circulatorio Inducido por Hipotermia Profunda/efectos adversos , Metabolismo Energético , Glucosa/líquido cefalorraquídeo , Glicerol/líquido cefalorraquídeo , Ácido Láctico/líquido cefalorraquídeo , Modelos Animales , Monitoreo Intraoperatorio , Perfusión/efectos adversos , Prosencéfalo/patología , Ácido Pirúvico/líquido cefalorraquídeo , Sus scrofa , Factores de TiempoRESUMEN
In this report, we present the first known case of Bartonella endocarditis in Sweden. IgG antibody titres to Bartonella spp. were elevated but blood cultures remained negative. Sequencing of a gltA fragment from DNA extracted from heart valve tissue specimens revealed sequence homology with B. quintana.