RESUMO
INTRODUCTION: Best oxygenation index on day 1 (BOId1) had been shown to predict survival in congenital diaphragmatic hernia (CDH). Serial oxygenation index (OI) may enable better assessment of response to cardiorespiratory support than BOId1. METHODS: All antenatally diagnosed CDH from one tertiary neonatal unit were retrospectively reviewed. Oxygenation index at 6, 12, 24, and 48 hours from birth, as well as BOId1, were compared between survivors and nonsurvivors. The area under the curve and receiver operating characteristic (ROC) curves were used to compare serial OI within the first 24 hours and BOId1 between survivors and nonsurvivors. Statistical significance was set at P < .05. RESULTS: Twenty-four patients with CDH (13 survivors, 11 nonsurvivors) were included. Both groups were comparable in demographics and variables that could affect outcome. In terms of nonsurvival, ROC curve analysis demonstrated a sensitivity of 78% for serial OI greater than 252 and 56% for BOId1 greater than 8.5, both having a specificity of 100%. The area under the ROC curve for serial OI and BOId1 were 0.96 and 0.85, respectively. The positive predictive value of serial OI (>252) and BOId1 (>11) for nonsurvival were both 100%, with an negative predictive value of 87% and 76%, respectively. CONCLUSIONS: Our preliminary study showed that serial OI in the first 24 hours of life is a good predictor of survival. It is simple to use and has the added advantage of assessing response to medical support in CDH. The results support the need for a large prospective study exploring the potential of serial OI to guide management and prognosis.
Assuntos
Hérnias Diafragmáticas Congênitas , Monitorização Fisiológica , Oxigênio/metabolismo , Biomarcadores/metabolismo , Hérnia Diafragmática/diagnóstico , Hérnia Diafragmática/metabolismo , Hérnia Diafragmática/mortalidade , Hérnia Diafragmática/cirurgia , Herniorrafia , Humanos , Recém-Nascido , Valor Preditivo dos Testes , Diagnóstico Pré-Natal , Prognóstico , Curva ROC , Estudos RetrospectivosRESUMO
BACKGROUND: Fatty liver disease (FLD), of either alcoholic (AFLD) or non-alcoholic (NAFLD) aetiologies, is characterised histologically by features that are lobulocentric that typically affect zone 3, in contrast with portal-based inflammation characteristics of other forms of chronic liver disease. AIM: The authors aimed to determine the prevalence and significance of portal inflammation in a cohort of adults diagnosed as having AFLD and NAFLD. METHODS: From a histology database, the authors identified 160 patients with biopsy proven AFLD and 214 with NAFLD diagnosed between 1991 and 2001. All liver biopsies were reviewed by one pathologist to evaluate various histological features. RESULTS: More than a mild degree of portal inflammation was found in 47% of AFLD compared with 30% in NAFLD subgroup. A higher degree of portal inflammation in AFLD was associated with a higher mean corpuscular volume, gamma glutamyl transferase (GGT) and alkaline phosphatase, and a lower platelet count and albumin, whereas in NAFLD this was associated with age, presence of diabetes, hypertension, body mass index (BMI), higher fasting blood glucose, cholesterol, alanine transaminase, GGT and ferritin. On regression analysis, portal inflammation was associated with the severity of steatosis (p=0.005), presence of ballooning (p=0.030) in NAFLD and severity of fibrosis in both AFLD and NAFLD (p<0.001). CONCLUSIONS: Portal inflammation is a common component of histological spectrum of both AFLD and NAFLD. In both conditions portal inflammation is associated with clinical and histological features suggestive of advanced disease.
Assuntos
Fígado Gorduroso/complicações , Hepatite Crônica/etiologia , Adulto , Idoso , Idoso de 80 Anos ou mais , Biópsia , Estudos de Coortes , Fígado Gorduroso/patologia , Fígado Gorduroso Alcoólico/complicações , Fígado Gorduroso Alcoólico/patologia , Feminino , Hepatite Crônica/patologia , Humanos , Fígado/patologia , Masculino , Pessoa de Meia-Idade , Adulto JovemRESUMO
A best evidence topic in cardiac surgery was written according to a structured protocol. The question addressed was whether pulmonary valve replacement (PVR) after repair of tetralogy of Fallot improved outcomes including right ventricular (RV) function. Altogether 730 relevant papers were identified using the below mentioned search, 19 papers represented the best evidence to answer the question. The author, journal, date and country of publication, patient group studied, study type, relevant outcomes, results and study weaknesses were tabulated. We conclude that PVR after tetralogy of Fallot repair has been shown to improve RV function and to offer symptomatic benefit. Several retrospective reviews report consistent reductions in RV end diastolic and systolic volumes and improvement in RV stroke volume, with one study also finding improvement in left ventricular stroke volume. PVR in this population appears to result in improved clinical outcome and can be performed with low mortality.
Assuntos
Procedimentos Cirúrgicos Cardíacos , Implante de Prótese de Valva Cardíaca , Valva Pulmonar/cirurgia , Tetralogia de Fallot/cirurgia , Função Ventricular Direita , Adolescente , Adulto , Idoso , Benchmarking , Criança , Medicina Baseada em Evidências , Feminino , Humanos , Masculino , Pessoa de Meia-Idade , Volume Sistólico , Tetralogia de Fallot/fisiopatologia , Resultado do Tratamento , Disfunção Ventricular Esquerda , Adulto JovemRESUMO
We report the case of an 18-year-old patient who underwent Ravitch procedure for pectus carinatum and subsequently had septic shock develop with severe cardiac dysfunction requiring treatment with extracorporeal membrane oxygenation. We advocate the use of extracorporeal membrane oxygenation in adult patients with intractable cardiorespiratory failure due to sepsis post-thoracic surgery unresponsive to conventional therapy.
Assuntos
Oxigenação por Membrana Extracorpórea/métodos , Insuficiência Cardíaca/terapia , Choque Séptico/terapia , Infecções Estafilocócicas/terapia , Infecção da Ferida Cirúrgica/terapia , Adolescente , Antibacterianos/uso terapêutico , Terapia Combinada , Progressão da Doença , Drenagem/métodos , Seguimentos , Tórax em Funil/diagnóstico , Tórax em Funil/cirurgia , Insuficiência Cardíaca/etiologia , Insuficiência Cardíaca/fisiopatologia , Humanos , Balão Intra-Aórtico , Masculino , Procedimentos de Cirurgia Plástica/efeitos adversos , Procedimentos de Cirurgia Plástica/métodos , Medição de Risco , Choque Séptico/etiologia , Choque Séptico/fisiopatologia , Infecções Estafilocócicas/diagnóstico , Infecção da Ferida Cirúrgica/microbiologia , Infecção da Ferida Cirúrgica/fisiopatologia , Toracotomia/efeitos adversos , Toracotomia/métodos , Resultado do TratamentoRESUMO
A best evidence topic in cardiac surgery was written according to a structured protocol. The question addressed was whether surgical correction of coarctation of the aorta in adults (>16 years) results in reduction in established hypertension. Altogether 484 relevant papers were identified using the below mentioned search, 11 papers represented the best evidence to answer the question. The author, journal, date and country of publication, patient group studied, study type, relevant outcomes, results and study weaknesses were tabulated. We conclude that surgical repair of coarctation of the aorta in adult patients is superior to conservative management in the reduction of established hypertension, with one meta-analysis and several retrospective reviews reporting low morbidity and low risk of re-stenosis. The reduction in blood pressure postoperatively has been demonstrated consistently, with most patients reported as normotensive without medication and the remainder having reduced requirements for antihypertensive medications. In all the papers included here (except one), there was no early mortality and no procedure-related late mortality during mean follow-up ranging from 2 to 14 years. Thus, surgical correction of aortic coarctation is a relatively safe procedure.
Assuntos
Coartação Aórtica/cirurgia , Pressão Sanguínea , Hipertensão/prevenção & controle , Procedimentos Cirúrgicos Vasculares , Adolescente , Adulto , Idoso , Anti-Hipertensivos/uso terapêutico , Coartação Aórtica/complicações , Coartação Aórtica/fisiopatologia , Benchmarking , Medicina Baseada em Evidências , Humanos , Hipertensão/etiologia , Hipertensão/fisiopatologia , Masculino , Pessoa de Meia-Idade , Recidiva , Reoperação , Medição de Risco , Resultado do Tratamento , Procedimentos Cirúrgicos Vasculares/efeitos adversos , Adulto JovemRESUMO
A best evidence topic in cardiac surgery was written according to a structured protocol. The question addressed was whether early primary repair for correction of tetralogy of Fallot (TOF) resulted in better outcomes than surgery after 6 months of age. Altogether 650 relevant papers were identified using the below mentioned search, eight papers represented the best evidence to answer the specific question. The author, journal, date and country of publication, patient group studied, study type, relevant outcomes, results and study weaknesses were tabulated. We conclude that early primary repair of TOF has been shown to be comparable to later repair, with several retrospective series concluding that there is no increase in mortality with children under 6 months of age. Freedom from reintervention has also been shown to be similar irrespective of the age primary repair is undertaken. However, it has been observed that length of intensive care unit stay, period of mechanical ventilation and the need for inotropes is increased in patients undergoing primary repair at <3 months of age.
Assuntos
Procedimentos Cirúrgicos Cardíacos , Tetralogia de Fallot/cirurgia , Fatores Etários , Benchmarking , Procedimentos Cirúrgicos Cardíacos/efeitos adversos , Procedimentos Cirúrgicos Cardíacos/mortalidade , Cardiotônicos/uso terapêutico , Medicina Baseada em Evidências , Feminino , Humanos , Lactente , Recém-Nascido , Unidades de Terapia Intensiva Pediátrica , Terapia Intensiva Neonatal , Tempo de Internação , Masculino , Seleção de Pacientes , Respiração Artificial , Medição de Risco , Tetralogia de Fallot/mortalidade , Resultado do TratamentoRESUMO
The question addressed by a best evidence topic approach using a structured protocol was whether pleurectomy using video-assisted thoracoscopic surgery (VATS) resulted in better outcomes than open pleurectomy for primary spontaneous pneumothorax. Altogether 45 relevant papers were identified of which nine papers represented the best evidence to answer the question. The author, journal, date and country of publication, patient group studied, study type, relevant outcomes, results and study weaknesses were tabulated. We conclude that VATS pleurectomy has been shown to be comparable to open pleurectomy in the treatment of spontaneous pneumothorax, with a meta-analysis and several RCTs showing reductions in length of hospital stay and analgesic requirements. Postoperative pulmonary dysfunction has also been shown to be reduced after VATS pleurectomy in two RCTs, although a third study found no significant difference. A concern may be a four-fold increase in the recurrence of pneumothorax following VATS pleurectomy as compared to open pleurectomy reported in a recent meta-analysis of four randomised and 25 non-randomised studies performed in 2007 and published in the Lancet, although a second meta-analysis of only the randomised trials did not show this difference.