Stents for bronchial stenosis after lung transplantation: should they be removed?

BACKGROUND: Airway complications after lung transplantation are the major cause of morbidity, affecting up to 33% of all cases. Bronchial stenosis is the most common complication. The use of stents has been established as the most effective therapy; however, their removal is recommended after 3-6 months of use. We have been using self-expandable stents as a definitive treatment and remove them only if necessary. For this report, we evaluated the use of self-expandable stents as a definitive treatment for bronchial stenosis after lung transplantation. METHODS: We performed a retrospective cohort study to evaluate patients with bronchial stenosis from August 2003 to April 2014. Clinical and pulmonary function test data were collected. RESULTS: Two hundred lung transplants were performed, 156 of which were bilateral. Sixteen patients experienced airway complications: 4 had dehiscence, 2 necrosis, and 10 bronchial stenosis. Of these patients, 7 had undergone bilateral procedures, and 2 patients developed stenosis in both sides. Twelve anastomotic stenoses were observed. The follow-up after stenting ranged from 1 to 7 years. All patients had increased lung function, and 4 remained stable with sustained increase in pulmonary function without episodes of infection. Three patients required removal of their prosthesis 6 months to 1 year after implantation because of complications. Two patients died owing to unrelated causes. CONCLUSIONS: Definitive treatment of bronchial stenosis with self-expandable stents is a viable option. The 1st year seems to be the most crucial for determining definitive treatment, because no patients required removal of their stent after 1 year.

Bronchial complications following lung transplantation.

INTRODUCTION: Bronchial complications owing to the airway anastomosis in lung transplantation are important causes of morbidity and mortality. They occur in up to 27% of cases as defined by stenosis, necrosis, and dehiscence. Treatment depends on the type of complication. OBJECTIVE: To report our experience to treat this complication. METHODS: Between 2000 and 2007, we performed 71 lung transplants of which 36 were bilateral. The total number of anastomoses was 107:52 to the right and 55 to the left. The telescoping technique was initially used (14 initial unilateral transplants), and after October, 2003 it was changed to an end-to-end anastomosis (57 transplants and 93 anastomoses). RESULTS: Eight patients developed bronchial complications including two that were bilateral. There were 4 stenosis, 3 dehiscences, and 3 necrosis complications (9.4%). The complication rate for telescoping anastomosis was 21.4%, and for the end-to-end technique, 7.5%. The treatment of the stenosis used metallic or plastic self-expandable stents. Two bronchial dehiscences resulted in case of bronchopleural fistulae, empyema, and death; the other patient experienced spontaneous resolution. Concerning bronchial necrosis, 1 patient developed fistulization to the pulmonary artery and massive hemoptysis, and the other with bilateral necrosis, a spontaneous resolution. CONCLUSION: Our bronchial anastomosis complication rate was comparable with that in other reports. The rate for the telescoping technique was greater compared with the end-to-end technique. The treatment of bronchial stenosis with a self-expandable prosthesis showed good results.

Tumour cell and stromal features in metastatic and non-metastatic non-small cell lung carcinomas.

AIMS: Tumour cell behaviour depends on the interactions between nuclear genetic changes in the malignant cells and a stroma favourable for growth, invasion and metastasis. To evaluate such interactions, we studied the relationship between tumour cell and stromal features for proliferative factors, p53, microvessel density and metalloproteinases, controlled for the extent of the primary lesion (T1 to T4), in early (non-metastatic) and late (metastatic) non-small cell lung carcinomas (NSCLC). METHODS AND RESULTS: Variables were examined for differences and correlations in the frequency of p53, AgNOR, CD34 and MMP-9 expression in primary lesions and metastases of NSCLC using a general linear model. The patients included 58 males and 22 females (mean age 62 +/- 9 years) with 19 T1 (23.8%), 40 T2 (50.0%), 14 T3 (17.5%) and seven T4 (8.8%). In late disease, AgNOR and p53 were statistically related to the extent of the primary lesion, whereas in early disease AgNOR tended to be increased in tumours without metastasis, while p53 expression tended to decrease progressively in tumours with metastasis. Microvessel density in late disease was of no statistical significance, whereas in early disease strong CD34 expression was seen in tumours with metastasis, being at its maximum in T3 primary lesions. The best marker for the extent of the lesion and its progression was MMP-9, with greater expression by tumours with metastasis than those without. CONCLUSIONS: Different tumour cell and stromal interactions control metastasis and therefore the biological risk of NSCLC. A panel of molecular markers, such as p53, MMP-9 and CD34 could help to identify subgroups of patients that could benefit from adjuvant therapy.

Recognition memory in normal aging and Parkinson's disease: behavioral and electrophysiologic measures.

To assess effects of normal aging and Parkinson's disease (PD) on recognition memory, we examined the N400 component of event-related potentials (ERPs) and behavioral measures during a recognition memory task in 17 normal young subjects, 17 normal elderly subjects, and 17 patients with PD. To elicit ERPs, some words were repeated immediately after initial presentation (at lag 0), while others were repeated after one intervening word (at lag 1) or at lag 6. Subjects were requested to push a button with the right thumb upon first presentation of a word and with the left thumb upon repeat presentation. Compared to the normal young subjects, normal elderly subjects showed reduced accuracy in recognizing repeated words at lags 1 and 6. Compared to the normal elderly group, PD patients showed decreased accuracy in recognizing lag 6 repetition. N400 amplitude did not differ between the two normal groups, while PD patients showed lower N400 amplitudes than normal elderly subjects. The N400 in the young group showed attenuation for lags 0, 1 and 6 repetitions, while attenuations in the elderly group and the PD group were noted only for lags 0 and 1 repetitions. These data suggest intact immediate but impaired delayed recognition memory in aging and in PD. In addition, recognition memory deficits in PD may result, at least partly from the impairment of context integration process.

Auditory event-related potentials in an amnesic patient with a left temporal lobe lesion.

We studied auditory event-related potentials (ERPs) in correlation with Rey's auditory verbal learning test (AVLT) in an amnesic patient with a left temporal lobe lesion. On the AVLT, the number of words recalled was limited to immediate memory capacity (nine words) throughout five trials, and recall after interference was remarkably decreased. In the ERPs, the P300 component was elicited normally, but no N400 component was apparent. Present findings suggest that these two ERP components may be associated with independent processes and support the view that the N400 may index a neural process involved in transfer of information from immediate memory to long-term storage.

Descending necrotizing mediastinitis: a retrospective surgical experience.

OBJECTIVE: Descending necrotizing mediastinitis (DNM) is a primary complication of cervical or odontogenical infections that can spread to the mediastinum through the anatomic cervical spaces. We reviewed the last 10 years of our surgical experience in DNM and commented on early diagnosis and aggressive surgical treatment in these patients. METHODS: Five males (71%) and two females (29%), mean age 34 years, with DNM, were surgically treated. Primary oropharyngeal infection occurred in three (43%) and odontogenic abscess in four (57%) patients. All had serious cervical and mediastinal infections with severe respiratory and hemodynamic repercussions, i.e. bacteremia, systemic arterial hypotension and obnubilation. Diagnosis was confirmed by computerized chest tomography. RESULTS: All patients underwent surgical drainage of the cervical region by bilateral transverse cervicotomy with debridement of the necrotic and infected tissues, associating ample mediastinal drainage with or without thoracotomy. Six patients (86%) evolved well and were discharged after a mean of 35 days. Two patients (29%) required reoperation due to local surgical complications: empyema and dehiscence of the sternum. One patient (14%) died on the second postoperative (p.o.) day due to renal and respiratory insufficiency. Cultures of DNM showed the development of associated aerobic and anaerobic flora in 71% of the operated patients and only aerobic in 29%. CONCLUSION: Early diagnosis by CAT scan of the neck and thorax aids in rapid indication of a surgical approach of DNM. Performing ample cervicotomy with mediastinal drainage generally associated with thoracotomy can significantly reduce the mortality rate for this condition to 14%.

Memory in patients with subcortical infarction--an auditory event-related potential study.

Event-related potentials (ERPs) were recorded from 21 patients with subcortical infarction (mean age, 62.1 years) and 14 normal control subjects (mean age, 62.7 years) as they listened to lists of words or pronounceable non-words. Some words were repeated immediately after initial presentation (lag 0), while others were repeated after five intervening words (lag 5), or after 2 to 4 min (lag 11-77). The subjects were asked to push a button upon hearing the occasional non-words. The Auditory-Verbal Learning Test (AVLT) also was administered to the patients to examine explicit memory. The mean N400 amplitude, appearing between 300 and 800 ms after the stimulus, was smaller in patients with subcortical infarction than in control subjects. The N400 in response to repeated words at lags 0, 5 and 11-77 was attenuated for both the patient and control groups. On the AVLT the total number of recalled words and number of words after interference were significantly decreased in patients relative to controls, while recognition was relatively preserved. The results suggest that lexical processing and retrieval mechanism of explicit memory are disturbed in patients with subcortical infarction, but implicit memory measured by this N400 paradigm is relatively preserved.

Repair of congenital sternal cleft in infants and adolescents.

BACKGROUND: Clinical and surgical aspects of sternal cleft repair are presented. Primary repair in the neonatal period is the best management for this rare condition, but none of the patients in this report were referred to us during that period. Autologous repair is suitable for older patients because it avoids problems related to the implant of prosthetic materials. METHODS: This article reviews 8 cases of sternal cleft not associated with ectopia cordis in patients presenting between October 1979 and November 1997. Surgical repair consisted of three sliding chondrotomies, three posterior sternal wall repairs, one combination with the Ravitch technique for pectus excavatum repair, and one posterior sternal wall repair associated with total repair of Cantrell's pentalogy. RESULTS: All patients who submitted to surgical correction had good aesthetic and structural results. The postoperative period was uneventful except that a subcutaneous fluid collection developed in 1 patient. The mean hospital stay was 5.8 days. The patients were followed up from 4 months to 18 years. CONCLUSIONS: Whether dealing with older children or young adults, the technique of reconstructing a new sternum with a posterior periosteal flap from sternal bars and chondral grafts is a simple, quick, inexpensive, and effective option.

Prognostic significance of argyrophilic nucleolar organizer region (AgNOR) in resected non-small cell lung cancer (NSCLC).

The expression of the nucleolar organizer regions (NORs) was quantified in paraffin sections of tumors and lymph node metastasis, by means of digital image analysis, in 75 patients with resected non-small cell lung cancer (NSCLC). Patients were divided in two groups: early stage (stages I and II) and advanced stage (stages IIIa, IIIb and IV). The prognostic significance of AgNOR expression was tested by Cox regression analysis in models controlled for age, sex, vital status, stage and histological type. Tumors at early stages had a lower expression of AgNOR than those at more advanced diseases. The mean values obtained for NORs in advanced disease were almost the same as those in the primary tumors when compared with the corresponding lymph node metastasis (r = 0.90; p < 0.01; linear regression). The prognostic role of AgNOR was significant only for tumors at stages I and II and not for advanced neoplasms (stages IIIa, IIIb and IV). These results encourage the inclusion of AgNOR quantitation in routine material, especially in early lung cancer.

Human pulmonary dirofilariasis: analysis of 24 cases from São Paulo, Brazil.

STUDY OBJECTIVE: To present the clinical, radiologic, and pathologic aspects of 24 cases of human pulmonary dirofilariasis (HPD) from São Paulo, Brazil. DESIGN: Retrospective study of 24 patients with a confirmed diagnosis of HPD over a 14-year period (from February 1982 to June 1996). SETTING: Thoracic Surgery and Pulmonary Division, University of São Paulo and Hospital Albert Einstein, São Paulo, Brazil. RESULTS: Seventeen patients were male (70.1%) and seven were female (29.9%). Their mean age was 51.4 years. Fifty-four percent of the patients were asymptomatic and 75% had a well-circumscribed noncalcified peripheral subpleural pulmonary nodule on the chest radiograph and thoracic CT scan, located preferentially in the lower lobes. The diagnosis was made after thoracotomy and wedge resections in 16 patients, by videothoracoscopy in six, after a pleural biopsy in one, and after necropsy in one. The pathologic examination of all the nodules revealed a central zone of necrosis, surrounded by a narrow granulomatous zone and peripherally by fibrous tissue. Pulmonary vessels exhibit varying degrees of endarteritis. In all cases, a dead worm, usually necrotic and fragmented, was found. CONCLUSIONS: A subpleural, noncalcified pulmonary nodule in the appropriate clinical and epidemiologic setting should alert the clinician, radiologist, or pathologist to the possibility of Dirofilaria. HPD should be considered in the differential diagnosis of pulmonary nodules.

Thoracoscopy in children and adolescents.

STUDY OBJECTIVES: Present the feature characteristics of the use and findings of thoracoscopy in children and adolescents. DESIGN: From February 1983 to February 1996, 77 thoracoscopic procedures were done on patients ranging in ages from 5 months to 18 years (mean, 9.8 years). Two-thirds (66.2%) were male. They were divided into three groups (1, 2, and 3) based on age (up to 2, from 2 to 8, and older than 8 years), predominance of certain diseases in these ages, and the size of the instruments utilized. They were operated on using general anesthesia with Carlens' mediastinoscope routinely used in 64 (83%) and videothoracoscopy in 13 (17%). The chief indication for therapeutic thoracoscopy was treatment of empyema, while for diagnostic thoracoscopy it was pleural biopsy and diagnosis of pleural effusions. RESULTS: In group 1, thoracoscopy was solely for the treatment of pleural disorders. In group 2, it was for the treatment of pleuropulmonary diseases. Group 3 behaved almost like adults, with broad diagnostic and therapeutic indications for thoracoscopic procedure. CONCLUSIONS: Thoracoscopy, which is a useful diagnostic and therapeutic procedure, has secured an important place in pediatric surgical practice.

Thoracoscopic surgery in Brazil. An overview.

The Video Assisted Thoracic Surgery (VATS) was introduced in Brazil in 1992 by Losso, Ghefter and Imaeda. Since its advent up to November 1994, 488 patients have been submitted to 497 VATS procedures in four Medical Centers of São Paulo city. The indications for the procedures were: lung diseases in 244 patients (50%), pleural disease in 155 patients (31.7%), thoracic traumas in 42 patients (8.6%), mediastinal diseases in 35 patients (7.1%), cardiovascular diseases in 7 patients (1.4%), chest wall diseases in 3 patients (0.6%) and esophageal diseases in 2 patients (0.4%). In the group of lung disease the most commonly used procedures were the lung biopsy in order to diagnose diffuse pulmonary disease and the indeterminate solitary nodule resection. Among the occurrences of pleural diseases, the most commonly used procedures were the pleurodesis with talc (talc poudrage) for the treatment of recurrent pleural effusion, the driven pleura biopsy and debridment or decortication of trapped lung in cases of pleural empyema. Concerning the mediastinal diseases, the pathology which was most frequently treated by VATS was the recurrent pericardic effusion through partial pericardiectomy. Among the patients presenting chest traumatic diseases, the VATS was used to explore thoracoabdominal penetrating injuries, to control bleeding, to remove clotted hemothorax, to suture diaphragm lesions and to remove intrapleural foreign bodies. Out of 497 procedures, there were 28 convertions to thoracotomy (5.7%) and two deaths occurred all over the cases. The complications, limitations and growth related to this method as well as a future overview of the VATS in Brazil will be presented.

Mitochondrial encephalomyopathy with elderly onset of stroke-like episodes.

A 52-year-old woman with a history of a hearing disturbance since age 20 experienced visual hallucinations and convulsions, followed by right hemiparesis and aphasia. On the basis of a muscle biopsy and mitochondrial DNA analysis, she was diagnosed as mitochondrial myopathy, encephalopathy, lactic acidosis, and stroke-like episodes (MELAS). This case is unique in that the stroke-like episodes occurred 30 years after disease onset.

Câncer de pulmão e retardo no diagnóstico: análise de 300 casos / Lung cancer and the delay in the diagnosis: analysis of 300 cases

This is a prospective study involving 300 persons with lung cancer admitted to the "Arnaldo Vieira de Carvalho" Cancer Institute (ICAVC). The intention of the survey was to detect delay in diagnosis after the initial symptoms. THe authors tried to identify causes of this delay and its implications. Patients were asked about the day that the symptoms started, medical care and specialists sought, number of physicians seen and their diagnosis, also examinations carried out and referrals. Results showed that 78 of cases were seen firstly by general practitioners and 69.6 looked for medical assistance at least 30 days after the clinical beginning of the disease. Chest X-rays could identify only 9 cases (3) without symptoms. The most common clinical diagnoses were: pneumonia (20), neoplasia (19), bronchitis/emphysema (9.3) and tuberculosis (8). The number of first appointments seen by the Public Health Services and Contracted Private Hospital Network was 64.1 and the second appointment was 70. Only 24 (8) of the patients were referred to ICAVC just after their first appointment and 64.4 after the third. The time lost between the first appointment and the diagnosis was longer than 90 days in 55.7 of cases. These people needed to see 3 to 4 doctors (as an average) to obtain a positive diagnosis. The diagnostic techniques used more frequently were bronchoscopy (59.7) and fine needle lung biopsy (18.4) and the delay was 20 and 10 days on average, respectively.(ABSTRACT TRUNCATED AT 250 WORDS)

[Lung cancer and the delay in the diagnosis: analysis of 300 cases]. / Câncer de pulmão e retardo no diagnóstico: análise de 300 casos.

This is a prospective study involving 300 persons with lung cancer admitted to the "Arnaldo Vieira de Carvalho" Cancer Institute (ICAVC). The intention of the survey was to detect delay in diagnosis after the initial symptoms. THe authors tried to identify causes of this delay and its implications. Patients were asked about the day that the symptoms started, medical care and specialists sought, number of physicians seen and their diagnosis, also examinations carried out and referrals. Results showed that 78% of cases were seen firstly by general practitioners and 69.6% looked for medical assistance at least 30 days after the clinical beginning of the disease. Chest X-rays could identify only 9 cases (3%) without symptoms. The most common clinical diagnoses were: pneumonia (20%), neoplasia (19%), bronchitis/emphysema (9.3%) and tuberculosis (8%). The number of first appointments seen by the Public Health Services and Contracted Private Hospital Network was 64.1% and the second appointment was 70%. Only 24 (8%) of the patients were referred to ICAVC just after their first appointment and 64.4% after the third. The time lost between the first appointment and the diagnosis was longer than 90 days in 55.7% of cases. These people needed to see 3 to 4 doctors (as an average) to obtain a positive diagnosis. The diagnostic techniques used more frequently were bronchoscopy (59.7%) and fine needle lung biopsy (18.4%) and the delay was 20 and 10 days on average, respectively.(ABSTRACT TRUNCATED AT 250 WORDS)

[Delay factors in the diagnosis of lung cancer: a public health problem]. / Fatores de retarde no diagnóstico do câncer de pulmão: um problema de saúde pública.

The authors try to identify causes of delay in the diagnosis of lung cancer, such causes being liable for low survival rates in five years. With this in mind, they developed a prospective study involving 100 patients admitted to the "Arnaldo Vieira de Carvalho" Cancer Institute, who were asked as to the date symptoms started, medical care searched, first diagnostic impressions, and number of physicians seen till the moment of diagnosis. They observed that 73 patients looked for medical assistance up to the 30th day from the beginning of disease, and only in 10 occasions this interval was longer than 120 days. 46 patients had a confirmed diagnosis in less than 90 days after their first medical appointment, and in 41 cases the delay in diagnosis was longer than 4 months. Upon the first exam with the physician, neoplasia was suspected 25 times, but only 11 patients were immediately referred to the Cancer Institute. Of the remaining 89 patients, 57 were referred only after their third medical appointment. 80 patients were first seen by general practitioners and, on average, patients went to 3 or 4 physicians to obtain a definite diagnosis. The most commonly used method to identify neoplasia was bronchofibroscopy (67 cases), with an average of 20 days of delay for its performance. Lung biopsy using transparietal fine needle was the second most used (14 cases), with an average delay of 10 days. The authors conclude that delay in the diagnosis is mostly due to the inadequacy of medical services, delay in referrals and in the performance of subsidiary tests.(ABSTRACT TRUNCATED AT 250 WORDS)

Timectomia. / Thymectomy

Os autores apresentam sete pacientes com miastenia gravis submetidos a tratamento cirurgico da Faculdade de Medicina de Mogi das Cruzes no periodo 1981-1983. A idade dos pacientes variou de 26 a 62 anos; o sexo feminino, em quatro, e a cor branca, em cinco, amarela, em um, e preta, em um.Cinco dos pacientes apresentavam forma generalizada moderada da doenca; um, generalizada intensa fulminante, e um, forma ocular pura, de acordo com a classificacao proposta por Osserman. O tempo de inicio dos sintomas e a cirurgia variou de quatro meses a seis anos. Cinco pacientes tinham grande limitacao funcional decorrente de fraqueza e insuficiencia respiratoria, enquanto que dois exibiam incapacidades relativas para os afazeres domesticos ou profissionais devido a ptose palpebral bilateral permanente. Todos tomaram anticolinesterasicos no periodo pre-operatorio, sendo que, em tres, foi realizada imunossupressao com 80 a 100mg diarios de predmisona durante 15 a 20 dias.Sao apresentados os dados clinicos, cirurgicos e a evolucao pos-operatoria dos pacientes