Multidisciplinary surgical approach to renal cancer with vena cava invasion and pulmonary embolism.

INTRODUCTION: Renal cancer is unique for many reasons. One reason is that renal cell carcinoma can grow directly into the drainage veins of the kidney, which enter the inferior vena cava leading to the heart. This growth of tumor cells into the veins is called a tumor thrombus and is a locally aggressive renal cancer. The present article informs about the experience of our cardiac surgery department together with the transplant surgery department in successful surgical removal of a kidney with tumor, with invasion into the inferior vena cava, right atrium of the heart and pulmonary artery in two case reports. CASE REPORTS: A 32 years old female without significant history, with suddenly evolving dyspnea was urgently admitted to hospital. Her condition was suspected to be caused by pulmonary artery embolisation. The diagnosis was confirmed by CT scan which revealed unknown tumor mass of the right kidney and tumor embolisation in inferior vena cava and pulmonary artery. The patient was urgently operated by a vascular surgeon and cardiothoracic surgeon. They successfully performed left radical nephrectomy and total thromboembolectomy of the tumorous masses from vena cava inferior and pulmonary artery. The postoperative course was without complications, postoperative CT revealed no residual masses, and the patient was discharged in a good condition from the hospital. A 58 years old male with arterial hypertension suffered from orchiepididymitis. CT scan showed a tumor of the left kidney with propagation of tumorous masses to inferior vena cava and pulmonary artery. In elective surgery the vascular surgeon and cardiothoracic surgeon successfully performed left radical nephrectomy with total thromboembolectomy of the tumorous masses from inferior vena cava and pulmonary artery. After surgery a temporary paralytic ileus and an episode of atrial fibrillation occurred. Both are common postoperative complications related to the given surgical procedure. Follow-up CT scan showed no residual tumor or thrombus in inferior vena cava and pulmonary artery. Echocardiography revealed persistent dilation of right compartments of the heart with good systolic functions of both ventricles. The patient was discharged from hospital in a good condition. CONCLUSION: Surgical removal of renal tumor and tumor thrombus - radical nephrectomy with tumor thrombectomy - can be a curative treatment and can ensure long-term survival of the patient. Depending on the extent of the tumor thrombus, these operations can be performed in different ways - mini-invasive, robotic or open. When open surgery is used, it is possible to perform the procedure with or without extracorporeal circulation (cardiopulmonary bypass - CPB) depending on the extent of the disease.

Peripheral i.v. analysis (PIVA) of venous waveforms for volume assessment in patients undergoing haemodialysis.

Background: The assessment of intravascular volume status remains a challenge for clinicians. Peripheral i.v. analysis (PIVA) is a method for analysing the peripheral venous waveform that has been used to monitor volume status. We present a proof-of-concept study for evaluating the efficacy of PIVA in detecting changes in fluid volume. Methods: We enrolled 37 hospitalized patients undergoing haemodialysis (HD) as a controlled model for intravascular volume loss. Respiratory rate (F0) and pulse rate (F1) frequencies were measured. PIVA signal was obtained by fast Fourier analysis of the venous waveform followed by weighing the magnitude of the amplitude of the pulse rate frequency. PIVA was compared with peripheral venous pressure and standard monitoring of vital signs. Results: Regression analysis showed a linear correlation between volume loss and change in the PIVA signal (R2=0.77). Receiver operator curves demonstrated that the PIVA signal showed an area under the curve of 0.89 for detection of 20 ml kg-1 change in volume. There was no correlation between volume loss and peripheral venous pressure, blood pressure or pulse rate. PIVA-derived pulse rate and respiratory rate were consistent with similar numbers derived from the bio-impedance and electrical signals from the electrocardiogram. Conclusions: PIVA is a minimally invasive, novel modality for detecting changes in fluid volume status, respiratory rate and pulse rate in spontaneously breathing patients with peripheral i.v. cannulas.

Hyperglycaemia in patients with no history of diabetes presenting to Internal Medicine Departments.

AIMS: Stress hyperglycaemia during hospitalisation may be the first sign of diabetes mellitus (DM). Most hospitals routinely measure blood glucose, which may enable early diagnosis. This study measured the prevalence of hyperglycaemia in hospitalised adults with no history of diabetes, and whether the discharge summary recommended work-up. METHODS: Files with at least one random blood glucose (RBG) sample were included and reviewed for specific discharge recommendations concerning elevated blood glucose. Hyperglycaemia was defined as serum glucose > 200 mg/dl. Length of stay, in-hospital mortality and 3-year mortality were examined. RESULTS: Among 5274 discharged patients, 1479 had DM. They were older and had a higher incidence of cerebrovascular risk factors. Among 3714 patients without known DM, 211 (5.7%) had at least one RBG > 200 mg/dl. Of these patients, 31 died and 24 left against medical advice. Of the remaining 156, 25(16%) files included instructions to the family physician. These patients were younger, more overweight and less frequently diagnosed with dementia or other mental illness. Patients with RBG > 200 mg/dl had prolonged hospital stay (6.5 ± 5.3 vs. 4.0 ± 4.8; p < 0.001). In-hospital mortality and 3-year mortality were increased by 5.1 and 1.89, respectively (p < 0.001 for both parameters) compared to those without RBG ≤ 200 mg/dl. RBG > 200 mg/dl emerged as a significant, independent predictor of prolonged hospital stay and death. CONCLUSIONS: Random blood glucose > 200 mg/dl is common in medical departments and is associated with increased in-hospital and 3-year out-hospital mortality.

Intermittent left bundle branch block (LBBB) as a clinical manifestation of myocardial contusion after blunt chest trauma.

Injury to the heart in blunt chest trauma is dependent on a number of factors. Symptoms are often non-specific, and there is no gold standard test for diagnosis. Injuries to small areas of the myocardium may only be identified at autopsy. We report a 38 year old man who sustained a number of injuries in a road traffic accident, and in whom the single clinical or ECG abnormality was a left bundle branch block (LBBB); he had a myocardial injury rated as grade II. The patient was treated for his injuries and later discharged. As this is a difficult diagnosis, algorithms of blunt chest trauma may save time and money by avoiding misleading diagnosis and unnecessary monitoring and admissions.

[Should fiber gastroscopy be standard in preoperative examinations for cardiac surgery?]. / Má byt' gastrofibroskopické vysetrenie pred operáciou srdca standardným vysetrením?

UNLABELLED: We introduced a gastrofibroscopy into a standard preoperative protocol for all patients indicated to the cardiac surgery. AIM OF THE STUDY: Validation of our protocol. MATERIAL AND METHODS: 957 consecutive patients operated on from May 1995 to January 2002 were divided to group A--gastrofibroscopy only for patients with positive history or clinical signs of peptic ulcer (151 pts.) and group B--patients with gastrofibroscopy as a standard procedure (806 pts). RESULTS: Significant difference in incidence of peptic ulcer complications between groups (A--5.9% versus B--1.1%, p < 0.05). Related mortality was 1.3% in-group A versus 0% in-group B. Positive history of peptic ulcer had only two patients (11% of 18) with postoperative complication. In-group B we found high incidence of peptic defects (B--35% versus A--9%, p < 0.01) requiring treatment by gastroenterologist. Majority (230 of 281-82%) of pts. with preoperative positive defect had negative history of a peptic ulcer. CONCLUSIONS: Current tendency to perform gastrofibroscopic examination only in patients with positive history of peptic ulcer is not able to detect "silent" lesions. Perioperative treatment with H2 blockers fails to prevent the manifestation of peptic ulcer complication. Gastrofibroscopy should be a routine part of the preoperative protocol in cardiac surgery.

[Intrapericardial rupture of the inferior vena cava caused by blunt trauma]. / Intraperikardiálna ruptúra dolnej dutej zily spôsobená tupou traumou.

A thirty-years-old man with pectus excavatum was unconscious, in shock and with a history of blunt trauma of the chest and epigastrium admitted to hospital. After a short time he developed signs of pericardial and peritoneal effusion with tamponade and circulatory failure. Urgent laparotomy and sternotomy was performed. We found approximately a 5 cm long rupture of the right atrium, anterior wall of the intrapericardial part of the vena cava inferior with short extension to the infradiaphragmatic part of the vena cava inferior. We controlled bleeding by hand and by application of a Satinsky partial vascular clamp. Final plastic correction of the rupture was performed by implantation of a native autologous pericardial flap. After a complicated postoperative course the patient was discharged on the 37th postoperative day. Seven months after surgery the patient is in a good condition and has no signs of stenosis at the place of correction.

Lead poisoning from drinking Kombucha tea brewed in a ceramic pot.

Kombucha tea is an alternative therapy that is gaining popularity as a remedy for a diverse range of ailments. We report two cases of symptomatic lead poisoning requiring chelation therapy in a married couple who had been drinking Kombucha tea for six months, brewing the tea in a ceramic pot. We postulate that acids in the tea eluted lead from the glaze pigment used in the ceramic pot, in a manner analogous to elution of lead from crystal decanters by wine and spirits.

[Main variations of the extrahepatic biliary system and their application to the so-called "split-liver" transplantation technique]. / Principais variações do sistema biliar extra-hepático e sua aplicação na técnica de transplante de fígado chamada "split-liver".

Sixty fresh adult livers were obtained from cadavers together with celiac trunk, head of the pancreas and superior mesenteric artery. We have found a single right hepatic duct in 13(21.6%) of the cases and a multiple right hepatic duct in 47(78.3%). A single left hepatic duct was found in 3(5%) of the cases and a multiple left hepatic duct in 57(95%). A median hepatic duct was found in 18(30%) of the cases, out of this 2(3.3%) was multiple median hepatic duct.

Attitudes to specialist recertification: results of a national survey among pathologists.

AIMS: to evaluate attitudes and preferred mechanisms in the establishment of specialist recertification for pathologists. METHODS: a national survey was conducted amongst the membership of the New Zealand Society of Pathologists. RESULTS: responses were received from 54 (62%) financial members of the society. The majority of respondents agreed with the concept of compulsory periodic recertification. The ideal recertification period should be 10 years and the system should be supervised by the New Zealand Society of Pathologists. The favoured recertification mechanism was by continuing medical education which should be funded by the individual candidate. The majority of respondents supported the establishment of voluntary recertification on a trial basis. CONCLUSIONS: the survey suggested a favourable attribute amongst pathologists to the introduction of continuing education based periodic recertification.

Rapid determination of glyphosate in postmortem specimens using 31P NMR.

Glyphosate was quantified, using 31P NMR, in postmortem blood, liver, and urine specimens taken from two suicide victims. Apart from addition of D2O to give an NMR lock signal, the only pretreatment required of any of the specimens was an enzymic digestion of the liver. Glyphosate was confirmed by its characteristic 31P chemical shift and proton spin coupling and by a downfield shift on addition of NH4OH. Quantitation can be achieved either by comparison with an external standard or by spiking the specimen with glyphosate. Levels of 1 mg/mL could be detected in less than a minute.