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1.
Artigo em Inglês | MEDLINE | ID: mdl-31221511

RESUMO

OBJECTIVES: The authors describe the experience of patient transfer on veno-arterial extracorporeal membrane oxygenation (VA-ECMO) used as a salvage therapy for refractory cardiogenic shock, examining feasibility and long-term outcomes. DESIGN: A retrospective case series. SETTING: A tertiary referral cardiothoracic transplantation center. PARTICIPANTS AND INTERVENTIONS: Since 2012, the authors' multidisciplinary team has traveled to the referring center of 15 patients referred with refractory cardiogenic shock. Of these, 13 were instituted on VA ECMO support (8 peripheral and 5 central) and subsequently transferred to the authors' center. A further 11 patients were transferred to the authors' institution by the referring team, already having been placed on VA-ECMO (8 peripheral and 3 central). MEASUREMENTS AND MAIN RESULTS: All patients were safely transferred. The distance travelled ranged from 16 to 341 miles. The median duration of support on VA-ECMO was 4 days, ranging from 1 to 24 days. The VA-ECMO support was weaned, or the patient underwent a definitive surgical management (including 4 undergoing cardiac transplantation and 3 pulmonary endarterectomy) in 15 (62.5%) patients. The median intensive care unit stay was 15 days (range 1-109). Overall 30-day survival for this patient cohort was 69.6% with 1-year survival of 59.8%. For patients who were weaned from VA-ECMO, the 30-day survival was 100% and 1-year survival 92.9%. CONCLUSIONS: The authors' experience demonstrates the feasibility and survival benefit of a salvage VA-ECMO retrieval service for carefully selected patients with refractory cardiogenic shock. The authors suggest that a system based on the model of nationally commissioned severe respiratory failure services could be organized to support the transfer of these patients.

2.
Am J Transplant ; 19(8): 2378-2382, 2019 Aug.
Artigo em Inglês | MEDLINE | ID: mdl-30945451

RESUMO

There is debate in the literature regarding management of patients with sickle cell trait (SCT) undergoing cardiac surgery, since it is recognized that cardiopulmonary bypass presents many precipitating risk factors for a sickling crisis. Despite this, many report successful outcomes without any modification to perioperative management. A 49-year-old woman with SCT (HbS 38%) with postpartum cardiomyopathy underwent cardiac transplantation. The patient was cooled to 34.0°C and retrograde cold blood cardioplegia was infused continuously. The cold ischemic time was 219 minutes and warm ischemic time 46 minutes. After weaning from bypass, she developed global cardiac dysfunction requiring veno-arterial extracorporeal membrane oxygenation. The circuit suddenly stopped, requiring emergency reinstitution of bypass; the circuit had clotted. Transesophageal-echocardiogram revealed thrombus within the left atrium and ventricle. There was no recovery of cardiac function and the patient developed multiorgan failure. At postmortem there was extensive myocardial infarction with evidence of widespread catastrophic intravascular red-cell sickling. This case highlights the danger of complacency in patients with SCT, offering a learning opportunity for the cardiothoracic community to highlight the most serious complication that can occur in this group of patients. We have learned that SCT and cardiac surgery is not a benign combination.

3.
Artigo em Inglês | MEDLINE | ID: mdl-30879041

RESUMO

OBJECTIVES: Diffuse cardiac amyloidosis is a significant diagnosis with a poor prognosis. Isolated atrial amyloidosis (IAA) is the most common form of cardiac amyloidosis caused by accumulation of alpha-atrial natriuretic peptide. IAA has been associated with dysrhythmia, but otherwise remains a poorly characterized condition. The impact of incidental IAA on postoperative outcome following cardiac surgery has not previously been reported. The purpose of this study was to examine the impact of isolated atrial amyloid on patient outcomes following cardiac surgery. METHODS: A retrospective analysis was performed of all patients having excision of the left atrial appendage during cardiac surgery at our centre over a 5-year period. Patients with histological evidence of IAA were compared to patients without this diagnosis. IAA was diagnosed by immunohistochemistry for atrial natriuretic peptide. RESULTS: A total of 167 patients underwent left atrial appendage excision and of these 26 (15.6%) were found to have IAA. Preoperative characteristics were similar between the 2 groups. A significantly greater proportion of patients with IAA experienced dysrhythmia requiring implantation of a permanent pacemaker (23.1% vs 7.8%, P = 0.03). There was also a significantly elevated incidence of perioperative death in the IAA group (11.5% vs 1.4%, P = 0.03) and inferior 1-year survival (84.6% vs 96.5%, P = 0.02). CONCLUSIONS: The presence of IAA may be associated with inferior outcomes following cardiac surgery, with increased morbidity in the early postoperative period and inferior long-term survival. Knowledge of the diagnosis preoperatively may facilitate management of patients.

4.
J Autoimmun ; 98: 44-58, 2019 Mar.
Artigo em Inglês | MEDLINE | ID: mdl-30528910

RESUMO

The development of humoral autoimmunity following organ transplantation is increasingly recognised, but of uncertain significance. We examine whether autoimmunity contributes independently to allograft rejection. In a MHC class II-mismatched murine model of chronic humoral rejection, we report that effector antinuclear autoantibody responses were initiated upon graft-versus-host allorecognition of recipient B cells by donor CD4 T-cells transferred within heart allografts. Consequently, grafts were rejected more rapidly, and with markedly augmented autoantibody responses, upon transplantation of hearts from donors previously primed against recipient. Nevertheless, rejection was dependent upon recipient T follicular helper (TFH) cell differentiation and provision of cognate (peptide-specific) help for maintenance as long-lived GC reactions, which diversified to encompass responses against vimentin autoantigen. Heart grafts transplanted into stable donor/recipient mixed haematopoietic chimeras, or from parental strain donors into F1 recipients (neither of which can trigger host adaptive alloimmune responses), nevertheless provoked GC autoimmunity and were rejected chronically, with rejection similarly dependent upon host TFH cell differentiation. Thus, autoantibody responses contribute independently of host adaptive alloimmunity to graft rejection, but require host TFH cell differentiation to maintain long-lived GC responses. The demonstration that one population of helper CD4 T-cells initiates humoral autoimmunity, but that a second population of TFH cells is required for its maintenance as a GC reaction, has important implications for how autoimmune-related phenomena manifest.

5.
Artigo em Inglês | MEDLINE | ID: mdl-30481292

RESUMO

A best evidence topic in cardiothoracic surgery was written according to a structured protocol. The question addressed was: Do patients undergoing pulmonary lobectomy using the non-intubated anaesthetic technique have superior clinical outcomes? Altogether, 324 papers were found using the reported search, of which 5 represented the best evidence to answer the clinical question. The authors, journal, date and country of publication, patient group studied, study type, relevant outcomes and results of these papers are tabulated. The non-intubated anaesthetic technique can be safely used in patients undergoing video-assisted thoracic surgery lobectomy. Low conversion rates to intubation are reported, and conversion has been safely managed with no associated morbidity or mortality reported. The technique has not been shown to impact on the incidence of postoperative complications. However, studies consistently demonstrate improved postoperative outcomes in terms of recovery from anaesthesia permitting earlier oral intake and mobilization which is associated with a reduced length of hospital stay.

6.
Artigo em Inglês | MEDLINE | ID: mdl-30346507

RESUMO

OBJECTIVES: Between 2% and 8% of patients return to the theatre for mediastinal bleeding following cardiac surgery. In the majority of patients, a surgical source of bleeding is identified. Both mediastinal bleeding and re-exploration are associated with increased morbidity and mortality and the use of blood products. The aim of this study was to develop a 'haemostasis checklist' with the intention of reducing mediastinal bleeding and re-exploration following cardiac surgery. METHODS: The Papworth haemostasis checklist was developed with a multidisciplinary collaboration. It consists of 2 components: surgical sites and coagulation status. The checklist is completed at a 'time-out' prior to sternal wire insertion. The analysis compared the outcomes of patients undergoing cardiac surgery in the 1 year before and after implementation. A propensity analysis assessed the impact of re-exploration on outcomes. RESULTS: Three thousand eight hundred and eleven patients underwent cardiac surgery during the study period. Re-exploration for bleeding was associated with inferior outcomes. Following checklist implementation, there was a significant reduction in the re-exploration rate (3.47% vs 2.08%, P = 0.01) and proportion of patients bleeding >1 l in 12 h (6.1% vs 3.49%, P < 0.001). There was a significant reduction in consumption of blood products saving £102 165 ($134 198). The checklist implementation was associated with reduced intensive care unit length of stay and hospital length of stay, adding to the financial benefit. CONCLUSIONS: The haemostasis checklist represents a simple intervention which is quick and easy to use but has had a substantial impact on clinical outcomes. We have observed a significant reduction in the mediastinal blood loss, return-to-theatre rate and consumption of blood products, which is associated with a significant clinical and financial benefit.

7.
Artigo em Inglês | MEDLINE | ID: mdl-30325417

RESUMO

A best evidence topic in cardiac surgery was written according to a structured protocol. The question addressed was: Do patients who require return to theatre (RTT) for bleeding have inferior outcomes following cardiac surgery? Altogether, 598 papers were found using the reported search, of which 8 represented the best evidence to answer the clinical question. The authors, journal, date and country of publication, patient group studied, study type, relevant outcomes and results of these papers are tabulated. In summary, patients who bleed following cardiac surgery and then RTT have increased mortality and experience greater morbidity, including neurological, respiratory and renal complications, which result in increased length of intensive care unit stay and hospital stay. It is not easy to dissect the relative contribution of the blood loss and consequent haemodynamic instability, the RTT and the increased blood product consumption to the inferior outcomes observed, as there is evidence that each is important. However, several studies have demonstrated RTT to be an independent predictor of morbidity and mortality, even when controlling for amount of transfusion. Patients who bleed and RTT beyond 12 h postoperatively appear to have the poorest outcomes, suggesting that the decision to RTT should not be delayed if there are concerns over significant bleeding, to ensure the best patient outcomes.

9.
Artigo em Inglês | MEDLINE | ID: mdl-30165611

RESUMO

A best evidence topic in cardiac surgery was written according to a structured protocol. The question addressed was: Does the use of a 'hot-shot' (terminal warm blood cardioplegia) lead to improved outcomes following adult cardiac surgery? Altogether, 567 papers were found using the reported search, of which 9 represented the best evidence to answer the clinical question. The authors, journal, date and country of publication, patient group studied, study type, relevant outcomes and results of these papers are tabulated. We conclude that evidence supporting the use of a hot-shot prior to weaning from cardiopulmonary bypass is rather limited. All 8 of the randomized trials to date are small studies which examine heterogeneous groups of patients, and unfortunately, the conclusions are inconsistent, perhaps in part related to the inability to demonstrate statistical significance with small group size. From the evidence, it appears likely that the use of a hot-shot results in more rapid biochemical, electrical and possibly functional myocardial recovery from cardiopulmonary bypass. However, no study has been able to demonstrate that this leads to improved clinical outcomes other than lower incidence of atrial fibrillation.

10.
Artigo em Inglês | MEDLINE | ID: mdl-30052992

RESUMO

A best evidence topic in cardiac surgery was written according to a structured protocol. The question addressed was: Do patients with liver cirrhosis undergoing cardiac surgery have inferior clinical outcomes? Altogether, 1627 papers were found using the reported search, of which 8 represented the best evidence to answer the clinical question. The authors, journal, date and country of publication, patient group studied, study type, relevant outcomes and results of these papers are tabulated. We conclude that these studies demonstrate that cirrhotic patients have significantly poorer clinical outcomes following cardiac surgery than would be predicted by conventional risk scoring systems. This includes both in-hospital mortality and rates of major complications (bleeding, cardiac, infective, renal and respiratory), which would likely lead to an increased hospital length of stay and, therefore, an associated cost. Evidence supports that the Model for End-stage Liver Disease and Child-Turcotte-Pugh cirrhosis severity scoring systems can be used to stratify risk in cirrhotic patients undergoing cardiac surgery and should be considered for inclusion in future cardiac surgery risk scoring systems.

11.
J Extra Corpor Technol ; 50(2): 83-93, 2018 06.
Artigo em Inglês | MEDLINE | ID: mdl-29921986

RESUMO

Despite the ubiquitous use of cardioplegia in cardiac surgery, there is a lack of agreement on various aspects of cardioplegia practice. To discover current cardioplegia practices throughout the world, we undertook a global survey to document contemporary cardiopulmonary bypass practices. A 16-question, Internet-based survey was distributed by regional specialist societies, targeting adult cardiac anesthesiologists. Ten questions concerned caseload and cardioplegia practices, the remaining questions examined anticoagulation and pump-priming practices. The survey was available in English, Spanish, and Portuguese. The survey was launched in June 2015 and remained open until May 2016. A total of 923 responses were analyzed, summarizing practice in Europe (269), North America (334), South America (215), and Australia/New Zealand (105). Inter-regional responses differed for all questions asked (p < .001). In all regions other than South America, blood cardioplegia was the common arrest technique used. The most commonly used cardioplegia solutions were: St. Thomas, Bretschneider, and University of Wisconsin with significant regional variation. The use of additives (most commonly glucose, glutamate, tris-hydroxymethyl aminomethane, and aspartate) varied significantly. This survey has revealed significant variation in international practice with regards to myocardial protection, and is a reminder that there is no clear consensus on the use of cardioplegia. It is unclear why regional practice groups made the choices they have and the clinical impact remains unclear.


Assuntos
Ponte Cardiopulmonar , Parada Cardíaca Induzida , Anestesiologistas/estatística & dados numéricos , Ponte Cardiopulmonar/métodos , Ponte Cardiopulmonar/estatística & dados numéricos , Estudos Transversais , Parada Cardíaca Induzida/métodos , Parada Cardíaca Induzida/estatística & dados numéricos , Humanos , Compostos de Potássio/uso terapêutico , Padrões de Prática Médica/estatística & dados numéricos , Inquéritos e Questionários
12.
Surg Innov ; 25(5): 485-491, 2018 Oct.
Artigo em Inglês | MEDLINE | ID: mdl-29938603

RESUMO

INTRODUCTION: Minimally invasive techniques have become the standard for a variety of procedures across all surgical specialties. There has been a recent move to integrate robotic technology into standard laparoscopic and thoracoscopic surgery with the aim of improving stability of the visual field with the use of robotic camera assistance. The aim of this study was to report on and examine the use of a headset-controlled robotic camera holder, FreeHand. METHODS: Between May 2013 and Dec 2016, 105 procedures were observed where the FreeHand robotic camera assistant was used. Observations were made of 43 consultant surgeons in 30 hospitals performing 21 different surgical procedures. During the surgery, the number of scope cleans and collisions were quantified, and surgeons were asked to score from 0 to 5 the setup, ergonomics, usability, and overall experience in a questionnaire. RESULTS: Overall surgeon satisfaction was rated as "good" for setup (4.29), ergonomics of the system (4.12), usability (4.39), and overall experience of the system (4.34). In 8 operations (7.6%), there was a conversion from robotic camera assistant to manual assistant. There were no reported adverse events attributable to the use of the system. CONCLUSION: This study demonstrates the breadth of surgical procedures that can be performed with a robotic camera assistant. The robotic camera assistant was found to be safe and simple to use and was positively perceived on assessment in multiple procedures spanning several surgical specialties. This work suggests that robotic camera assistants may offer significant benefits to laparoscopic and thoracoscopic surgeons.

13.
Ann Transl Med ; 6(5): 95, 2018 Mar.
Artigo em Inglês | MEDLINE | ID: mdl-29666818

RESUMO

Lung cancer is a common disease and the leading cause of cancer-related mortality, with non-small cell lung cancer (NSCLC) accounting for the majority of cases. Following diagnosis of lung cancer, accurate staging is essential to guide clinical management and inform prognosis. Positron emission tomography (PET) in conjunction with computed tomography (CT)-as PET-CT has developed as an important tool in the multi-disciplinary management of lung cancer. This article will review the current evidence for the role of 18F-fluorodeoxyglucose (FDG) PET-CT in NSCLC diagnosis, staging, response assessment and follow up.

14.
Innovations (Phila) ; 13(1): 23-28, 2018 Jan/Feb.
Artigo em Inglês | MEDLINE | ID: mdl-29462051

RESUMO

OBJECTIVE: The primary objective was to investigate the long-term survival of patients who underwent single-vessel coronary revascularization with minimally invasive direct coronary artery bypass surgery with or without hybrid revascularization. The secondary outcome measures were repeat revascularization either by coronary artery bypass grafting or by percutaneous coronary intervention and the incidence of myocardial infarction or recurrent angina. METHODS: This is a retrospective study of prospectively collected data of patients who underwent minimally invasive direct coronary artery bypass procedure in our center between January 2001 and December 2015. Procedures were performed either through small left anterolateral thoracotomy or lower midline sternotomy. RESULTS: A total of 182 patients were identified: 100 underwent minimally invasive direct coronary artery bypass to the left anterior descending artery and 82 underwent hybrid revascularization (percutaneous coronary intervention to coronary arteries other than the left anterior descending artery along with minimally invasive direct coronary artery bypass to the left anterior descending artery). The mean ± SD age was 62 ± 10.1 years. Preoperatively 82% were male, and 72.5% patients had good left ventricular function. The median follow-up period was 10.9 years. There was no in-hospital or 30-day mortality. The 10-year actuarial survival was 84.8%. Freedom from repeat revascularization was 98.9% at 1 year and 89.9% at 10 years. At follow-up, freedom from myocardial infarction was 96.7% whereas freedom from angina was 92.9%. CONCLUSIONS: Within the limitations imposed by retrospective analyses, our study demonstrates excellent long-term outcome in patients undergoing minimally invasive direct coronary artery bypass with or without hybrid revascularization. For isolated left anterior descending artery disease minimally invasive direct coronary artery bypass should be considered, whereas hybrid revascularization (percutaneous coronary intervention and minimally invasive direct coronary artery bypass) should be considered for multivessel disease.


Assuntos
Angina Pectoris/epidemiologia , Ponte de Artéria Coronária/métodos , Doença da Artéria Coronariana/cirurgia , Procedimentos Cirúrgicos Minimamente Invasivos/métodos , Infarto do Miocárdio/epidemiologia , Idoso , Angina Pectoris/complicações , Feminino , Humanos , Incidência , Masculino , Pessoa de Meia-Idade , Procedimentos Cirúrgicos Minimamente Invasivos/efeitos adversos , Infarto do Miocárdio/complicações , Revascularização Miocárdica/tendências , Intervenção Coronária Percutânea/efeitos adversos , Estudos Retrospectivos , Esternotomia/métodos , Análise de Sobrevida , Toracotomia/métodos , Resultado do Tratamento
15.
Interact Cardiovasc Thorac Surg ; 26(6): 932-937, 2018 Jun 01.
Artigo em Inglês | MEDLINE | ID: mdl-29373658

RESUMO

OBJECTIVES: Pulmonary endarterectomy (PEA) is the treatment of choice for patients with chronic thromboembolic pulmonary hypertension (PH). Despite excellent outcomes following PEA, a small proportion of patients have residual proximal disease or present with recurrent chronic thromboembolic PH and may benefit from further surgery. The aim of this study was to analyse outcomes following reoperative PEA at a high-volume national tertiary referral centre for the management of chronic thromboembolic PH. METHODS: This retrospective analysis was performed using our prospectively maintained PH database to identify all patients who underwent reoperative PEA surgery between the commencement of the programme in 1997 and January 2017, and the patients' data were collected for analysis. RESULTS: Twelve patients underwent reoperative PEA during the period of study. The mean interval between primary procedure and reoperative procedure was 6.3 years. Significant improvements were observed in pulmonary haemodynamics following reoperative PEA. Mean pulmonary arterial pressure decreased from 46.8 to 29.8 mmHg (P < 0.0001) and pulmonary vascular resistance decreased from 662 to 362 dyne·s·cm-5 (P = 0.0007). A significant functional improvement in the 6-min walking test distance was also observed, increasing from 327 to 460 m at 6 months postoperatively (P = 0.0018). Median length of hospital stay was 12 days. In-hospital mortality was 8.3% with 1-year survival of 83.3%. CONCLUSIONS: Reoperative PEA is technically possible and relatively safe, achieving good functional and physiological outcomes. Patients must be carefully selected by a multidisciplinary team, and surgery should be performed in experienced centres.

16.
Front Immunol ; 9: 3038, 2018.
Artigo em Inglês | MEDLINE | ID: mdl-30728823

RESUMO

Different profiles of alloantibody responses are observed in the clinic, with those that persist, often despite targeted treatment, associated with poorer long-term transplant outcomes. Although such responses would suggest an underlying germinal center (GC) response, the relationship to cellular events within the allospecific B cell population is unclear. Here we examine the contribution of germinal center (GC) humoral alloimmunity to chronic antibody mediated rejection (AMR). A murine model of chronic AMR was developed in which T cell deficient (Tcrbd -/-) C57BL/6 recipients were challenged with MHC-mismatched BALB/c heart allografts and T cell help provided by reconstituting with 103 "TCR75" CD4 T cells that recognize self-restricted allopeptide derived from the H-2Kd MHC class I alloantigen. Reconstituted recipients developed Ig-switched anti-Kd alloantibody responses that were slow to develop, but long-lived, with confocal immunofluorescence and flow cytometric characterization of responding H-2Kd-allospecific B cells confirming persistent splenic GC activity. This was associated with T follicular helper (TFH) cell differentiation of the transferred TCR75 CD4 T cells. Heart grafts developed progressive allograft vasculopathy, and were rejected chronically (MST 50 days), with explanted allografts displaying features of humoral vascular rejection. Critically, late alloantibody responses were abolished, and heart grafts survived indefinitely, in recipients reconstituted with Sh2d1a -/- TCR75 CD4 T cells that were genetically incapable of providing TFH cell function. The GC response was associated with affinity maturation of the anti-Kd alloantibody response, and its contribution to progression of allograft vasculopathy related principally to secretion of alloantibody, rather than to enhanced alloreactive T cell priming, because grafts survived long-term when B cells could present alloantigen, but not secrete alloantibody. Similarly, sera sampled at late time points from chronically-rejecting recipients induced more vigorous donor endothelial responses in vitro than sera sampled earlier after transplantation. In summary, our results suggest that chronic AMR and progression of allograft vasculopathy is dependent upon allospecific GC activity, with critical help provided by TFH cells. Clinical strategies that target the TFH cell subset may hold therapeutic potential. This work is composed of two parts, of which this is Part II. Please read also Part I: Alsughayyir et al., 2019.

17.
Front Immunol ; 9: 3039, 2018.
Artigo em Inglês | MEDLINE | ID: mdl-30740108

RESUMO

Humoral alloimmunity is now recognized as a major determinant of transplant outcome. MHC glycoprotein is considered a typical T-dependent antigen, but the nature of the T cell alloresponse that underpins alloantibody generation remains poorly understood. Here, we examine how the relative frequencies of alloantigen-specific B cells and helper CD4 T cells influence the humoral alloimmune response and how this relates to antibody-mediated rejection (AMR). An MHC-mismatched murine model of cardiac AMR was developed, in which T cell help for alloantibody responses in T cell deficient (Tcrbd -/-) C57BL/6 recipients against donor H-2Kd MHC class I alloantigen was provided by adoptively transferred "TCR75" CD4 T cells that recognize processed H-2Kd allopeptide via the indirect-pathway. Transfer of large numbers (5 × 105) of TCR75 CD4 T cells was associated with rapid development of robust class-switched anti-H-2Kd humoral alloimmunity and BALB/c heart grafts were rejected promptly (MST 9 days). Grafts were not rejected in T and B cell deficient Rag2 -/- recipients that were reconstituted with TCR75 CD4 T cells or in control (non-reconstituted) Tcrbd -/- recipients, suggesting that the transferred TCR75 CD4 T cells were mediating graft rejection principally by providing help for effector alloantibody responses. In support, acutely rejecting BALB/c heart grafts exhibited hallmark features of acute AMR, with widespread complement C4d deposition, whereas cellular rejection was not evident. In addition, passive transfer of immune serum from rejecting mice to Rag2 -/- recipients resulted in eventual BALB/c heart allograft rejection (MST 20 days). Despite being long-lived, the alloantibody responses observed at rejection of the BALB/c heart grafts were predominantly generated by extrafollicular foci: splenic germinal center (GC) activity had not yet developed; IgG secreting cells were confined to the splenic red pulp and bridging channels; and, most convincingly, rapid graft rejection still occurred when recipients were reconstituted with similar numbers of Sh2d1a -/- TCR75 CD4 T cells that are genetically incapable of providing T follicular helper cell function for generating GC alloimmunity. Similarly, alloantibody responses generated in Tcrbd -/- recipients reconstituted with smaller number of wild-type TCR75 CD4 T cells (103), although long-lasting, did not have a discernible extrafollicular component, and grafts were rejected much more slowly (MST 50 days). By modeling antibody responses to Hen Egg Lysozyme protein, we confirm that a high ratio of antigen-specific helper T cells to B cells favors development of the extrafollicular response, whereas GC activity is favored by a relatively high ratio of B cells. In summary, a relative abundance of helper CD4 T cells favors development of strong extrafollicular alloantibody responses that mediate acute humoral rejection, without requirement for GC activity. This work is composed of two parts, of which this is Part I. Please read also Part II: Chhabra et al., 2019.

18.
Artigo em Inglês | MEDLINE | ID: mdl-28958011

RESUMO

Surgical venous bypass is an effective treatment option in the management of benign superior vena caval obstruction. Here, we present CorMatrix® as a novel conduit choice, supported internally by an endovascular stent in an attempt to prevent stenosis and reduce reintervention rate following surgical bypass.

19.
J Vis Surg ; 3: 146, 2017.
Artigo em Inglês | MEDLINE | ID: mdl-29302422

RESUMO

The development of video-assisted thoracoscopic surgery (VATS) has contributed to reduced pain and improved recovery following thoracic surgery. However, pain remains a major issue. Patients with bilateral pulmonary pathology requiring operative intervention may have even more pain due to bilateral transthoracic incisions. The recently described uniportal subxiphoid VATS approach provides an opportunity to undertake bilateral thoracic surgery through a single incision that avoids the bilateral intercostal nerve damage caused by transthoracic incision and drainage. Here we report a case of a patient requiring bilateral bullectomy and pleurectomy for the management of pneumothorax that was performed successfully by the subxiphoid VATS approach.

20.
J Vis Surg ; 3: 147, 2017.
Artigo em Inglês | MEDLINE | ID: mdl-29302423

RESUMO

Thoracic surgery is rapidly evolving with minimally invasive strategies now dominating. Thymectomy has traditionally been performed through a sternotomy, but more recently video-assisted thoracoscopic surgery (VATS) approaches have become increasingly popular. To further minimise surgical impact, the uniportal subxiphoid VATS technique has recently been described, using a muscle sparing incision that avoids intercostal nerve injury. A potential advantage that makes this approach particularly suited to thymectomy includes the ability to access both sides of the chest with a single incision. There is also the potential for reduced post-operative pain and chronic thoracostomy neuralgia. Here we describe the management of a patient with thymoma, reporting our procedure and technique for performing uniportal subxiphoid VATS thymectomy.

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