Transposition of greater omentum in deep sternal wound infection caused by methicillin-resistant Staphylococci, with differing clinical course for MRSA and MRSE.

BACKGROUND: Methicillin-resistant Staphylococcus aureus (MRSA) and Staphylococcus epidermidis (MRSE) are an increasing problem in deep sternal wound infections (DSWI) after cardiac surgery. METHODS: Between 2005 and 2009, recalcitrant methicillin-resistant Staphylococcus was found in 21 patients with complicated DSWI, and a transposition of the greater omentum (TGO) was finally performed. A positive microbial culture at the time of procedure was present in all patients. The hospital course was reviewed discretely for MRSA and MRSE. RESULTS: Median patient age was 72.3 years (range 60.8-79.7); 76 % of patients were male. Time from the first sternal revision until consecutive open wound therapy due to re-infection and total hospital stay was longer for MRSA compared to MRSE (38 vs. 14 days, P = 0.003, and 141 vs. 91 days, P = 0.007, respectively). The period from cardiac surgery to TGO was likewise prolonged for MRSA (78 vs. 55 days, P = 0.045), whereas in-hospital mortality and one-year mortality rate did not differ. CONCLUSION: TGO remains a good treatment option for DSWI type IV. Microbial findings determine the clinical course; nevertheless in-hospital mortality remains low for both MRSA and MRSE infection.

Non-programmed clamping of superior vena cava. The anesthesiologist's Achilles' heel.

This case presentation focuses on the hemodynamic alterations due to acute clamping of superior vena cava (SVC) during a right pneumonectomy for lung cancer and on the alternatives for drug administration. In a 71-yr-old female patient without clinical manifestations of SVC syndrome, this large vein was clamped for 22 minutes for patch placement after sudden and unpredictable hemorrhage. The patient became acutely cyanotic and edematous in the face and upper extremities, arterial blood pressure dropped and the venous pressure in the right internal jugular vein was elevated. Drugs for managing the patient were given endobronchially and via an established right atrium line. Postoperatively, no neurologic deficit was noted. This case demonstrates the difficulties for managing patients without superior vena cava syndrome in which acute, non-programmed intra-operative SVC clamping is performed, as this is followed by systemic and brain hemodynamic deteriorations that may lead to bad outcome.

A comparative study of invasive and oscillometric methods of arterial blood pressure measurement in the anesthetized rabbit.

INTRODUCTION: The aim of this project was to evaluate the reliability and accuracy of direct, using the central ear artery (CEA), and oscillometric, using limb-cuffs, methods of arterial blood pressure (AP) measurement in the anesthetized rabbit. METHODS: New Zealand rabbits were anesthetized using a xylazine-ketamine-isoflurane protocol. Using the abdominal aorta (ABA) as direct "gold standard" for AP measurements, ABA pressure readings, via femoral artery catheterization, were compared with those made simultaneously from the ascending aorta after median sternotomy. Thereafter, direct CEA as well as forelimb-(FL) and hindlimb-(HL) cuff oscillometric readings were compared with those made simultaneously from ABA. RESULTS: The blood pressure in the ABA correlated with that from ascending aorta. Furthermore, CEA correlated with the ABA readings. Nevertheless, at high pressures, their divergence from "true" pressure tended to increase. Oscillometric readings at the FL site correlated well with "true" pressure while those at the HL site did not. Their divergence tended to increase at high pressures when using the FL site, while it varied when using the HL site. The accuracy of measurements was moderate for the FL site while poor for the HL site. DISCUSSION: Our results suggest that the CEA can be readily used with high reliability and accuracy for direct AP measurements in the anesthetized rabbit. On the other hand, the FL-cuff oscillometric method should only be used for the evaluation of AP at low and normal pressure ranges.

Pulmonary artery stenosis after systemic-to-pulmonary shunt operations.

OBJECTIVE: Systemic-to-pulmonary shunt operations are still required for palliation of certain congenital heart defects. The aim of this study was to analyze the incidence and etiology of the development of pulmonary artery stenosis after these procedures. METHODS AND RESULTS: Pre- and post-operative angiograms of 59 patients who underwent 54 peripheral and 12 central shunt operations were analyzed retrospectively. Patients without prior cardiovascular interventions (group I, n = 47) were differentiated from patients with prior interventions (group II, n = 12). In group I, all peripheral shunts were inserted contralaterally to the ductus arteriosus. Follow-up for all patients was 1.8 years (4 days-7.8 years). Pulmonary artery stenosis was diagnosed in 12/59 patients (20.3%, group I 12/47; group II 0) after a time interval of 4 days up to 5.3 years and only after Blalock-Taussig shunts (one classical, 11 modified) (12/40 = 30%). The stenoses were located ipsilaterally to the shunt in 7/12 and contralaterally in 5/12. Statistical analysis did not show any impact of age, weight, sex, shunt type or size, pulmonary artery diameters, Nakata and McGoon indices and prior interventions on the development of pulmonary artery stenosis. However, a patent ductus arteriosus and administration of Prostaglandin E1 had a significant impact on the development of pulmonary artery stenosis on the side of the ductus arteriosus. CONCLUSION: Pulmonary artery stenosis is not a rare event after systemic-to-pulmonary shunt operations. A patent ductus arteriosus with or without administration of Prostaglandin E1 is related to pulmonary artery stenosis on the side of the ductus arteriosus. Pulmonary artery stenosis on the side of a peripheral shunt may be caused by inappropriate surgical technique, increased intimal proliferation, or pulmonary artery kinking. Treatment depends on severity of cyanosis and on further surgical plans.

Prevention of perioperative neurological dysfunction. A six year perspective of cardiac surgery.

Neurological dysfunction following cardiac surgical procedures is now well recognized. In order to minimise this serious complication, we instituted various protocols related to the potential causes of perioperative stroke such as: (1) components and use of the heart-lung machine; (2) air embolization; (3) intrinsic cerebro-vascular disease; (4) atheroemboli from the ascending aorta and (5) clot emboli from the left ventricle. We employed certain methods of operation of the heart-lung machine, air evacuation manoeuvres and a pharmacological brain protection protocol. These protocols were applied in a series of 1487 consecutive cardiac surgical procedures performed between 1984 and 1989; 127 patients died (8.54% mortality) and 16 patients (1.08%) suffered major neurological syndromes. Among the latter patients, 4 distinct groups were identified. Group A consisted of 6 patients who remained unresponsive after operation. In group B were 6 patients who awakened after operation but had clinical evidence of focal cerebral infarction. Group C included 3 patients who were initially intact neurologically but in whom neurological deficits developed later. Group D contained 1 patient who had severe mental aberration but no focal neurological deficits. Causative factors, including atheromatous embolism, perioperative hypotension and air embolism, were suspected in 12 of these 16 patients (75%) in groups A, B and C. The outcome was poor for unresponsive patients and 9 out of the 16 died or remained comatose (56.6%).

Spontaneous pneumothorax resulting from congenital cystic adenomatoid malformation in a pre-term infant: case report and literature review.

In the literature there are only three reported cases of spontaneous pneumothorax resulting from congenital cystic adenomatoid malformation in children under 1 year and for whom any resuscitative efforts were made. We present here a fourth case of a pre-term baby girl who was in perfect health, until she suffered a spontaneous pneumothorax as the initial manifestation of congenital cystic adenomatoid malformation of the lung at 10 weeks of age. Atypical segmentectomy with the use of stapling devices was successful. The characteristics of this particular manifestation are discussed.

Imprint cytology for rapid evaluation of lung and mediastinal lesions.

BACKGROUND: Frozen-section biopsy (FSB) of pulmonary and mediastinal tumors is commonly used in the evaluation of diagnostic tissue in thoracic surgery. However, FSB can be labor intensive for the pathology department and time-consuming while the patient is anaesthetised. Imprint cytology is more rapid than the FSB procedure (average, 1 min versus 10 min per tissue sample) and allows more extensive sampling of the specimen. METHODS: In this preliminary study we compared the diagnostic accuracy of imprint cytology and permanent sections on lung and mediastinal lesions from 38 patients. RESULTS: There were no false-positive results and 2 false-negative results. The sensitivity was 99.13%, the specificity was 100% and the positive predictive value was 100%, as no false-positive results were observed. These results match favorably with those in other studies comparing the diagnostic accuracy of imprinting cytology with that of FSB and with reported accuracy rates of the FSB method. CONCLUSION: Our findings confirm the usefulness of this procedure as an adjunt or alternative for FSB in the pathologic evaluation of lung and mediastinal space-occupying lesions.

Immunocytochemical profile of malignant pleural effusions of small-cell lung cancer.

BACKGROUND: Small-cell lung carcinoma (SCLC) is a highly malignant tumour of a somewhat distinctive cell type. The aim of this study was to determine the immunocytochemical profile of tumor cells and lymphoid cell in SCLC pleural fluids. METHODS: Nine cases of malignant pleural fluids of SCLC were studied using cell block preparation. In pleural effusions cytologically proven to be malignant in 9 patients with SCLC, the immunocytological features of tumor cells, together with the determination of lymphocytic subsets were documented. RESULTS: In all 9 cases, tumor cells reacted with neuron-specific enolase (NSE) (100%), whereas in 6 of 9 cases (66,66%) tumor cell expressed synaptophysin, thyroid transciption factor-1 (TTF-1) and chromogranin A antigens. Phenotyping of the lymphocytes revealed in the majority of cases an expression of CD3 and CD4 antigens (8 and 7 cases, respectively) in contrast to CD8 and CD20 expression (1 and 1 case, respectively). CONCLUSIONS: The reactivity pattern of the tumor cells with the markers used in our study is a specific for SCLC. No significant difference in the distribution of lymphocytic subpopulations is observed in correlation with other malignant and no malignant processes involving the pleural cavity.

Evaluation of the oscillometric technique for intermittent non-invasive arterial blood pressure measurement in the anaesthetized pig.

This study was designed to evaluate the oscillometric technique for intermittent non-invasive measurement of arterial pressure (AP) in the anaesthetized pig. In six pigs under sevoflurane anaesthesia, intermittent (every 2 minutes) oscillometric measurements of AP made at a forelimb (FL), a hindlimb (HL) and the tail base were compared with simultaneous direct AP measurements made at the aortic arch (AA) over a wide pressure range (30-140 mmHg of mean AP). All oscillometric measurements strongly correlated (Pearson correlation coefficient >0.837, P < 0.001) with direct AP measurements, with those made at the FL exhibiting the highest correlation. On the basis of consistency of difference between oscillometric and AA pressure readings at graded pressure levels, measurements made at the tail base provided reliable prediction of systolic AP, at the FL of diastolic AP and at both the tail base and the FL of mean AP. In conclusion, oscillometric measurements at the FL and the tail base offer reliable prediction of AP in the anaesthetized pig.

Catamenial pneumothorax.

Catamenial pneumothorax is a rare entity of spontaneous, recurrent pneumothorax occurring in synchrony with the menstrual cycle. The etiology is not completely known, but in most cases it is associated with thoracic endometriosis and/or diaphragmatic fenestrations. We report a case of a 35-year-old woman with three episodes of catamenial pneumothorax. The surgical findings were thoracic endometriosis and diaphragmatic holes. She underwent resection of the affected part of the diaphragm and pleurodesis via a mini-thoracotomy and videothoracoscopy assistance.

The minimized extracorporeal circulation system causes less inflammation and organ damage.

The minimized extracorporeal circulation system (MECC) is being used to reduce priming volume and blood/polymer contact during cardiac procedures. In this study, we evaluated the efficacy and potential advantages of the system in coronary artery bypass graft (CABG) patients. We included two groups of patients destined for CABG in a prospective, randomized study: Group A was operated on the usual pump (n = 30) while Group B was operated using the MECC (n = 50). Pre-operative demographics, intra-operative times and values as well as a series of post-operative outcome data (blood loss, transfusion requirements, ventilation time, ICU and hospital stay) were recorded. CK, CK-MB, troponin-T, IL-6 and IL-8 were measured. Pre-operative and post-operative lung function were assessed. In the MECC-operated group, patients developed less post-operative troponin-T (0.2 +/- 0.3 vs. 0.5 +/- 0.5 ng/mL, p=0.031) and less IL-8 (13.8 +/- 5 vs. 22.5 +/- 0.5 microg/L, p = 0.05). While blood loss was comparable in both groups, packed red blood cells and fresh frozen plasma were given less frequently in the MECC group (p = 0.015 resp. 0.022). The one-tailed Student's t-test revealed shorter bypass time in the MECC group (74 +/- 17 vs. 82 +/- 24 min). There was no difference in ventilation and ICU-time (patients were not treated in a fast-track fashion). The FEV1 was better in the MECC group (relative values: 70.1 +/- 18.2% vs. 61.1 +/- 12.3%, p = 0.02). Utilization of the MECC may cause less cytokine (IL-8) liberation, owing to less blood/tubing contact, as well as less red blood cell and fresh frozen plasma demand. It may also be the circuit in patients with chronic obstructive pulmonary disease (COPD).

Aortic prosthesis re-replacement due to concealed stenosing subvalvular pannus ring.

In a patient with mechanical aortic valve prosthesis, a high transvalvular gradient was detected 16 years following the procedure, without echocardiographic clues for the underlying etiology. Intraoperatively, a stenosing pannus ring was found and excised. This pathological entity should be considered in cases of unclear transprosthetic gradient and early operation should be encouraged in symptomatic patients.

Multifocal hydatid disease in a child.

One of the most serious helminth infections in humans with widespread occurrence is hydatid disease. Although the majority of the cases are referred in adults, many of them have to do with children. The hydatid cysts can occur in any organ of the human body and in rare cases in a combination of different sites. We present the case of a young boy with hydatid cysts in both lungs and in the upper pole of the left kidney. The rarity of this case is the unusual combination of the cyst development in these organs without the involvement of the liver.

Lactate dehydrogenase-5 (LDH-5) overexpression in non-small-cell lung cancer tissues is linked to tumour hypoxia, angiogenic factor production and poor prognosis.

Lactate dehydrogenase-5 (LDH-5) catalyses the reversible transformation of pyruvate to lactate, having a principal position in the anaerobic cellular metabolism. Induction of LDH-5 occurs during hypoxia and LDH-5 transcription is directly regulated by the hypoxia-inducible factor 1 (HIF1). Serum LDH levels have been correlated with poor prognosis and resistance to chemotherapy and radiotherapy in various neoplastic diseases. The expression, however, of LDH in tumours has never been investigated in the past. In the present study, we established an immunohistochemical method to evaluate the LDH-5 overexpression in tumours, using two novel antibodies raised against the rat muscle LDH-5 and the human LDH-5 (Abcam, UK). The subcellular patterns of expression in cancer cells were mixed nuclear and cytoplasmic. In direct contrast to cancer cells, stromal fibroblasts were reactive for LDH-5 only in a minority of cases. Serum LDH, although positively correlated with, does not reliably reflect the intratumoral LDH-5 status. Lactate dehydrogenase-5 overexpression was directly related to HIF1alpha and 2alpha, but not with the carbonic anhydrase 9 expression. Patients with tumours bearing high LDH-5 expression had a poor prognosis. Tumours with simultaneous LDH-5 and HIF1alpha (or HIF2alpha) overexpression, indicative of a functional HIF pathway, had a particularly aggressive behaviour. It is concluded that overexpression of LDH-5 is a common event in non-small-cell lung cancer, can be easily assessed in paraffin-embedded material and provides important prognostic information, particularly when combined with other endogenous markers of hypoxia and acidity.