Biomedical subjects
Publications and source records attributed to P Fuentes.
Isolated pericardial rupture is probably a frequently overlooked injury. We present a case of delayed heart herniation through a left pericardial tear resulting from blunt trauma. Diagnosis was achieved by video-assisted thoracoscopy, which was also helpful in the selection of the appropriate site and extent for the thoracotomy incision.
The purpose of this prospective postmortem study was to assess the diagnostic accuracy of bronchoscopic techniques (bronchoalveolar lavage [BAL] and protected specimen brush [PSB]) and nonbronchoscopic techniques (blind bronchial sampling [BBS] and mini-BAL) in the diagnosis of ventilator-associated pneumonia (VAP). The results of each technique were compared with histology and culture of lung tissue specimens obtained by surgical pneumonectomies in 38 patients who died after at least 72 h of mechanical ventilation. Histology was positive for VAP in 18 patients and negative in 20 patients. There were 12 definite VAP (positive histology and positive lung cultures) and 6 histologic VAP (positive histology and negative cultures). Clinical pulmonary infection score (CPIS) at a threshold of 6 achieved a sensitivity of 72% and a specificity of 85%. When the CPIS was combined with the logarithmic concentration of the predominant microorganism obtained from the BBS sample culture, specificity was increased to 95%, for a threshold of 10. Using 10(3) cfu/ml as the threshold of positivity for cultures obtained with PSB and mini-BAL samples and 10(4) cfu/ml for cultures obtained with BBS and BAL, the respective sensitivities of these techniques for definite VAP were 42, 67, 83, and 58%. The sensitivity of BBS was significantly higher than that of PSB (p < 0.05). The area under the receiver operator characteristic curve was significantly greater for BBS than PSB (p < 0.05). Given that it is more sensitive and noninvasive, BBS is preferable to PSB for the diagnosis of VAP.
A protein constituent of the outer membrane from Neisseria meningitidis (hereafter called P64K) has been crystallized using the hanging drop technique. Crystals are tetragonal with unit cell dimensions a = b = 136.84 A and c = 78.44 A, compatible with a single monomer of 64 kDa in the asymmetric unit. When exposed to high intensity synchrotron radiation, these crystals diffract X-rays to at least 2.9 A resolution, indicating that a high resolution structure analysis is feasible.
Cerebral organization has been seen to vary in different social or ethnic groups; also, sociocultural retardation is a serious obstacle to development in poorer countries. The ability of the right hemisphere to recognize facial emotions in a tachistoscopic task was tested in university and low-socioeconomic-level subjects. All were male and right-handed. The university students recognized facial emotions projected to their left field-right hemisphere significantly better than with their right field-left hemisphere; the low-socioeconomic-level subjects showed no differences in hemispheric performance. The explanation of laterality as a function of social class may be of importance in dealing with sociocultural retardation.
Between 1981 and 1991, 845 patients were operated on for right lung cancer. Among them, 50 (6%) had a tumor invading the superior vena cava (SVC). Fifteen patients (14 men and 1 woman, mean age: 58 years) underwent radical resection with concomitant vascular reconstruction. Two patients presented with a superior vena caval syndrome. The SVC was invaded by direct extension from the tumor (n = 11) or by paratracheal nodal involvement (n = 4). The patients required pneumonectomy (n = 13) or upper lobectomy (n = 2), with lateral (n = 11) or circumferential resection (n = 4) of the SVC. The venous pathway was repaired by direct suture (n = 9), prosthetic patch (n = 2) or polytetrafluoroethylene (PTFE) graft (n = 4). Tumor resection was considered macroscopically complete in 12 patients (80%). One patient died postoperatively (7%) and non-fatal complications occurred in 3 (20%). Early patency of the four grafts was assessed by phlebography. In the late course, pulmonary embolism occurred in two patients and extended superior vena caval thrombosis in one; the overall clinical patency rate was 75.7% at 1 and 5 years. Two patients (13.3%) experienced mediastinal recurrence; the overall survival rates at 1 year, 2 years and 5 years were, respectively, 46.7%, 32% and 24% (median: 8.5 months). We conclude that extended resection for lung cancer invading the SVC, when feasible, is justified given the effective control of the primary tumor thereby provided, with an acceptable operative risk.
Video-assisted thoracic surgery is emerging as a viable approach to increasingly complex intrathoracic therapeutic procedures. From February to July 1993, 35 patients (25 male, 10 female; mean age = 60 years, range: 17-74) underwent a major pulmonary resection using a video-assisted technique: lobectomy (n = 30) or pneumonectomy (n = 5). Pathology disclosed bronchogenic carcinomas (n = 26), metastases (n = 3), and miscellaneous disorders (n = 6). All procedures required one 10.5 mm port for the video-camera, one 3.5 to 5 cm utility thoracotomy through which surgical instrumentation was inserted and the operative specimen removed, and one occasional supplementary 12 mm port. Lung resections were performed with separated dissection and division of each component of the pedicle. The mean operative time was 145 min (SD: +/- 17). There were two postoperative deaths (5.7%) that were not directly related to the technique. Seven patients (20%) experienced non-fatal complications. After lobectomy, the mean duration of chest tube placement was 7.3 days (SD: +/- 1.6). The mean hospital stay was 11 days (SD: +/- 3). All the patients experienced minor postoperative chest pain. We conclude that video-assisted lung resections are technically feasible without an increased risk.
Video-assisted thoracic surgery is emerging as a viable approach to increasingly complex intrathoracic therapeutic procedures. We present a case of delayed diagnosis of a ruptured right diaphragm caused by a closed trauma in a young woman. The diaphragm was repaired successfully using a video-assisted procedure. Limited postoperative chest pain and muscular impairment allowed early physical therapy that resulted in an excellent outcome. Video-assisted thoracic surgery is suggested as a new treatment option for traumatic diaphragmatic disorders.
Between 1987 and 1992, 21 patients who presented with potentially resectable non-small cell lung cancer and coronary artery disease, underwent a preoperative cardiac catheterization in order to assess the coronary artery anatomy and left ventricular function. There were 20 men and 1 woman whose ages ranged from 57 to 77 years. Patients with triple-vessel disease and poor distal circulation or impaired ventricular function (n = 2) were excluded from myocardial revascularization and pulmonary surgery. Patients with a curable left-main or triple-vessel disease (group I) first underwent surgical (n = 3) or transluminal (n = 4) myocardial revascularization. The remaining patients presented with single- or double-vessel disease, and were operated on without prior myocardial revascularization (group II; n = 12). The thoracic procedures consisted of exploratory thoracotomy in two cases, lung-sparing resection in one, lobectomy in ten, bilobectomy in one and pneumonectomy in five. The overall mortality and morbidity rates were 5.3% and 31.6%, respectively. Four patients (21%) experienced postoperative cardiac complications: fatal myocardial infarction (n = 1) and dysrhythmia (n = 2) in three group II patients (25%), and transient myocardial ischemia in one group I patient (14.3%). The overall survival rate at 5 years was 57.4% for the 17 patients who underwent resection of their cancer. We conclude that 1) lung surgery in patients with non-small cell lung cancer and coronary artery disease is justified in selected cases, 2) previous myocardial revascularization appears to confer protection against the development of postoperative cardiac morbidity.
A case of myasthenia associated with Hodgkin's disease with probable invasion of the thymus is reported. Five cases of association between lymphomatous thymoma and myasthenia (2 Hodgkin's thymomas and 3 non-Hodgkin's lymphomatous thymomas) have previously been reported. Myasthenia healed after the lymphoma was treated. This association raises pathogenic problems in the 3 cases of non-Hodgkin's thymoma where invasion of the thymus erased all its normal structure.
Ten patients (eight men, two women) who underwent surgical reconstruction of the superior vena cava using an expanded polytretrafluoroethylene (ePTFE) prosthesis between 1981 and 1991 were reviewed to assess the therapeutic value of such surgery. The mean (s.d.) age was 55(12) years. Obstruction of the superior vena cava was caused by pulmonary or mediastinal cancer in nine patients and chronic mediastinitis in one. Eight patients had superior vena cava syndrome and two had symptoms of lung disease. The diagnosis of superior vena cava obstruction was made before surgery by computed tomography or superior venacavography in eight patients and during the surgical procedure in two. Tumour resection was performed in five patients. Venous reconstruction was achieved by interposition of an ePTFE graft between the proximal and distal end of the vena cava in three patients and between one (four cases) or two (three cases) tributaries of the superior vena cava and the right atrium in seven. No patient died during the perioperative period. Symptoms of superior vena cava obstruction disappeared promptly after operation in all patients. Postoperative patency was assessed by cavography or computed tomography; all the grafts were patent. During follow-up no patients presented with recurrent superior vena cava syndrome. Eight patients died. The cumulative survival rates were 70, 25 and 12.5% at 1, 2 and 5 years, respectively. Surgical reconstruction of the superior vena cava with an ePTFE prosthesis provided immediate and long-term relief of symptoms of superior vena cava obstruction with a low surgical morbidity, even in patients with unresectable malignancy.
Video-assisted thoracic surgery (VATS) is a compromise between conventional thoracic surgery performed via a thoracotomy of variable dimensions and surgical videothoracoscopy, which, using only small operating channels, requires the use of specific instruments, gives a field of vision exclusively by video camera and raises the delicate problem of extraction of the resection specimen. VATS is performed via a minithoracotomy, 3.5 to 5 cm long, using a video camera. In this way, the operator has two forms of vision throughout the operation: direct vision through the orifice of the minithoracotomy and visualization of the video screen. This technique also allows extraction of the resection specimen at the end of the operation. Between February and May 1993, 20 patients (14 males and 6 females with a mean age of 56 years) underwent lung resection by VATS (18 lobectomies and 2 pneumonectomies). Eighty-eight patients had a malignant tumour and 2 had a benign disease. Lymph node dissection was routinely performed in patients with a malignant lesion. The mean size of the tumours was 3.2 cm. The operative mortality was nil. The mean operating time was 154 minutes. The postoperative course was uneventful in 14 patients, but two cases of atelectasis on DO, one bronchial infection and one chylothorax, treated medically, were observed. The authors report the current criteria of their indications as the feasibility and reliability of this new technique. Results on pain and patient comfort, postoperative analgesia requirements, recovery of respiratory function and possible long-term sequelae remain to be demonstrated, which is the objective of a current prospective study.
Tracheal rupture from within is uncommon and always iatrogenic. We report a case of a tracheal rupture following the use of a Sengstaken-Blakemore tube to control a gastroesophageal hemorrhage. Emergency surgical repair was required. Although complications associated with balloon tamponade are well-documented, no major tracheal injury has ever been reported.
The authors review the recent changes observed in the indications for lung transplantation. Several classical contra-indications have been alleviated or even cancelled. Chronic infection presenting as cystic fibrosis has become one of the first indications for lung replacement. Respirator-dependent patients are at an operative risk comparable to the overall results. Long-term corticosteroid therapy and pleural adhesions are no longer formal contraindications but should be approached with extreme caution. In recent years, single lung transplantation has been extended to diseases, such as emphysema and pulmonary hypertension, which were formerly indications for double-lung or heart-lung transplantation. The reasons for this include donor shortage and the better 1-year survival following single lung transplantation. The most recent development is paediatric lung transplantation. The legitimacy of redo transplantation is controversial.
An algorithm for medical diagnosis assistance is described. In this algorithm, the patient is identified following the simultaneous evaluation of its degree of similarity with a given disease, as well as the extent of disagreement with the rest of diseases considered in the differential diagnosis. In an example the algorithm is applied to the diagnosis assistance of some neuropathies.
From January 1980 through January 1985, 452 consecutive patients underwent pulmonary resection for primary non-small cell bronchogenic cancer. Forty-seven patients (10.4%) were 70 years old or older: there were 45 men and 2 women, with a mean age of 72.4 years (S.D.: 2.6; range: 70-79). This population was comparable to the 405 younger patients with respect to the type of resection, histology and TNM staging. Whereas the non-fatal complication rate was similar in both groups (25.5% versus 29.9%), the in-hospital mortality rate was significantly higher in the older patients (12.8% versus 4.7%; P < or = 0.05). The mortality rate after extended resections was significantly higher among the older patients (33.3% versus 6%, P < or = 0.01). The cause of death was myocardial infarction in half the cases; the underlying coronary disease was unrecognized preoperatively in one-third. Five-year survival was comparable in both groups: 29.8% and 33%, respectively. We conclude that pulmonary resection for bronchogenic cancer is justified in patients over 70 years; a careful preoperative assessment ought to be performed and standard resections should be preferred.
To improve resectability for bulky esophageal tumors and/or tumors evolving close to the pharyngo-esophageal junction (PEJ), a combined preoperative chemotherapy plus radiotherapy (CT+RT) was given in 25 patients. There were 23 men and 2 women (mean age: 55 years); 21 had squamous cell carcinoma and 4 had adenocarcinoma. According to TNM classification based on computed tomography, the tumor was graded T3 in 20 cases, T4 in 2, T2 in 2 and T1 in 1. The preoperative treatment included two sessions of continuous infusion of 5-fluorouracil (800 mg/m2 per day) and cisplatin (20 mg/m2 per day), and combined radiotherapy (3 Gy/day). The overall tolerance was acceptable. The tumoral mass decreased in 23 patients (92%). All the patients underwent a wide esophagectomy; among the six patients with a tumor close to the PEJ, two required an associated pharyngolaryngectomy. The operative mortality rate was 8%. Major non-fatal complications occurred in 52%. On histology, there was no evidence of residual disease in seven patients (28%). The median survival was 18 months and the overall survival rate was 22.1% at 2 years. For the patients who had a complete histological response, the 2-year survival rate was 35%. Our data suggest that combined CT+RT may improve resectability of esophageal carcinoma. Improved survival rates seem to be appreciable in patients with a complete histologic response.
The authors report on an analysis concerning the healing of tracheobronchial anastomoses after lung and heart-lung transplantation. The present study includes 64 anastomoses selected from a total of 80. Sixteen were excluded because of early postoperative death; none of these deaths was related to an airway complication. Bronchial healing was assessed with bronchoscopic follow-up; the aspect of the suture line was classified according to the grades of Couraud. The initial reference was the examination at 2 weeks postoperatively, which was compared to subsequent follow-ups. At the initial assessment, 42 anastomoses were grade I, 4 were grade II, and 18 were grade III. The subsequent anatomic result was satisfactory for 52 sutures (81%). The complications observed in the remaining patients were malacia in 2, stenosis treated with a stenting device in 4 and dehiscence in 6. The duration of ischemia and postoperative mechanical respiratory support, as well as the proximal or distal location of the anastomosis appeared to be of significant prognostic value.
A total of 27 mandibular, buccal class II furcation defects were treated in 16 subjects using a coronally positioned flap procedure, with or without citric acid conditioning of the root surfaces. The effect of the therapies was evaluated from a series of soft and hard tissue measurements. Mean improvements were slightly greater for acid treated than for non-acid treated defects. However, none of the mean differences reached statistical significance, indicating that citric acid conditioning may not be a necessary part of the regenerative, coronally positioned flap procedure in mandibular furcations.