A pathological fracture and a solitary mass in the right clavicle: an unusual first presentation of HCC and the role of immunohistochemistry

<p>Absrtract</p> <p>Hepatocellular carcinoma (HCC) is an aggressive malignant tumor that occurs throughout the world. Μetastases from hepatocellular carcinoma (HCC) were generally considered to be rare in the past, because the carcinoma had an aggressive clinical course. In our era, has been reported that extra-hepatic metastases occur in 13.5%-41.7% of HCC patients and this is considered as terminal-stage cancer. The prognosis for patients at this stage continues to be poor due to limited effective treatment. The common sites of extrahepatic metastases in patients with HCC are the lungs, regional lymph nodes, kidney, bone marrow and adrenals. We present here an extremely infrequent case of a patient, without known liver disease, in which the presenting symptom was a pathological-in retrospect-fracture of his right clavicle which wasn't properly evaluated, until he presented a bulky mass in the region 6 months later. For our patient, the added diagnostic difficulty alongside the unknown liver disease, has been that the clavicular metastases was the first presentation of any metastatic disease, rather than the more common sites of HCC spread to adjacent lung or lymph nodes.</p

Are there independent predisposing factors for postoperative infections following open heart surgery?

<p>Abstract</p> <p>Background</p> <p>Nosocomial infections after cardiac surgery represent serious complications associated with substantial morbidity, mortality and economic burden. This study was undertaken to evaluate the frequency, characteristics, and risk factors of microbiologically documented nosocomial infections after cardiac surgery in a Cardio-Vascular Intensive Care Unit (CVICU).</p> <p>Methods</p> <p>All patients who underwent open heart surgery between May 2006 and March 2008 were enrolled in this prospective study. Pre-, intra- and postoperative variables were collected and examined as possible risk factors for development of nosocomial infections. The diagnosis of infection was always microbiologically confirmed.</p> <p>Results</p> <p>Infection occurred in 24 of 172 patients (13.95%). Out of 172 patients, 8 patients (4.65%) had superficial wound infection at the sternotomy site, 5 patients (2.9%) had central venous catheter infection, 4 patients (2.32%) had pneumonia, 9 patients (5.23%) had bacteremia, one patient (0.58%) had mediastinitis, one (0.58%) had harvest surgical site infection, one (0.58%) had urinary tract infection, and another one patient (0.58%) had other major infection. The mortality rate was 25% among the patients with infection and 3.48% among all patients who underwent cardiac surgery compared with 5.4% of patients who did not develop early postoperative infection after cardiac surgery. Culture results demonstrated equal frequencies of gram-positive cocci and gram-negative bacteria. A backward stepwise multivariable logistic regression model analysis identified diabetes mellitus (OR 5.92, CI 1.56 to 22.42, p = 0.009), duration of mechanical ventilation (OR 1.30, CI 1.005 to 1.69, p = 0.046), development of severe complications in the CICU (OR 18.66, CI 3.36 to 103.61, p = 0.001) and re-admission to the CVICU (OR 8.59, CI 2.02 to 36.45, p = 0.004) as independent risk factors associated with development of nosocomial infection after cardiac surgery.</p> <p>Conclusions</p> <p>We concluded that diabetes mellitus, the duration of mechanical ventilation, the presence of complications irrelevant to the infection during CVICU stay and CVICU re-admission are independent risk factors for the development of postoperative infection in cardiac surgery patients.</p

A Versatile Hybrid Mock Circulation for Hydraulic Investigations of Active and Passive Cardiovascular Implants

During the development process of active or passive cardiovascular implants, such as ventricular assist devices or vascular grafts, extensive in-vitro testing is required. The aim of the study was to develop a versatile hybrid mock circulation (HMC) which can support the development of such implants that have a complex interaction with the circulation. The HMC operates based on the hardware-in-the-loop concept with a hydraulic interface of four pressure-controlled reservoirs allowing the interaction of the implant with a numerical model of the cardiovascular system. Three different conditions were investigated to highlight the versatility and the efficacy of the HMC during the development of such implants: 1) biventricular assist device (BiVAD) support with progressive aortic valve insufficiency, 2) total artificial heart (TAH) support with increasing pulmonary vascular resistance, and 3) flow distribution in a total cavopulmonary connection (TCPC) in a Fontan circulation during exercise. Realistic pathophysiologic waveforms were generated with the HMC and all hemodynamic conditions were simulated just by adapting the software. The results of the experiments indicated the potential of physiologic control during BiVAD or TAH support to prevent suction or congestion events, which may occur during constant-speed operation. The TCPC geometry influenced the flow distribution between the right and the left pulmonary artery, which was 10% higher in the latter and led to higher pressures. Together with rapid prototyping methods, the HMC may enhance the design of implants to achieve better hemodynamics. Validation of the models with clinical recordings is suggested for increasing the reliability of the HMC

Κυκλοφοριακές μεταβολές από τη χορήγηση φυσικής Σωματοστατίνης και του αναλόγου αυτής Σαντοστατίνης κατά τη μετεγχειρητική περίοδο

Aim of the study: The aim of this blind, prospective, placebo controlled study was to investigate the circulatory effects of somatostatin (SMS) and it's derivative sandostatin (SDS) on cancer patients during the early postoperative period. Using similar protocol, the study also included the hemodynamic changes during the intraoperative period as well as the possible alterations that could evolve after clonidine pretreatment. Methods: The protocol included the following: ¨ Intraoperative period: · During anesthesia with propofol and sufentanil one group of patients received a bolus dose of SMS 3.5 μg/kg followed by an infusion of SMS at 3.5 μg/kg/min. The second group of patients, received a bolus dose of SDS 3 μg/kg, followed by an infusion of normal saline and the third group received a 20 ml bolus dose and a consecutive infusion of normal saline. (Studies 1 & 2) · Another group of patients received SDS during anaesthesia in order to investigate possible effects on Heart Rate Variability (Study 3) ¨ Postoperative period: · During the early postoperative period, another group of patients received randomly a similar scheme of drugs that consisted of the consecutive (with appropriate breaks in - between) administration of SMS, SDS or normal saline according to the following: rank: either normal saline - SMS - SDS or SMS - normal saline - SDS at doses similar to the previous studies 1 and 2 (Studies 4 & 5). · The same consecutive scheme of studies 4 and 5 was also administered to patients during the early postoperative period in order to evaluate it's effect on electrocardiographic recordings and on acid base status and blood gas analysis (Studies 6 & 7) · Finally, three more groups of patients received the scheme of studies 1 & 2 during the early postoperative period that was preceded by clonidine pretreatment. (Study 8) The following parameters were monitored during all studies: arterial blood pressure, heart rate, central venous pressure and when applicable: pulmonary artery pressure, pulmonary capillary wedge pressure, cardiac output, indices of oxygen transport and utilization, lead II recordings of the electrocardiogram and heart rate variability (HRV). Results: One hundred and eleven (111) patients were studied. Forty two of them received SMS, 32 patients received SDS, 20 patients received both agents and 11 received only normal saline. Immediately after the administration of SMS or SDS a slowing of heart rate was noticed, that was both clinically and statistically significant, and which was followed by an increase of arterial blood pressure, pulmonary artery pressure and the central venous pressure. Cardiac output, pulmonary capillary wedge pressure, indices of oxygen transport and utilization, HRV, acid base balance and blood gases did not presend any significant changes. There were not detected any changes of the QRS complex of the ECG. However there were a few arrhythmias detected, which were mainly bradyarrhythmias of very short duration. Of the groups of patients that were pretreated with clonidine, we observed similar hemodynamic changes though of diminished power. Conclusion: The hemodynamic effects of the peptides Somatostatin and Sandostatin are manifested with a vasopressor effect on the systemic and pulmonary circulation during anaesthesia and the postoperative period, without modulating the sympathetic discharge of autonomic nervous system to the cardiovascular system. These effects can be diminished but not abolished by clonidine pretreatment and are most probably produced by a direct action on the physical receptors of somatostatin, located on the myocardium and the peripheral vessels. The administration of SMS and SDS at doses used in this study, proved to be safe when administered to cancer patients.Σκοπός: Σκοπός αυτής της τυφλής, προοπτικής, ελεγχόμενης με placebo μελέτης ήταν η διερεύνηση των κυκλοφορικών επιδράσεων της σωματοστατίνης (SMS) και του παραγώγου αυτής σαντοστατίνης (SDS), κατά την άμεση μετεγχειρητική περίοδο σε καρκινοπαθείς ασθενείς. Με την χρήση αντίστοιχου πρωτοκόλλου περιέλαβε και τις αιμοδυναμικές επιπτώσεις κατά την διεγχειρητική περίοδο καθώς και τις διαφοροποιήσεις που θα μπορούσαν να εμφανιστούν μετά από προηγούμενη χορήγηση κλονιδίνης. Μέθοδος: Το πρωτόκολλο περιελάμβανε τα εξής: ¨ Διεγχειρητική περίοδος: · Την χορήγηση της SMS σε μία ομάδα ασθενών κατά την διάρκεια αναισθησίας με προποφόλη και σουφεντανίλη σε εφ' άπαξ δόση 3,5 μg/kg και συνεχή έγχυση 3,5 μg/kg/min. Στη δεύτερη ομάδα, χορηγήθηκε SDS σε εφ' άπαξ δόση 3 μg/kg και συνεχή έγχυση φυσιολογικού ορού και σε μία τρίτη ομάδα φυσιολογικός ορός σε εφ' άπαξ δόση 20 ml και συνεχή έγχυση. (Μελέτες 1& 2) · Μια άλλη ομάδα ασθενών έλαβε κατά την διάρκεια αναισθησίας SDS για την παρακολούθηση των επιπτώσεων στην μεταβλητότητα του καρδιακού ρυθμού (Μελέτη 3) ¨ Μετεγχειρητική περίοδος: · Αντίστοιχο τροποποιημένο σχήμα εφαρμόστηκε κατά την διάρκεια της άμεσης μετεγχειρητικής περιόδου, σε μια άλλη διαφορετική ομάδα ασθενών οι οποίοι με τυχαία επιλογή έλαβαν διαδοχικά (με τα απαραίτητα ενδιάμεσα διαλείμματα) τους παραπάνω φαρμακευτικούς παράγοντες, συμπεριλαμβανομένου και του φυσιολογικού ορού. Η σειρά χορήγησης ήταν είτε φυσιολογικός ορός - SMS - SDS είτε SMS - φυσιολογικός ορός - SDS. (Μελέτες 4& 5) · Το ίδιο πρωτόκολλο εφαρμόστηκε και σε μετεγχειρητικούς ασθενείς με σκοπό τον προσδιορισμό πιθανών ηλεκτροκαρδιογραφικών μεταβολών και των επιπτώσεων στα αέρια αίματος. (Μελέτες 6 & 7) · Τέλος άλλες τρείς ομάδες μετεγχειρητικών ασθενών έλαβαν το σχήμα των μελετών 1 & 2 αφού όμως είχε προηγηθεί η χορήγηση κλονιδίνης.(Συνοδός μελέτη 8). Οι παράμετροι που μετρήθηκαν στις διάφορες ομάδες ήταν: αρτηριακή πίεση, καρδιακή συχνότητα, κεντρική φλεβική πίεση και όπου ήταν εφικτό παρακολουθήθηκαν επίσης: η πίεση της πνευμονικής αρτηρίας, η πίεση εξ ενσφηνώσεων των πνευμονικών τριχοειδών, η καρδιακή παροχή, δείκτες μεταφοράς και κατανάλωσης οξυγόνου και η ηλεκτροκαρδιογραφική καταγραφή της απαγωγής ΙΙ και η μεταβλητότητα του καρδιακού ρυθμού (Heart Rate Variability - HRV). Αποτελέσματα: Συνολικά μελετήθηκαν 111 ασθενείς. Από αυτούς οι 42 έλαβαν μόνο SMS, οι 32 μόνο SDS, οι 20 έλαβαν και τους δύο παράγοντες και 17 ασθενείς έλαβαν μόνο φυσιολογικό ορό. Σε όλες τις ομάδες αμέσως μετά την χορήγηση τόσο της SMS όσο και της SDS παρατηρήθηκε επιβράδυνση του καρδιακού ρυθμού, ορισμένες φορές κλινικά σημαντική, που ακολουθήθηκε από αύξηση της αρτηριακής πίεσης, της πίεσης της πνευμονικής αρτηρίας και της κεντρικής φλεβικής πίεσης. Δεν διαπιστώθηκαν μεταβολές της καρδιακής παροχής, της πίεσης εξ ενσφηνώσεων των πνευμονικών τριχοειδών, των δεικτών μεταφοράς και κατανάλωσης οξυγόνου, του HRV και των αερίων αίματος. Τα επάρματα του συμπλέγματος QRS δεν παρουσίασαν μεταβολές και οι λίγες αρρυθμίες που παρατηρήθηκαν ήταν βραδυαρρυθμίες πολύ περιορισμένης χρονικής διάρκειας. Στις ομάδες όπου είχε προηγηθεί η χορήγηση κλονιδίνης εμφανίστηκαν παρόμοιες μεταβολές των αιμοδυναμικών παραγόντων, περιορισμένης όμως ισχύος. Συμπέρασμα: Τα πεπτίδια σωματοστατίνη και σαντοστατίνη, τόσο κατά την διάρκεια της αναισθησίας όσο και κατά την άμεση μετεγχειρητική περίοδο, εμφάνισαν αγγειοσυσπαστική δράση τόσο στην συστηματική όσο και στην πνευμονική κυκλοφορία χωρίς όμως να μεταβάλουν την συμπαθητική εκροή του αυτόνομου νευρικού συστήματος προς το καρδιαγγειακό σύστημα. Η δράση αυτή μετριάζεται αλλά δεν εξαλείφεται από την προχορήγηση κλονιδίνης και πιθανότατα οφείλεται σε άμεση δράση στους φυσικούς υποδοχείς της σωματοστατίνης στο μυοκάρδιο και τα περιφερικά αγγεία. Η χρήση των παραγόντων αυτών, στις δόσεις που χρησιμοποιήθηκαν, αποδεικνύεται ασφαλής σε καρκινοπαθείς ασθενείς

A versatile hybrid mock circulation for hydraulic investigations of active and passive cardiovascular implants

During the development process of active or passive cardio-vascular implants, such as ventricular assist devices or vascular grafts, extensive in-vitro testing is required. The aim of the study was to develop a versatile hybrid mock circulation (HMC) which can support the development of such implants that have a complex interaction with the circulation. The HMC operates based on the hardware-in-the-loop concept with a hydraulic interface of four pressure-controlled reservoirs allowing the in-teraction of the implant with a numerical model of the cardi-ovascular system. Three different conditions were investigated to highlight the versatility and the efficacy of the HMC during the development of such implants: 1) biventricular assist device (BiVAD) support with progressive aortic valve insufficiency, 2) total artificial heart (TAH) support with increasing pulmonary vascular resistance, and 3) flow distribution in a total cavo-pulmonary connection (TCPC) in a Fontan circulation during exercise. Realistic pathophysiologic waveforms were generated with the HMC and all hemodynamic conditions were simulated just by adapting the software. The results of the experiments indicated the potential of physiologic control during BiVAD or TAH support to prevent suction or congestion events, which may occur during constant-speed operation. The TCPC geom-etry influenced the flow distribution between the right and the left pulmonary artery, which was 10% higher in the latter and led to higher pressures. Together with rapid prototyping meth-ods, the HMC may enhance the design of implants to achieve better hemodynamics. Validation of the models with clinical recordings is suggested for increasing the reliability of the HMC.ISSN:1058-2916ISSN:1538-943

A Novel Multi-objective Physiological Control System for Rotary Left Ventricular Assist Devices

ISSN:1573-9686ISSN:0090-696