Risk-prediction for postoperative major morbidity in coronary surgery

OBJECTIVE: Analysis of major perioperative morbidity has become an important factor in assessment of quality of patient care. We have conducted a prospective study of a large population of patients undergoing coronary artery bypass surgery (CABG), to identify preoperative risk factors and to develop and validate risk-prediction models for peri- and postoperative morbidity. METHODS: Data on 4567 patients who underwent isolated CABG surgery over a 10-year period were extracted from our clinical database. Five postoperative major morbidity complications (cerebrovascular accident, mediastinitis, acute renal failure, cardiovascular failure and respiratory failure) were analysed. A composite morbidity outcome (presence of two or more major morbidities) was also analysed. For each one of these endpoints a risk model was developed and validated by logistic regression and bootstrap analysis. Discrimination and calibration were assessed using the under the receiver operating characteristic (ROC) curve area and the Hosmer-Lemeshow (H-L) test, respectively. RESULTS: Hospital mortality and major composite morbidity were 1.0% and 9.0%, respectively. Specific major morbidity rates were: cerebrovascular accident (2.5%), mediastinitis (1.2%), acute renal failure (5.6%), cardiovascular failure (5.6%) and respiratory failure (0.9%). The risk models developed have acceptable discriminatory power (under the ROC curve area for cerebrovascular accident [0.715], mediastinitis [0.696], acute renal failure [0.778], cardiovascular failure [0.710], respiratory failure [0.787] and composite morbidity [0.701]). The results of the H-L test showed that these models predict accurately, both on average and across the ranges of patient deciles of risk. CONCLUSIONS: We developed a set of risk-prediction models that can be used as an instrument to provide information to clinicians and patients about the risk of postoperative major morbidity in our patient population undergoing isolated CABG

Non-cardioplegic coronary surgery in patients with severe left ventricular dysfunction

OBJECTIVES: Although most surgeons use cardioplegia for myocardial protection during coronary artery bypass grafting (CABG), some still use non-cardioplegic methods with very good early and long-term outcome. However, the results in patients with severe left ventricular dysfunction remain unproved. This study evaluates the perioperative mortality and morbidity in patients with severe left ventricular dysfunction submitted to CABG using non-cardioplegic methods. METHODS: From April 1990 through December 1997, 3,180 patients were consecutively subjected to isolated CABG using non-cardioplegic methods, for construction of the distal anastomoses. This prospective study is based on the 107 (3.4%) patients with severe impairment of the left ventricular function (ejection fraction 20 mmHg. Cardiopulmonary bypass time was 73.1 +/- 21.7 min. The mean number of grafts per patient was 3.2. At least one internal mammary artery was used in all cases and 16 patients (14.9%) had bilateral internal mammary artery grafts (1.2 arterial grafts/patient). Endarterectomies were performed in 23 (21.5%) patients. RESULTS: Perioperative mortality was 2.8% (respiratory-1; cardiac-2). Forty one (38.3%) patients required inotropes, but for longer than 24 h in only 12 (11.2%), and two (1.9%) needed intra-aortic counterpulsation. The incidence of myocardial infarction was 2.8%. Two (1.9%) patients had reintervention for haemorrhage and another five (4.6%) for sternal complications. The incidences of supraventricular arrhythmias, renal failure and cerebrovascular accident were 16.8%, 3.6% and 2.8%, respectively. The mean time of hospital stay was 9.3 +/- 6.4 days. CONCLUSION: These results appear to demonstrate that non-cardioplegic methods afford good myocardial protection and operating conditions with excellent applicability, even in patients with severe left ventricular dysfunction

Ausência De Expectativa De Suporte Para O Cuidado Aos Idosos Da Comunidade

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Primary gastric plasmacytoma: a rare entity

Extramedullary plasmacytomas (EP) are tumours composed by a monoclonal population of plasma cells that arise in extraosseus tissues, comprising <5% of all plasma cell neoplasms. Usually, EP arise in the head and neck region, and the stomach is the second most common location-gastric plasmacytoma (GP). Clinical and radiological manifestations are unspecific and may mimic other tumours like gastric adenocarcinomas, gastric stromal tumours and lymphomas, mainly marginal cell lymphoma (MALT lymphoma) and usually definitive diagnosis is provided by pathological evaluation. We present a case of primary GP, discovered incidentally as a polypoid lesion. Tumour was composed by sheets of mature and immature plasmocytes positive for CD138 on immunohistochemistry, without Helicobacter pylori identification. The patient is alive 6 years later and without tumour relapse.info:eu-repo/semantics/publishedVersio

Thorotrast Related Hepatic Malignancies. Two Case Reports

Os A.A apresentam dois casos clínicos de tumores hepáticos associados ao torotraste, dois colangiocarcinomas, observados numa enfermaria de Medicina Interna de um hospital de Lisboa. É feito um comentário sobre o efeito nefasto das radiações ionizantes em geral sobre o organismo humano, particularizando os efeitos do torotraste. Comenta-se, ainda, o prolongado tempo de latência que existiu nestes dois casos, bem como o facto de, provavelmente, estarmos perante os últimos casos de tumores induzidos pelo torotraste

Left ventricular aneurysms: early and long-term results of two types of repair

OBJECTIVE: Controversy still exists regarding the optimal surgical technique for postinfarction left ventricular (LV) aneurysm repair. We analyze the efficacy of two established techniques, linear vs. patch remodeling, for repair of dyskinetic LV aneurysms. METHODS: Between May 1988 and December 2001, 110 consecutive patients underwent repair of LV aneurysms. These represent 2.0% of a total group of 5429 patients who underwent isolated CABG during the period. Seventy-six (69.1%) patients were submitted to linear repair and 34 (30.9%) to patch remodelling. There were 94 (84.5%) men and 17 women, with a mean age of 59.2+/-9.2 years. Coronary surgery was performed in all patients (mean no. of grafts/patient, 2.7+/-0.8) and 14 (12.7%) had associated coronary endarterectomy. Forty-four (40.0%) patients had angina CCS class III/IV (linear 43.4%, patch 32.4%, NS) and the majority was in NYHA class I/II (88.2% in both groups). Left ventricular dysfunction (EF>40%) was present in 72 (65.5%) patients (linear 61.8%, patch 73.5%, NS). RESULTS: There was no perioperative mortality, and major morbidity was not significantly different between linear repair and patch repair groups. During a mean follow-up of 7.3+/-3.4 years (range 4-182 months) 14 patients (14.3%) had died, 12 (85.7%) of possible cardiac-related cause. Actual global survival rate was 85.7%. Actuarial survival rates at 5, 10 and 15 years were 91.3, 81.4 and 74%, respectively. There was no significant difference in late survival between the patch and the linear groups. At late follow-up the mean angina and NYHA class were, 1.3 (preoperative 2.4, P<0.001) and 1.5 (preoperative 1.7, NS), respectively, with no difference between the groups. There was no significant difference in hospital readmissions for cardiac causes (linear 22.8% and patch 37.0%). CONCLUSIONS: The technique of repair of postinfarction dyskinetic LV aneurysms should be adapted in each patient to the cavity size and shape, and the dimension of the scar. Both techniques achieved good results with respect to perioperative mortality, late functional status and surviva

Behçet's Disease. The Experience of an Internal Medicine Service

Os autores apresentam um estudo retrospectivo dos doentes com Doença de Behçet observados num Serviço de Medicina Interna entre 1982 e 2000. Foram analisados 33 doentes, sendo 20 do sexo masculino e 13 do sexo feminino. A primeira manifestação surgiu, em média, aos 24 anos e a média de idades, na altura do diagnóstico, foi de 32 anos. Todos os doentes apresentaram na sua evolução aftose oral recorrente, surgindo aftose genital em 84,8%, patologia ocular em 81,8%, articular em 75,7%, cutânea em 69,6%, alterações do sistema nervoso central em 27,3%, gerais em 24,2%, vasculares em 21,2%, gastrintestinais em 18,1%, neuropatia periférica em 12,1% e vasculite em 3% dos doentes observados

A rare cause of neonatal persistent jaundice

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Atypical Presentation of Langerhans Cell Histiocytocis

info:eu-repo/semantics/publishedVersio