1/12. The first histological demonstration of pancreatic oxidative stress in human acute pancreatitis.Necrotizing acute pancreatitis is associated with an inflammatory explosion involving numerous pro-inflammatory mediator cascades and oxidative stress. Acinar oxygen free radical production aggravates pancreatic tissue damage, and promotes cellular adhesion molecule upregulation resulting in leukocyte adherence and activation. The cerium capture oxygen free radical histochemistry combined with reflectance confocal laser scanning microscopy allows the "in situ" histological demonstration of oxygen free radical formation in live tissues. Here we present a case report, where oxidative stress is demonstrated on a histological level for the first time in human acute pancreatitis. A 44-year-old male patient suffering from acute exacerbation of his chronic pancreatitis developed a pancreato-pleural fistula with amylase-rich left pleural exudate causing respiratory compromise. Subsequent to an urgent thoracic decompression a distal pancreatectomy and splenectomy was performed with the closure of abdomino-thoracic fistula. The postoperative course was uneventful, except for a transient pancreatico-cutaneous fistula, which healed after conservative treatment. To carry out cerium capture oxygen free radical histochemistry the resected pancreas specimen was readily perfused with cerium-chloride solution through the arteries on the resection surface. frozen sections were cut, E-, p-selectin, ICAM and VCAM were labeled by immunofluorescence. The tumor-free margin of an identically treated pancreas carcinoma specimen served as a control. Intrapancreatic oxidative stress and cellular adhesion molecule expression were detected by confocal laser scanning microscopy. Numerous pancreatic acini and neighboring capillaries showed oxygen free radical-derived cerium-perhy-droxide depositions corresponding to strong local oxidative stress. Acinar cytoplasmic reflectance signals suggested xanthine-oxidase as a source of oxygen free radicals. These areas presented considerably increased endothelial p-selectin expression with adherent, oxygen free radical-producing polymorphonuclear leukocytes displaying pericellular cerium-reflectance. Modest ICAM upregulation was noted, e-selectin and VCAM expression was negligible. The control pancreas specimen showed minimal oxidative stress with weak, focal p-selectin expression. The development of deleterious pancreatic oxidative stress was based on indirect evidence in human acute pancreatitis. To the best of our knowledge this is the first report demonstrating persistent intrapancreatic oxidative stress histologically in human acute pancreatitis. We have noted p-selectin overexpression with a preponderance in the areas of acinar oxidative stress.- - - - - - - - - - ranking = 1keywords = suffering (Clic here for more details about this article) |
2/12. Surgical treatment of lone atrial fibrillation in an awake patient.Surgical treatment of atrial fibrillation recently gained new popularity since the introduction of different energy sources and the development of minimally invasive techniques as an alternative to the original "cut-and-sew" technique. However, closed-chest ablation procedures are not feasible in presence of pericardial or pleural adhesions. To our knowledge, this is the first report of surgical treatment of atrial fibrillation in a conscious patient by means of a high epidural anesthesia. Since evidence of fibrothorax was found, a conscious patient suffering from lone atrial fibrillation underwent a beating-heart pulmonary veins isolation with a microwave device through a standard sternotomic approach. At 6 months follow-up, the patient is in stable sinus rhythm, without any palpitation nor electrocardiographic evidence (Holter monitoring) of recurrent atrial fibrillation.- - - - - - - - - - ranking = 1keywords = suffering (Clic here for more details about this article) |
3/12. Presternal gastric bypass for late postpneumonectomy esophagopleural fistula.SUMMARY: A 71-year-old diabetic patient underwent right pneumonectomy with wide mediastinal lymph node dissection for lung cancer (right upper lobe). Postoperatively he developed pleura empyema that was successfully treated - drainage and Eloesser window, followed by adjuvant radiotherapy. Two months later he developed an esophagopleural fistula. Due to the patient's physical condition primary repair of the esophageal rupture was considered a high-risk operation. Stenting was also considered as inappropriate due to the existing contamination. Bypassing with the use of the stomach as conduit was preferred due to its simplicity compared to the colon. In order to avoid mediastinum after the postradiation alterations and because of the Eloesser window we adopted a presternal subcutaneous position. Twenty-eight months after the by pass procedure the patient is in good health being able to eat and drink, has gained weight and shows no evidence of malignancy. Presternal gastric esophageal bypass has never been reported as a treatment for esophagopleural fistula. This case report indicates its possible successful use in this debilitating setting, although more experience is needed.- - - - - - - - - - ranking = 0.87085132997154keywords = physical (Clic here for more details about this article) |
4/12. Chronic pleuritic pain in four patients with asbestos induced pleural fibrosis.Four patients occupationally exposed to asbestos, each suffering at least eight years of disabling, persistent, and often bilateral pleuritic pain are described. Radiographic evidence of pleural disease ranged from plaques seen only on computed tomography to typical bilateral plaques or diffuse thickening to extensive diffuse and circumscribed pleural fibrosis and calcification. There was no history or evidence of acute pleuritis or pleural effusion in three patients. Intermittent pleural friction rubs have been present in all four; one patient showed pleural uptake of gallium-67. Extensive workups including repeated pulmonary ventilation-perfusion scans and cardiac catheterisation have not yielded other diagnoses to explain the pain. It is proposed that persistent pleuritic pain be added to the manifestations of benign asbestos induced pleural disease.- - - - - - - - - - ranking = 1keywords = suffering (Clic here for more details about this article) |
5/12. Diagnostic value of lung uptake of indium-111 oxine-labeled white blood cells.One hundred sixty-two white-blood-cell scans were retrospectively reviewed to determine the sensitivity and specificity of the test for pulmonary and pleural infection. All scans were performed 18-24 hr after injection of indium-111 oxine-labeled autologous or donor cells. Pulmonary activity was graded on a scale of 0-4: 0 = equal to soft tissue; 1 = greater than soft tissue but less than rib; 2 = equal or greater than rib but less than liver; 3 = equal or greater than liver but less than spleen; 4 = equal to spleen. Activity was also characterized as being focal or diffuse. The white-blood-cell scan findings were correlated with the clinical diagnosis on the basis of physical examination, laboratory results, chest radiographs, clinical course, and pathologic studies when available. As pulmonary activity increased from grade 1 to 4, sensitivity declined from 93% to 14% and specificity increased from 64% to 100%. The sensitivity and specificity of focal uptake were 31% and 89% vs 62% and 74% for diffuse pulmonary activity. Making a distinction between focal and diffuse activity did not improve the specificity of low grades of pulmonary activity. The white-blood-cell scan can be very sensitive or very specific for pulmonary or pleural infection, depending on the criteria selected for a positive scan.- - - - - - - - - - ranking = 0.87085132997154keywords = physical (Clic here for more details about this article) |
6/12. M-mode ultrasonic localization of pleural effusion. Use in patients with nondiagnostic physical and roentgenographic examinations.Fifty patients had nondiagnostic physical and roentgenographic examinations and were believed at high risk for exploratory thoracentesis. Negative echograms for pleural fluid were recorded for 13 patients. For 34 patients, the characteristic M-mode display of a central echo-free space, indicative of pleural fluid, was recorded. Aspiration yielded fluid that was localized by echography in 30 (88%). Of the 30 patients, 13 (43%) had normal lateral decubitus views, and 10 (33%) had experienced unsuccessful aspiration before ultrasound localized the fluid loculation. The remaining seven patients, including three receiving mechanical ventilation who were believed to have increased risk for thoracentesis had successful initial tap based on echographic localization of fluid. Ultrasound allows detection and localization of pleural fluid when roentgenographic and physical diagnostic means are not helpful.- - - - - - - - - - ranking = 5.2251079798292keywords = physical (Clic here for more details about this article) |
7/12. The bronchial leak squeak: a new sign for the physical diagnosis of bronchopleurocutaneous fistula.We describe a unique physical diagnostic sign that we have observed in seven patients with bronchopleurocutaneous fistulas. Such patients have a highpitched squeak over the affected chest area during sustained valsalva maneuver. We postulate that turbulence across the bronchial fistula due to high transbronchial pressure gradient during the valsalva maneuver produces the squeaking sound. The pitch of the leak squeak sign is higher in smaller fistulas than in larger fistulas; decreases in intensity and increases in pitch occurred in two patients in whom the bronchial fistula slowly closed. The absence of the leak squeak sound in patients with spontaneous pneumothorax suggests that this sign can be used to differentiate central airways from alveolar air leaks.- - - - - - - - - - ranking = 4.3542566498577keywords = physical (Clic here for more details about this article) |
8/12. octreotide therapy for pancreaticopleural fistula.Pancreaticopleural fistula is a rare but remediable complication of pancreatitis. Hitherto, treatment by means of total parenteral nutrition and thoracocentesis had resulted in an overall success rate of 40% only. Surgical obliteration of persistent fistulae is required in many cases, as the underlying pancreatic duct lesion often prevents spontaneous closure of the fistula. We report a patient suffering from pancreaticopleural fistula with a tightly strictured pancreatic duct. The fistula was successfully obliterated with the use of octreotide addition to thoracocentesis and total parenteral nutrition. Pancreatic bypass surgery was later performed only for pain relief. We believe that octreotide can effectively suppress pancreatic secretion and promote closure of pancreaticopleural fistula even in the presence of severe pancreatic duct lesions. Thus the risk of infection and early surgery for persistent fistula can be minimized.- - - - - - - - - - ranking = 1keywords = suffering (Clic here for more details about this article) |
9/12. A bronchopleurocutaneous fistula caused by an unusual foreign body aspiration simulating acute abdomen.A 12-year-old boy was admitted to hospital for abdominal pain, vomiting and fever. On physical examination he had rales on the lower right hemithorax without any respiratory complaints. Chest X-ray revealed a condensation in the right lower chest. Abdominal findings were secondary to lobar pneumonia. Treatment of pneumonia with antibiotics showed no improvement over 2 days. On bronchoscopy no foreign body was seen, but pus was aspirated. Two days later a mass appeared on the right hemithorax and fistulized. An organic foreign body, hordeum murinum, with 3-5 ml of pus was observed. Chest X-ray taken at the day of fistulization showed no pneumothorax or subcutaneous emphysema. Less than 11 cases of pneumocutaneous fistulas secondary to aspiration of grasses have been reported in literature. Why an ear of hordeum murinum can migrate only in a forward direction and why a pneumothorax had not developed is discussed.- - - - - - - - - - ranking = 0.87085132997154keywords = physical (Clic here for more details about this article) |
10/12. A case of bronchopleural fistula detected by monitoring plasma endothelin-1.Levels of endothelin (ET)-1 peptide are transiently increased after major physical stress. While studying sequential changes in plasma ET-1 levels during various types of stress, we noticed that the level of plasma ET-1 began to rise 10 days post-operatively in one patient with lung cancer who had undergone a left lower lobectomy. 35 days postoperatively a bronchopleural fistula became clinically manifest. The case is presented and the use of plasma ET-1 as an indicator is discussed.- - - - - - - - - - ranking = 0.87085132997154keywords = physical (Clic here for more details about this article) |
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