Showing papers by "Hospital General Universitario Gregorio Marañón published in 1993"

Microsurgery in gaining paediatric vascular access for haemodialysis

Abstract: One hundred and one surgical procedures performed in children for construction and maintenance of vascular accesses for haemodialysis were retrospectively analyzed. There were 86 operations performed to create a new fistula in patients without vascular access or with nonrecoverable failed angioaccess. Fifteen surgical procedures were performed to treat fistula complications. The new fistulas were radiocephalic n = 60 (70%), ulnar-basilic n = 5 (5.8%), antecubital n = 9 (10.3%), and PTFE grafts n = 12 (14%). Microsurgical techniques were used in all cases, including PTFE graft fistulas. A microscope was used in 56 cases (55.4%) and magnifying loupes (× 2.5 magnification) in the rest of the operations. Early-failure rate for radiocephalic fistulas was 10%. Cumulative patency rates in radiocephalic fistulas were 79%, 75%, and 70% at 1, 2, and 5 years, respectively. No statistical differences were found from the cumulative patency curve of 730 radial-cephalic fistulas performed in adults during the same period of time. Radiocephalic fistulas can be constructed in most paediatric cases using microsurgical technique. Elbow fistulas can be the second-choice vascular access, and PTFE grafts can be reserved for children with exhaustion of autologous veins. Brachial-jugular PTFE grafts can be used in cases of subclavian vein stenosis. © 1993 Wiley-Liss Inc. Se ban analizado 101 intervenciones quirugicas realizadas para mantenimiento de accesos vasculares para hemodialisis. Se construyeron 86 fistulas nuevas, bien en pacientes sin acceso vascular previo o con fistula fallida y no recuperable. Se realizaron 15 intervenciones para tratamiento de complicaciones. Las fistulas nuevas fueron: radio-cefalicas n=60 (70%); cubito-basilicas n=5 (5.8%); antecubitales n=9 (10.3%); Protesis de PTFE N=12 (14%). Se empleo en todos los casos tecnica microquirurgica, incluidos los casos en que se usaron protesis de PTFE. Se uso microscopic en 56 casos y gafa-lupa de 2,5 aumentos en el resto. El fallo precoz, solo observado en fistulas radiocefalicas, fue de 10%. La curva acumulativa de permeabilidad de las fistulas mostro que la posibilidad de supervivencia de las fistulas radio-cefalicas es de 79%, 75% y 70% a 1, 2 y 5 anos respectivamente. No hubo diferencia significativa con respecto a la permeabilidad de 730 fistulas radio-cefalicas realizadas en el adulto por nuestro grupo en el mismo periodo de tiempo. Las fistulas radio-cefalicas pueden ser realizadas en la mayoria de los casos pediatricos usando tecnica microquinirgica. Las fistulas en el pliegue del codo pueden ser el acceso vascular de segunda eleccion, y las fistulas protesicas deben leservarse para ninos con agotamiento de las venas autologas. Las protesis humeroyugulares pueden ser utilizadas en caso de estenosis de la vena subclavia. © 1993 Wiley-Liss Inc.

Initial outcome of percutaneous balloon valvuloplasty in rheumatic tricuspid valve stenosis

Abstract: Percutaneous balloon valvuloplasty (PBV) has been used as an effective treatment for some cases of valvular stenosis, mainly in the mitral, 1 pulmonary 2 and aortic 3 valves. Less experience has been achieved with this procedure for valvular tricuspid stenosis. 4–7 We present the immediate results of 5 cases of PBV in stenotic tricuspid valves.

Altered production of PGE2, IL-1 beta and TNF-alpha by peripheral blood monocytes from HIV-positive individuals at early stages of HIV infection.

Abstract: We analyzed the in vitro synthesis and release of PGE2, IL-1 beta, and TNF-alpha by peripheral blood monocytes from HIV-infected injection drug users at the early clinical stages of HIV infection. We investigated whether there is a concomitant altered production of PGE2 and proinflammatory cytokines by HIV-positive monocytes. We also evaluated T-cell subsets and lymphocyte transformation response to pokeweed mitogen (PWM) in HIV-positive patients and healthy controls. PGE2 and IL-1 beta levels in supernatants from monocyte cultures were determined by radioimmunoassay (RIA), and TNF-alpha by enzyme immunoassay (EIA). Monocytes from asymptomatic HIV-positive individuals produced spontaneous and significantly increased quantities of PGE2, IL-1 beta, and TNF-alpha. Concomitant increased production of PGE2 and IL-1 beta by monocytes from HIV-positive asymptomatic patients was significantly associated with low CD4+ T-cell numbers (< 500 cells/mm3). We also found a strong association between spontaneous and concomitantly increased production of PGE2 and cytokines by monocytes from asymptomatic HIV-positive individuals and a low lymphocyte transformation response to PWM. Further studies are necessary to establish whether this altered production of PGE2 and proinflammatory cytokines by monocytes from HIV-positive individuals might play a role in the mechanisms involved in the progressive impairment of cell-mediated immunity in HIV infection.

The Impact of Preexisting Disease Conditions for Host Defense Integrity in Traumatized and Critically Ill Patients

Abstract: Trauma affects both components of host defense in that specific immunity is altered as well as nonspecific immunity. The question remains whether these changes are beneficial or detrimental for the host. Preexisting disease conditions such as cancer, inflammatory diseases, nutritional deficits, infection, and immunosuppressive drugs are all associated with alterations in host defense that may influence changes in host immunocompetence seen following trauma [1]. There are several methods for testing the host defense capacity of trauma victims. Some of these use single in vitro measurements such as lymphocyte responses to phytohemaglutinin (PHA). Others use in vitro multiple measures such as measurement of the cytokines tumor necrosis factor (TNF), interleukin-1 (IL-1), IL-2, IL-6, IL-8 or several of the immunoglobulins. Lastly, there are in vivo measurements such as response to skin test antigens [2].

Initial treatment of pyonephrosis using percutaneous nephrostomy. Value of the technique

Abstract: Until early in the eighties, the initial treatment of choice for pyonephrosis was by emergency surgical excision, which carried a high intraoperative and early postoperative morbidity and mortality. The introduction of percutaneous nephrostomy, a technique with a low complication rate that permits easy access in dilated excretory tracts and is highly effective, as shown by the clinical and analytical course of the patients with pyonephrotic kidney and by the number of nephrectomies performed, represented a substantial change in the initial therapeutic approach. The present article reports our experience of 123 percutaneous nephrostomies performed in 118 pyonephrotic kidneys over a period of 10 years, which constitutes one of the largest series reported in the literature. The clinical features and the findings disclosed by imaging techniques that permit making the diagnosis are presented. We describe the PCN procedure and its advantages, with special reference to the reduced morbidity and mortality, particularly in those cases complicated by septic shock. The procedure also permits evaluation of the underlying obstructive uropathy and function of the compromised kidney, therefore more renal units can be preserved, nephrectomy can be avoided and morbidity is minimal. For all the foregoing reasons, PCN guided by an imaging technique is currently the most effective initial treatment of pyonephrosis.

Renal abscess in patients diagnosed with AIDS and disseminated tuberculosis

Abstract: Presentation of two cases of renal abscess formation in patients with stage IV C-1 AIDS and active associated tuberculosis. The microorganism isolated in the first case was S. aureus. Culture of the second cases was artefacted since antibiotic administration had already been started. Also, both patients showed abdominal abscesses, at spleen and liver level in the first case, and prostatic level in the second case, both compatible with Mycobacterium tuberculosis dissemination. Both cases showed a lethal evolution. The role played by the immunodeficiency as a precipitating agent in the extrapulmonary tuberculosis and in the formation of renal abscesses is analyzed.

[Experience with the Palmaz-Schatz stent in the treatment of postangioplasty coronary dissection]

Abstract: Some authors have proposed the use of coronary stenting as a good therapeutic strategy for post angioplasty acute coronary dissection. We present our experience with the Palmaz-Schatz stent for the treatment of acute coronary dissection after percutaneous coronary angioplasty. Twenty five stents were deployed in nineteen patients with occlusion (7) or threatened occlusion (12). Eleven patients (58%) had multivessel disease, seven (37%) unestable angina and six (32%) previous myocardial infarction. The attempted lesion was type A in four patients (21%), type B in thirteen (68%) and type C in two (11%) according to the American College of Cardiology/American Heart Association classification. To cover the dissection was necessary to deploy three stents in two patients, and two stents in two more. The other fifteen patients received one stent each. In eighteen patients (95%) the stent deployment was accomplished with immediate angiographic success. Twelve stents were deployed in the right coronary artery, eight in the left anterior descending and five in the circumflex. In sixteen patients (84%) the stent successfully solved the occlusion or threatened occlusion reassuming a normal coronary flow. There were 10 complications in six patients: one death (5%), 3 cases of emergency coronary artery bypass graft (16%), 2 acute myocardial infarction (11%), 2 hemorrhagic complications (11%) and 2 cases of subacute thrombosis of the stent (11%). The Palmaz-Schatz stent seems to be a useful tool for the management of acute coronary dissection with a fair number of complications. The results obtained during hospitalization are maintained with a more than acceptable restenosis rate.

Growth hormone-releasing hormone: clinical aspects.

Abstract: Growth hormone (GH) secretion is under hypothalamic control by the stimulating action of GH releasing hormone (GHRH) and the inhibitory action of somatostatin /I/. These are both under the neurochemical control of cholinergic, adrenergic and dopaminergic pathways. Pharmacological modifications of the function of these neurotransmitters are able to exert important influences on GH secretion. It is now well established that cholinergic agonist drugs are able to potentiate GHRHinduced GH release 121, whereas antagonists, such as atropine and pirenzapine, are able to block this response /3/. This is due to the fact that the activation of central muscarinic receptors inhibits somatostatin secretion whereas the blockade of central muscarinic receptors induces an increase in hypothalamic somatostatinergic tone. The lack of GH response to GHRH which is found in the obese and the elderly, as well as in normal subjects after oral glucose load, is restored following administration of the cholinergic agonist pyridostigmine /4/. Adrenergic pathways exert a dual effect on GH secretion. ^-Adrenergic agonist drugs increase plasma GH levels. Based on this finding, the ^-adrenergic agonist Clonidine has been used for diagnostic and therapeutic purposes in children with short stature /5/. The stimulatory effect of Clonidine on GH secretion has been attributed to an increase in hypothalamic GHRH release, but recent data have demonstrated that it is mainly mediated by an inhibition of somatostatin secretion /6-8/. In contrast to α-adrenergic pathways, jS-adrenergic receptors are mainly inhibitory. Thus, administration of /8-adrenergic receptor antagonists, such as propranolol, is able to potentiate GH responses to GHRH. This effect seems to be mediated through the inhibition of somatostatin at the hypothalamic level /8/. Finally, the role of dopaminergic pathways in the control of GH secretion is still controversial. In normal subjects dopaminergic pathways stimulate GH secretion, but inhibitory effects have also been described. This could be explained by considering the dopaminergic system as a modulatory element, since this pathway is also a precursor of the adrenergic system /8/.

[The implantable endocavitary cardioverter-defibrillator: the initial and short-term results].

Abstract: Utilization of endocavitary defibrillation electrodes avoids thoracotomy used in implantable cardioverter-defibrillator procedures, reducing associated morbi-mortality. In our institution we have used this approach in 16 patients during a two years period (July 1990-July 1992). Fifteen were males, with a mean age of 56.9 +/- 10.6 (range 32-73). Nine patients suffered ischemic cardiomyopathy, 4 non ischemic cardiomyopathy and in three there was no structural heart disease. Mean ejection fraction was 44.3 +/- 18.3% (range 20-73%). Clinical arrhythmia was ventricular tachycardia in 8 cases, ventricular fibrillation in 6 cases and both types in 2. Endocavitary implantation procedure was not completed in 3 patients, thus an open trans-sternal approach was performed. In 13 patients it was completed successfully, using a total amount of 14 units (1 patient required two procedures due to sepsis in the generator pouch). Most important intraoperative incidences have been defibrillation thresholds between 20-24 J in 4 cases, displacement of defibrillation electrode from vena cava into coronary sinus in 4 cases, epicardial patch implantation via subcostal approach in 1 case and right ventricle perforation in 1 case. No operative mortality was registered. One patient suffered sudden death during follow-up. Surgical complications were few: 1 case of lead dislodgement and 1 infected wound in the generator's pouch. Non-surgical complications were also few: 1 case with superior vena cava syndrome and 1 patient with inadequate discharges. In conclusion, due to our early experience, we believe that endocavitary implantation of an implantable cardioverter-defibrillator is the procedure of choice at the present time.

Intravascular Activation of Polymorphonuclear Neutrophils in Critically Ill Anergic Patients

Abstract: Two major immune alterations are common among patients with multiple organ failure syndrome: a downregulation of the T-cell-mediated immunity and an aggressive neutrophil-endothelial interaction at the microvascular level. We intend to address the question whether in critical surgical illness the erosion of both arms of the immune system (specific and nonspecific) progress in parallel.