Tumores neuroendocrinos de origen pulmonar: reporte de un caso / Neuroendocrine tumors of lung’s origin, a case report

Introduction or case story: Young female patient (24 years-old), without known morbid precedents. She comes for a ten-days period of symptoms characterized by fever of up to 38.5 °C and a dyspnoea grade III. Physical exam showed decreased vesicular murmur on the right pulmonary base with dullness and positive vocal vibrations. Exams: Thorax X-ray: Atelectasis condensation on the right pulmonary base. CT chest scan without contrast: Nodule located in an intermediate bronchus which generates atelectasis in the basal bronchi. Fibro-bronchoscopy (FOB): A tumour-like injury blocking 100% of the right intermediate bronchus’ duct. Biopsy: Pulmonary tissue with haemorrhagic areas, granular tissue with small cellular clusters of lobular disposal and glandular shape with eccentric central nuclei cells, with homogenous chromatin and without atypical mitosis. Immunohistochemistry: Intensely positive cells to synaptophysin and CD56. Diagnosis: Neuroendocrine Typical Carcinoid Tumor. Comments: The patient evolves without progression of dyspnoea, she is waiting for a surgical resolution of tumour at National Institute of Thorax.

Introducción o historia del caso: Mujer joven de 24 años de edad, sin antecedentes mórbidos, acudió por cuadro de 10 días de evolución, de fiebre de hasta 38,5 °C y disnea grado III. Al examen físico destacó a nivel pulmonar: murmullo pulmonar disminuido en base pulmonar derecha, matidez de la misma zona y vibraciones vocales positivas. Exámenes: Radiografía de Tórax: Condensación atelectásica en base pulmonar derecha. TAC de Tórax sin contraste: Imagen nodular a nivel de bronquio intermedio, que genera atelectasia en bronquios basales. Fibrobroncoscopía (FBC): Lesión tumoral que ocluye el 100% del lumen para bronquio intermedio derecho. Biopsia: Tejido pulmonar con áreas de hemorragia, tejido granulatorio y tumor con acúmulos celulares de disposición lobular y glanduliforme, con núcleos centrales excéntricos, cromatina homogénea, sin atipias. Inmunohistoquímica: Células intensamente positivas para sinaptofisina, y CD-56. Diagnóstico: Tumor Neuroendocrino Carcinoide típico Comentarios: Paciente evoluciona sin progresión de su disnea, esperando resolución quirúrgica del tumor en Instituto Nacional del Tórax.

Nitrous oxide (N(2)O) reduces postoperative opioid-induced hyperalgesia after remifentanil-propofol anaesthesia in humans.

BACKGROUND: The aim of this study was to test if intraoperative administration of N(2)O during propofol-remifentanil anaesthesia prevented the onset of postoperative opioid-induced hyperalgesia (OIH). METHODS: Fifty adult ASA I-II patients undergoing elective open septorhinoplasty under general anaesthesia were studied. Anaesthesia was with propofol, adjusted to bispectral index (40-50), and remifentanil (0.30 µg kg(-1) min(-1)). Patients were assigned to one of the two groups: with N(2)O (70%) and without N(2)O (100% oxygen). Mechanical pain thresholds were measured before surgery and 2 and 12-18 h after surgery. Pain measurements were performed on the arm using hand-held von Frey filaments. A non-parametric analysis of variance was used in the von Frey data analysis. P<0.05 was considered statistically significant. RESULTS: Baseline pain thresholds to mechanical stimuli were similar in both groups, with mean values of 69 [95% confidence interval (CI): 50.2, 95.1] g in the group without N(2)O and 71 (95% CI: 45.7, 112.1) g in the group with N(2)O. Postoperative pain scores and cumulative morphine consumption were similar between the groups. The analysis revealed a decrease in the threshold value in both groups. However, post hoc comparisons showed that at 12-18 h after surgery, the decrease in mechanical threshold was greater in the group without N(2)O than the group with N(2)O (post hoc analysis with Bonferroni's correction, P<0.05). CONCLUSIONS: Intraoperative 70% N(2)O administration significantly reduced postoperative OIH in patients receiving propofol-remifentanil anaesthesia.

[Effect of the administration of statins in non-cardiac critical disease]. / Efecto de la administración de las estatinas en la patología crítica no cardiológica.

Administration of statins has been shown to be effective in reducing cardiovascular mortality. Their benefit could expand towards other areas of intensive medicine, it being possible to decrease mortality of the critically ill patient. There are several studies, although without a high level of evidence, that have detected a possible benefit when they are administered as well as clinical deterioration when they are discontinued, compared to those patients who had previously taken them. Even though most of the patients who had previously taken statins did so as primary or secondary prevention, thus having greater comorbidity, overall, a decrease is detected in the mortality of these subgroups. This benefit could be generalized to all the critical conditions, although studies with a higher level of evidence are needed for their adequate comparison.

Muscular strength and vibration thresholds during two years after acute poisoning with organophosphate insecticides.

AIMS: To evaluate the association of acute organophosphate (OP) poisoning with chronic sensory and motor neurological impairment. METHODS: This study concerns the third of a series of three examinations of hand strength and vibration thresholds in a two year period after acute OP poisoning among 48 Nicaraguan men. The first two examinations were performed at hospital discharge and seven weeks after poisoning, and the present examination two years later. Twenty eight cattle ranchers and fishermen who had never experienced pesticide poisoning were examined as controls, also three times over the two year period. The poisonings were categorised as caused by "non-neuropathic" OPs and "neuropathic" OPs, each subdivided in moderate and severe poisonings. RESULTS: Men poisoned with OP insecticides had persistent reduced hand strength. We previously reported weakness at hospital discharge for OP poisoned in all categories that worsened seven weeks later for those severely poisoned with neuropathic OPs. Strength improved over time, but the poisoned were still weaker than controls two years after the poisoning, most noticeably among the subjects most severely poisoned with neuropathic OPs. Also, index finger and toe vibration thresholds were slightly increased at the end of the two year period, among men with OP poisonings in all categories, but patterns of onset and evolvement of impairment of vibration sensitivity were less clear than with grip and pinch strength. CONCLUSIONS: Persistent, mainly motor, impairment of the peripheral nervous system was found in men two years after OP poisoning, in particular in severe occupational and intentional poisonings with neuropathic OPs. This finding is possibly due to remaining organophosphate induced delayed polyneuropathy.

Clinical, epidemiologic, and virologic features of dengue in the 1998 epidemic in Nicaragua.

From July to December 1998, a hospital- and health center-based surveillance system for dengue was established at selected sites in Nicaragua to better define the epidemiology of this disease. Demographic and clinical information as well as clinical laboratory results were obtained, and virus isolation, reverse transcriptase-polymerase chain reaction, and serologic assays were performed. World Health Organization criteria were used to classify disease severity; however, a number of patients presented with signs of shock in the absence of thrombocytopenia or hemoconcentration. Therefore, a new category was designated as "dengue with signs associated with shock" (DSAS). Of 1,027 patients enrolled in the study, 614 (60%) were laboratory-confirmed as positive cases; of these, 268 (44%) were classified as dengue fever (DF); 267 (43%) as DF with hemorrhagic manifestations (DFHem); 40 (7%) as dengue hemorrhagic fever (DHF); 20 (3%) as dengue shock syndrome (DSS); and 17 (3%) as DSAS. Interestingly, secondary infection was not significantly correlated with DHF/DSS, in contrast to previous studies in Southeast Asia. DEN-3 was responsible for the majority of cases, with a minority due to DEN-2; both serotypes contributed to severe disease. As evidenced by the analysis of this epidemic, the epidemiology of dengue can differ according to geographic region and viral serotype.

Organophosphate neuropathy due to methamidophos: biochemical and neurophysiological markers.

Neuropathy target esterase (NTE), the putative target enzyme for organophosphate induced delayed polyneuropathy (OPIDP), can be measured in lymphocytes but has rarely been assessed in acute human poisoning. Serum autoantibodies to nervous system proteins develop in hens poisoned with neuropathic insecticides and also have not been studied after human poisoning. Serial lymphocyte NTE (LNTE) was measured in a 16-year-old boy after acute poisoning with methamidophos for evaluation as a predictor of subsequent neuropathy. The profiles of serum autoantibodies to neurofilament triplet proteins, myelin basic protein, and glial fibrillary acidic protein were measured in order to characterize changes occurring as a result of OPIDP. Clinical neuropathy characterized by steppage gate and profound lower extremity weakness, decreased grip and pinch strength, and decreased ulnar and absent tibial compound muscle action potentials developed 2 weeks following poisoning. Sensory examination and nerve conduction studies were normal. On day 3 following poisoning LNTE was depressed (77% compared with subsequent baseline enzyme activity). Marked increases in serum immunoglobulin G (IgG) autoantibodies to glial fibrillary acidic protein and to neurofilament 200 were observed after the development of OPIDP. We conclude that inhibition of lymphocyte NTE is predictive of subsequent OPIDP. Serum autoantibody titers to nervous system proteins may be useful markers of neuropathy.

Hepatic tumors in patients with cirrhosis: an autopsy study.

The incidence and characteristics of hepatic tumors -primitive or secondary- were analyzed in a series of 596 patients with cirrhosis and on whom an autopsy was carried out. A hepatic tumor was discovered in 43.6%: 96.5% with histological findings of malignant disease and only 3.4% with benign disease. The tumors discovered showed the following in order of frequency: hepatocellular carcinoma (90.3%), hepatic metastases (4.2%), cholangiocarcinoma (2.3%), adenoma (1.5%), hemangioma (1.2%) and hamartoma (0.8%). Therefore, 10% of the neoplasms located in the cirrhotic liver were different from the hepatocellular carcinoma. In 2% of the subjects with hepatic tumors, two histologically different lesions were found to co-exist in the liver, and in every case it was found to be a hepatocellular carcinoma related to another tumor, which further complicated the diagnosis. The most frequent type of hepatocellular carcinoma was multinodular, although diffuse tumors most frequently developed metastases. When the hepatocellular carcinoma was uninodular and small, distal spread was exceptional. Metastatic infiltration of the liver by neoplasms of different origin, characteristically infrequent in cirrhosis, was always accompanied by spread to other organs and did not appear as a single nodule in any case. We conclude that the correct diagnosis of tumor-related lesions located, in a cirrhotic liver is occasionally difficult during life, especially when the neoplasms are different from the hepatocellular carcinoma.

Gallstone ileus.

A retrospective analysis of 74 patients with gallstone ileus detected during the period between 1975 and 1987 was performed at the Surgical Department. The group comprised 55 females and 19 males, with a mean age of 64.8 years. Previous biliary symptoms had been observed in 76% of the cases and in 58% there had been concomitant disease. The main duration of symptoms previous to admission was 3.4 days. In 85% of the cases complementary diagnostic procedures were performed. The triad of air in the biliary tract, air-fluid levels and ectopic stone was found in only 9.5% of the cases. The preoperative diagnosis of gallstone ileus was made in 31% of the patients. The preoperative period was 2.2 days. The main surgical procedure was enterolithotomy in 92% of the cases, the site of impaction being the terminal ileum in 65%. Only in 1 case was simultaneous biliary tract surgery and enterolithotomy performed. Overall, the 30-day postoperative mortality rate was 13.5%, with intra-abdominal sepsis as the main cause of death. Sixteen patients were submitted to biliary surgery 2 to 6 months later, and no deaths occurred.

[Duodenal diverticula and its relations with choledocholithiasis]. / Divertículos duodenales y su relación con coledocolitiasis.

The incidence of duodenal diverticula was accomplished by four different methods (autopsy, post operative cholangiography, ERCP and upper gastrointestinal X rays); the relationship with common bile duct stones, also was analyzed. The study was developed in the José Joaquín Aguirre Clinic Hospital and Paula Jaraquemada Hospital. The lower incidence was 0.72% in autopsy group and the highest was 8% in patients diagnosed by ERCP. All the diverticula were unique and located in the second duodenal portion. A minimal difference in sex groups was encountered. We did'nt find a major incidence of choledocholithiasis in the population with duodenal diverticula.

Divertículos duodenales y su relación con coledocolitiasis. / [Duodenal diverticula and its relations with choledocholithiasis]

The incidence of duodenal diverticula was accomplished by four different methods (autopsy, post operative cholangiography, ERCP and upper gastrointestinal X rays); the relationship with common bile duct stones, also was analyzed. The study was developed in the José Joaquín Aguirre Clinic Hospital and Paula Jaraquemada Hospital. The lower incidence was 0.72

in autopsy group and the highest was 8

in patients diagnosed by ERCP. All the diverticula were unique and located in the second duodenal portion. A minimal difference in sex groups was encountered. We didnt find a major incidence of choledocholithiasis in the population with duodenal diverticula.

Treatment of residual common bile duct stones after cholecystectomy.

This study was conducted to determine the occurrence of "open" residual common bile duct stones after cholecystectomy to establish predisposing factors and possible alternative treatments. Correct diagnosis of choledocholithiasis before or during surgery, adequate exploration of the common bile duct, and suitable selection of technical procedures are the most important points in preventing retained CBD stones. If these occur, an adequate alternative treatment may prove helpful. Classical "clysis" of the bile duct is least recommended because of its high failure rate. The best method of chemical dissolution seems to be the use of mono-octanoin with 60% good results and a no-response rate of 30-40%. Instrumental extraction has been reported to be very successful (80-98%). Endoscopic sphincterotomy is currently the most frequently employed procedure for retained CBD stones, especially in poor risk patients. The reported success rate is 82-93% according to literature, with an extremely low mortality (0.2%). Reoperation should be resorted to only if all the other methods fail. Sphincteroplasty or choledochoduodenostomy, whenever indicated, are good alternative operations, with a mortality rate of approx. 3.5%.

Indications and results of sphincteroplasty in benign biliary diseases.

A retrospective analysis of 143 patients submitted to sphincteroplasty at the Department of Surgery, University of Chile Clinical Hospital was performed. A significant percentage of these patients (90%) were admitted due to acute biliary tract disease with or without cholangitis. The standard operative procedure was anterior transduodenal sphincteroplasty with supraduodenal choledochal exploration leaving a choledochostomy. A high number of our cases presented with intrahepatic lithiasis (23.8%). The morbidity was 15.4% and the 30 days post operative mortality rate was 4.9%, similar to other reports. Residual stones were observed in 10 patients (7%), and were successfully removed by other procedures. Three patients showed recurrent stenosis of the papilla and were operated on again with good results.

Indications and results of choledochoduodenostomy in benign biliary tract diseases.

During a 12-year period ending December 1987, 17,200 operations for biliary tract disease were performed at the Dept. of Surgery of the University of Chile. Choledochoduodenostomy was performed in 140 of these patients operated upon for benign biliary tract and/or gallbladder diseases. The indications for this procedure were choledocholithiasis, stenosis of the sphincter of Oddi, compression of the extrahepatic biliary duct, stenosis of the distal biliary duct and duodenal diverticula. The postoperative course was uncomplicated in 126 patients (90%). The mortality rate was 4.2%. Although the mortality was somewhat greater in patients with acute cholangitis, the difference was not significant, and no significant relation could be established with other factors that might affect mortality. Choledocholithiasis is the main cause of benign obstruction of the biliary tract in Chile. This is also the most frequent indication for external choledochoduodenostomy and is a promising method even in the presence of an infection of the biliary duct.

Surgical treatment of high gastric ulcer.

The purpose of this study has been to review the late results of surgical treatment of 244 patients with endoscopically proved benign chronic gastric ulcer located 5 cm or less from the cardia. In five patients, a total gastrectomy with esophagojejunostomy was performed. Proximal gastrectomy was used in 3 patients, mesogastrectomy in 5 patients, a partial Schoemaker's procedure in 73 patients, Pauchet's procedure in 70 patients, and Csendes' procedure in 23 patients. Nonresective procedures were employed in 67 patients and included the Kelling-Madlener procedure in 23 patients, pyloroplasty alone in 10 patients, gastrojejunostomy alone in 4 patients, local or wedge excision of the ulcer in 9 patients, and vagotomy and pyloroplasty in 21 patients. The follow-up evaluation was performed in 91 percent of the patients (mean 9 years postoperatively, range 5 to 15 years), with emptying endoscopy in all nonresected patients. A high mortality was observed after total or proximal gastrectomy, as well as after nonresective procedures. After the other resective techniques, low postoperative morbidity and mortality were observed. No recurrent ulcer was seen after the resective procedures. Based on these results, we propose that when the ulcer is located 5 cm below the cardia, Schoemaker's or Pauchet's procedure should be performed; if the ulcer is located 2 cm or less from the cardia, Csendes' procedure or the Kelling-Madlener procedure should be employed.