Joseph Galea

Expression of soluble endothelial adhesion molecules in clinical cardiopulmonary bypass

Soluble endothelial adhesion molecule expression in clinical cardiopulmonary bypass (CPB) was investigated. Neutrophil-mediated endothelial injury plays an important role in CPB-induced organ dysfunction. The adhesion of neutrophil to the endothelium is central to this process. It has been well documented that CPB induces neutrophil activation and changes in neutrophil adhesion molecule expression, but the effect of CPB on endothelial cell activation is not known. This study was designed to measure soluble endothelial adhesion molecules during CPB. We made serial measurements (by specific enzyme-linked immunoabsorbent assay) of plasma levels of the soluble endothelial adhesion molecules, ICAM-1 and E-selectin in patients undergoing routine CPB (n =7) and in a control group (thoracotomy, n = 3). The results show an initial significant decrease during CPB followed by an increase in plasma E-selectin from 29.3 ± 5.1 ng/ml (mean ± SEM) prebypass to 34.0 ± 5.4 ng/ml at 48 h postbypass. Likewise, plasma ICAM-1 significantly decreased during CPB and then increased from 246.3 ± 38.0 ng/ml before bypass to 324.8 ± 25.0 ng/ml and 355.0 ± 23.0 ng/ml at 24 and 48 h after bypass, respectively. The rise in levels is statistically significant (p < 0.05). This study shows a decrease in circulating ICAM-1 and soluble E-selectin during CPB and an increase in their levels at 48 h after CPB.

Two cases of aspiration of calcium tablets

Two clinical cases of aspiration are reported in elderly ladies with differing presentations following inhalation of the same brand of calcium tablet. One of the patients distinctly recalled the choking episode, whereas the other failed to do so making the diagnosis of aspiration difficult. One of the aspirated tablets was successfully retrieved during rigid bronchoscopy after the patient reported several months of cough requiring multiple courses of antibiotics. The other aspirated tablet was coughed up by the patient after the successful treatment of a pneumonia complicated by a parapneumonic effusion.

Red blood cell distribution width and myocardial scar burden in coronary artery disease

Introduction Red blood cell distribution width (RDW) is a novel independent marker of cardiovascular disease including heart failure, coronary artery disease and myocardial ischaemia. The aim of the study was to investigate a possible relationship between RDW and myocardial scar burden, as assessed by a MIBI viability scan. A secondary objective was to assess whether there is an association between RDW and left ventricular ejection fraction (LVEF). Methods The study comprised 123 subjects with ischaemic heart disease who underwent a myocardial viability scan between June 2008 and July 2014. Haemoglobin, mean corpuscular volume, RDW, platelet count, mean platelet volume (MPV), estimated glomerular filtration rate, fasting blood glucose, liver and lipid profiles were evaluated for all patients. The extent of myocardial scarring and LVEF were noted. Data were analysed using IBM SPSS Statistics 22.0. Univariate followed by multivariate analyses were performed to assess for independent predictors of myocardial scarring and LVEF, respectively. Results The mean age of the study population was 63.5 years; most of the subjects were men. The median LVEF was 31% and median percentage of myocardial scarring was 8.7%. Multivariate analyses revealed that RDW, HDL-cholesterol and alanine transaminase were independent predictors of myocardial scarring while RDW, MPV, LDL-cholesterol and gamma-glutamyl transpeptidase were independent predictors of LVEF. Conclusions Increased RDW is an independent predictor both of myocardial scar burden and of impaired left ventricular function in subjects with coronary artery disease.

Method of Hemorrhage Control From the Aorta After Repair of a Dissected Aortic Aneurysm

Patients with Marfan syndrome and presenting with acute aortic dissection have fragile aorta, causing bleeding problems in the anastomosis between the graft and the aorta. Hemostatic impairment following circulatory arrest and prolonged cardiopulmonary bypass contribute to these problems. We describe a technique to control persistent bleeding from the anastomosis in the aortopulmonary recess using two kissing inflated balloons at the tip of two Foley catheters to tamponade the bleeding sites.

Excision of an Elusive Tiny Ectopic Parathyroid Adenoma

An elderly lady was diagnosed with primary hyperparathyroidism after being admitted to hospital with pyelonephritis and constipation. A sestamibi parathyroid scan demonstrated increased uptake in the upper mediastinum, suggesting an ectopic mediastinal parathyroid adenoma. The 4-mm adenoma was successfully removed through a mini-sternotomy incision using a gamma probe to identify the gland from the surrounding tissue. The patient made an uneventful recovery.

The physical and psychological effects of breast reconstruction in breast cancer patients. A retrospective quantitative analysis between 2009 and 2011 at Mater Dei Hospital, Malta

Breast cancer is a devastating disease afflicting many women. The aim of this retrospective review was to assess the physical and psychological effects of patients who underwent breast reconstruction after breast cancer surgery.MethodsClearance from the patients’ consultants, data protection officer and medical ethics committee was sought and granted. A participation letter was sent to 67 eligible patients who had reconstructive breast surgery between 2009 and 2011. Forty-two (63%) patients agreed to participate. These patients had a short personal interview during which two questionnaires (SF-36v2 health survey and one on the physical aspects) were completed.ResultsThe patients’ mean age was 53.9 years (range 31-75). Reconstructive breast surgery using implant-only was performed in twenty-eight (66.7%) cases. Twenty-three (54.8%) of the forty-two patients had complications, with 1.35 complications/per person affected. The complication rate did not differ significantly amongst the different reconstruction groups (p=0.196). Patients who underwent autologous and oncoplastic reconstructive procedures scored significantly higher satisfaction scores than the prosthesis and prosthesis/autologous group (p= 0.01). Whether or not the reconstruction was immediate or delayed or the patients had complications, did not have statistically significant effects on the patients’ health domain scores (p>0.05). The difference of two proportions between the sample studied and the norm showed that the sample studied had a statistically significant higher depression risk than the norm population (p=0.0154).Major conclusionsComplication rates were comparable amongst the different reconstruction techniques. A higher than normal depression risk was found in the sample studied and therefore improvement of the support services given to patients is recommended.

Urgent Coronary Artery Bypass Surgery in a Patient with Postinfarction Angina and Active Myelomonocytic Leukaemia

Chronic myelomonocytic leukaemia (CMML) is a myelodysplastic/myeloproliferative neoplasm affecting the production and differentiation of the monocyte cell lineage. Cardiac surgery in the context of CMML poses challenges that are not routinely encountered. This is the first reported case in the literature of a patient with active CMML undergoing urgent on-pump coronary artery bypass grafting. A 68-year-old Caucasian man with a history of hypertension, hyperlipidaemia, hypothyroidism, and hypercholesterolaemia, who had been diagnosed by the haematologists with CMML a few months earlier but had remained untreated, underwent urgent surgical coronary revascularisation because of postinfarction angina following a non-ST elevation myocardial infarction associated with troponin I rise. The patient had fulminant postoperative myelomonocytic leukaemoid reaction, with a clinical picture of severe systemic inflammatory response syndrome and multiple organ dysfunction syndrome. This led to extensive vasodilation and heart failure that resulted in the death of the patient. Various authors have suggested different techniques and treatment options, each attempting to mitigate the effect of the postoperative inflammatory response. However, this is a high-risk endeavour with a myriad of inflammatory signals mobilised into action because of the surgical insult. Off-pump surgery or preoperative pharmacological attenuation of CMML activity might have dampened this response and resulted in a positive outcome for the patient.

Extragastric Dieulafoy's lesion

A 74-year-old man on warfarin for aortic valve replacement presented with recurrent episodes of melaena. An initial oesophagogastroduodenoscopy (OGD) was normal, as were red cell scanning and colonoscopy. It was a third OGD that revealed the cause of the melaena—a vascular lesion in the duodenum, at the junction between D1 and D2. An extragastric Dieulafoys lesion was diagnosed, and the lesion was injected with epinephrine and tattooed. Over the following months, episodes of bleeding recurred despite further attempts at injection. Percutaneous radiologically assisted embolisation of the gastroduodenal artery, and eventually duodenotomy and oversuturing of the lesion were performed to no avail. The patient has undergone over 10 endoscopies, and has received over 70 units of packed red cells to date, since his initial presentation 6 years ago. Attempts to stop the bleeding permanently have been difficult, highlighting the complexity of managing such a lesion.