Pekka Rainio

Value of the Glasgow Aneurysm Score in predicting the immediate and long-term outcome after elective open repair of infrarenal abdominal aortic aneurysm.

This study aimed to explore the value of the Glasgow Aneurysm Score in predicting the immediate and long‐term outcome after elective open repair of abdominal aortic aneurysm (AAA).

Apoptosis in operated small cell lung carcinoma is inversely related to tumour necrosis and p53 immunoreactivity

The present study was undertaken to analyse the extent of apoptosis in operated small cell lung carcinoma (SCLC) by using in situ labelling of the oligonucleosomal DNA fragments by terminal transferase. The extent of apoptosis was compared with the cell proliferation activity, as determined by Ki‐67 immunohistochemistry; with the volume density of necrosis (per cent), as determined by the morphometric point counting method; and with the occurrence of immunohistochemically detectable p53 and bcl‐2 proteins. By in situ labelling, remarkably high apoptotic indices (from 0·08 to 8·10 per cent) were seen in SCLC. A high percentage of SCLSs also showed an exceptionally high proliferation activity. Aberrant accumulation of p53 protein was seen in 37·5 per cent and bcl‐2 overexpression in 50 per cent of SCLCs. Necrosis was seen in 82·5 per cent of SCLCs. The extent of apoptosis was inversely related to the extent of tumour necrosis (P=0·05) and to p53 protein accumulation (P=0·008). A positive association was found between the extent of apoptosis and bcl‐2 immunoreactivity (P=0·02). The apoptotic indices (per cent) correlated with the age (P<0·05) and total smoking time of the patients (P=0·06).

Preoperative C-reactive protein and outcome after coronary artery bypass surgery

BACKGROUND C-reactive protein (CRP) is a predictor of early and late outcome after coronary angioplasty, but there is scant data on its impact on the outcome after coronary artery bypass grafting (CABG). METHODS The predictive value of preoperative CRP was evaluated in a series of 764 patients who underwent on-pump CABG. RESULTS During the in-hospital stay, 13 patients (1.7%) died, 45 (4.5%) developed low cardiac output syndrome, and 28 (3.7%) suffered minor or major cerebrovascular complications. Patients with a preoperative serum concentration of CRP>/=1.0 mg/dL had a higher risk of overall postoperative death (5.3% vs 1.1%, p = 0.001), cardiac death (4.4% vs 0.8%, p = 0.002), low cardiac output syndrome (8.8% vs 3.7%, p = 0.01), and any cerebrovascular complication (4.4% vs 3.5%, p = 0.66). Preoperative serum concentration of CRP>/=1.0 mg/dL was significantly more frequent among patients with history of myocardial infarction, diabetes, lower limb ischemia, low left ventricular ejection fraction, NYHA class IV, and in those undergoing urgent or emergency operation. At multivariate analysis, preoperative serum concentration of CRP >/= 1.0 mg/dL (p = 0.01, O.R.: 6.97) and left ventricular ejection fraction (p = 0.01, O.R.: 0.95) were independent predictors of postoperative death. Postoperative mortality rate was 0.3% among patients with preoperative CRP < 1.0 mg/dL and an ejection fraction >/=50%, whereas it was 21.4% among those with a preoperative CRP >/= 1.0 mg/dL and an ejection fraction less than 50% (p < 0.0001). CONCLUSIONS Preoperative serum concentration of CRP in patients undergoing on-pump coronary artery bypass surgery is an important determinant of postoperative outcome.

Strategies for Spinal Cord Protection during Descending Thoracic and Thoracoabdominal Aortic Surgery: Up-to-date Experimental and Clinical Results - A review

Surgery of the descending thoracic and thoracoabdominal aorta, apart from postoperative mortality, is threatened by spinal cord ischemic complications resulting in paraplegia or paraparesis. These, in turn, are associated with an increased risk of postoperative and late mortality. Signie cant advances in understanding the pathogenesis of spinal cord ischemic injury occurring after descending thoracic and thoracoabdominal aortic aneurysm repair hasled tothedevelopment of different strategies,whichinseveral seriesdecreasedthe rate of postoperative paraplegia to below 5%. However, since none of these methods alone seems to reduce to nil the riskof postoperative paraplegia, each ofthemshould be wisely supplemented by other neuroprotective maneuvers or drugs. This review article summarizes the current knowledge originating from experimental and clinical studies and the most signie cant advancements achieved in this e eld during the last decade. Furthermore, some of the mostusedsurgical approaches are presented in their fundamental steps.

Outcome after emergency repair of symptomatic, unruptured abdominal aortic aneurysm: results in 42 patients and review of the literature.

Objective To evaluate the results of our experience in the management of patients with symptomatic, unruptured abdominal aortic aneurysm (AAA), to identify the predictors of immediate outcome and to define the worldwide postoperative mortality rate through a review of previous studies on this condition. Patients and methods Forty-two patients underwent emergency repair for symptomatic, unruptured AAA. Results Four patients (9.5%) died during the in-hospital stay, three of myocardial infarction and one of multiorgan failure. Only preoperative creatinine was predictive of postoperative death (p=0.04, OR 1.31). The Glasgow Aneurysm Score tended to be predictive of postoperative death (p=0.06), survivors having had a median score of 76.0 (IQR, 75.5–82.1) and patients who died of 87.1 (78.9–89.9). The receiver operating characteristic (ROC) curve analysis showed that the Glasgow Aneurysm Score had an area under the curve of 0.789 (95% CI: 0.596–0.983, SE: 0.099, p=0.06). Its best cut-off value in predicting postoperative death was 85 (specificity 86.8%, sensitivity 75.0%). The postoperative mortality rate among patients with a Glasgow Aneurysm Score <85 was 2.9%, whereas it was 37.5% among those with a score >85 (p=0.003). A review of the results of previous studies on this condition, including also the present series, showed that 207 out of 1312 patients (15.8%) died after emergency operation for symptomatic, unruptured AAA. Conclusion Emergency open repair of symptomatic, unruptured AAA is associated with a high risk of postoperative death. The results of this study suggest that a rather good postoperative survival rate can be expected in patients with a Glasgow Aneurysm Score <85. A watchful waiting policy or, alternatively, emergency endovascular repair should be advocated in patients with a higher score.

High concentrations of chromium in lung tissue from lung cancer patients.

The pulmonary chromium content was determined by plasma atomic emission spectrometer (DCP‐AES) from 53 lung cancer and 43 control patients, and compared with smoking habits, severity of emphysema and occupational history. The chromium content from the lung cancer patients was higher than that from the smoking (P < 0.025) or nonsmoking control patients (6.4 ± 4.3, 4.0 ± 4.0, and 2.2 ± 0.6 μg/g dry weight, respectively). A positive correlation between the pulmonary chromium and smoking time (P < 0.025) and the severity of emphysema (P < 0.001) was found in the control but not in the cancer patients. The difference in the pulmonary chromium content was greatest between those lung cancer and control patients who were light smokers or had mild emphysema. This group of lung cancer patients included subjects with occupational exposure to chromium. The possibility of occupational cancer should be considered especially with light smokers. The grade of emphysema and metals such as chromium accumulating from tobacco could serve as objective indicators of smoking.

Ten-Year Survival after Resection for Lung Carcinoma: Effect of Blood Transfusion and Tumour Stage on Outcome

The objectives were to evaluate the prognosis in resected lung cancer and to observe if perioperative blood transfusion adversely affects the prognosis. Of 208 patients with resection for lung cancer in 1978-1980, all but five were smokers: 127 had squamous cell and 81 non-squamous cell carcinoma. Stage I disease was found in 143 patients. (69%), stage II in 18 (9%) and stage IIIa in 47 (23%). Five-year survival was 52% in stage I, 29% in stage II and 7% in stage IIIa tumour; the respective 10-year rates were 37, 19 and 3%. Patients given perioperative blood transfusion (n = 95) had poorer prognosis than the non-transfused patients. According to Cox multivariate analysis, however, the relative risk of death was only slightly increased by perioperative transfusion (p = 0.07). In patients with stage II or IIIa carcinoma at diagnosis, this relative risk was 2.17 and 4.99 times higher than in stage I (p = 0.004 and p = 0.0001). Long-term survival thus was related to extent of the disease at diagnosis rather than to numbers of blood transfusions.

Ultrastructural changes during continuous retrograde warm and mild hypothermic blood cardioplegia for coronary bypass operations

Ultrastructural changes in myocardial tissue were studied in 21 patients undergoing elective aorta-coronary bypass operation. The patients were randomized into two groups, with 10 of them receiving continuous retrograde warm and 11 continuous retrograde mild hypothermic blood cardioplegia. Biopsy specimens for electron microscopy were taken from the apical part of the left ventricle before and at the end of the aortic crossclamp period and after reperfusion of the myocardium. The ultrastructural changes were analyzed with use of a semiquantitative scoring system and classified as mild, moderate, or severe. Slight ultrastructural changes were found in both groups even before the aortic crossclamp period. At the end of the aortic crossclamp period the most prominent ultrastructural changes were mitochondrial swelling, damage of capillary endothelium, and clearing of the nucleoplasm or margination of chromatin, but some enlargement in intercalated discs was also discernible. Reperfusion of the myocardium for 15 minutes somewhat further increased the overall score of the ultrastructural changes. Two patients in the warm cardioplegia group had a perioperative myocardial infarction, and this may be one reason for the higher postoperative creatine kinase MB efflux in this patient group. Despite this finding, no major differences in the ultrastructural changes between the two cardioplegia groups could be observed. We conclude that only mild to moderate and principally reversible ultrastructural changes occur in myocardium during continuous retrograde warm and mild hypothermic blood cardioplegia for coronary bypass operation.

Fatal complications after use of the symmetry aortic connector in coronary artery bypass surgery

During the last 2 years, 103 aortic saphenous vein graft anastomoses were performed in 68 patients undergoing off-pump coronary artery bypass by using the Symmetry Bypass System Aortic Connector. Of these patients, 2 died during the early postoperative period. In the first patient, after an episode of ventricular fibrillation and closed-chest cardiac massage, the sternum was opened and hemopericardium secondary to leakage of the proximal anastomotic device was found. The second patient died of ascending aortic dissection, the tear of which was likely to have originated from the proximal anastomotic site.

Ultrastructural changes in myocardium during mild hypothermic retrograde blood cardioplegia.

Uniformity of myocardial protection during retrograde blood cardioplegia is still a controversial area. We conducted a study on electron microscopic changes in the myocardium during mild hypothermic retrograde cardioplegia (31-32 degrees C) in 12 patients undergoing coronary artery bypass grafting. Biopsies for electron microscopy were taken from the right and left ventricular myocardium before and at the end of aortic cross-clamping and after 15 min reperfusion. The intercellular junctions, intracellular and extracellular oedema, mitochondria, capillaries, nuclei and myofibrils were analysed separately in each specimen, using a semiquantative method with scoring from 0 (unchanged) to 3 (severe changes), and the total scores were correlated with the severity of right and left coronary artery disease and with ischaemia time during aortic cross-clamping. Mild to moderate ultrastructural changes occurred in the myocardium during the cardiopolegia, most typically myofibrillar injury and oedema. These changes increased during aortic cross-clamping and reperfusion, especially in the right ventricle. The total ultrastructural score for the right ventricle correlated negatively with the severity of right coronary artery disease at the end of cross-clamping. No such correlation was found in the left ventricle. Apart from one case of perioperative myocardial infarction, the clinical outcome was unproblematic. Myocardial structure thus was by and large well preserved during mild hypothermic retrograde blood cardioplegia, with the right ventricle seemingly somewhat less protected than the left.