Torkel Åberg

Vein Invasion in Renal Cell Carcinoma: Impact on Metastatic Behavior and Survival

PURPOSE The development of a thrombus extending into the veins is well recognized in renal cell carcinoma. We investigated the hypothesis that vein invasion alone has no adverse impact on survival but is a highly negative factor in other tumors. MATERIALS AND METHODS In 200 consecutive patients invasion of the renal vein and vena cava was evaluated and compared with the clinical course. RESULTS A total of 26 patients had vena caval and 47 had renal vein invasion. Patients with venous invasion had a significantly shorter survival but no survival difference was demonstrated based on the level of involvement. CONCLUSIONS Our study indicates that vein invasion itself seems to be an important prognostic factor in renal cell carcinoma.

Delirium after Coronary Bypass Surgery Evaluated by the Organic Brain Syndrome Protocol

Objective : The aim was to evaluate symptoms of delirium from a psychogeriatric perspective occurring postoperative to coronary bypass surgery. Design : Patients, S 60 years, scheduled for coronary bypass surgery ( n = 52) were enrolled in a prospective descriptive study. The patients were evaluated before and several times after surgery by the Organic Brain Syndrome scale, and delirium was diagnosed according to psychiatric codes. Results : Of the 52 patients, 23% presented delirium. These patients were older than the control group, 73.5 - 4.2 and 69.3 - 5.9 years, respectively (mean - SD, p < 0.01), and had more frequently a history of previous stroke ( p < 0.05). Emotional delirium was seen in 83%, hyperactive delirium in about 40%, and 25% were classified to have a psychotic delirium. A major finding was a 58% frequency of hallucinations and illusions among patients with delirium, and a similar rate among those without delirium. Conclusion : Delirium is common after cardiac surgery in particular in older patients, but is often under-diagnosed. Hallucinations were common in both delirious and non-delirious patients.

Clinical effects of the heparin coated surface in cardiopulmonary bypass

OBJECTIVE In a randomised study of 120 patients, undergoing primary operation for coronary heart decease, two groups were investigated as regards to the effects of heparin coated cardiopulmonary bypass on brain function parameters and general clinical outcome. The study group (n = 56) was perfused using an extra-corporeal circuit treated with covalent bonded heparin; the control group (n = 59) used an identical set-up without heparin treatment. Systemic heparin doses were calculated to achieve ACT levels of 250 and 500 s, respectively. Postoperative course was evaluated by examining a set of clinically relevant parameters including a detailed registry of postoperative deviations. Brain function was assessed by the biochemical marker S-100 and tests of memory performance. RESULTS There were several signs of reduced operative trauma in the study group. Hospital stay was reduced by nearly 1 day (P < 0.05). Time on postoperative ventilatory support was approximately 4 h shorter (P = 0.009). Chest drain blood loss was decreased both at 8 (P = 0.01) and 24 h (P = 0.007) postoperatively. Body temperature was lower after surgery and especially on days 2 (P = 0.03) and 3 (P = 0.01). Perioperative creatinine elevation was significantly reduced (P = 0.03). Neurological deviations were fewer (P = 0.01). Brain function assessment revealed reduced plasma levels of S-100 both at termination of cardiopulmonary bypass (P = 0.008) and 7 h later (P = 0.04). However, no remediation of memory impairment could be demonstrated. CONCLUSIONS Cardiopulmonary bypass with covalent bonded heparin attached to the extra-corporeal circuit in combination with a reduced systemic heparin dose seems to reduce safely and effectively the operative stress to the patient. There were also signs of improved cerebral protection.

Appropriateness of referral of coronary angiography patients in Sweden

OBJECTIVE To evaluate the appropriateness of referral following coronary angiography in Sweden. DESIGN Prospective survey and review of medical records. PATIENTS Consecutive series of 2767 patients who underwent coronary angiography in Sweden between May 1994 and January 1995 and were considered for coronary revascularisation. MAIN OUTCOME MEASURES Percentage of patients referred for coronary artery bypass graft surgery (CABG) and percutaneous transluminal coronary angioplasty (PTCA) for indications that were judged necessary, appropriate, uncertain, and inappropriate by a multispecialty Swedish national expert panel using the RAND/University of California Los Angeles (UCLA) appropriateness method, and the percentage of patients referred for continued medical management who met necessity criteria for revascularisation. RESULTS Half the patients were referred for CABG, 25% for PTCA, and 25% for continued medical therapy. CABG was judged appropriate or necessary for 78% of patients, uncertain for 12% and inappropriate for 10%. For PTCA the figures were 32%, 30% and 38%, respectively. Two factors contributed to the high inappropriate rate. Many of these patients did not have “significant” coronary artery disease (although all had at least one stenosis > 50%) or they were treated with less than “optimal” medical therapy. While 96% of patients who met necessity criteria for revascularisation were appropriately referred for revascularisation, 4% were referred for continued medical therapy. CONCLUSIONS Using the RAND/UCLA appropriateness method and the definitions agreed to by the expert panel, which may be considered conservative today, it was found that 19% of Swedish patients were referred for coronary revascularisation judged inappropriate. Since some cardiovascular procedures evolve rapidly, the proportion of patients referred for inappropriate indications today remains unknown. Nevertheless, physicians should actively identify those patients who will and will not benefit from coronary revascularisation and ensure that they are appropriately treated.

Bubble and Membrane Oxygenators—Comparison of Postoperative Organ Dysfunction with Special Reference to Inflammatory Activity

Bubble and membrane oxygenators (2 types of each) were compared in a randomized study of 96 patients undergoing coronary bypass grafting. Cardiac performance, assessed from postoperative need of inotropic support, was significantly better in the membrane oxygenator group. After perfusion lasting more than 2 hours, respiratory function, measured as alveolar-arterial oxygen pressure gradient, was less compromised in that group and renal function, quantified as postoperative rise of serum creatinine was less disturbed. Cerebral function, studied in terms of psychometric test results and concentration of adenylate kinase in cerebrospinal fluid, did not differ between the bubble and membrane oxygenator groups. In investigations concerning changes in inflammatory activity during bypass, complement activation could not be related to the mentioned clinical parameters. Release of the neutrophil granulocyte factors lactoferrin and myeloperoxidase was greater in the bubble oxygenator group and correlated to impaired cardiac and renal performance, but not to pulmonary or cerebral dysfunction.

Use of heparin-bonded circuits in cardiopulmonary bypass improves clinical outcome.

Objective : The use of heparin-coated surfaces in cardiopulmonary bypass has been shown to decrease the inflammatory response imposed by the contact between blood and artificial surfaces. One would expect this reaction to improve clinical outcome. However, this has been difficult to verify. This investigation is based on an aggregation of two randomized studies from our institution and highlights possible effects of heparin coating on a number of clinically oriented parameters. Design : Departmental analysis of patients subjected to coronary artery bypass surgery using heparin-coated circuits. Cardiopulmonary bypass was employed using either the Carmeda or Duraflo heparin coatings compared with a control. The systemic heparin dose was reduced in the heparin-coated groups (ACT > 250 s) vs control group patients (ACT > 480 s). The effects of heparin coating related to clinical outcome were studied. Results : The use of heparin-coated circuits reduced the mean length of stay in hospital from 7.8 - 2.5 to 7.3 - 1.8 days ( p = 0.040) and postoperative ventilation time from 9.7 - 9.2 to 8.2 - 8.5 h ( p = 0.018), blood loss 8 h post surgery from 676 - 385 to 540 - 245 ml ( p = 0.001), individual perioperative change of haemoglobin loss ( p = 0.001), leukocyte count ( p = 0.000) and creatinine elevation ( p = 0.000), proportion of patients exposed to allogenous blood transfusions 39.2 vs 23.9% ( p = 0.001), postoperative coagulation disturbances 4.4 vs 0.4% ( p = 0.006), postoperative deviations from the normal postoperative course 47.2 vs 36.7% ( p = 0.035), neurological deviations 9.4 vs 3.9% ( p = 0.021) and atrial fibrillation 26.4 vs 18.0% ( p = 0.041). No effects were found with respect to perioperative platelet count, postoperative fever reaction and 5-year survival. Conclusion : Based on several indicators, the use of heparin coating in cardiopulmonary bypass is associated with improved clinical results.

Inflammatory System Activation During Cardiopulmonary Bypass as an Indicator of Biocompatibility: A Randomized Comparison of Bubble and Membrane Oxygenators

As the exposure of blood to foreign material during cardiopulmonary bypass (CPB) leads to triggering of inflammatory systems, the inflammatory response was used as an indicator of the biocompatibility of oxygenators. Activation of complement and neutrophil granulocytes during CPB was studied in 96 patients undergoing coronary bypass, with randomized comparisons between four different oxygenators, two of bubble and two of membrane type. Seven patients undergoing thoracotomy without CPB served as controls. During CPB there was significant complement activation, measured as changes in the ratio C3d/C3, with no demonstrable difference between the bubble and membrane oxygenator groups. Such change was not seen in the controls. Neutrophil granulocytes released significant amounts of the granule proteins lactoferrin and myeloperoxidase during CPB, but not during thoracotomy without CPB. The plasma concentrations of lactoferrin and myeloperoxidase were significantly lower in the membrane oxygenator groups, possibly indicating better biocompatibility. The strong inflammatory response with both oxygenator types, however, indicates that presently used CPB devices have unsatisfactory biocompatibility.

Neurological and general outcome in low-risk coronary artery bypass patients using heparin coated circuits

OBJECTIVE The clinical significance of heparin coating in cardiopulmonary bypass has previously been investigated. However, few studies have addressed the possible influence on brain function and memory disturbances. METHODS Three hundred low-risk patients exposed to coronary bypass surgery were randomised into three groups according to type of heparin coating: Carmeda Bioactive Surface, Baxter Duraflo II and a control group. Outcome was determined from a number of clinically oriented parameters, including a detailed registry of postoperative deviations from the normal postoperative course. Brain damage was assessed through S100 release and memory tests, including a questionnaire follow-up. RESULTS Clinical outcome was similar for all groups. Blood loss (Duraflo only), transfusion requirements and postoperative creatinine elevation were reduced in the heparin-coated groups. A lower incidence of atrial fibrillation was noted in the Duraflo group. Heparin coating did not uniformly attenuate the release of S100 or the degree of memory impairment. CONCLUSIONS Cardiopulmonary bypass (CPB) with heparin coating and a reduced dose of heparin seems to be safe. Clinical outcome and neurological injury seem not to be associated with type of heparin coating used for CPB. However, blood loss and transfusion requirements may be reduced.

Signs of brain cell injury during open heart operations: Past and present

Signs of brain cell injury have been studied during the evolution of open heart surgery in the last quarter century. At the beginning of the period, it was possible to elucidate signs of brain injury with rather crude psychometric tests and clinical observations in seemingly normal patients having routine operations. Over the next 5 years, a marked improvement in psychometric scores was observed. However, a biochemical cerebral cell injury marker (adenylate kinase) showed increased levels in the cerebrospinal fluid, a finding indicative of brain cell injury. There was a correlation between cerebrospinal fluid levels of adenylate kinase and psychometric test results as well as between the marker levels and clinical signs. Because of the relative insensitivity of the psychometric tests used and the increasing difficulty in receiving permission for spinal fluid taps, other methods were sought. Refined psychometric memory tests were used and showed that even in the 1990s, there are subtle signs of brain cell injury during open heart operations. This finding was corroborated by using a highly brain-specific and brain-sensitive biochemical cell injury marker (S-100 beta) that increased during extracorporeal circulation and showed a correlation with clinical cerebral complications.

Cerebral damage during open-heart surgery. Clinical, psychometric, biochemical and CT data.

The incidence and extent of cerebral damage following open-heart surgery were prospectively investigated in 103 patients, using clinical assessment, psychometry, adenylate kinase analysis in cerebrospinal fluid (CSF-AK) and computed tomography (CT) of the brain. The surgical mortality was 1.9%. Clinically there was obvious cerebral dysfunction in four cases, subtle evidence of brain damage (mainly undue fatigue) in 16 and no evidence in 81 cases. In the 16 patients the mean CSF-AK was substantially increased (0.122 U/l) and the psychometric performance distinctly impaired (-12 points) postoperatively; in the 81 patients the figures were 0.55 U/l and -3.4. Psychometrically, 60% of the patients showed cerebral dysfunction, which was pronounced in 16%. CSF-AK analysis indicated cerebral damage as absent or trival in 45%, moderate in 33% and marked in 22%. CT revealed postoperative cerebral infarction in two cases. Results from the various methods showed reasonable correlation, but also considerable overlap. Open-heart surgery thus can cause brain damage additional to that neurologically discernible. Fatigue is an important sign in this context. In research on postoperative brain damage, the relative insensitivity of routine neurologic investigation calls for supplementary, refined methods.