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European Journal of Cardio-thoracic... Apr 2019Between 2% and 8% of patients return to the theatre for mediastinal bleeding following cardiac surgery. In the majority of patients, a surgical source of bleeding is...
OBJECTIVES
Between 2% and 8% of patients return to the theatre for mediastinal bleeding following cardiac surgery. In the majority of patients, a surgical source of bleeding is identified. Both mediastinal bleeding and re-exploration are associated with increased morbidity and mortality and the use of blood products. The aim of this study was to develop a 'haemostasis checklist' with the intention of reducing mediastinal bleeding and re-exploration following cardiac surgery.
METHODS
The Papworth haemostasis checklist was developed with a multidisciplinary collaboration. It consists of 2 components: surgical sites and coagulation status. The checklist is completed at a 'time-out' prior to sternal wire insertion. The analysis compared the outcomes of patients undergoing cardiac surgery in the 1 year before and after implementation. A propensity analysis assessed the impact of re-exploration on outcomes.
RESULTS
Three thousand eight hundred and eleven patients underwent cardiac surgery during the study period. Re-exploration for bleeding was associated with inferior outcomes. Following checklist implementation, there was a significant reduction in the re-exploration rate (3.47% vs 2.08%, P = 0.01) and proportion of patients bleeding >1 l in 12 h (6.1% vs 3.49%, P < 0.001). There was a significant reduction in consumption of blood products saving £102 165 ($134 198). The checklist implementation was associated with reduced intensive care unit length of stay and hospital length of stay, adding to the financial benefit.
CONCLUSIONS
The haemostasis checklist represents a simple intervention which is quick and easy to use but has had a substantial impact on clinical outcomes. We have observed a significant reduction in the mediastinal blood loss, return-to-theatre rate and consumption of blood products, which is associated with a significant clinical and financial benefit.
Topics: Aged; Blood Component Transfusion; Cardiac Surgical Procedures; Checklist; Female; Hemostatic Techniques; Humans; Male; Mediastinal Diseases; Postoperative Hemorrhage; Propensity Score; Reoperation
PubMed: 30346507
DOI: 10.1093/ejcts/ezy362 -
Chest May 2020Guidelines recommend mediastinal sampling first for patients with mediastinal lymphadenopathy with suspected lung cancer. The objective of this study was to describe...
BACKGROUND
Guidelines recommend mediastinal sampling first for patients with mediastinal lymphadenopathy with suspected lung cancer. The objective of this study was to describe practice patterns and outcomes of diagnostic strategies in patients with lung cancer.
METHODS
This study included a retrospective cohort of 15,914 patients with lung cancer with T1-3N1-3M0 disease diagnosed from 2004 to 2013 in the National Cancer Institute's Surveillance, Epidemiology, and End Results or Texas Cancer Registry Medicare-linked databases. Patients who had mediastinal sampling as their first invasive test were classified as guideline consistent; all others were guideline inconsistent. Propensity matching was used to compare the number of tests performed, and multivariable logistic regression was used to compare the incidence of complications.
RESULTS
Guideline-consistent care increased from 23% to 34% of patients from 2004 to 2013 (P < .001). Use of endobronchial ultrasound-guided transbronchial needle aspiration increased from 0.1% to 25% of all patients (P < .001), and mediastinal sampling increased from 54% to 64% (P < .0001). Guideline-consistent care was associated with fewer thoracotomies (38% vs 71%; P < .001) and CT scan-guided biopsies (10% vs 75%; P < .001) than guideline-inconsistent care but more transbronchial needle aspirations (59% vs 12%; P < .001). Guideline-consistent care was associated with fewer pneumothoraxes (5.1% vs 22%; P < .001), chest tubes (0.9% vs 4.4%; P < .001), hemorrhages (3.5% vs 5.8%; P < .001), and respiratory failure events (2.7% vs 3.7%; P = .047) than guideline-inconsistent care. Bronchoscopic mediastinal sampling was associated with fewer complications than surgical mediastinal sampling.
CONCLUSIONS
Guideline-consistent care with mediastinal sampling first was associated with fewer tests and complications. Quality gaps decreased with the introduction of endobronchial ultrasound-guided transbronchial needle aspiration but persist. Gaps include failure to sample the mediastinum first, failure to sample the mediastinum at all, and overuse of thoracotomy.
Topics: Aged; Aged, 80 and over; Female; Guideline Adherence; Humans; Image-Guided Biopsy; Lung Neoplasms; Lymphatic Metastasis; Male; Mediastinum; Medicare; Neoplasm Staging; Postoperative Complications; Quality of Health Care; Registries; Retrospective Studies; SEER Program; Texas; Thoracotomy; United States
PubMed: 31610159
DOI: 10.1016/j.chest.2019.09.025 -
Revue Des Maladies Respiratoires Mar 2015Epicardial fat necrosis is a rare cause of benign chest pain. Its physiopathological mechanism is unknown. Diagnosis is easily performed through radiological...
Epicardial fat necrosis is a rare cause of benign chest pain. Its physiopathological mechanism is unknown. Diagnosis is easily performed through radiological investigations that show a round opacity of fat density limited by a dense pseudo-capsule in the anterior mediastinum, close to the heart.
Topics: Abdominal Pain; Accidental Falls; Adult; Anti-Inflammatory Agents, Non-Steroidal; C-Reactive Protein; Chest Pain; Diagnosis, Differential; Fat Necrosis; Female; Fibrin Fibrinogen Degradation Products; Gastrointestinal Hemorrhage; Humans; Leukocytosis; Mediastinal Diseases; Pulmonary Embolism; Smoking; Tomography, X-Ray Computed
PubMed: 25725982
DOI: 10.1016/j.rmr.2014.05.008 -
Annales de Cardiologie Et D'angeiologie Nov 2016Posterior mediastinal hematoma in a rare and potentially lethal disease and is frequently consecutive to a traumatism. We report the original case of a 88-year-old male...
Posterior mediastinal hematoma in a rare and potentially lethal disease and is frequently consecutive to a traumatism. We report the original case of a 88-year-old male admitted to our department for lipothymia and syncope related to a severe compression of the left atrium by an important mediastinal hematoma mimicking in transthoracic echocardiography an obstructive intraatrial mass.
Topics: Aged, 80 and over; Anticoagulants; Atrial Appendage; Calcinosis; Constriction, Pathologic; Diagnosis, Differential; Dilatation, Pathologic; Echocardiography; Hematoma; Hematoma, Subdural; Humans; Long-Term Care; Magnetic Resonance Imaging; Male; Mediastinal Diseases; Spinal Fractures; Syncope; Thoracic Vertebrae; Watchful Waiting
PubMed: 27697300
DOI: 10.1016/j.ancard.2016.09.017 -
Current HIV Research 2022Acquired immunodeficiency syndrome is a chronic infectious disease with high mortality and is caused by the Human Immunodeficiency Virus (HIV). Pneumonia caused by HIV...
BACKGROUND
Acquired immunodeficiency syndrome is a chronic infectious disease with high mortality and is caused by the Human Immunodeficiency Virus (HIV). Pneumonia caused by HIV is common, but it rarely causes spontaneous mediastinal and subcutaneous emphysema.
CASE PRESENTATION
A 21-year-old man with severe pneumonia was hospitalized owing to dyspnea that had been persisting for 1 day; blood test results confirmed HIV infection. Initial chest Computed Tomography (CT) did not reveal mediastinal or subcutaneous emphysema. However, after 21 days of treatment, the patient experienced discomfort in the neck region and experienced the feeling of snowflakes on applying pressure. Chest CT showed mediastinal and subcutaneous emphysema, located in the bilateral cervical roots, anterior upper chest wall, left axillary chest wall, mediastinum, and other parts. Metagenomic Next Generation Sequencing (mNGS) of the sputum and blood samples suggested multiple pathogenic infections. Antiinfection treatment was initiated, and changes in the patient's condition were monitored. The patient's subcutaneous emphysema improved during the follow-up.
CONCLUSION
In HIV-infected patients with sudden mediastinal and subcutaneous emphysema, mNGS can be used to determine the etiological agent during symptomatic treatment. Targeted antipathogen therapy is helpful in improving the condition of patients with subcutaneous emphysema.
Topics: Male; Humans; Young Adult; Adult; Mediastinal Emphysema; Mediastinum; HIV; HIV Infections; Subcutaneous Emphysema
PubMed: 36043739
DOI: 10.2174/1570162X20666220829143802 -
Ginekologia Polska 2020Fetal cardiac assessment is an integral part of the obstetric ultrasound. The inclusion of the outflow tracts and the three-vessel and tracheal view into the ultrasound... (Review)
Review
Fetal cardiac assessment is an integral part of the obstetric ultrasound. The inclusion of the outflow tracts and the three-vessel and tracheal view into the ultrasound screening enhances the detection rate for cardiovascular anomalies. Both, international and Polish guidelines recommend routine evaluation of the upper mediastinum. The aim of the study was to present the principles for assessing the structures of the upper mediastinum in normal conditions and to draw attention to the pathologies which may be visible in this plane.
Topics: Female; Fetal Heart; Heart Defects, Congenital; Humans; Mediastinum; Pregnancy; Retrospective Studies; Ultrasonography, Prenatal
PubMed: 33184831
DOI: 10.5603/GP.a2020.0092 -
Journal of Immunology (Baltimore, Md. :... Feb 2021Although fibrotic disorders are frequently assumed to be linked to T cells, quantitative tissue interrogation studies have rarely been performed to establish this link...
Although fibrotic disorders are frequently assumed to be linked to T cells, quantitative tissue interrogation studies have rarely been performed to establish this link and certainly many fibrotic diseases do not fall within the type 2/allergic disease spectrum. We have previously linked two human autoimmune fibrotic diseases, IgG4-related disease and systemic sclerosis, to the clonal expansion and lesional accumulation of CD4CTLs. In both these diseases T cell accumulation was found to be sparse. Fibrosing mediastinitis linked to infection histologically resembles IgG4-related disease in terms of the inflammatory infiltrate and fibrosis, and it provides an example of a fibrotic disease of infectious origin in which the potentially profibrotic T cells may be induced and reactivated by fungal Ags. We show in this study that, in this human disease, CD4CTLs accumulate in the blood, are clonally expanded, infiltrate into disease lesions, and can be reactivated in vitro by Ags. T cells are relatively sparse at lesional sites. These studies support a general role for CD4CTLs in inflammatory fibrosis and suggest that fibrosing mediastinitis is an Ag-driven disease that may provide important mechanistic insights into the pathogenesis of idiopathic fibrotic diseases.
Topics: Adult; CD4 Antigens; Cells, Cultured; Cohort Studies; Female; Histoplasma; Histoplasmosis; Humans; Immunoglobulin G4-Related Disease; Lymphocyte Activation; Male; Mediastinitis; Middle Aged; Sclerosis; T-Lymphocytes, Cytotoxic; Th2 Cells
PubMed: 33328214
DOI: 10.4049/jimmunol.2000433 -
Journal of Laparoendoscopic & Advanced... Dec 2019Minimally invasive (video-assisted thoracoscopic surgery) mediastinal parathyroidectomy has been described as a technique for surgical management of primary...
Minimally invasive (video-assisted thoracoscopic surgery) mediastinal parathyroidectomy has been described as a technique for surgical management of primary hyperparathyroidism due to ectopic parathyroid adenoma. Herein, we present the largest cohort of patients ( = 8) treated with robot-assisted mediastinal parathyroidectomy and describe our technique for this procedure, pre- and intraoperative variables, and postoperative outcomes. A single surgeon, single institution case series of eight consecutive robot-assisted mediastinal parathyroidectomies performed from April 2013 to March 2018. Preoperative workup, intraoperative variables, and postoperative outcomes were evaluated. Of the eight patients, seven were women. Average age was 54 years (range: 28-69) and average body mass index 33.6 (range: 24.8-42.9). Seven patients had a preoperative diagnosis of primary hyperparathyroidism with preoperative parathyroid hormone (PTH) and calcium levels (PTH: 137 (70-192); Ca: 10.9 (10.2-12), and one patient had preoperative diagnosis of thymoma. Preoperative imaging studies included computed tomography (CT)-sestamibi ( = 3), CT neck ( = 4), CT chest ( = 6), and neck ultrasound ( = 6). Intraoperative PTH measurements found >50% reduction in all cases. Average length of surgery was 108.6 minutes (range: 76-186); average blood loss 26 cc. All specimens were parathyroid adenomas, with an average size of 16 mm (range: 7-35 mm). Seven of eight patients were discharged on postoperative day 1. No complications or recurrences occurred at a median follow-up of 18.5 days (range: 15-1,066 days). Robot-assisted thoracoscopic parathyroidectomy is a safe and effective technique, with immediate improvement in PTH levels. Thorough clinical, biochemical, and radiologic preoperative workup assists in operative planning and may improve diagnostic accuracy of anterior mediastinal masses.
Topics: Adult; Aged; Female; Humans; Male; Mediastinum; Middle Aged; Neoplasm Recurrence, Local; Parathyroid Neoplasms; Parathyroidectomy; Surgery, Computer-Assisted; Thoracic Surgery, Video-Assisted; Thymoma; Thymus Neoplasms; Tomography, Emission-Computed, Single-Photon; Tomography, X-Ray Computed
PubMed: 31188050
DOI: 10.1089/lap.2019.0266 -
Journal of Bronchology & Interventional... Oct 2015Endobronchial ultrasound-guided transbronchial needle aspiration (EBUS-TBNA) is well established for the staging and diagnosis of lung cancer and mediastinal...
BACKGROUND
Endobronchial ultrasound-guided transbronchial needle aspiration (EBUS-TBNA) is well established for the staging and diagnosis of lung cancer and mediastinal lymphadenopathy. Central mediastinal vascular structures may preclude EBUS-TBNA access to lymph nodes in the aortopulmonary window and certain centrally located parenchymal lesions. Thus, a transvascular approach is necessitated. Few such reports exist in the literature.
METHODS
We retrospectively analyzed the results of endobronchial ultrasound-guided transvascular needle aspiration (EBUS-TVNA) performed over 1 year to sample mediastinal lymph nodes (stations: 5) and lung lesions inaccessible by standard bronchoscopy or EBUS-TBNA. Data regarding the indication, location, size, and relationship to adjacent blood vessels, the number of transvascular passes, EBUS-TVNA diagnosis, the final diagnosis, procedural images, and complications were collected. Patients' charts were reviewed for 6 months after the procedure for evidence of late complications, including mediastinitis or mediastinal hemorrhage.
RESULTS
Of 865 EBUS-TBNA procedures, 10 were performed by traversing the pulmonary artery or its branches. Nine were for left-sided lesions, 3 for hilar parenchymal nodules, 6 for hilar or mediastinal LN, and the remainder for a right-sided mass. Rapid-onsite evaluation was either diagnostic or positive for lymphoid cells in 9 patients and the final cytopathology was diagnostic in 9 patients: 5 non-small cell lung cancer, 1 small cell cancer, 1 metastatic colon cancer, and 2 normal lymphoid tissue. One patient had necrosis and required video assisted thoracoscopic surgery to diagnose histoplasmosis. Bleeding was insignificant, with no short-term/long-term complications.
CONCLUSIONS
From our single-center experience, we conclude that in experienced hands, EBUS-TVNA is feasible, with a high yield, but without complications. Larger prospective trials are warranted to explore its diagnostic potential.
Topics: Endoscopic Ultrasound-Guided Fine Needle Aspiration; Humans; Lung Neoplasms; Lymph Nodes; Male; Mediastinum; Retrospective Studies; Tomography, X-Ray Computed
PubMed: 26492603
DOI: 10.1097/LBR.0000000000000227 -
Virchows Archiv : An International... Nov 2015The mediastinum is an anatomically defined space in which organs and major blood vessels reside with surrounding soft tissue elements. The thymus is an important organ... (Review)
Review
The mediastinum is an anatomically defined space in which organs and major blood vessels reside with surrounding soft tissue elements. The thymus is an important organ in the mediastinum, and many of the masses encountered in the mediastinum are related to this organ. Most neoplasms diagnosed in the mediastinum are epithelial tumours (thymomas and thymic carcinomas), lymphomas or germ cell tumours. In contrast, soft tissue tumours of the mediastinum are rare. In 1963, Pachter and Lattes systematically reviewed soft tissue pathology of the mediastinum, covering the hitherto described [2, 226, 227] In this review, based on the 2013 WHO classification of soft tissue tumours and the 2015 WHO classification of tumours of the lung, pleura, thymus and heart, we provide an updated overview of mesenchymal tumours that may be encountered in the mediastinum.
Topics: Diagnosis, Differential; Humans; Mediastinum; Mesoderm; Neoplasm Grading; Thymoma; Thymus Neoplasms
PubMed: 26358059
DOI: 10.1007/s00428-015-1830-8