ABSTRACT Throughout the history of surgery many inaccuracies have surrounded the chapter related to the emergence of thoracic incisions. It will always be very difficult to determine the exact date and names of those who actually performed the first thoracotomies; obviously those who published or reported the first descriptions should be assumed as such, but the history has not always been well told. In some cases, only surnames are known; in some others, the inconsistency of time lapses opposes all logic. A thorough historical research has been carried out, which has made it possible to compile a brief account about the emergence of the most important thoracotomies, as well as to reveal some findings that are unknown to most thoracic surgeons. This is the first part of a brief account about the known facts, but also, it is especially about the unknown history of the thoracic incisions’ origin, which has overcome the test of time.

RESUMEN A lo largo de la historia de la cirugía numerosas inexactitudes han rodeado el capítulo relacionado con el surgimiento de las incisiones torácicas. Siempre será muy difícil precisar la fecha exacta y el nombre de quienes realmente realizaron las primeras toracotomías; obviamente debe asumirse como tales a quienes publicaron o informaron las descripciones originales, pero la historia no siempre ha sido correctamente contada. En unos casos solo se conocen apellidos; en otros, la incongruencia de los lapsos de tiempo se opone a toda lógica. Se ha realizado una profunda investigación histórica que ha permitido confeccionar un breve recuento del surgimiento de las toracotomías más importantes y descubrir algunos hallazgos desconocidos para la mayoría de los cirujanos torácicos. Esta es la primera parte de un breve relato de hechos conocidos, pero especialmente, de la historia desconocida del origen de las incisiones torácicas que han vencido la prueba del tiempo.

ABSTRACT Axillary thoracotomies are among the most described and modified in the history of surgery. Despite the sustained development of video-assisted thoracic surgery, the role of classic thoracotomies in current surgical practice is unavoidable, especially when minimally invasive options are not available. Extended posterior vertical axillary thoracotomy emerged almost 30 years ago from the introduction of innovative modifications to axillary thoracic incisions previously described. An extensive literature review makes it possible to affirm that an axillary thoracotomy, which contains all the distinctive features that the one presented herein, has never been reported before. Its main advantages are discussed in relation to the decrease in the operating time and complications during and after surgery.

RESUMEN Las toracotomías axilares están entre las más descritas y modificadas en la historia de la cirugía. A pesar del sostenido desarrollo de la cirugía torácica video-asistida, es ineludible el protagonismo de las toracotomías clásicas en la práctica quirúrgica actual, en especial cuando no están disponibles las opciones mínimamente invasivas. La toracotomía axilar vertical posterior extendida, surgió hace casi 30 años a partir de la introducción de innovadoras modificaciones a incisiones torácicas axilares previamente descritas. Una extensa revisión bibliográfica permite afirmar que nunca antes ha sido informada una toracotomía axilar que contenga al unísono todas las características distintivas que la que ahora se presenta. Se discuten sus principales ventajas en relación con la disminución del tiempo operatorio y de las complicaciones durante y después de la cirugía.

ABSTRACT Germ cell tumors are not so frequent; among them, teratomas are most common in the mediastinal location. Teratomas in young men are usually malignant (teratocarcinoma), with a gender ratio of 13.5:1, and an average age of 26 years. We describe the evolution of a 19-year-old man with a mediastinal tumor, with pulmonary metastases and intracardiac infiltration, successfully removed; whose most frequent symptoms were: dyspnea, retrosternal pain, fever, cough, weight loss and superior vena cava syndrome. The diagnosis was made by chest x-ray and computed tomography. Total removal of the tumor and metastases was achieved, as well as the intracardiac tumor, with tricuspid valve repair. The patient had a satisfactory outcome during the first follow-up year.

RESUMEN Los tumores de células germinales no son tan frecuentes, dentro de ellos se encuentra el teratoma como el más usual en ubicación mediastinal, es más habitual en hombres jóvenes cuando es maligno (teratocarcinoma), con una relación por género de 13,5:1, y una edad promedio de 26 años. Se describe la evolución de un hombre de 19 años de edad con un tumor mediastinal, con metástasis pulmonares e infiltración intracardíaca, resecado satisfactoriamente, cuyos síntomas más frecuentes fueron: disnea, dolor retroesternal, fiebre, tos, pérdida de peso y síndrome de vena cava superior. El diagnóstico se realizó por radiografía de tórax y tomografía axial computarizada. Se logró realizar la excéresis total del tumor y las metástasis, así como la tumoración intracardíaca, con reparación de la válvula tricúspide. El paciente ha tenido una evolución satisfactoria durante el primer año de seguimiento.

Hereditary hemorrhagic telangiectasia is an autosomal dominant disorder of the walls of the blood vessels that become tortuous and dilated. Clinically, patients with this disease develop recurrent bleeding, which may occur spontaneously or following minor trauma. We present the case of a 68-year-old male patient who was admitted due to an upper gastrointestinal bleeding and diagnosed with Rendu-Osler-Weber disease. After application of treatment, the patient recovered and was discharged from the hospital.

La telangiectasia hemorrágica hereditaria es un trastorno autosómico dominante de la pared de los vasos sanguíneos que se presentan tortuosos y dilatados. Clínicamente los pacientes con esta enfermedad pueden presentar hemorragias recurrentes que pueden ser espontáneas o secundarias a traumatismos leves. Se presenta el reporte de un paciente de sexo masculino, de 68 años, que fue ingresado por presentar un sangrado digestivo alto a quien se le diagnosticó una enfermedad de Rendu-Osler-Weber. Luego de la aplicación de tratamiento médico el paciente evolucionó satisfactoriamente y egresó de la institución.

INTRODUCTION Alcohol withdrawal syndrome is an important problem for management of alcoholism. It is known that alcohol alters the function of neurotransmitters such as serotonin, but our review found no studies associating serotonin concentration changes with patient clinical status during detoxification. The authors hypothesized that total platelet serotonin concentration should significantly increase during alcohol detoxification. OBJECTIVE Assess possible association between total (endogenous and captured) platelet serotonin concentration and clinical status of patients with alcohol withdrawal syndrome, at beginning and end of detoxification with clomethiazole. METHODS Thirty-one alcohol-dependent patients, diagnosed with alcohol withdrawal syndrome according to DSM-IV and classified in three clinical groups (18-20, 21-22 and 23-26 points) per the Clinical Institute Withdrawal Assessment for Alcohol Scale, were included in a prospective case series from May 2009 through May 2011 at the Hermanos Ameijeiras Clinical-Surgical Teaching Hospital in Cuba. Patients were predominantly male (87%), ranging in age from 22 to 57 years; 40% were white, 40% mestizo and 20% black. All had been hospitalized for detoxification in the hospital's psychiatry service. Blood samples taken were mixed with 1% EDTA and centrifuged for isolating platelets. Serotonin concentrations (endogenous and captured) were measured within 2 hours of blood collection and mean values at treatment days 1 and 12 compared by t test (p <0.05). RESULTS Total serotonin concentration mean values (µg of serotonin per mg of total platelet protein) were statistically different between days 1 and 12 of treatment (1.329±0.916 µg/mg vs. 2.573±1.224 µg/mg; p <0.001). There was a direct association between total serotonin concentration and patient clinical classification both initially and at day 12. At day 1, the 29 patients in the group with 18-20 points had mean serotonin of 1.358±0.0.94 µg/mg; one patient with 21 points had serotonin of 1.25 µg/mg; and one patient with 24 points had serotonin of 0.740 µg/mg. At day 12, 26 patients had 0-1 points, with mean serotonin 2.688±1.244 µg/mg; and 5 patients had 2-8 points, with mean serotonin 1.244±0.596 µg/mg. No patient had >8 points at day 12. CONCLUSIONS Serotonin is a potential biomarker for initial clinical classification and outcome monitoring and could be useful to psychiatrists working with patients in this area of medical practice and research. Further studies including more patients and variables are necessary to support these preliminary results.

INTRODUCTION: Nosocomial pneumonia associated with use of mechanical ventilators is one of the greatest challenges confronted by intensivists worldwide. The literature associates several bacteria with this type of infection; most common in intensive care units are Acinetobacter baumannii, Pseudomonas aeruginosa, methicillin-resistant Staphylococcus aureus and some of the Enterobacteriaceae family. OBJECTIVES: To identify the causal agents of nosocomial ventilatorassociated pneumonia in patients receiving mechanical ventilation in the intensive care units of Havana's Hermanos Ameijeiras Clinical-Surgical Teaching Hospital in 2011, and to characterize their antibiotic resistance. METHODS: A cross-sectional descriptive study was conducted using hospital administrative data of quantitative cultures from positive tracheal aspirates for January through December, 2011. Records were analyzed from 77 intensive care unit patients who developed nosocomial ventilator-associated pneumonia. Variables examined were age and sex, and pathogens identified from culture of tracheal aspirate and related antibiotic susceptibility. RESULTS: Species most frequently isolated were: Acinetobacter baumannii in 53 patients (68.8%), Pseudomonas aeruginosa in 34 patients (44.2%), other species of Pseudomonas in 15 patients (19.5%), and Serratia marcescens, Klebsiella pneumoniae, and Escherichia coli in 12 patients each (15.6%). Some patients presented more than one pathogen in concurrent or successive infections. Antimicrobial susceptibility testing found high percentages of resistance to antibiotics in all these pathogens. Least resistance was found to colistin. CONCLUSIONS: The prevalence of antibiotic resistance in bacteria causing nosocomial ventilator-associated pneumonia is of concern. Colistin is the drug of choice among the antibiotics reviewed, but sensitivity to other antibiotics should be assessed to search for more appropriate broad-spectrum antibiotics for treating nosocomial ventilator-associated pneumonia. Our results also suggest the need to strengthen infection control efforts, particularly in intensive care units, and to reassess compliance with quality control procedures. Multidisciplinary research involving microbiologists, epidemiologists, internists and intensivists is needed to fully understand the etiological and resistance patterns observed.

CB.Hep-1 monoclonal antibody (mAb) has been used in Hepatitis B vaccine manufacture. The mAb production was performed by ascites method inoculating cells previously frozen and cultivated in fetal bovine serum supplemented medium (SSM). It is expensive at risk and can be contaminated with adventitious pathogens. Therefore, the main objective of this study was to replace the SSM by the chemically defined medium Filocethplus (cell freezing) and the protein free medium HyQ(r)SFM4CHOTM (cell growing). As results, cells cryo-preserved in Filocethplus for 180 days and cultivated in HyQ(r)SFM4CHOTM showed no significant differences in regards to viability, maximum viable cell density and growth conditions with the same cells cultivated and frozen in SSM. In addition, CB.Hep-1 cells that were frozen in Filocethplus and cultivated in HyQ(r)SFM4CHOTM exhibited similar performance to those frozen and cultivated in SSM in agitated culture, which point out the application of these media for CB.Hep-1 mAb and Hepatitis B vaccine production.

El anticuerpo monoclonal (AcM) CB.Hep-1 se utiliza en la fabricación de la vacuna contra la hepatitis B. Se produce por el método de ascitis: inoculando células previamente congeladas y cultivadas en medios suplementados con suero fetal bovino (MSS). Este AcM es caro y puede contaminarse con agentes patógenos adventicios. Por ello, el objetivo de este estudio fue la sustitución del MSS por el medio químicamente definido Filocethplus durante la congelación de células y por el medio libre de proteínas HyQ(r)SFM4CHOTM durante el crecimiento celular. Los resultados con las células crioconservadas en Filocethplus durante 180 días y cultivadas en HyQ(r)SFM4CHOTM no mostraron diferencias significativas en cuanto a la viabilidad, la densidad máxima de células viables y las condiciones de crecimiento con respecto a las células cultivadas y congeladas en MSS. Las células CB.Hep-1, congeladas en Filocethplus y cultivadas en HyQ(r)SFM4CHOTM, también mostraron resultados similares a los de las células congeladas y cultivadas en MSS en cultivo agitado. Ello indica que estos otros dos medios se pueden emplear para la producción del AcM CB.Hep-1 y la vacuna contra la hepatitis B.

OBJECTIVE: To characterize mechanical ventilation-associated pneumonia (MVAP). METHOD: This is an observational descriptive study to characterize MVAP in 61 ventilated patients admitted in the intensive care units of the Hermanos Ameijeiras hospital during 2011. This study also aimed to isolate the bacteria causing MVAP and characterize their resistance to antibiotics. RESULTS: 51 (83.60%) patients presented pulmonary infiltrates and 35 (50.81%) presented a clinical score > 6 according to the Clinical Pulmonary Infection Score. Acinetobacter baumannii and Pseudomonas aeruginosa were the most frequently isolated microorganisms from patients with MVAP. Both microorganisms showed a high resistance to antibiotics. Carbapenems were the most frequent used antimicrobial therapeutic agents; elective antibiotic combinations were directed against both bacterial wall structure and nucleic acid synthesis. CONCLUSION: Patients with MVAP identified during the studied period showed similar frequency to those reported in medical literature. Thus, this study corroborated that this is still a relevant medical problem in this hospital. Acinetobacter baumannii and Pseudomonas aeruginosa were the most frequently isolated microorganisms from patients with MVAP. Antimicrobial treatment, empirical or not, are still the main risk factors for the development of multidrug-resistant strains of bacteria. The rate of resistance to antibiotics of Acinetobacter baumannii and Pseudomonas aeruginosa strains isolated from patients with MVAP was higher than those isolated from infected patients without MAVP. Tigecycline and colistin were the only antibiotics fully effective against Acinetobacter baumannii strains isolated in 2011 from patients with MVAP; against Pseudomonas aeruginosa strains, only colistin was fully effective.

OBJECTIVE: This observational study described the characterization of bacteria isolated from the lower respiratory tract of ventilated patients hospitalized in intensive care units. The demonstration of isolated microorganism resistance to antibiotics and a time-trend analysis of infection comparing a 48-month period were also other objectives. METHOD: Semi-quantitative assays of 1254 samples taken from 741 ventilated patients were performed, while pathogens were identified using the Enterotube II assay and VITEK 2 Compact equipment. Bacterial resistance to antibiotics was assessed by the Kirby-Bauer disc diffusion method and time-trend analysis of infection was based on data recorded by hospital microbiology laboratories. RESULTS: The most prevalent isolated bacteria from the patient's lower respiratory tract were with Gram-negative bacteria (67.8%) mostly represented by: Acinetobacter spp. (25.2%), Pseudomonas spp. (18.3%) and Klebsiellas spp. (9.4%). Acinetobacter spp. showed moderate high to very high resistance to ceftriaxone (CRO), gentamicin (CN), amikacin (AK), meropenem (MRP), aztreonam (ATM) and piperacillin/tazobactam (TZP). Some isolates of Acinetobacter spp. resistant to colistin (CS) were identified in this patient population. Pseudomonas spp. and Klebsiella spp. were very highly resistant to ampicillin/sublactam (AMS) and with moderate or low resistance to CRO, ATM, MRP, AK, CN and TZP. A decrease in the Pseudomonas spp. prevalence rate was observed, whereas an increase in Acinetobacter spp. and Klebsiella spp. prevalence rates were observed in a 48-month period. CONCLUSION: This research corroborated that these nosocomial infections are a relevant medical problem in our context. The most prevalent bacterial infections in the lower respiratory tract of ventilated patients were by Acinetobacter spp., Pseudomonas spp. and Klebsiella spp. The panel of antibiotics used as preventive therapy was not the solution of infections and probably induced drug-resistance mechanisms in these isolated microorganisms.

The ascites production method of inoculating hybridoma B cells in histocompatible mice can successfully produce monoclonal antibodies (MAb). The aim of this paper is to study the influence of the number of animals on MAb CB.Hep-1 production by the ascites production method. CB.Hep-1 mouse hybridoma cells were inoculated in different groups of animals (I, 750 mice; II, 1000 mice, III, 3500 mice; IV, 4000 mice and V, 6000 mice) previously irritated with mineral oil. The ascitic fluid was harvested through abdominal paracentesis and the results showed a marked influence of the number of animals on the amount of MAb CB.Hep-1 produced by the mice (I, 15.70 mg; II, 19.74 mg; III, 9.91 mg; IV, 8.46 mg; V, 5.30 mg). In conclusion, the concept of Reduction (3R concepts) was rigorously studied in this paper, determining the lowest number of inoculated animals needed for the highest amount of the MAb CB.Hep-1. Results indicate that the number of mice with tumors and the MAb CB.Hep-1 production decrease with the increase in the number of animals inoculated. Therefore between 50 000 and 250 000 animals could be spared each year if the number of animals was of ≤ 3500 per inoculation under the conditions studied here.

El método de producción de ascitis mediante la inoculación de hibridomas histocompatibles con los ratones puede producir anticuerpos monoclonales (AcM). El objetivo de este trabajo fue estudiar la influencia del número de animales sobre la producción del AcM CB.Hep-1 mediante la producción de ascitis. Las células del hibridoma de ratón CB.Hep-1 se inocularon en diferentes grupos de animales (I, 750; II, 1000; III, 3500; IV, 4000 and V, 6000) previamente irritados con aceite mineral. El fluido ascítico se cosechó mediante paracentesis abdominal y los resultados demostraron una marcada influencia del número de animales sobre la cantidad de AcM CB.Hep-1 por ratón (I, 15.70 mg; II, 19.74 mg; III, 9.91 mg; IV, 8.46 mg; V, 5.30 mg). En conclusión, el concepto de Reducción (conceptos 3R) fue rigurosamente estudiado en este trabajo, determinándose el mínimo número de animales que permite obtener la máxima cantidad del AcM CB.Hep-1. Los resultados indican que el número de animales con tumor y la producción del AcM CB.Hep-1 disminuyen con el incremento del número de animales inoculados y por lo tanto entre 50 000 y 250 000 animales por año podrían ser salvados si el número de animales inoculados fueran ≤ 3500 por cada inoculación bajos las condiciones estudiadas.