Risk factors for prolonged air leak and need for intervention following lung resection

 Open in a separate windowOBJECTIVESProlonged air leak (PAL; >5 days) following lung resection is associated with postoperative morbidity. We investigated factors associated with PAL and PAL requiring intervention.METHODSRetrospective review of all patients undergoing lobectomy, segmentectomy or wedge resection from 2016 to 2019 at our institution. Bronchoplastic reconstructions and lung-volume reduction surgeries were excluded. Incidence and risk factors for PAL and PAL requiring intervention were evaluated.RESULTSIn total, 2384 patients were included. PAL incidence was 5.4% (129/2384); 22.5% (29/129) required intervention. PAL patients were more commonly male (56.6% vs 39.7%), older (mean age 69 vs 65 years) and underwent lobectomy or thoracotomy (all P < 0.001). Patients with PAL had longer length of stay (9 vs 3 days), more discharge needs and increased odds of complication (all P < 0.050).Twenty-nine patients required intervention (9 chest tubes; 4 percutaneous drains; 16 operations). In 50% of operative interventions, an air leak source was identified; however, the median time from intervention to resolution was 13 days. Patients requiring intervention had increased steroid use, lower diffusion capacity for carbon monoxide and twice the length of stay versus PAL patients (all P < 0.050).On univariable analysis, forced expiratory volume in 1 s (FEV1) <40%, diffusion capacity for carbon monoxide <50%, steroid use and albumin <3 had increased odds of intervention (P < 0.050).CONCLUSIONSAge, gender and operative technique were related to PAL development. Patients with worse forced expiratory volume in 1 s or diffusion capacity for carbon monoxide, steroid use or poor nutrition were less likely to heal on their own, indicating a population that could benefit from earlier intervention.     

Risk factors for development of dehydration in young children with acute watery diarrhoea: a case-control study

In a case-control study to understand the risk factors for development of life-threatening dehydration, a total of 379 children comprising 243 cases (moderate or severe dehydration) and 136 controls (non or mild dehydration) up to 2 years of age suffering from acute watery diarrhoea were studied. By univariate analysis, the presence of vibrios in stool, withdrawal of breast feeding during diarrhoea, not giving fluids, including oral rehydration solution (ORS), during diarrhoea, frequent purging (> 8/ day), vomiting (> 2/day) and undernutrition were identified as risk factors. However, by multivariate analysis after controlling for confounders, withdrawal of breast feeding during diarrhoea (odds ratio (OR) = 6.8, p < 0.00001) and not giving ORS during diarrhoea (OR = 2.1, p < 0.006) were identified as significant risk factors. The confounding variables which also contributed significantly to increasing the risk were age (≤ 12 months; OR = 2.7, p = 0.001), frequent purging (> 8/day; OR = 4.1, p < 0.00001), vomiting (> 2/day; OR = 2.4, p = 0.001) and severe undernutrition (%median <60 weight-for-age of Indian Academy of Paediatrics classification; OR = 3.1, p = 0.001). We feel that these findings will be useful for Global and National Diarrhoeal Diseases Control Programmes for formulating intervention strategies for preventing death due to diarrhoeal dehydration.     

Laparoscopic vs open approach for the treatment of gastroesophageal reflux in children

Background: The laparoscopic approach has become increasingly popular for fundoplication over the last few years; however many surgeons are skeptical about its real advantages. Methods: We conducted a prospective comparative study of children operated on for gastroesophageal reflux (GER). Exclusion criteria included age <1 YEAR AND >14 years, previous surgery on the esophagus or stomach, and neurologic impairment. We compared two groups of patients who met the same inclusion/exclusion criteria. One group was treated via a laparotomic approach between January 1993 and December 1997; the other was treated via a laparoscopic approach between September 1998 and December 2000. A 360° wrap was performed in each group. Results: Group 1 (laparotomic approach) included 17 patients; mean operative time was 100 min and postoperative time was 7 days. Group 2 comprised 49 children operated on via a laparoscopic approach; mean operative time was 78 min and postoperative time was 48 hours. No major complications were encountered in either group. In postoperative period, two patients in group 1 had complications. One had a prolonged bout of gastroplegia, which required nasogastric drainage, and then recovered spontaneously after 20 days; the other had stenosis of the wrap, which required dilation. No relapses occurred during a follow-up of 6 months. Long-term follow-up data are not presented. Comparative analysis of the short-term functional results indicated that there were no differences between the two groups. Conclusion: This study confirms that the minimally invasive approach is safe and effective for the treatment of primary gastroesophageal reflux disease in children.     

Analysis of the evolution in the management of endometrial cancer in Italy: a CTF study

OBJECTIVE: In 1994 we mailed questionnaires to referral centers in Italy in order to evaluate the different opinions concerning aspects of endometrial cancer treatment, which is still controversial. The data processing showed a significant nonhomogeneity in disease management and prompted the Italian Society of Gynecologic Oncology to define guidelines for endometrial cancer adjuvant treatment. In 2001, we mailed again the same questionnaire to the same referral Centers in Italy. The aim of the second enquiry was the evaluation of changes in endometrial cancer management and the effective impact of the guidelines published. METHODS: The enquiry used the same questionnaires mailed in 1994; actually, we mailed those questionnaires to the same referral centers in Italy twice: in December 2000 and March 2001.The results of both the enquiries were collected in a relational data base, and the statistical evaluations were calculated using SPSS-statistics (Window ver. 8). RESULTS: Endometrial cancer treatment consists in abdominal hysterectomy and bilateral salpingo-oophorectomy. The unique relevant difference as to 1994 consists in the systemic performing of peritoneal cytology in endometrial cancer staging. Unlike the previous enquiry, adjuvant radiotherapy is not systematically performed in disease at stage Ic because of the substantial absence of confirmed data demonstrating a real benefit in terms of survival rate.The comparison between the two enquiries shows a significant change in medical planning and diversification attitude according to patient age and menopausal state. The disease management changes in patients over 75 years old, mainly with respect to surgery and primary therapy. CONCLUSIONS: We noted a resistance of many centers to accept some trends actually widespread in the literature but not yet performed in practical clinical.     

Cationic charge determines the distribution of liposomes between the vascular and extravascular compartments of tumors

Tumor vessels possess unique physiological features that might be exploited for improving drug delivery. In the present study, we investigate the possibility of modifying polyethylene glycol-ylated liposome cationic charge of polyethylene glycol coated liposomes to optimize delivery to tumor vessels using biodistribution studies and intravital microscopy. The majority of liposomes accumulated in the liver, and increasing charge resulted in lower retention in the spleen and blood. Although overall tumor uptake was not affected by charge in the biodistribution studies, intravital microscopy showed that increasing the charge content from 10 to 50 mol % doubled the accumulation of liposomes in tumor vessels, suggesting a change in intratumor distribution; no significant effect of charge on interstitial accumulation could be detected, possibly attributable to spatial heterogeneity. Increased vascular accumulation of cationic liposomes was similar in two different tumor types and sites. Our results suggest that optimizing physicochemical properties of liposomes that exploit physiological features of tumors and control the intratumor distribution of these drug carriers should improve vascular-specific delivery.     

Bilateral pheochromocytoma associated with duodeno-jejunal GIST in patient with von Recklinghausen disease: report of a clinical case

The authors present the case of a 60-year-old male patient suffering from von Recklinghausen's disease (neurofibromatosis type I, NF1) with bilateral pheochromocytoma and occasional intraoperative reports of duodenojejunal GIST (GastroIntestinal Stromal Tumour). Through a review of the literature the authors analyze the frequency and the features of bilateral pheochromocytoma and its rare histological variant, the so-called composite pheochromocytoma, characterized by the combination of pheochromocytoma and ganglioneuroma or ganglioneuro-blastoma. Bilaterality of pheochromocytoma is more frequent in patients with familiarity for pheochromocytoma without NF1. Composite pheochromocytoma accounts for about 3% of total pheochromocytomas. In addition, the authors summarize the present knowledge about gastrointestinal stromal tumours and investigate the possible association between them and NF1 or pheochromocytoma, concluding that any such association is purely casual, while confirming the well known, genetically determined association between NF1 and pheochromocytoma.     

The role of antiplatelet therapy in the management of acute coronary syndromes

The benefit of aspirin use in the emergent care of acute coronary syndromes (ACS) has been well-established. Recent studies have further demonstrated the importance of antiplatelet therapy in the acute setting, primarily with the use of intravenous glycoprotein IIb/IIIa receptor inhibitors. Aspirin and the thienopyridines (ticlopidine and clopidogrel) are oral antiplatelet agents that interfere with platelet activation in complementary, but separate pathways. Combination therapy of aspirin with other antiplatelet agents has demonstrated a benefit for the management of ACS. This article reviews the pathophysiology of platelet activation in ACS, landmark trials regarding antiplatelet agents, and the current recommendations for the use of both intravenous and oral antiplatelet agents in the management of patients with ACS.     

Vocal fold augmentation by autologous fat injection with lipostructure procedure.

BACKGROUND: Fat is theoretically the ideal implant for vocal fold augmentation because it is soft, easily available and biocompatible. However, reabsorption is a frequent cause of long-term failure. OBJECTIVE: We prospectively tested Coleman's "lipostructure" technique used for facial recontouring in the treatment of glottic incompetence. STUDY DESIGN AND SETTING: Fourteen patients (aged 18-74 years, mean 48) with breathy dysphonia secondary to laryngeal hemiplegia (7) or anatomical defects (7) underwent vocal fold lipoinjection. Fat harvested by liposuction was centrifuged, and the fat cell layer injected into the vocalis muscle. The patients underwent pre- and postoperative videolaryngostroboscopy, maximum phonation time (MPT) measurements, GRBAS perceptual evaluations, and Voice Handicap Index (VHI) self-assessments. RESULTS: Voice quality improved soon after surgery and remained stable over 3-26 months (mean 10.6), being confirmed by the GRBAS, MPT and VHI evaluations ( P < 0.005). The results were best in the seven patients with paralytic dysphonia. CONCLUSION: Lipostructure is a valuable technique for voice rehabilitation in glottic incompetence.     

Resistance of human astrocytoma cells to apoptosis induced by mitochondria-damaging agents: possible implications for anticancer therapy

The success of anticancer chemotherapy is often hampered by resistance to apoptosis, which may depend on defects in intracellular cell death pathways. Characterizing the alterations of these pathways is a prerequisite for developing alternative and effective antitumoral strategies. Here, we investigated the susceptibility of a human astrocytoma cell line, ADF, to apoptotic cell death induced by mitochondria-damaging agents. Neither the anticancer agent betulinic acid nor the "mitochondriotropic" poisons 2-deoxy-d-ribose and potassium cyanide induced apoptosis of these cells, despite induction of highly significant mitochondrial depolarization, eventually resulting in necrotic death. Resistance to apoptosis was not due to presence of the multidrug resistance pump or to impaired expression of caspase-8, caspase-9, or "executioner" caspase-3. Cloning of caspase-9 revealed the presence of full-length caspase-9alpha and a short variant (caspase-9beta), which, in other tumors, acts as a dominant negative of the long isoform. All analyzed clones showed a point mutation in the prodomain region that is known to interact with mitochondria-released factors. Thus, in these human astrocytoma cells, mitochondria-damaging agents induce a regulated form of mitochondrial-dependent necrotic cell death (oncosis). Resistance to apoptosis is due to an intrinsic defect of caspase-9, leading to inhibition of enzyme activation and/or impaired interaction with proteins released from depolarized mitochondria. These results may have implications for developing strategies aimed at overcoming tumor resistance to chemotherapy.