Surgical management of tuberculosis-related hemoptysis

Background

Tuberculosis is a disease that is often treated with chemotherapy. However, medical treatment usually fails in the management of tuberculosis-related hemoptysis. In this paper, we review our experience in the surgical treatment of tuberculosis-related hemoptysis.

Methods

Fifty-nine patients with tuberculosis-related hemoptysis (46 men, 13 women) who underwent surgical treatment were enrolled in this study. A thoracotomy was performed urgently in 21 patients with massive (>600 mL daily) hemoptysis, and within the first 2 days in 24 with major (200 to 600 mL daily) hemoptysis, and within the first 4 days in 14 with persistent minor (<200 mL daily) hemoptysis.

Results

A chest roentgenogram showed cavitary lesion in all of the patients with massive hemoptysis (21 patients), in 22 of 24 patients with major hemoptysis, and in 3 of 14 patients with persistent minor hemoptysis. Pneumonectomy was performed in 4 patients, lobectomy in 39 patients, and segmentectomy or wedge resection in 16 patients. The average hospitalization period was 13 days. The mortality rate was 6.8% perioperatively. Of the patients deceased, 3 were intubated with a single-lumen endotracheal tube and 1 with a double-lumen endotracheal tube. During the postoperative period, empyema and bronchopleural fistula developed in 3 patients, and no other severe complications occurred. The average postoperative follow-up period was 3 years. The number of thoracotomies for tuberculosis performed in the years from 1995 to 2003 was significantly decreased, compared with the years between 1985 to 1994 (p = 0.042).

Conclusions

In tuberculosis-related hemoptysis, thoracotomy with double-lumen endotracheal intubation and resection of the cavity may be curative and lifesaving.     

Prospective, Randomized, Placebo-controlled Study of the Effect of TENS on Postthoracotomy Pain and Pulmonary Function

We investigated the efficacy of transcutaneous electrical nerve stimulation (TENS) for postthoracotomy pain control in a prospective, randomized, double-blind, placebo-controlled study. We studied two groups of patients undergoing posterolateral thoracotomy. In group 1, TENS was used postoperatively on 60 patients for 5 days. Group 2 contained 56 patients without TENS. In both groups a visual analog scale (VAS) was used to indicate if analgesia was needed. When the VAS was higher than 4, an analgesic was administered. We observed the forced expiratory volume in 1 second (FEV₁), the forced vital capacity (FVC), partial arterial oxygen pressure (PaO₂), partial arterial carbon dioxide pressure (PaCO₂), and how many doses of analgesia were given at postoperative 0 (extubation time), 2, 6, 12, 24, 48, 72, and 120 hours. TENS was not employed in patients with cardiac or neurologic disease. In group 1, TENS reduced the need to administer opioids during the 5-day postoperative period. This result is statistically significant (P = 0.013). Additionally, following the sixth postoperative hour, TENS increased the spirometric breath function. The FEV₁, FVC, and PaO₂ were high and PaCO₂ was low when the first group is compared to the second. All these results are statistically significant (P = 0.012, P = 0.01, P = 0.024, and P = 0.02 respectively). We observed that TENS produced no evidence of side effects or intolerance in the patients of group 1. TENS is thus beneficial for pain relief following thoracotomy and has no side effects. Consequently, the routine use of TENS following thoracic surgery is recommended.     

Delirium and extrapyramidal symptoms due to a lithium-olanzapine combination therapy: a case report

We report an elderly patient who developed severe delirium and extrapyramidal signs after initiation of lithium-olanzapine combination. On hospital admission, serum levels of lithium were found to be 3.0 mM/L which were far above toxic level. Immediate discontinuation of both drugs resulted in complete resolution of most of the symptoms except for perioral dyskinesia which persisted for three more months. We critically discussed the differential diagnosis of lithium intoxication and assessed confounding factors which induce delirium and extrapyramidal signs related with combination therapy of lithium and olanzapine.     

Antioxidant properties of propofol and erythropoietin after closed head injury in rats

Reactive oxygen species play a role during brain injury due to closed head trauma. Enzymatic or nonenzymatic antioxidants may protect brain tissue against oxidative damage. The present study was performed to assess the changes of endogenous indices of oxidative stress in serum from rats subjected to head trauma and whether treatment with propofol and/or erythropoietin (EPO) modifies the levels of endogenous indices of oxidative stress. For these purposes, female Wistar Albino rats were divided into five groups: non-traumatic sham group, trauma performed control, trauma with propofol (i.p.), trauma with EPO (i.p.) and trauma with propofol and EPO performed study groups. At the end of the experimental procedure, blood was taken by cardiac puncture to determine superoxide dismutase (SOD) and xanthine oxidase (XO) activities as well as malondialdehyde (MDA) and nitric oxide (NO) levels in serum. Serum MDA level of control traumatic brain injury (TBI) group was significantly higher than sham operation group (p<0.012). Serum MDA levels in propofol, EPO and propofol+EPO groups were found to be decreased in comparison with control group (p<0.039, p<0.030 and p<0.018, respectively). Serum NO level was found to be increased in TBI group, but difference was not statistically significant when compared to sham-operated group (p=0.092). Propofol, EPO and propofol+EPO administration efficiently reduced serum NO levels to reach sham-operated group (p<0.002, p<0.001 and p<0.015, respectively). These results suggested that acute administration of both propofol and EPO altered the indices of oxidative stress similarly against brain injury due to trauma.     

Diffusion-weighted and conventional MR imaging in neurotrichinosis

Central nervous system involvement in trichinosis is not rare. Brain lesions in trichinosis have been defined on computed tomography and magnetic resonance imaging (MRI) as multifocal small lesions located in the cerebral cortex and white matter. We present a case of trichinosis with multifocal lesions of the brain detected by MRI and diffusion weighted MRI. Evolutions of these lesions from acute through chronic stages on follow up studies are also presented. This is the first report describing sequential MRI findings and diffusion weighted imaging appearance of brain lesions in trichinosis. Sequential evaluation of conventional and diffusion MR data allowed us to conclude that multifocal lesions in the brain were related to multiple infarctions rather than true inflammatory infiltration of the brain parenchyma.     

Brain abscess and cystic brain tumor: discrimination with dynamic susceptibility contrast perfusion-weighted MRI

Differentiating between brain abscesses and cystic brain tumors such as high-grade gliomas and metastases is often difficult with conventional MRI. The goal of this study was to evaluate the diagnostic utility of perfusion MRI to differentiate between these pathologies. MRI was performed in 19 patients with rim-enhancing brain lesions (4 pyogenic abscesses, 8 high-grade gliomas, 7 metastases). In addition to standard MR sequences, trace diffusion-weighted MRI with apparent diffusion coefficient (ADC) maps and perfusion-weighted MRI by using a first-pass gadopentetate dimeglumine T2*-weighted gradient echo single-shot echo-planar sequence were performed. Relative cerebral blood volume (rCBV) ratios were obtained via the values of the capsular portions of the lesions and the normal white matter. All the abscesses had markedly hyperintense signals in trace diffusion images, whereas they had significant hypointense signals in ADC images. In perfusion-weighted images, the capsular portions of the abscesses demonstrated low colored areas compared with the normal white matter and the rCBV ratio calculated was 0.76 +/- 0.12 (mean +/- SD). All but two of the cystic tumors showed low signal intensity on trace diffusion-weighted images and high signal intensity on ADC maps. Hyperintense signal was found in two brain tumors mimicking brain abscesses on trace diffusion images. The rCBV values in high-grade gliomas and metastases were 5.51 +/- 2.08 and 4.58 +/- 2.19, respectively. The difference between abscesses and cystic tumors was statistically significant (P = 0.003). Perfusion MRI may allow the differentiation of pyogenic brain abscess from cystic brain tumors, making it a strong additional imaging modality in the early diagnosis of these two entities.     

The prevalence of stress urinary incontinence among women operated on for abdominal wall hernias

The high co-occurrence of an abdominal wall hernia (AWH) and stress urinary incontinence (SUI) suggests that there is a common factor in the etiopathogenesis of these disorders in these patients.     

Immunohistochemical detection of 1,25-dihydroxyvitamin D receptor in rat vaginal epithelium

OBJECTIVE: To determine the distribution of 1,25-dihydroxyvitamin D receptor (VDR) in rat vaginal epithelium during the estrus cycle and in ovariectomized rats. DESIGN: Animal study performed in two groups of rats. The expression of VDR was examined in the first group during the estrous cycle and in the second group after ovariectomy. SETTING: University animal laboratory. ANIMAL(S): Balb/c female rats. INTERVENTION(S): Vaginas were removed and processed for immunohistochemical analysis. MAIN OUTCOME MEASURE(S): We recorded the localization, distribution, and expression of VDR in vaginal epithelium during the rat estrus cycle and in ovariectomized rats. RESULT(S): In cyclic rats, VDR was detected in basal and suprabasal cells during all of the cycle periods. In apical cells, VDR was positive in diestrus and estrus but negative in proestrous. In ovariectomized rats, VDR was not detected in any layers of vaginal epithelium. CONCLUSION(S): In vaginal epithelium, the presence of VDR was shown by using immunohistochemical techniques. During the estrous cycle, VDR has an important role in the proliferation and differentiation of vaginal squamous epithelium that is similar to the effects of estrogen.     

Dose-dependent activation of Ca2+-activated K+ channels by ethanol contributes to improved endothelial cell functions

BACKGROUND: Regular moderate alcohol (EtOH) intake seems to protect against both coronary artery disease and ischemic stroke, whereas the risk increases with heavy EtOH consumption. Effects of EtOH on endothelial cell function may be relevant to these disparate effects. Potassium channels play an important role in the regulation of endothelial cell functions. Therefore, we investigated whether Ca-activated K channels (BKCa) are modulated by EtOH. Furthermore, we examined whether EtOH-induced changes of endothelial nitric oxide (NO) formation and cell proliferation are due to BKCa activation. METHODS: The patch-clamp technique was used to investigate BKCa activity in cultured human umbilical vein endothelial cells (HUVEC). NO formation was analyzed by using the fluorescence dye 4,5-diaminofluorescein. Endothelial proliferation was examined by using cell counts and measuring [H]thymidine incorporation. RESULTS: EtOH dose-dependently (10-150 mmol/liter) modulated BKCa-activity, with the highest increase of open-state probability at a concentration of 50 mmol/liter (n = 13; p < 0.05). Inside-out recordings revealed that this effect was due to direct BKCa activation, whereas open-state probability was not changed in cell-attached recordings after pertussis toxin preincubation. EtOH (10 and 50 mmol/liter) caused a significant increase of NO levels, which was blocked by the highly selective BKCa inhibitor iberiotoxin (100 nmol/l; n = 30; p < 0.05). Higher concentrations of EtOH (100 and 150 mmol/liter) significantly reduced NO synthesis (n = 30; p < 0.05). Both methods revealed a significant increase of HUVEC proliferation, which was inhibited by iberiotoxin (n = 30; p < 0.05). At a concentration of 150 mmol/liter, EtOH caused a significant reduction of endothelial proliferation. CONCLUSIONS: EtOH directly activates BKCa in HUVEC, leading to an increase of endothelial proliferation and production of NO. These results indicate a possible beneficial effect of low-dose EtOH on endothelial function, whereas higher concentrations must be considered as harmful.