Video-assisted thoracoscopic surgery for primary spontaneous pneumothorax: clinicopathological correlation.

OBJECTIVE: To compare the identifiable pulmonary abnormalities during thoracoscopy with the histological findings in patients requiring surgical intervention for recurrent or persistent primary spontaneous pneumothorax (PSP) and correlate these with the postoperative events. METHODS: From January 1999 to December 2002, 94 consecutive patients underwent video-assisted thoracoscopic wedge excision and apical pleurectomy for PSP. Vanderschueren's classification was used for macroscopic staging and histological observation for microscopic features. Clinical data of these patients and the outcome of surgery were described. RESULTS: All patients were successfully treated using video-assisted thoracoscopic technique. Recurrent pneumothorax was the most frequent indication for surgery, occurring in 60 cases. The method of management was stapling of an identified bleb or apex of the upper lobe and apical pleurectomy. In 67 cases (71%), clear bullae were found in types III and IV. In 15 cases (16%), type II pleuropulmonary adhesions were identified and in 12 (13%) cases thoracoscopy failed to reveal any abnormality (type I). The actual site of air leakage could be located during thoracoscopy in 24 (26%) patients. Histologically, 74 patients had subpleural bullae/blebs formation and 20 had emphysema without bullae. Fifty-three patients had cellular infiltration and 82 had pleural fibrosis. In the microscopic examination, the actual site of air leakage could be located at the site of subpleural blebs or bullae in 15 patients and elsewhere at the lung surface in five other patients. Postoperative prolonged air leak occurred in 4 out of 12 patients in type I and in two of the remaining patients, p=0.001. Mean follow-up is 48 months (range, 30-60 months) for all patients. Pneumothorax recurred in three patients (3.1%). Two patients from type I (16.6%) and one patient from the other types (1.2%) had recurrence (p=0.01). CONCLUSIONS: Video-assisted thoracoscopic stapling of an identified bleb or apex of the upper lobe and apical pleurectomy represents the standard treatment for the majority of recurrent or persistent PSP. Most patients with surgically treated PSP have subpleural blebs or bullae or isolated emphysema. In type I cases, simple apical excision and apical pleurectomy are not sufficient and perhaps additional talc poudrage might be indicated.     

Stress-hyperglycemia,insulin and immunomodulation in sepsis

Stress-hyperglycemia and insulin resistance are exceedingly common in critically ill patients, particularly those with sepsis. Multiple pathogenetic mechanisms are responsible for this metabolic syndrome; however, increased release of pro-inflammatory mediators and counter-regulatory hormones may play a pivotal role. Recent data suggests that hyperglycemia may potentiate the pro-inflammatory response while insulin has the opposite effect. Furthermore, emerging evidence suggests that tight glycemic control will improve the outcome of critically ill patients. This paper reviews the pathophysiology of stress hyperglycemia in the critically ill septic patient and outlines a treatment strategy for the management of this disorder.     

Bifurcation of brachial artery into a common radial–interosseous trunk and superficial ulnar artery: a rare variation

Variations in the branching pattern of brachial artery and abnormal course of its branches are not uncommon. The present article describes a case of bifurcation of the brachial artery into a common radial–interosseous trunk and superficial ulnar artery. The embryological basis behind the present case report could be, the radial artery establishing a connection with the axis artery just below the level of origin of ulnar artery, the posterior interosseous artery arising from the axis artery distal to the origin of the radial artery. The part of axis artery between origin of ulnar and radial artery must have developed into the common radial–interosseous trunk. The part of axis artery between origin of radial and posterior interosseous arteries develops as the common interosseous artery. The superficial position of ulnar artery could enable the surgeons in raising a free ulnar forearm flap for head and neck reconstructive surgeries.     

Effects of neem limonoids on the malaria vector Anopheles stephensi Liston (Diptera: Culicidae)

The effects of the neem (Azadirachta indica A. Juss) limonoids azadirachtin, salannin, deacetylgedunin, gedunin, 17-hydroxyazadiradione and deacetylnimbin on Anopheles stephensi Liston (Diptera: Culicidae) were investigated. In exploring advantages of pure neem limonoids, we studied the larvicidal, pupicidal, adulticidal and antiovipositional activity of neem limonoids. Azadirachtin, salannin and deacetylgedunin showed high bioactivity at all doses, while the rest of the neem limonoids were less active, and were only biologically active at high doses. Azadirachtin was the most potent in all experiments and produced almost 100% larval mortality at 1 ppm concentration. In general, first to third larval instars were more susceptible to the neem limonoids. Neem products may have benefits in mosquito control programs.     

Stenting versus aggressive medical therapy for intracranial arterial stenosis: more harm than good

EXPANDED ABSTRACT: CITATION: Chimowitz MI, Lynn MJ, Derdeyn CP, Turan TN, Fiorella D, Lane BF, Janis LS, Lutsep HL, Barnwell SL, Waters MF, Hoh BL, Hourihane JM, Levy EI, Alexandrov AV, Harrigan MR, Chiu D, Klucznik RP, Clark JM, McDougall CG, Johnson MD, Pride GL Jr, Torbey MT, Zaidat OO, Rumboldt Z, Cloft HJ, for the SAMMPRIS Trial Investigators. N Engl J Med 2011, 365:993-1003. PubMed PMID: 21899409. This is available on http://www.pubmed.gov. BACKGROUND: Atherosclerotic intracranial arterial stenosis is an important cause of stroke that is increasingly being treated with percutaneous transluminal angioplasty and stenting (PTAS) to prevent recurrent stroke. However, PTAS has not been compared with medical management in a randomized trial. METHODS: Objective: To determine whether intracranial stenting (using the Wingspan self-expanding nitinol stent, Boston Scientific) and intensive medical therapy is superior to intensive medical therapy alone for preventing stroke in recently symptomatic patients with severe intracranial atherosclerotic stenosis.Design: Phase III, multi-center, randomized, open label, clinical trial.Setting: 50 sites in the USSubjects: Patients who had a recent transient ischemic attack or stroke attributed to stenosis of 70 to 99% of the diameter of a major intracranial artery.Intervention: Eligible patients were randomized to receive either aggressive medical medical management alone or aggressive medical management plus PTAS with the use of the Wingspan stent system.Outcomes: The primary end point was stroke or death within 30 days after enrollment or after a revascularization procedure for the qualifying lesion during the follow-up period or stroke in the territory of the qualifying artery beyond 30 days. Patients in the medical arm who undergo angioplasty for recurrent TIAs (i.e. crossovers) and who have a stroke or death within 30 days will also meet this endpoint. RESULTS: Of the 451 patients who underwent randomization, 227 were assigned to the medical management group and 224 to the PTAS group. The 30-day rate of stroke or death was 14.7% in the PTAS group (nonfatal stroke, 12.5%; fatal stroke, 2.2%) and 5.8% in the medical-management group (nonfatal stroke, 5.3%; non-stroke-related death, 0.4%) (P = 0.002). Beyond 30 days, stroke in the same territory occurred in 13 patients in each group. The probability of the occurrence of a primary end-point event over time differed significantly between the two treatment groups (P = 0.009), with 1-year rates of the primary end point of 20.0% in the PTAS group and 12.2% in the medical-management group. CONCLUSIONS: In patients with intracranial arterial stenosis, aggressive medical management was superior to PTAS with the use of the Wingspan stent system, both because the risk of early stroke after PTAS was high and because the risk of stroke with aggressive medical therapy alone was lower than expected.