The results of treatment of complicated pleural empyema with VATS combined with the use of fibrinolytic agents

ObjectivesThis study summarizes the effects of treatment of complicated PE.MethodsIn the period of 2004–2010, 11 children with PE aged 1–19 needed surgical treatment. Before having been referred to our department, all children were managed for sustained pneumonia by local pediatricians using broad-spectrum antibiotics. Next, children were ineffectively treated in general hospitals using conventional pleural drainages maintained for 1 week to 2 months.ResultsIn 7 cases, a single video-assisted thoracoscopy (VATS), debridement, placement of pleural tubes under visual control, active suction drainage, and rehabilitation resulted in lung expansion, efficient ventilation, rapid relief of symptoms, and full recovery. Starting from the 2nd post-operative day, all children received fibrinolytics 3–6 times via chest tubes. In 3 patients, lack of lung expansion made the second VATS debridement necessary. In 1 patient in organizing stage of PE, re-VATS was supported by mini-thoracotomy allowing effective decortication and lung expansion. The average hospitalization time was 17 days. Surprisingly, even in the most neglected patients of our group, the follow-up CT scans done 3–4 months after discharge, were almost uneventful. The majority of spirometric parameters normalized within 6 months, and no child claimed dyspnoe due to physical strain.ConclusionsEarly VATS combined with early rehabilitation offers excellent results, radically improving the outcome in both the fibrinopurulent, as well as in organizing stages of PE in children, nonetheless surgeon should be experienced in the minimally invasive technique. The method seems to be successful even in very neglected cases, if not, patient could benefit from fibrinolytic therapy.     

Temporal complexity of repolarization and mortality in patients with implantable cardioverter defibrillators

Increased repolarization variability has been observed in various cardiac conditions. However, data on its relation to heart rate variability and on its value in predicting adverse outcomes in high risk patients are limited. Forty-seven patients with decreased left ventricular function and ICDs had high resolution 10-minute ECG recordings and were followed for 781 +/- 258 days (mean +/- SD) on average. The interval from the R peak to the T wave peak with maximum amplitude (RTmax) and from the R peak to the T wave offset (RToff) were determined automatically on a beat-to-beat basis. Temporal beat-to-beat RTmax and RToff variability were analyzed using traditional summary statistics, a complexity measure (approximate entropy [ApEn]), and the short-term scaling exponent (alpha1). Eight (17%) patients died and 16 (34%) patients experienced death/appropriate ICD shock during follow-up. RTmax-ApEn was significantly higher in patients who died compared with patients who survived (1.24 +/- 0.13 vs 1.01 +/- 0.21, respectively, P=0.008). When RTmax-ApEn was tested together with the alpha1 of the RR intervals, occurrence of ventricular arrhythmias before ICD implantation, and beta-blockers usage in the Cox regression analysis, it still independently predicted mortality; hazard ratio=3.36 (1.28-8.83, 95% CI, P=0.014) for every 0.10-increase in RTmax-ApEn. None of the repolarization variability parameters independently predicted death/appropriate ICD shocks. Increased temporal complexity of repolarization (RTmax-ApEn) independently predicts mortality in ICD patients.     

Granulomatosis With Polyangiitis in Otolaryngologist Practice: A Review of Current Knowledge

Granulomatosis with polyangiitis (GPA) is an idiopathic vasculitis of medium and small arteries, characterized by necrotizing granulomatous inflammation. GPA typically affects upper and lower respiratory tract with coexisting glomerulonephritis. This disease is generally characterized by antineutrophil cytoplasm antibodies (ANCA), nevertheless, there are rare cases with negative ANCA. GPA affects people at any age, with predominance of the sixth and seventh decade of life. In 80%–95% of the patients the first symptoms of GPA are otorhinolaryngological manifestations of head and neck including nose/sinuses, ears, eyes, larynx/trachea, oral cavity, and salivary glands. Diagnosis of GPA is based on Criteria of the American College of Rheumatology. In clinical practice diagnosis, the presence of distinctive ANCA antibodies and biopsy of affected organ are crucial. GPA must be differentiated from neoplastic, infectious or inflammatory ulcerative lesions of the head and neck. The standard treatment procedure is divided into two essential phases, induction and maintenance. The induction phase is based on combination of systemic corticosteroid and immunosuppressant therapy, whereas the maintenance phase comprises corticosteroids and azathioprine/methotrexate supplementation. Surgical treatment ought to be considered for patients who are not responding to pharmacotherapy.     

Bilateral endogenous fungal endophthalmitis

Endogenous endophthalmitis is a rare and severe intraocular infection which can be vision-threatening. We describe a case of bilateral fungal endogenous endophthalmitis in a 64-year-old male which was successfully treated with systemic administration of fluconazole followed by pars plana vitrectomy with an intravitreous injection of amphotericin B.     

Multifractality, sample entropy, and wavelet analyses for age-related changes in the peripheral cardiovascular system: preliminary results

Using signal processing measures we evaluate the effect of aging on the peripheral cardiovascular system. Laser Doppler flowmetry (LDF) signals, reflecting the microvascular perfusion, are recorded on the forearm of 27 healthy subjects between 20-30, 40-50, or 60-70 years old. Wavelet-based representations, H?lder exponents, and sample entropy values are computed for each time series. The results indicate a possible modification of the peripheral cardiovascular system with aging. Thus, the endothelial-related metabolic activity decreases, but not significantly, with aging. Furthermore, LDF signals are more monofractal for elderly subjects than for young people for whom LDF signals are weakly multifractal: the average range of Holder exponents computed with a parametric generalized quadratic variation based estimation method is 0.13 for subjects between 20 and 30 years old and 0.06 for subjects between 60 and 70 years old. Moreover, the average mean sample entropy value of LDF signals slightly decreases with age: it is 1.34 for subjects between 20 and 30 years old and 1.19 for subjects between 60 and 70 years old. Our results could assist in gaining knowledge on the relationship between microvascular system status and age and could also lead to a more accurate age-related nonlinear modeling.     

Volume-of-change cone-beam CT for image-guided surgery

C-arm cone-beam CT (CBCT) can provide intraoperative 3D imaging capability for surgical guidance, but workflow and radiation dose are the significant barriers to broad utilization. One main reason is that each 3D image acquisition requires a complete scan with a full radiation dose to present a completely new 3D image every time. In this paper, we propose to utilize patient-specific CT or CBCT as prior knowledge to accurately reconstruct the aspects of the region that have changed by the surgical procedure from only a sparse set of x-rays. The proposed methods consist of a 3D-2D registration between the prior volume and a sparse set of intraoperative x-rays, creating digitally reconstructed radiographs (DRRs) from the registered prior volume, computing difference images by subtracting DRRs from the intraoperative x-rays, a penalized likelihood reconstruction of the volume of change (VOC) from the difference images, and finally a fusion of VOC reconstruction with the prior volume to visualize the entire surgical field. When the surgical changes are local and relatively small, the VOC reconstruction involves only a small volume size and a small number of projections, allowing less computation and lower radiation dose than is needed to reconstruct the entire surgical field. We applied this approach to sacroplasty phantom data obtained from a CBCT test bench and vertebroplasty data with a fresh cadaver acquired from a C-arm CBCT system with a flat-panel detector. The VOCs were reconstructed from a varying number of images (10-66 images) and compared to the CBCT ground truth using four different metrics (mean squared error, correlation coefficient, structural similarity index and perceptual difference model). The results show promising reconstruction quality with structural similarity to the ground truth close to 1 even when only 15-20 images were used, allowing dose reduction by the factor of 10-20.     

Increased concentration of serum TNF alpha and its correlations with arterial blood pressure and indices of renal damage in dogs infected with Babesia canis

Canine babesiosis is a tick-borne disease caused by parasites of the genus Babesia. Tumour necrosis factor alpha (TNF-α) is a cytokine that plays a role in the pathogenesis of canine babesiosis. In this study, the authors determined the concentration of serum TNF-α in 11 dogs infected with Babesia canis and calculated Spearman’s rank correlations between the concentration of TNF-α and blood pressure, and between TNF-α and indices of renal damage such as: fractional excretion of sodium (FE(Na⁺)), urinary creatinine to serum creatinine ratio (UCr/SCr), renal failure index (RFI), urine specific gravity (USG) and urinary protein to urinary creatinine ratio (UPC). The results demonstrated statistically significant strong negative correlations between TNF-α and systolic arterial pressure (r?=??0.7246), diastolic arterial pressure (r?=??0.6642) and mean arterial pressure (r?=??0.7151). Serum TNF-α concentration was also statistically significantly correlated with FE(Na⁺) (r?=?0.7056), UCr/SCr (r?=??0.8199), USG (r?=??0.8075) and duration of the disease (r?=?0.6767). The results of this study show there is an increase of serum TNF-α concentration during canine babesiosis, and the increased TNF-α concentration has an influence on the development of hypotension and renal failure in canine babesiosis. This probably results from the fact that TNF-α is involved in the production of nitric oxide and induction of vasodilation and hypotension, which may cause renal ischaemia and hypoxia, and finally acute tubular necrosis and renal failure.     

Increased serum urea to creatinine ratio and its negative correlation with arterial pressure in canine babesiosis

The increase of the serum urea to creatinine ratio (UCR) was observed in dogs infected with Babesia canis. Previous studies have suggested that decrease of blood pressure can be one of the reasons for this phenomenon. In this work statistically significant increase of the UCR was observed in dogs with babesiosis. Comparison of the UCR between 23 azotaemic dogs and 25 non-azotaemic dogs infected with Babesia canis showed statistically significantly higher mean of the UCR in azotaemic dogs. Correlations between UCR and systolic, diastolic and mean arterial pressure (SAP, DAP and MAP) in 48 dogs infected with B. canis were negative (UCR and SAP: r = ?0.3909; UCR and DAP: r = ?0.3182; UCR and MAP: r = ?0.3682) and statistically significant (p < 0.05). This result may indicate contribution of hypotension in the increase of the UCR in canine babesiosis. However, the correlations were not high, and there was no statistically significant correlation between UCR and arterial pressures in azotaemic dogs. Thus, it seems that decrease of blood pressure in dogs with babesiosis explains only partially the cause of increased UCR in infected dogs. The other authors suggested hyperureagenesis and myocardial injury as a potential reason for the increased UCR in canine babesiosis. Thus, further studies are needed to determine causes of increased UCR in dogs with babesiosis, especially on the connection between UCR changes and the concentrations of plasma cardiac troponins and ammonia, and the occurrence of occult blood on fecal examination.