Efficacy and safety of topical application of human fibrinogen/thrombin-coated collagen patch (TachoComb) for treatment of air leakage after standard lobectomy.

OBJECTIVES: Persisting air leakage after pulmonary resection remains a significant problem. The aim of the study was to evaluate the incidence of air leakage after standard lobectomy and test the efficacy and safety of TachoComb (TC). METHODS: A total of 189 patients undergoing lobectomy were enrolled in a multi-centre, open, randomised, and prospective study to test the efficacy and safety of TachoComb (TC) for air leakage treatment. Air leakage was assessed by water submersion test, and scored as grades 0 if no, 1 if countable, 2 if a stream of and 3 if coalescent bubbles have been observed. Any sites with grade 3 air leakage received further stapling or limited suturing until grade 0, 1 or 2 was obtained. Treatment of air leakage was done with TC or suturing according to randomisation. Air leakage was assessed by further submersion tests. Postoperative air leakage was assessed using the Pleur-Evac system. RESULTS: Overall incidence of air leakage 48+/-6 h after surgery was 34% for TC and 37% for standard treatment (P=0.76). The reduction of intra-operative air leak intensity in the subgroup with grades 1-2 was significantly higher for the TC group (P=0.015). Postoperative air leakage intensity in the subgroup with air leakage grades 1-2 was lower for TC than standard treatment (P=0.047). The mean duration of postoperative air leakage in the subgroup with grades 1-2 was shorter for the TC group than for standard treatment, i.e. 1.9+/-1.4 vs. 2.7+/-2.2 days (P=0.015). CONCLUSIONS: TC could be proven as well-tolerated and safe. In the subgroup of patients with established air leakage, TC showed superior potential in reduction of intra-operative air leakage as well as in reduction of intensity and duration of postoperative air leakage.     

Location and morphology of chloride cells during the post-embryonic development of the european sea bass,Dicentrarchus labrax

Location and morphology of chloride cells were studied in the sea bass ( Dicentrarchus labrax) from hatching to the juvenile stage to determine the development of the adult osmoregulatory function as seen in adult fish. During the studied developmental sequence changes were observed in the location, number, size and structure of these cells, that were studied by microscopy (light, scanning electron, transmission electron and confocal) and immunocytochemistry. Chloride cells were found on the tegument and on the gills. They were present on the tegument already at hatching, before the development of the gills. Their density as well as their association in multicellular complexes decreased during the postembryonic development. In old larvae and in juveniles, cutaneous chloride cells were associated with the fins, the developing scales and the lateral line. Gills developed gradually during the prelarval stage and the gill arches were present at mouth opening. At that time chloride cells were already numerous on the gill arches. In older larvae, during the progressive development of the gill filaments, chloride cells were numerous on these structures and formed multicellular complexes. Several stages in the differentiation of these cells were studied, including the development of the tubulovesicular system at the end of the prelarval stage, as well as the stratification appearance of the cytoplasm that was concomitant with the considerable development of the tubular system and its association with the endoplasmic reticulum during the larval period. The involvement of different epithelia in the osmoregulatory process during the postembryonic development of this species, as well as the role of chloride cells during successive developmental stages, is discussed.     

Arthrodesis of the first metatarsophalangeal joint: The “when and how”

Arthrodesis of the first metatarsophalangeal (MTP) joint has been established as the “gold standard” for the treatment of several first ray disorders, due to its perceived efficacy and the consistently reported good results in the literature. Arthrodesis is a commonly performed procedure for the treatment of end stage arthritis, rheumatoid arthritis with severe deformity, selected cases of severe hallux valgus (with or without signs of degenerative joint disease), as well as a salvage procedure after failed previous operation of the first ray. The goals of a successful 1^st MTP arthrodesis are pain alleviation and deformity correction in order to restore a comfortable gait pattern and to improve shoe wear. Several techniques have been reported with several proposals regarding the preparation of the articular surfaces and the method of definitive fixation. As with any given surgical procedure, various complications may occur after arthrodesis of the 1^st MTP joint, namely delayed union, nonunion, malunion, irritating hardware, etc.      

Buttressing the staple line in lung volume reduction surgery: a randomized three-center study

Background. The intention of buttressing the staple line in lung volume reduction surgery is to reduce air leaks and to shorten the hospital stay. A randomized three-center study was carried out to test this hypothesis.

Methods. Sixty-five patients with a mean age of 59.2 ± 1.2 years underwent bilateral lung volume reduction surgery by video-assisted thoracoscopy using endoscopic staplers (ET 45B; Ethicon Endo-Surgery, Cincinnati, OH) either without or with bovine pericardium for buttressing (Peri-Strips Dry; Bio-Vascular, Inc, Saint Paul, MN). There were no differences between the control and treatment groups in lung function, degree of dyspnea, and arterial blood gases before and 3 months after LVRS.

Results. Seven patients (3 in the treatment group) needed a reoperation because of persistent air leak. The median duration of air leaks was shorter in the treatment group (0.0 day [range, 0 to 28 days versus 4 days [range, 0 to 27 days); p < 0.001), confirmed by a shorter median drainage time in this group (5 days [range, 1 to 35 days] versus 7.5 days [range, 2 to 29 days); p = 0.045). Hospital stay was comparable between the two groups (9.5 days [range, 6 to 44 days] versus 12.0 days [range, 5 to 46 days]; p = 0.14).

Conclusions. Buttressing the staple line significantly shortens the duration of air leaks and the drainage time. As hospital stay did not differ significantly between the two groups, cost-effectiveness may depend on the local situation.     

Nasogastric aspiration/lavage in patients with gastrointestinal bleeding: a review of the evidence

Introduction: The usefulness of nasogastric aspiration and nasogastric lavage in patients with gastrointestinal bleeding is controversial, as evidenced by conflicting recommendations, both among and within society guidelines.

Areas covered: Considering these controversies, we reviewed the evidence regarding the following questions: 1) Can nasogastric lavage stop or slow down the bleeding and improve subsequent endoscopic visualization? 2) Is nasogastric aspiration helpful for the localization of bleeding? 3) Can nasogastric aspiration identify high risk patients that might benefit from earlier endoscopy? 4) Is there evidence for benefit in terms of outcomes from using nasogastric aspiration? 5) Is nasogastric intubation safe in patients with possible esophageal varices? Our review was conducted according to PRISMA guidelines.

Expert commentary: Based on the available literature, nasogastric lavage or aspiration cannot be routinely recommended unless a large properly designed randomized trial (which is currently lacking) proves otherwise. It is a painful and time-consuming procedure with no demonstrated benefit for the patient in terms of outcomes. Other clinical and laboratory parameters, and risk scores, are less invasive and are effective for guiding the stratification and management of patients, while pre-endoscopic erythromycin infusion is a good if not better alternative for improving visualization of the stomach.     

Tracheo?sophageale Fistel

Congenital deformities, various forms of trauma, foreign bodies, granulomatous infection and tumors are the most common causes of tracheoesophageal fistulas. This is a rare but life-threatening complication with mortality rates up to 60% due to chronic aspiration and innominate artery arrosion and bleeding. Bronchoscopy should be done promptly if a fistula is suspected, followed by esophagoscopy. Radiologic examinations are only helpful for operational planning. Surgical treatment is mandatory for benign fistulas with excellent short-term and long-term results. However, for malignant fistulas the survival time is often only weeks to months and are best treated by palliative stenting, which offers a short-term improvement in the quality of life.     

Are computational applications the “crystal ball” in the IVF laboratory? The evolution from mathematics to artificial intelligence

Mathematics rules the world of science. Innovative technologies based on mathematics have paved the way for implementation of novel strategies in assisted reproduction. Ascertaining efficient embryo selection in order to secure optimal pregnancy rates remains the focus of the in vitro fertilization scientific community and the strongest driver behind innovative approaches. This scoping review aims to describe and analyze complex models based on mathematics for embryo selection, devices, and software most widely employed in the IVF laboratory and algorithms in the service of the cutting-edge technology of artificial intelligence. Despite their promising nature, the practicing embryologist is the one ultimately responsible for the success of the IVF laboratory and thus the one to approve embracing pioneering technologies in routine practice. Applied mathematics and computational biology have already provided significant insight into the selection of the most competent preimplantation embryo. This review describes the leap of evolution from basic mathematics to bioinformatics and investigates the possibility that computational applications may be the means to foretell a promising future for the IVF clinical practice.     

Pattern of sensitization to honeybee venom in beekeepers: a 5-year prospective study.

Beekeepers are at increased risk for honeybee (Hb) venom allergy and they represent a unique population for Hymenoptera venom studies. The aim of this was to prospectively examine the pattern of Hb venom sensitization over a 5-year period in new beekeepers and define possible predisposing factors. Thirty-five beekeepers were tested every 6 months for 5 years with in vivo and in vitro methods to detect the possible development of sensitization to Hb and common wasp (Cw) venom. Inclusion criteria included the lack of previous beekeeping activity and absence of sensitization or reported reaction to Hymenoptera stings. Subjects with both in vivo and in vitro tests that were definitely positive or with one definitely positive and the other doubtful were considered sensitized. Ten of 35 new beekeepers (28.6%) and 3 of 36 controls (8.3%) developed sensitivity to Hb venom during the 5-year period. The risk ratio in incidence studies was calculated at 3.43 (SE of log risk ratio = 0.61; 95% CI of risk ratio = 1.03-11.42). All sensitized beekeepers were detected within the first 18 months of occupational exposure; 8 of 10 (80%) beekeepers were detected during the initial 12 months and the 2 remaining beekeepers were detected between 12 and 18 months. One of 35 (2.9%) beekeepers and 1 of 36 controls (2.8%) were sensitized to Cw venom. The number of stings per year and atopy had no effect on sensitization rate. Although predisposing factors to sensitization or anaphylaxis could not be identified, beekeepers developed sensitization to bee venom in <18 months.     

Surgery for pulmonary aspergilloma and pleural aspergillosis

Pulmonary aspergilloma and pleural aspergillosis are a potentially lifethreatening disease resulting from the colonization of lung or pleural cavities by the ubiquitous fungus Aspergillus fumigatus. Twenty four patients with pulmonary aspergilloma and five with pleural aspergillosis underwent major thoracic procedures at our hospital between 1976 and 1986. Fourteen of the patients had haemoptysis, in 9 it was recurrent, and in 5 life-threatening. Tuberculosis, pneumonia, and sarcoidosis were the most common preexisting lung lesions. Surgical procedures included 7 pleuropneumonectomies, 18 lobectomies and 4 wedge resections. The postoperative mortality rate was approximately 7% (2 pat.). Based on the pathological examination 4 patients had unexpectedly a bronchial carcinoma in addition to the aspergilloma. Bronchopleural fistula with persistent air space was a serious complication only for patients after pleuropneumonectomy. 23 patients including those with complex aspergilloma and pleural infection had no postoperative complications; in none of the 27 operative survivors were there any recurrent symptoms over a follow-up between one and ten years. Good-risk patients with documented aspergilloma, even asymptomatic, should be resected, because of the danger of exsanginating haemorrhage. For patients with pleural aspergillosis only the aggressive resection can provide effective long term palliation.