Antibiotic prophylaxis in invasive urodynamics, a Delphi consensus of the Italian Society of Urodynamics (SIUD)

INTRODUCTION

Although antibiotic prophylaxis (AB) demonstrated a statistically significant reduction in bacteriuria after invasive urodynamics (UDS), no significant decrease in the incidence of urinary tract infections (UTI) has been confirmed. No absolute recommendations on the use of AB in case of relevant potential risk of UTI have been reported, though some categories of patients at increased infective probability after UDS have been recognized. The aim of this study is to report the experts' consensus on the best practice for the use of AB before UDS in the main categories of patients at potential risk of developing UTI.

MATERIALS AND METHODS

A systematic literature review was performed on AB before UDS in males and females. A panel of experts from the Italian Society of Urodynamics, Continence, Neuro-Urology, and Pelvic Floor (SIUD) assessed the review data and decided by a modified Delphi method on 16 statements proposed and discussed by the panel. The cut-off percentage for the consensus was a ≥70% of positive responses to the survey. The study was a Delphi consensus with experts' opinions, not a clinical trial involving directly patients.

RESULTS

The panel group was composed of 57 experts in functional urology and UDS, mainly urologists, likewise gynaecologists, physiatrists, infectivologists, pediatric urologists, and nurses. A positive consensus was achieved on 9/16 (56.25%) of the statements, especially on the need for performing AB before UD in patients with neurogenic bladder and immunosuppression. Urine analysis and urine culture before UDS are mandatory, and in the event of their positivity, UDS should be postponed. A consensus was reached on avoiding AB in menopausal status, diabetes, age, gender, bladder outlet obstruction, high postvoid residual, chronic catheterization, previous urological surgery, lack of urological abnormalities, pelvic organ prolapse, and negative urine analysis.

CONCLUSIONS

Antibiotic prophylaxis is not recommended for patients without notable risk factors and with a negative urine test due to the potential morbidities that may result from antibiotic administration. However, AB can be used for risk categories such as neurogenic bladder and immunosuppression. The evaluation of urine analysis and urine culture and postponing UDS in cases of positive tests were considered good practices, as well as performing AB in the neurogenic bladder and immunosuppression.

In-label, off-label prescription, efficacy and tolerability of dalbavancin: report from a National Registry

PURPOSE

Although dalbavancin is currently approved for the treatment of ABSSIs, several studies suggest its efficacy and tolerance as long-term therapy for other off-label indications requiring prolonged intravenous antibiotic administration.

METHODS

We conducted a prospective nationwide study of dalbavancin use in real-life settings for both approved and off-label indications analysing for each case the clinical and microbiological characteristics of infection the efficacy and safety of treatments.

RESULTS

During the study period (from December 2018 to July 2021), the ID specialists from 14 different centres enrolled 223 patients treated with dalbavancin [141 males (63%) and 82 females (37%); male/female ratio 1.72; mean age 59 (SD 17.2) years, (range 15-96). Most patients in the study population (136/223; 61.0%) came from community rather than health care facilities and most of them were visited in Infectious Diseases wards (93/223; 41.7%) and clinics (55/223; 24.7%) even though some patients were cured in other settings, such as surgery wards (18/223; 8.1%), orthopaedic wards (11/223; 4.9%), Emergency Rooms (7/223; 3.1%) and non-surgical other than ID wards (6/223; 2.7%). The most common ID diagnoses were osteomyelitis (44 cases/223; 19.7%; of which 29 acute and 15 chronic osteomyelitis), cellulitis (28/223; 12.5%), cutaneous abscess (23/223; 10.3%), orthopaedic prosthesis-associated infection (22/223; 9.9%), surgical site infection (20/223; 9.0%) and septic arthritis (15/223; 6.7%).

CONCLUSION

In conclusion, by virtue of its PK/PD properties, dalbavancin represents a valuable option to daily in-hospital intravenous or outpatient antimicrobial regimens also for off-label indications requiring a long-term treatment of Gram-positive infections.

Mortality Attributable to Bloodstream Infections Caused by Different Carbapenem-Resistant Gram-Negative Bacilli: Results From a Nationwide Study in Italy (ALARICO Network)

BACKGROUND

Our aim was to analyze mortality attributable to carbapenem-resistant (CR) gram-negative bacilli (GNB) in patients with bloodstream infections (BSIs).

METHODS

Prospective multicentric study including patients with GNB-BSI from 19 Italian hospitals (June 2018-January 2020). Patients were followed-up to 30 days. Primary outcomes were 30-day mortality and attributable mortality. Attributable mortality was calculated in the following groups: Klebsiella pneumoniae carbapenemase (KPC)-producing Enterobacterales, metallo-β-lactamases (MBL)-producing Enterobacterales, CR-Pseudomonas aeruginosa (CRPA), CR-Acinetobacter baumannii (CRAB). A multivariable analysis with hospital fixed-effect was built to identify factors associated with 30-day mortality. Adjusted OR (aORs) were reported. Attributable mortality was calculated according to the DRIVE-AB Consortium.

RESULTS

Overall, 1276 patients with monomicrobial GNB BSI were included: 723/1276 (56.7%) carbapenem-susceptible (CS)-GNB, 304/1276 (23.8%) KPC-, 77/1276 (6%) MBL-producing CRE, 61/1276 (4.8%) CRPA, and 111/1276 (8.7%) CRAB BSI. Thirty-day mortality in patients with CS-GNB BSI was 13.7% compared to 26.6%, 36.4%, 32.8% and 43.2% in patients with BSI by KPC-CRE, MBL-CRE, CRPA and CRAB, respectively (P < .001). On multivariable analysis, age, ward of hospitalization, SOFA score, and Charlson Index were factors associated with 30-day mortality, while urinary source of infection and early appropriate therapy resulted protective factors. Compared to CS-GNB, MBL-producing CRE (aOR 5.86, 95% CI 2.72-12.76), CRPA (aOR 1.99, 95% CI 1.48-5.95) and CRAB (aOR 2.65, 95% CI 1.52-4.61) were significantly associated with 30-day mortality. Attributable mortality rates were 5% for KPC-, 35% for MBL, 19% for CRPA, and 16% for CRAB.

CONCLUSIONS

In patients with BSIs, carbapenem-resistance is associated with an excess of mortality, with MBL-producing CRE carrying the highest risk of death.

Superinfections caused by carbapenem-resistant Enterobacterales in hospitalized patients with COVID-19: a multicentre observational study from Italy (CREVID Study)

Objectives

To describe clinical characteristics and outcomes of COVID-19 patients who developed secondary infections due to carbapenem-resistant Enterobacterales (CRE).

Methods

Retrospective observational study including COVID-19 patients admitted to 12 Italian hospitals from March to December 2020 who developed a superinfection by CRE. Superinfection was defined as the occurrence of documented bacterial infection &gt;48 h from admission. Patients with polymicrobial infections were excluded. Demographic, clinical characteristics and outcome were collected. Isolates were classified as KPC, metallo-β-lactamase (MBL) and OXA-48-producing CRE. A Cox regression analysis was performed to identify factors independently associated with 30 day mortality.

Results

Overall, 123 patients (median age 66 years, IQR 59–75) were included. The majority of infections occurred in the ICU (81, 65.9%), while 42 (34.1%) in medical wards. The most common types of infection were bloodstream infections (BSI) (n = 64, 52%), followed by urinary-tract infections (UTI) (n = 28, 22.8%), hospital-acquired/ventilator-associated pneumonia (HAP/VAP) (n = 28, 22.8%), intra-abdominal infections (n = 2, 1.6%) and skin infections (n = 1, 0.8%). Sixty-three (51.2%) infections were caused by KPC-, 54 (43.9%) by MBL-, and 6 (4.8%) by OXA-48-producing CRE. Thirty-day mortality was 33.3% (41/123). On Cox regression analysis, HAP/VAP compared with UTI (HR 7.23, 95% CI 2.09–24.97, P = 0.004), BSI compared with UTI (HR 3.96, 95% CI, 1.33–11.77, P = 0.004), lymphopenia on admission (HR 3, 95% CI 1.44–6.26, P = 0.003) and age (HR 1.05, 95% CI 1.02–1.08, P = 0.002) were predictors of 30 day mortality.

Conclusions

Superinfections by CRE were associated with high risk of 30 day mortality in patients with COVID-19. HAP/VAP was the strongest predictor of death in these patients.

SAT0267 ROLE OF AGGRESSIVE IMMUNOSUPPRESSION ON SUBGLOTTIC STENOSIS IN GRANULOMATOSIS WITH POLYANGIITIS: RETROSPECTIVE ANALYSIS OF A MONOCENTRIC COHORT

Background:

Subglottic stenosis (SGS) is defined as airway narrowing below the vocal cords and is a common and potentially life-threatening manifestation of Granulomatosis with Polyangiitis (GPA), with an estimated prevalence of 16-23% (1). Balloon catheter dilation is effective in GPA-related SGS, but relapses are frequent. Little is known about the role of immunosuppression in this setting.

Objectives:

to analyse the clinical characteristics of a monocentric GPA cohort, describe phenotype differences among patients with and without SGS and investigate the role of surgical and medical treatments on relapse risk and general outcome.

Methods:

Biopsy-proven patients with SGS were identified by review of medical charts among a cohort of patients with GPA, classified according to the algorithm of the European Medicine Agency (2). The clinical characteristics of patients with SGS were retrospectively collected over a median follow-up time of 15.9 years and compared to those of patients without SGS.

Results:

Fourteen patients with SGS-GPA were identified, with a female to male ratio of 1:1 and a prevalence of 29.2% among the cohort. The mean ± SD age at GPA onset was 30.8 ± 14.4 years, with a mean time from GPA diagnosis to SGS onset of 4.7 ± 4.2 years. ANCA were positive in 78.6% (54.0% anti-PR3, 18.1% anti-MPO and 27.9% IFI only). The mean Birmingham Vasculitis Activity Score (BVAS) at onset was 10.0 ± 5.6. The main clinical manifestations associated with SGS were crusty rhinitis (100%), sinusitis (78%), pulmonary disease (72.7%), otitis/mastoiditis (50%), glomerulonephritis (42.9%), orbital pseudotumor (28.6%). Six patients (42.9%) received medical treatment only, other six (42.9%) had one to three balloon dilations and two (14.2%) underwent four or more procedures. Eight patients had no SGS relapse (maximum one dilation) and they all received immunosuppression with rituximab (RTX), cyclophosphamide (CYC) or azathioprine (AZA). All patients who received no immunosuppression, methotrexate (MTX) or mycophenolate (MMF) had at least one relapse. Patients treated with MTX or MMF had a mean relapse-free survival of 13.1 months, which was comparable to the one of patients not receiving medical treatment (40.2 months; p=NS) and shorter than the one of patients receiving CYC or RTX (153.2 months; p=0.032). CYC use also inversely correlated with the number of surgical procedures (r=-0.691, p=0.006). Compared to patients without SGS (31 consecutive patients with at least 4 years of follow-up), patients with SGS-GPA had an earlier disease onset (mean age 30.8 vs 50.4 years; p<0.001), but with lower BVAS (mean 10.0 vs 15.3; p=0.013) and showed a higher prevalence of crusty rhinitis (100% vs 67.7%; p=0.019). No difference was observed in damage accrual over time between the two groups.

Conclusion:

Subglottic stenosis is highly prevalent in patients with GPA and may define a milder disease subset occurring more frequently in younger patients. MTX and MMF might be insufficient to prevent SGS relapses requiring balloon dilation. Aggressive immunosuppression (CYC or RTX) might have a non-redundant role in this setting and reduce the risk of relapses.

References:

[1]Quinn KA, et al. Subglottic stenosis and endobronchial disease in granulomatosis with polyangiitis. Rheumatology 2019; 58 (12), 2203-2211.

[2]Watts R, et al. Development and validation of a consensus methodology for the classification of the ANCA associated vasculitides and polyarteritis nodosa for epidemiological studies. Ann Rheum Dis 2007; 66: 222-7.

Disclosure of Interests:

Luca Moroni: None declared, Laura Giudice: None declared, Giuseppe Alvise Ramirez: None declared, Silvia Sartorelli: None declared, adriana cariddi: None declared, Angelo Carretta: None declared, Enrica Bozzolo: None declared, Lorenzo Dagna Grant/research support from: The Unit of Immunology, Rheumatology, Allergy and Rare Diseases (UnIRAR) received unresctricted research/educational grants from Abbvie, Bristol-Myers Squibb, Celgene, Janssen, Merk Sharp & Dohme, Mundipharma Pharmaceuticals, Novartis, Pfizer, Roche, Sanofi-Genzyme, and SOBI., Consultant of: Prof Lorenzo Dagna received consultation honoraria from Abbvie, Amgen, Biogen, Bristol-Myers Squibb, Celltrion, Novartis, Pfizer, Roche, Sanofi-Genzyme, and SOBI.

Spontaneous pneumothorax in cocaine users

BACKGROUND

Pneumothorax is one of the respiratory toxic effects of cocaine inhalation. The literature counts several cases, some associated to other respiratory conditions such as pneumomediastinum, haemoptysis and others not requiring surgical treatment.

AIM

We present a series of nonHIV cocaine-inhaler subjects who underwent video-assisted thoracoscopic surgery (VATS) for isolated spontaneous pneumothorax.

DESIGN

Nine subjects, with a mean age of 24 ± 4 years, admitting cocaine inhalation, developed spontaneous pneumothorax and underwent 10 surgical treatments by means of VATS, at our Institution.

RESULTS

Previous pneumothorax occurred in six cases episodes ranged from 0 to 5 (mean 1.6 ± 1.6). Chest computed tomography (CT) scan showed abnormalities in seven cases. All subjects underwent lung apicectomy, apical pleurectomy and mechanical pleurodesis. Seven subjects had also bullectomy. In all cases the visceral pleura was partially covered by fibrinous exudate. Histology of the lung showed small foreign body granulomatous inflammation in fibrotic and/or emphysematous pulmonary parenchyma. Relapse of pneumothorax occurred in one subject at 60 days and it was surgically treated. Mean follow-up was 150 ± 38 months (range 120-239). All subjects are now well, with no evidence of pneumothorax.

CONCLUSIONS

Spontaneous pneumothorax in cocaine-inhaler subjects is a reality of which physicians need to be aware. Chest CT scan might not reveal abnormalities. Macroscopically the lung might presents bullae and/or peculiar visceral pleura. Foreign body granulomas observed in the specimens suggest that the particulate component of inhaled substances can injure the lung. Surgical treatment of the bullous disease and mechanical pleurodesis can provide a long-term follow-up without relapse of pneumothorax.

Epidemiology and Microbiology of Skin and Soft Tissue Infections: Preliminary Results of a National Registry

Skin and soft tissue infections (SSTIs) represent a wide range of clinical conditions characterized by a considerable variety of clinical presentations and severity. Their aetiology can also vary, with numerous possible causative pathogens. While other authors previously published analyses on several types of SSTI and on restricted types of patients, we conducted a large nationwide surveillance programme on behalf of the Italian Society of Infectious and Tropical Diseases to assess the clinical and microbiological characteristics of the whole SSTI spectrum, from mild to severe life-threatening infections, in both inpatients and outpatients. Twenty-five Infectious Diseases (ID) Centres throughout Italy collected prospectively data concerning both the clinical and microbiological diagnosis of patients affected by SSTIs via an electronic case report form. All the cases included in our database, independently from their severity, have been managed by ID specialists joining the study while SSTIs from other wards/clinics have been excluded from this analysis. Here, we report the preliminary results of our study, referring to a 12-month period (October 2016-September 2017). During this period, the study population included 254 adult patients and a total of 291 SSTI diagnoses were posed, with 36 patients presenting more than one SSTIs. The type of infection diagnosed, the aetiological micro-organisms involved and some notes on their antimicrobial susceptibilities were collected and are reported herein. The enrichment of our registry is ongoing, but these preliminary results suggest that further analysis could soon provide useful information to better understand the national epidemiologic data and the current clinical management of SSTIs in Italy.

The surgical treatment of lung cancer in patients with previous lymphoproliferative disorders: a historical cohort study

OBJECTIVES

We undertook a historical cohort study to compare, in terms of morbidity, mortality and long-term survival associated with lung cancer resection, a group of patients with previous lymphoproliferative disorders and a group without a hematological history.

METHODS

We identified 29 patients with a previous lymphoproliferative disorder who underwent lung cancer resection. These subjects (Group-A) were matched with 87 patients without a hematological history who underwent pulmonary resection during the same period (Group-B).

RESULTS

We found no significant difference between the two groups in length of hospitalization, comorbidities, spirometric parameters, type of surgery, histology, neoadjuvant chemotherapy, morbidity, mortality, median survival (Group-A = 37 months; Group-B = 52 months) and 5-year survival (Group-A = 37%; Group-B = 42%). The mean age of Group-A patients was significantly lower than that of Group-B patients (62 vs 66 years; p = 0.024). Group-A patients had a well differentiated lung cancer more frequently than Group-B patients (p = 0.001). Group-A patients had transitory bacteraemies more frequently than Group-B patients (p = 0.005). Multivariate Cox regression analysis showed that age (p = 0.01) and lung cancer stage (p = 0.04) were significantly associated with survival.

CONCLUSIONS

Patients with lymphoproliferative disorders had a lower age and more differentiated lung cancers than those without lymphoproliferative disorders. Patients with lymphoproliferative disorders and those without a hematological history had similar morbidity, mortality and long-term survival after pulmonary resection. Distinguishing patients with and without a lymphoproliferative disorder seems to be of limited value in the decision-making process of evaluating the indications for surgical treatment of lung cancer.

[Management of infections from cardiac implantable electronic devices: recommendations from a study panel]

Cardiac Implantable Electronic Device (CIED) infections are an emerging clinical issue. There are no national recommendations on the management of these infections, also due to the limited number of dedicated and high quality clinical studies. Therefore, researchers from southern Italian centres have decided to share the clinical experience gathered so far in this field and report practical recommendations for the diagnosis and treatment of adult patients with CIED infection or endocarditis. Here we review the risk factors, diagnostic issues (microbiological and echocardiographic) and aetiology, and describe extensively the best therapeutic approach. We also address the management of complications, follow-up after discharge and the prevention of CIED infections. In this regard, a multidisciplinary approach is fundamental to appropriately manage the initial diagnostic process and the comorbidities, to plan proper antimicrobial treatment and complete percutaneous hardware removal, with the key support of microbiology and echocardiography.

Combined treatment of non-small cell lung cancer with synchronous brain metastases: a single center experience

AIM

The aim of this study was to analyze our experience with combined treatment of non-small cell lung cancer with synchronous brain metastases.

METHODS

Between 1992 and 2008, 31 patients were treated by performing neurosurgery (or stereotactic radiosurgery) and lung surgery. Patients were divided into two groups according to their preoperative mediastinal work-up: group A (CT scan) and group B (FDG-PET scan).

RESULTS

Twenty-six patients had one brain metastasis and five had two. Neurosurgery was performed in 10 patients, stereotactic radiosurgery in 20 and both approaches in 1. Seven patients underwent chemotherapy after cerebral procedure. Pulmonary resection was complete in 27 cases and incomplete in 4. Histological findings showed: adenocarcinoma in 19 cases, squamous cell carcinoma in 8 and large cell carcinoma in 4. All patients underwent adjuvant chemotherapy. Overall 1, 2 and 5-year survival rates were 83%, 47% and 21%, respectively. The median survival was 22 months. Univariate analysis showed a better prognosis for complete resection (P=0.008), adenocarcinomas (P=0.015), N0 disease (P=0.038), and Group B (P=0.045). Multivariate analysis showed that only the radicality of the resection (P=0.027) and Group B (P=0.047) were independent prognostic factors.

CONCLUSION

Our experience confirms that selected patients with non-small cell lung cancer and synchronous brain metastases may be effectively treated by combined therapy. Complete resection, adenocarcinoma histology and N0 disease were prognostic factors. The incorporation of FDG-PET scan into the preoperative work-up may translate into a survival benefit.

Incidence of allergic diseases in an elderly population

Recent years have shown a progressive increase of allergic disease in the elderly population worldwide. Naturally, this phenomenon has coincided with attempts to guarantee the best possible quality of life for this age group. As a result, diseases that were previously overlooked are attracting ever greater attention. An epidemiological study of allergic manifestations in the elderly conducted in all consecutive patients referred to an Allergology Unit over a three-month period at the beginning of 2008 showed that 15% belonged to the elderly population and among these, 51.8 % were suffering from an allergic reaction to drugs. Skin manifestations, including both urticaria and eczema, accounted for 71.4% of cases but only in 13.8% of these patients was there a diagnosis of an allergic reaction made and the allergen responsible individuated. Rhinitis was present in 16.8 % of the patients and food allergy in 8 %. Certainly, age-induced modifications in the immunological system can be responsible for allergic reactions. In fact, non specific immunity components such as the production of mucus or a reduced function of the T- and IL-2 cells can induce the onset of symptoms referable to allergic disease. Further studies are ongoing to gain a better understanding of the pathogenic mechanisms that could justify the development in the elderly population of a cytokine phenotype that is more prone to develop allergic manifestations, and to assess the true incidence of respiratory, food and drug allergies in this stage of life.

Effects of 50 Hz electromagnetic fields on rat cortical synaptosomes

Nerve cells are very responsive to weak pulsed electromagnetic fields (EMFs). Such non-ionizing radiation, with frequencies of 0-300 Hz and 0.1-100 mT, can affect several cellular activities, with unusual dose-response characteristics. The present study examined the effect of a 2-h exposure of synaptosomes on a system generating a peak magnetic field of 2 mT. We evaluated the changes of the synaptosomal mitochondrial respiration rate and ATP production, membrane potential, intrasynaptosomal Ca2+ concentration, and the release of free iron and F2-isoprostanes. O2 consumption and ATP production remained unchanged in exposed synaptosomes. The intrasynaptosomal Ca2+ concentration decreased slowly and no depolarization of the synaptosomal membrane was detected. Finally, the release of free iron and F2-isoprostanes by synaptosomal suspensions also remained unchanged after EMF exposure. These results indicate that the physiological behavior of cortical synaptosomes was unaffected by weak pulsed EMFs.

Clinical Data and Inflammation Parameters in Patients with Cypress Allergy Treated with Sublingual Swallow Therapy and Subcutaneous Immunotherapy

The clinical efficacy of immunotherapy, either by high dose sublingual-swallow therapy (SLIT) or subcutaneous immunotherapy (SCIT), has been demonstrated in patients with pollinosis but few studies have been carried out analysing differences in these treatments in terms of an improvement of clinical and allergic phlogosis parameters. The aim of this double-blind placebo-controlled study is to investigate the efficacy of high dose SLIT and SCIT using a purified standardized Juniperus ashei extract in a population of allergic patients monosensitized to cypress. Forty patients with cypress-allergic rhino conjunctivitis were administered therapeutic or placebo SLIT or SCIT for 12 months. Laboratory parameters were studied, namely the eosinophil cationic protein (ECP) level in nasal lavage and in serum, as well as the number of eosinophils (EOS) in peripheral blood and in nasal lavage and the level of eosinophil chemotactic activity (ECA). These parameters were correlated with clinical symptoms, evaluated by means of the clinical symptoms score (CSS). After SCIT and SLIT the levels of ECP and ECA were reduced in nasal lavage. We also observed a significant reduction in the values of ECP in serum in the patients treated with SLIT. EOS were unchanged in peripheral blood, but significantly reduced in nasal lavage. These data were in accordance with the improvement of clinical symptoms, supported by the close correlation between CSS and laboratory parameters. Our data confirm a clinical improvement correlated with a decline in inflammation parameters after one year of immunotherapy, supporting the hypothesis that treatment with a major allergen of cypress is able to change the course of allergic rhinitis.

Surgical treatment of multiple primary adenocarcinomas of the lung

INTRODUCTION

The incidence of lung adenocarcinomas has steadily increased over the last decades. The aim of this study was to assess the results of surgical treatment of multiple primary adenocarcinomas of the lung (MPAL) analyzing the radiological and histological features.

METHODS

From 1988 to 2005, 26 patients underwent surgical treatment for MPAL at our department, for a total of 52 tumors. Three patients had synchronous and 23 had metachronous tumors.

RESULTS

Thirty-seven tumors were classified as solid, two as ground-glass opacities (GGO) and 13 as mixed solid/GGO tumors on the basis of CT scan evaluation. Histology revealed 26 adenocarcinomas, five adenocarcinomas with a bronchioloalveolar (BAC) pattern and 21 BAC. There was no postoperative mortality. Five-year survival of patients with synchronous tumors was 66 %. Survival of patients with metachronous tumors was 95 % and 70 % from the first and second operation. Patients with stage II and III a tumors had significantly reduced survival rates ( P < 0.05). Survival was 60 % after lobectomy and 78 % after wedge resection.

CONCLUSIONS

Surgical treatment of MPAL is associated with favorable results. Sublobar resections, when technically feasible, provide adequate oncological management.

Synaptosome behaviour is unaffected by weak pulsed electromagnetic fields

The present study examined the effect on rat cortical synaptosomes of a 2 h exposure to 50-Hz electromagnetic fields (EMFs) with a peak magnetic field of 2 mT. We measured modifications of synaptosomal mitochondrial respiration rate, ATP production, membrane potential, intrasynaptosomal Ca(2+) concentration and free iron release. The O(2) consumption remained unvaried in exposed synaptosomes at about 2 nM O(2)/min/mg proteins; ATP production was also unchanged. The intrasynaptosomal Ca(2+) concentration decreased slowly and there was a slight, but non-significant, depolarisation of the synaptosomal membrane. Finally, the free iron release by synaptosomal suspensions, a useful predictor of neuro-developmental outcome, remained unchanged after EMF exposure. On the whole, our results indicate that the physiological behaviour of cortical synaptosomes is not affected by weak pulsed EMFs.

Systemin regulates both systemic and volatile signaling in tomato plants

The prevailing reaction of plants to pest attack is the activation of various defense mechanisms. In tomato, several studies indicate that an 18 amino acid (aa) peptide, called systemin, is a primary signal for the systemic induction of direct resistance against plant-chewing pests, and that the transgenic expression of the prosystemin gene (encoding the 200 aa systemin precursor) activates genes involved in the plant response to herbivores. By using a combination of behavioral, chemical, and gene expression analyses, we report that systemin enhances the production of bioactive volatile compounds, increases plant attractivity towards parasitiod wasps, and activates genes involved in volatile production. Our data imply that systemin is involved in the systemic activation of indirect defense in tomato, and we conclude that a single gene controls the systemic activation of coordinated and associated responses against pests.

Preoperative assessment in patients with postintubation tracheal stenosis : Rigid and flexible bronchoscopy versus spiral CT scan with multiplanar reconstructions

BACKGROUND

Postintubation stenosis remains the most frequent indication for tracheal surgery. Rigid bronchoscopy has traditionally been considered the technique of choice for the preoperative diagnostic assessment. However, this technique is not routinely available, and new techniques such as flexible videobronchoscopy and spiral computed tomography (CT) scan with multiplanar reconstructions have been proposed as alternatives to rigid bronchoscopy. The aim of this study was to compare these techniques in the diagnostic assessment of patients with tracheal stenosis submitted to surgical treatment.

METHODS

Twelve patients who underwent airway resection and reconstruction for postintubation tracheal and laryngotracheal stenosis were preoperatively evaluated with rigid and flexible bronchoscopy and with spiral CT scan with multiplanar reconstructions. The following parameters were examined: involvement of subglottic larynx, length of the stenosis, and associated lesions. The results were compared with the intraoperative findings.

RESULTS

The accuracy of rigid bronchoscopy, flexible bronchoscopy, and CT scan in the evaluation of the involvement of subglottic larynx was, respectively, 92%, 83%, and 83%. The evaluation of the length of the stenosis was correct in 83%, 92%, and 25% of the patients, respectively, with rigid bronchoscopy, flexible bronchoscopy, and CT scan. A significant correlation was observed between the length of the stenosis measured intraoperatively and preoperatively with rigid (p < 0.001) and flexible bronchoscopy (p < 0.05) but not with CT scan (p = 0.08). The three techniques correctly showed the presence of an associated tracheoesophageal fistula in two patients, but CT scan did not correctly show the exact location of the fistula in relation to the airway. Flexible bronchoscopy was the only effective technique in the assessment of laryngeal function.

CONCLUSIONS

Rigid bronchoscopy remains the procedure of choice in the evaluation of candidates for tracheal resection and reconstruction for postintubation stenosis, and it should be available in centers that perform surgery of the airway. Flexible bronchoscopy and CT scan have to be considered complementary techniques in the evaluation of laryngeal function and during follow-up.

The effect of mild and severe hypoxia on rat cortical synaptosomes

Brain ischemia results in neuronal injury and neurological disability. The present study examined the effect of mild (6% O2) and severe (2% O2) hypoxia on mitochondria of rat cortical synaptosomes. During mild and severe hypoxia, JO2 and ATP production significantly decreased and mitochondrial membranes depolarized. Synaptosomal calcium concentration increased slightly, albeit not significantly. After a 1 h re-oxygenation period, JO2, ATP production and mitochondrial membrane potential returned to control levels in synaptosomes incubated in 6% O2. In synaptosomes incubated in 2% O2, however, the ATP production was not restored after re-oxygenation and intrasynaptosomal Ca2+ significantly increased. The results indicate that both mild and severe hypoxia influence the physiology of synaptosomal mitochondria; the modifications are reversible after mild hypoxia and but partly irreversible after severe hypoxia.

Endobronchial migration of prosthetic patch after congenital diaphragmatic hernia repair

Surgical repair of congenital diaphragmatic hernia (CDH) can be performed by means of either direct suturing of the diaphragm or positioning of a prosthetic patch. However, half of all prosthetic patches show evidence of reherniation. We describe the case of an 8-year-old girl who presented with prosthesis dislocation and fistulization in the right lower bronchus as a complication of a CDH repair that she underwent when she was 1 year old. Abdominal ultrasound and magnetic resonance imaging suggested a hernia relapse, whereas chest computed tomographic scan failed to identify the diaphragmatic defect. Only fibrobronchoscopy allowed fistulization of the prosthesis into the bronchi to be correctly diagnosed.

Thoracoscopic treatment of a pericardial diverticulum

A 35-year-old female patient presented with a history of recurrent chest pain. On chest x-ray, a regularly shaped lesion at the right cardiophrenic angle was observed. The lesion appeared smaller on a subsequent x-ray. Magnetic resonance imaging showed a cystic lesion that could be differentiated from the pericardium only in its lower part. Thoracoscopy revealed a pericardial diverticulum. Resection of the lesion was performed thoracoscopically, with complete remission of the symptoms.

Effects of age and calving season on lactation curves of milk production traits in Italian water buffaloes

Test day (TD) records of milk production traits (milk yield, fat, and protein percentages) of 534 Italian buffalo cows were analyzed with a mixed linear model in order to estimate lactation curves pertaining to different ages at calving and different seasons of calving. Milk yield lactation curves of younger animals were lower than those of older animals until 20 wk from parturition. No effect of age at calving could be observed for fat and protein percentages. Season of calving affected milk yield only in the first phase of lactation, with the lowest production levels for summer calvings; no effect could be observed on fat and protein contents. Average correlations among TD measures within lactation were 0.59, 0.31, and 0.36 for milk yield, fat, and protein percentages, respectively. Five standard linear functions of time were able to reconstruct the average lactation curves. Goodness of fit was satisfactory for all models considered, although only the five-parameter model was flexible enough to fit all the three traits considered with excellent results.

Surgical tracheostomy versus percutaneous dilatational tracheostomy. A prospective-randomized study with long-term follow-up

BACKGROUND

To compare surgical tracheostomy (ST) versus percutaneous dilatational tracheostomy (PDT) in terms of complication rates. In particular we specifically studied the late tracheal complications of both methods by means of endoscopic controls of patients up to 6 months after the procedures.

METHODS

DESIGN

prospective-randomized clinical study.

SETTING

University-affiliated tertiary care referral hospital.

PATIENTS

50 consecutive translaryngeally intubated patients with respiratory failure were randomized to undergo either ST (25 patients) or endoscopic guided PDT (25 patients).

RESULTS

ST was performed in 41+/-14 min versus 14+/-6 min for PDT (p<0.0001). There was no procedure-related death. In the ST group there were no intraoperative complications. In the PDT group 2 intraoperative complications (minor hemorrhages) were observed. In the ST group 9 early postoperative complications occurred: one minor bleeding, 7 stomal infections and one accidental decannulation. In the PDT group only one early postoperative complication (minor bleeding) occurred. Early postoperative complication rates were 36% for ST and 4% for PDT. In the ST group there were no late tracheal complications. In the PDT group 2 late tracheal complications (one segmental malacia and one stenosis at the level of the stoma) were observed.

CONCLUSIONS

This study confirms that PDT is a simpler and quicker procedure than ST and that it has a lower rate of early postoperative complications. Late tracheal complications were more frequent, although the difference was not statistically-significant, in the PDT group. Further investigations of long-term outcome following PDT are therefore necessary.

Evaluation of radiological and pathological prognostic factors in surgically-treated patients with bronchoalveolar carcinoma

OBJECTIVE

The incidence of adenocarcinoma and bronchoalveolar carcinoma has increased in recent years. The aim of this study was to retrospectively evaluate radiological and pathological factors affecting survival in patients with bronchoalveolar carcinoma (BAC) or BAC associated with adenocarcinoma who underwent surgical treatment.

METHODS

From May 1988 to September 1999, 49 patients with BAC or BAC and adenocarcinoma underwent surgical treatment. Complete resection was performed in 42 patients. In these patients the impact of the following factors on survival was evaluated: stage, TNM status, radiological and pathological findings (percentage of bronchoalveolar carcinoma in the tumour, presence or absence of sclerosing and mucinous patterns, vascular invasion and lymphocytic infiltration).

RESULTS

Twenty-nine patients were male and 20 female. Mean age was 63 years. Five-year survival was 54%. Univariate analysis of the patients who underwent complete resection demonstrated a favourable impact on survival in stages Ia and Ib (P = 0.01) and in the absence of nodal involvement (P = 0.02) and mucinous patterns (P = 0.02). Mucinous pattern was also prognostically relevant at multivariate analysis (P = 0.02). In the 27 patients with stage Ia and Ib disease, univariate analysis demonstrated that the absence of mucinous pattern (P = 0.006) and a higher percentage of BAC (P = 0.01) favourably influenced survival. The latter data were also confirmed by multivariate analysis (P = 0.01).

CONCLUSION

Surgical treatment of early-stage BAC and combined BAC and adenocarcinoma is associated with favourable results. However, the definition of prognostic factors is of utmost importance to improve the results of the treatment. In our series tumours of the mucinous subtype and with a lower percentage of BAC had a worse prognosis.

[Treatment of malignant pleural mesothelioma]

BACKGROUND

In this study all patients observed between January 1993 and October 1997 with malignant pleural mesothelioma (MPM) have been analyzed in order to describe the impact of treatment modality on survival.

METHODS

Medical records of 56 patients with MPM (44 male, 12 female, median age = 59 yrs) were reviewed. In 34 cases the histotype was epithelial, in 4 sarcomatoid, in 4 mixed, in 3 desmoplastic, and in 11 not specified. Four treatment modalities were identified: 1) Surgery (subtotal pleurectomy) = 20 patients; 2) Chemotherapy = 19 patients; 3) Surgery+Chemo-therapy = 8 patients; 4) Supportive care = 9 patients.

RESULTS

The median survival was: 1) Surgery = 12.4 months; 2) Chemotherapy = 7.5 months; 3) Surgery+Chemotherapy = 12 months; 4) Supportive care = 11.4 months. Using univariate analysis, 8 prognostic factors were studied (age, sex, asbestos exposure, side, histotype, performance status, stage, treatment). Among these, only the stage and the performance status had shown a prognostic value on survival (p<0.05), while the treatment modality had not significantly influenced the prognosis. Using multivariate analysis only performance status showed to be significatively associated with survival (p=0.01 and odds ratio = 1.9, I.C. 1.2-3.2).

CONCLUSIONS

Despite the limits of a retrospective study, personal experience confirms the ineffectiveness of current therapeutical approaches to MPM. A better understanding of MPM is required to develop new therapeutical approaches and alter the dismal prognosis of this disease.

Diagnostic and therapeutic management of neuroendocrine lung tumors: a clinical study of 44 cases

Neuroendocrine tumors of the lung (NTL) are a distinct subset of tumors with a wide range of histological patterns and clinical behavior. Controversy still exists as to the ideal diagnostic and therapeutic approach to these neoplasms. A series of 44 consecutive NTL patients operated on at our Institution was retrospectively reviewed in order to critically analyze the diagnostic and therapeutic management. A preoperative diagnosis was obtained in 11 patients (25%). All patients underwent an anatomical surgical resection with lymphoadenectomy. Pathological diagnosis was typical carcinoid (TC) tumor in 36 cases, atypical carcinoid (AC) in three and large-cell neuroendocrine carcinoma (LCNEC) in five. One patient had preoperative chemotherapy. Node-positive patients received postoperative radiotherapy on the mediastinal area. Median follow-up time was 40 months for TC and 51.5 months for AC/LCNEC. Recurrence of disease was observed in three patients with TC and in two with AC/LCNEC. Actuarial 5-year survival was 93% for TC and 70% for AC/LCNEC. Survival was not influenced by tumor size, while lymph node metastases were associated with a worse prognosis. However, due to the limited number of patients, no statistical significance was observed. In conclusion, our study confirms findings in the literature showing that TC and AC/LCNEC are clinically different, and that a differential preoperative diagnosis and treatment is necessary. Although the results of new diagnostic techniques such as octreotide scintigraphy are encouraging, they need to be validated in a larger number of patients. Surgery, with anatomical resection and lymphoadenectomy, remains the treatment of choice in all these tumors. Laser treatment should be considered only as a palliative procedure or as a complementary technique to surgery. The role of adjuvant treatments in AC and LCNEC is uncertain and should be evaluated in larger trials. The prognostic role of biological factors such as cytometry and genetic markers requires further investigation before any definitive conclusions can be drawn.

[Congenital lobar emphysema in adults]

Due to the severity of respiratory symptoms, congenital lobar emphysema often requires surgical treatment in the early stages of life. Diagnosis of congenital lobar emphysema in adult life is therefore unusual, often presenting with mild symptoms. Diagnostic assessment is therefore of great importance in the treatment of these patients. A case of congenital lobar emphysema in an adult is reported and the diagnostic and therapeutical approach are discussed. The use of new diagnostic techniques such as dynamic RMN and SPET V/Q lung scan may improve the accuracy of the diagnostic evaluation. Pulmonary lobectomy led to marked improvement in respiratory function. Accurate diagnosis and appropriate management of congenital lobar emphysema in adult patients can lead to favourable results.

18-FDG positron emission tomography in the evaluation of malignant pleural diseases - a pilot study

OBJECTIVE

The diagnostic approach to pleural diseases may be difficult. The CT scan, which is the current diagnostic technique, has limited accuracy both in the differentiation between benign and malignant pleural diseases and in the diagnosis of primary and metastatic pleural neoplasms. Invasive procedures, such as thoracoscopy, are therefore frequently required to complete the diagnostic approach. The increasing incidence of malignant pleural mesothelioma has led to the development of new treatment strategies, which still need to be fully validated. There is, therefore, a need for new diagnostic techniques that can lead to a definite diagnosis and a satisfactory evaluation of the response to treatment. Encouraging results have been reported with the F-18-labeled analogue of 2-deoxyglucose (18-FDG) positron emission tomography (PET) in the evaluation of chest tumors such as lung cancer. The aim of this study was to evaluate the role of 18-FDG PET in the diagnostic assessment of pleural diseases.

METHODS

Patients with CT scan evidence of pleural thickening, or fluid, entered a study to evaluate the accuracy of 18-FDG PET in diagnosing pleural diseases. Image analysis was performed both with visual interpretation and using a semiquantitative method, standardized uptake values (SUV), on coronal, sagittal and axial reconstructions. The results of PET imaging were compared to histological data. PET was also performed before and after treatment in patients who underwent chemotherapy to evaluate the accuracy of this technique in the assessment of the response.

RESULTS

Fourteen patients entered the study. Histology demonstrated a malignant pleural disease in 13 patients; malignant pleural mesothelioma in ten patients, adenocarcinoma in two and liposarcoma in one. Benign pleural disease was diagnosed in the remaining patient. PET assessment demonstrated significant 18-FDG uptake in 12 of the 13 patients with a malignant disease, also revealing distant metastases in two of them. A false-negative result was observed in a patient with an epithelial mesothelioma. The overall accuracy was 92%. A benign pleural disease without significant uptake was correctly diagnosed in another patient. An aspecific uptake was observed in two patients who had undergone pleurectomy and intrapleural chemotherapy. A decreased tracer uptake was observed after chemotherapy in four patients.

CONCLUSIONS

These preliminary results demonstrate that 18-FDG PET may have a great potential, both in the differential diagnosis of pleural diseases and in the evaluation of the response to treatment. At present, however, histological thoracoscopic diagnosis remains mandatory before planning treatment. Further studies in larger groups of patients are needed to draw definite conclusions on the role of PET in the assessment of pleural diseases.

FDG/PET and spiral CT image fusion for medistinal lymph node assessment of non-small cell lung cancer patients

BACKGROUND

To assess the potential usefulness of 18F-FDG/PET and spiral-CT images concurrent assessment and coregistration in staging mediastinal lymph node involvement in patients with non small cell lung cancer.

METHODS

28 patients waiting to undergo surgical treatment underwent spiral-CT and PET examinations on the same day. The results of the two studies were interpreted separately, together (CT&PET) and following their fusion in a single image (CT+PET). Results of spiral-CT, PET, CT&PET and CT+PET were assessed with respect to the histological diagnosis.

RESULTS

A correct assessment of mediastinal lymph nodes was achieved by spiral-CT in 21 of the 28 patients, in 22 of the 28 patients by PET, in 24 patients by CT&PET and in 25 patients by CT+PET.

CONCLUSIONS

CT+PET is more accurate than spiral-CT and PET alone in staging mediastinal lymph node involvement in lung cancer patients, with possible implications for their prognosis and therapy.

[Percutaneous or surgical trachetomy. Prospective, randomized comparison of the incidence of early and late complications]

BACKGROUND

To compare early and late complications after either conventional surgical or percutaneous dilatational tracheostomy.

DESIGN

Prospective, randomized study.

SETTING

General intensive care unit and neuro-surgical intensive care unit in a university hospital.

PATIENTS

50 consecutive patients, requiring tracheostomy for prolonged mechanical ventilation.

INTERVENTIONS AND MEASUREMENTS

Patients were randomly allocated to receive either surgical (surgical group, n = 25) or percutaneous dilatational tracheostomy (percutaneous group, n = 25). Occurrence of perioperative complication were carefully evaluated during ICU stay. Late complications were evaluated with both physical and endoscopic examination at 1, 3 to 6 months after tracheostomy.

RESULTS

All surgical and percutaneous tracheostomies were successfully completed and no deaths directly related to the tracheostomy procedures were reported. Completion of the procedure required 41 +/- 14 min in the surgical group and 14 +/- 6 min in the percutaneous one (p < 0.0001). The incidence of early perioperative complications was higher in the surgical group (36%) than in percutaneous one (12%), (p < 0.05). The endoscopic follow-up demonstrated one segmental malacia and one stenosis of the trachea in the percutaneous group only (p = n.s.). Skin repair was better after percutaneous tracheostomy than in the surgical group (p < 0.01).

CONCLUSIONS

In experienced hands, percutaneous dilatational tracheostomy is as safe and effective as the conventional surgical tracheostomy. The percutaneous technique is less time-consuming and has a lower rate of early infectious complications with better cosmetic results than the surgical technique.

Improvement of pulmonary function after lobectomy for non-small cell lung cancer in emphysematous patients

OBJECTIVE

Pulmonary emphysema is frequently associated with lung cancer and, because of the impaired pulmonary function involved, it may contraindicate surgical treatment. However, improvement of pulmonary function has been observed after surgical resection in patients with advanced emphysema. The aim of this study was to evaluate whether pulmonary emphysema, as assessed by pulmonary function tests and radiological evaluation, can influence postoperative respiratory function after lobectomy for non-small cell lung cancer (NSCLC).

METHODS

Respiratory function was evaluated before and after lobectomy for NSCLC. Radiological evaluation of emphysema was performed on chest X-ray and CT scan. Patients that had undergone chemo- or radiotherapy or had segmental or lobar atelectasis were excluded from the study.

RESULTS

Thirty-five patients entered the study. A decrease in static lung volumes was observed after surgery. Total lung capacity (TLC) decreased from 6.58+/-0.92 to 5.46+/-0.77 l; functional residual capacity (FRC) from 3.70+/-0.88 to 2.96+/-0.73 1 and residual volume (RV) from 2.93+/-0.78 to 2.2+/-0.53 l. However, in a subgroup of 10 patients (Group 1), dynamic volumes after surgery were unchanged or slightly increased (forced vital capacity (FVC) from 3.23+/-0.65 to 3.3+/-0.68 l; forced expiratory volume in 1 s (FEV1) from 2.14+/-0.51 to 2.25+/-0.54 l), and airway resistances (sRaw) decreased from 15.58+/-5.18 to 11.42+/-5.25 cm H2O/s. Preoperative data showed that these patients had a greater obstruction, with FEV1 changing from 69+/-12.42 to 72.70+/-13.72% of predicted, as compared with a change from 87+/-12.7 to 72.08+/-13.10% in the other group of 25 patients (Group 2). Correlation analysis reached statistical significance between FEV1% variation (deltaFEV1%) and preoperative FEV1 and FVC% (r = -0.49, P = 0.002 and r = -0.5, P = 0.001, respectively) and between delta (FEV1)% and radiological scores for 3-level CT (r = 0.39, P = 0.04) and the sum of chest X-ray, single and 3-level CT scores (r = 0.49, P = 0.01).

CONCLUSIONS

Pulmonary function may remain unchanged or even increase after lobectomy in patients with a pronounced emphysematous component of airway obstruction. The identification of preoperative parameters that identify this group of patients could extend the indications for the treatment of lung cancer in patients with pulmonary emphysema.

[Laryngotracheal resection and reconstruction by Grillo's technic for postintubation stenosis]

BACKGROUND

Tracheal resection and reconstruction is the standard treatment for postintubation stenosis. However, when the stenosis extends proximally to the subglottic larynx surgical treatment is particularly difficult. Specific surgical techniques have to be used in order to preserve the recurrent laryngeal nerves. The aim of this study is to evaluate the results obtained at our Department with laryngotracheal resection and reconstruction with the Grillo technique for postintubation stenosis.

METHODS

From January 1984 to December 1997, 83 patients with tracheal and laryngotracheal lesions underwent surgical treatment. Eighteen patients had postintubation stenosis of the upper trachea and subglottic larynx and underwent single-stage laryngotracheal resection and reconstruction. Mean stenosis length was 3.5 cm (range 3-5 cm). Twelve patients underwent anterolateral laryngotracheal reconstruction, and 6 patients had a circumferential laryngotracheal reconstruction. A Montgomery suprahyoid laryngeal release was required in 4 cases.

RESULTS

There was no surgical mortality. Surgical results were excellent or good in 17 cases and satisfactory in one case. No recurrence of stenosis has been observed.

CONCLUSIONS

Cricoid cartilage involvement in postintubation stenosis should not be considered a contraindication to surgical treatment. However, laryngotracheal resection and reconstruction is technically difficult and should be performed only in selected cases.

Combined lung volume reduction surgery and thoracic aortic aneurysm resection

Postoperative improvement of respiratory function has been reported with lung volume reduction surgery (LVRS) in patients with severe emphysema. Since smoking is an established risk factor for lung cancer, vascular diseases and emphysema, it is not infrequent to find these diseases associated in the same patient. Combined treatment of lung cancer and emphysema has already been reported. Surgical treatment of vascular diseases in emphysematous patients could also benefit from the application of LVRS techniques. We report resection of an aortic aneurysm combined with LVRS in a patient with concomitant thoracic aortic aneurysm and severe emphysema. Respiratory function improved in the postoperative period.

Surgical treatment of non-small cell lung cancer in patients 70 years of age or older

BACKGROUND

Indications to surgical treatment of lung cancer in the elderly are still being discussed. The aim of this study was to evaluate postoperative complications and survival after surgery for non-small cell lung cancer (NSCLC) in patients 70 years of age or older.

METHODS

During a 4 year and 6 month period, 76 patients (67 men and 9 women) entered the study.

RESULTS

Postoperative complications occurred in 15 cases (19.7%) and the 30-day operative mortality was 1.3%. The overall 54 month actuarial survival was 53%. Mortality at 12 months wasn't related to stage of disease, histology or lobectomy versus wedge resection but was higher in those patients who had had postoperative cardiopulmonary complications. Results of preoperative spirometry, blood gas and cardiac status were predictive of mortality at twelve months (p < 0.05).

CONCLUSIONS

Surgery for NSCLC in the elderly should not be denied on the basis of age alone. Postoperative outcome is mainly related to concomitant cardiopulmonary disease.

Imaging of bronchial carcinoid tumors associated to Cushing syndrome with 111In-Octreoscan scintigraphy and immunoscintigraphy with anti-chromogranin monoclonal antibodies. Report of two cases

Bronchial carcinoid tumors are neuroendocrine neoplasms capable of expressing somatostatin receptors and of secreting neuromediators such as ACTH and chromogranins. Radiologic appearance is usually non-specific and has to be distinguished from benign pulmonary nodules and other malignant diseases. Standard radiological techniques have limited accuracy in the evaluation of such lesions. Radioisotopic imaging techniques may increase the specificity of diagnostic assessment. The role of immunoscintigraphy with anti-chromogranin A and B monoclonal antibodies (MoAbs) and of 111In-Octreoscan scintigraphy is evaluated in two cases of bronchial carcinoid tumors associated to Cushing syndrome.

Temporary main bronchial occlusion under bronchoscopic control in the evaluation of candidates for pneumonectomy

BACKGROUND

In this study we report our experience with temporary main bronchial occlusion in the preoperative evaluation of candidates for pneumonectomy.

METHODS

Between January 1991 and January 1994, 57 candidates for pneumonectomy underwent a 15-minute temporary main bronchial occlusion with an inflatable balloon during fiberoptic bronchoscopy. The following parameters were monitored during bronchial occlusion: general status, ECG, arterial pressure, heart rate and respiratory rate. Arterial blood gases were measured after 7 and 14 minutes. Values at 7 and at 14 minutes were compared with those obtained before the procedure. Patients were considered suitable surgical candidates for pneumonectomy if PaCO2 < 42 mmHg and pH > 7.35.

RESULTS

Fifty-three patients were considered functionally operable. Three patients were considered functionally inoperable (PaCO2 > 42 mmHg, pH < 7.35 and appearance of dyspnea). One patient was excluded from the analysis because of balloon mispositioning due to a coughing fit. Sixteen of the operable patients underwent pneumonectomy and all did well without clinical evidence of respiratory insufficiency. At present 11 patients are alive, all without chronic respiratory insufficiency (mean follow-up 14 months). No postoperative mortality related to cardiorespiratory problems was observed.

CONCLUSIONS

Temporary main bronchial occlusion is a simple and inexpensive test that can correctly predict functional resectability in candidates for pneumonectomy.

Efficacy of ketorolac tromethamine and extrapleural intercostal nerve block on post-thoracotomy pain. A prospective, randomized study

BACKGROUND

Post-thoracotomy pain causes severe impairment of the respiratory function. Epidural analgesia is effective in the treatment of post-thoracotomy pain but may give rise to significant side-effects. Other low-risk and cost-effective analgesic treatments are therefore required.

METHODS

Thirty male patients who had undergone pulmonary lobectomy entered a prospective, randomized trial to evaluate the efficacy of ketorolac tromethamine (Group 2) and extrapleural intercostal nerve block (Group 3) with intermittent low-dose bupivacaine. Objective and subjective assessment was carried out at 8, 16, 24 and 48 hours postoperatively.

RESULTS

There were no significant differences between Groups 1 (control group) and 2. Vital capacity was significantly lower in Group 3 (p<0.05) than in Group 1 after 16 hours. Forced Vital Capacity was significantly higher in Group 2 than in Group 3 after 16 and 24 hours (p<0.05). Peak expiratory flow was also significantly better in Group 2 than in Group 3 after 16 hours (p<0.05). On-demand opioid consumption was significantly lower in Group 2 (p<0.001) and Group 3 (p<0.05). No side-effects were observed.

CONCLUSIONS

Ketorolac tromethamine was effective in the treatment of post-thoracotomy pain. Extrapleural intercostal nerve block allowed a significant reduction in the consumption of opioids. These analgesic techniques could be useful as low-risk, cost-effective and reproducible treatments when more effective techniques, such as epidural analgesia, are contraindicated.

[Blood preservation in thoracic surgery: feasibility and limitations]

The transfusion of homologous blood carries risks associated with reactions to transfusion and the transmission of diseases. Minimizing surgery-related blood use is therefore of utmost importance. However, the application of blood-saving methods in surgery is restricted by a number of factors. Thoracic surgery poses particular problems in this regard due to the type of diseases treated, patients' general status and the use of neoadjuvant chemotherapy protocols. The aim of this study was to analyse the feasibility of a blood conservation program for thoracic surgery. A detailed analysis of blood-sparing techniques was carried out and the factors influencing blood consumption were evaluated in the preoperative, intraoperative and postoperative periods. Although pre-operative autologus blood donation is an extremely important factor, its effect is limited in thoracic surgery since only a few patients are suitable candidates for such a procedure. Our personal experience confirms the difficulty of applying a blood sparing program to thoracic surgery. Nevertheless the risks associated to transfusions, especially those related to the use of homologous blood, can be reduced by optimizing existing blood sparing techniques or developing new hemostatic agents.

Self-expanding stents in the treatment of tracheobronchial obstruction

The self-expandable stainless steel stents (Gianturco, William Cook, Bjaeverskov, Denmark) used extensively in biliary ducts and the vascular system have recently been modified for use in the tracheobronchial tree. Between March 1991 and September 1992, six patients with unresectable tracheobronchial and mediastinal diseases were treated with the placement of one or more self-expanding stents under direct vision with a fiberoptic bronchoscope. All patients had been intubated for severe respiratory insufficiency. In all cases, immediate relief of respiratory symptoms was achieved and all patients were extubated 1 or 2 days after stent placement. Tolerance of the stents was excellent. No patient complained of pain, discomfort, or foreign body sensation. No infection or obstruction of the stents was observed. The chest roentgenogram and the bronchoscopies performed during follow-up have shown no change in the position of the stents. Our results seem promising since these devices provide effective palliation of airway obstructions and are well tolerated.

Surgery following neoadjuvant MPV chemotherapy (mitomycin, cisplatin, vinblastine) in locally advanced (IIIa and IIIb) non-small cell lung cancer

From November 1990 to August 1993, 32 patients with non-small cell lung cancer (NSCLC) entered a multimodality treatment study with neoadjuvant Mitomycin, Cisplatin and Vinblastine (MPV), surgery and radiotherapy at the San Raffaele Hospital in Milan, Italy. Neoadjuvant chemotherapy was performed on an outpatient basis. To date 23 patients (11 stage IIIa and 12 stage IIIb) have completed the chemotherapy treatment and are available for evaluation of response, toxicity, surgical eligibility and resection rate. The overall major response to MPV chemotherapy was 87%. The overall resection rate after major response to treatment was 60% (90% in stage IIIa and 17% in stage IIIb). After a median follow-up of 21 months (8-31) 17 patients are still alive (74%). Ten patients (83%) who had a complete resection are alive after a median follow-up of 23 months (21-30) and eight of them (66%) are in complete pathological remission. No treatment-related mortality was observed. The authors conclude that MPV is a highly effective neoadjuvant regimen for NSCLC and is feasible on an outpatient basis. Favorable resection rates can be obtained in stage IIIa patients. Stage IIIb patients can be downstaged and undergo complete resection. A longer follow-up is needed to assess the impact of this multimodality approach on long-term survival and to evaluate the role of adjuvant radiotherapy.