Development of clinical tools to estimate the breathing effort during high-flow oxygen therapy: A multicenter cohort study

INTRODUCTION AND OBJECTIVES

Quantifying breathing effort in non-intubated patients is important but difficult. We aimed to develop two models to estimate it in patients treated with high-flow oxygen therapy.

PATIENTS AND METHODS

We analyzed the data of 260 patients from previous studies who received high-flow oxygen therapy. Their breathing effort was measured as the maximal deflection of esophageal pressure (ΔPes). We developed a multivariable linear regression model to estimate ΔPes (in cmH2O) and a multivariable logistic regression model to predict the risk of ΔPes being >10 cmH2O. Candidate predictors included age, sex, diagnosis of the coronavirus disease 2019 (COVID-19), respiratory rate, heart rate, mean arterial pressure, the results of arterial blood gas analysis, including base excess concentration (BEa) and the ratio of arterial tension to the inspiratory fraction of oxygen (PaO2:FiO2), and the product term between COVID-19 and PaO2:FiO2.

RESULTS

We found that ΔPes can be estimated from the presence or absence of COVID-19, BEa, respiratory rate, PaO2:FiO2, and the product term between COVID-19 and PaO2:FiO2. The adjusted R2 was 0.39. The risk of ΔPes being >10 cmH2O can be predicted from BEa, respiratory rate, and PaO2:FiO2. The area under the receiver operating characteristic curve was 0.79 (0.73-0.85). We called these two models BREF, where BREF stands for BReathing EFfort and the three common predictors: BEa (B), respiratory rate (RE), and PaO2:FiO2 (F).

CONCLUSIONS

We developed two models to estimate the breathing effort of patients on high-flow oxygen therapy. Our initial findings are promising and suggest that these models merit further evaluation.

Integrated monitoring of AMR and enterotoxins genes of S. aureus isolated in Lombardy

Background

S. aureus is a widespread pathogen responsible for mild to severe human and animals’ infections. The abuse of antimicrobials provides the potential for selection of resistant strains in livestock, which represents a public health concern. S. aureus can carry several virulence factors of which staphylococcal enterotoxins (SEs) play a key role during food poisoning in human populations. The aim of this study is to monitor the prevalence of antimicrobial resistance factors in S. aureus isolates and their ability to produce enterotoxins.

Methods

Within an ongoing monitoring plan for the assessment of antimicrobial resistance in S. aureus strains, a total of 83 isolates collected from food, and swine and dairy farms, between 2020-2022, were characterized using MLST and then screened for the presence of methicillin resistance and SEs genes. The isolates were tested for susceptibility to a panel of 14 antimicrobial agents using the disc agar diffusion method on Mueller-Hinton agar.

Results

Among 83 S. aureus isolates, 53% carried at least one SEs gene. Eighteen isolates were methicillin-resistant of which 17 were no-enterotoxigenic strains belonging to ST398, and one was a food origin ST8 strain and harbored SEs genes. Among the ST398 isolates, only one was a food origin strain, while the others were from swine farms. The antibiogram showed that a few isolates were susceptible to nalidixic acid, and 42% resulted multidrug-resistant.

Conclusions

Our results showed that more than half of S. aureus isolates were enterotoxigenic, the majority belonging to food industries. Numerous tested isolates resulted multidrug-resistant, confirming that antimicrobial resistance is a critical public health threat in a food safety perspective.

Key messages

• The antimicrobial resistance profiles of S. aureus isolates underlines the importance of monitoring plans with a One Health perspective.

• The prevalence of enterotoxins genes in S. aureus strains in Lombardy confirms the relevance of the microorganism as a foodborne pathogen.

Rare internalin A premature stop codon on Listeria monocytogenes on Italian PDO cheeses isolates

Background

Listeria monocytogenes is a widespread foodborne pathogen that causes listeriosis, a human infection with low morbidity but high mortality. Internalin A (InlA), a L. monocytogenes virulence factor, has a key role in the invasion of human intestinal epithelium through the interaction with E-cadherin receptor. Truncated InlA caused by premature stop-codons (PMSC) have been correlated with attenuated virulence. To date, 29 mutations leading to a PMSC have been reported. In this study, we identified a rare PMSC mutation widespread in isolates from the production chain of the Gorgonzola and Taleggio PDO cheeses.

Methods

Within an ongoing monitoring plan for the characterization of L. monocytogenes, a total of 81 isolates collected in Lombardy (Northern Italy) from food, food processing environments, and clinical cases, between 2013-2021, were characterized using multilocus sequence tying (MLST) and then screened for the presence of PMSC by sequencing the 2400 pb inlA gene.

Results

A mutation leading to PMSC was identified on the position 277 (PMSC mutation type 26). To date, this mutation has been reported only on a CC7 strain from a clinical case. In our study, all isolates harbouring this mutation (n = 21) belong to ST325 (CC31, serotype 1/2a). Among these, 86% (n = 18) belong to the production chain of the Gorgonzola and Taleggio PDO cheeses.

Conclusions

To the best of our knowledge, this is the first report of PMSC mutation type 26 on food and environmental isolates. Although PMSC 26 is rarely found worldwide, our findings suggest that ST325 with this mutation is widespread in the production chain of the two PDO cheeses, and the presence of this PMSC may be correlated with the low incidence of ST325 clinical cases.

Key messages

A rare mutation leading to truncated InlA has been identified in a cluster of isolates correlated to the production chain of two PDO cheeses. Truncated inlA is suggestive of adaptation to the niche to the detriment of virulence.

Coronary microvascular function is impaired in patients with cerebral autosomal dominant arteriopathy with subcortical infarcts and leukoencephalopathy (CADASIL)

 

Cerebral autosomal dominant arteriopathy with subcortical infarcts and leukoencephalopathy (CADASIL; OMIM 125310) is a rare inherited disease, caused by NOTCH3 gene mutations. Main clinical manifestations of CADASIL include recurrent subcortical ischemic events, migraine, cognitive impairment and psychiatric disturbances. CADASIL is a systemic microangiopathy and cardiac involvement has been observed in a series of Dutch patients, presenting higher frequency of myocardial infarction compared to non-mutated relatives and general population. In particular, electron microscopic examination of myocardial tissue of a study participant demonstrated CADASIL characteristics.

We sought to investigate the relationship between CADASIL and microvascular dysfunction (MVD).

Seventeen patients with genetically-confirmed CADASIL, aged <60 years, with ≤1 cardiovascular risk factor (current smoke, diabetes, hypertension, dyslipidemia), recent (<3 months) neurological evaluation with neuropsychological tests and 3 Tesla brain magnetic resonance imaging (MRI) underwent 12-lead ECG, echocardiography, and measurement of maximal myocardial blood flow following Regadenoson infusion (Reg-MBF) by 13NH3positron emission tomography (PET), to investigate the presence of coronary microvascular dysfunction (CMD). Coronary flow reserve (CFR) was defined as Reg-MBF/resting MBF. PET results were compared to those of 15 healthy controls matched for age and sex recruited among a historical cohort of healthy patients. The study was approved by the institutional review board and all the subjects gave informed consent.

Mean age was 40±9 years (range 28–57 years); 6 patients (35%) were male. One was a current smoker and 3 ex-smokers; 1 patient was on aspirin, 1 on acetazolamide and 2 on escitalopram, none was taking statins. 12 patients (71%) presented with migraine, 9 (53%) had psychiatric disturbances and 1 (6%) had a previous stroke. Brain MRI showed mild-moderate and severe leukoencephalopathy in 11 (65%) and 5 (29%) patients respectively, lacunes were present in 14 patients and microbleeds in 1; one patient had normal findings. Both Reg-MBF and CFR were blunted in CADASIL patients compared with controls (Reg-MBF 2.46±0.54 versus 3.09±0.44 ml/gr/min respectively, p<0.001; CFR 2.74±0.36 vs. 3.28±0.66, respectively, p<0.01). In 3 male patients (17%), CFR reduction was severe (<2). Segmental Reg-MBF analysis of left ventricular flow showed diffuse hypoperfusion, excluding preferential regional involvement. No correlations were found between Reg-MBF values and neuropsychological performance or cerebral lesion burden, suggesting that neurological and cardiac involvement might be independent in CADASIL.

These data represent the first documentation of coronary microvascular involvement in a group of young and mildly symptomatic CADASIL patients, confirming the systemic nature of the disease. This proof of concept study expands our understanding of genetically-driven CMD.

Funding Acknowledgement

Type of funding source: None

Rates of Amyloid Imaging Positivity in Patients With Primary Progressive Aphasia

Importance

The ability to predict the pathology underlying different neurodegenerative syndromes is of critical importance owing to the advent of molecule-specific therapies.

Objective

To determine the rates of positron emission tomography (PET) amyloid positivity in the main clinical variants of primary progressive aphasia (PPA).

Design, Setting, and Participants

This prospective clinical-pathologic case series was conducted at a tertiary research clinic specialized in cognitive disorders. Patients were evaluated as part of a prospective, longitudinal research study between January 2002 and December 2015. Inclusion criteria included clinical diagnosis of PPA; availability of complete speech, language, and cognitive testing; magnetic resonance imaging performed within 6 months of the cognitive evaluation; and PET carbon 11-labeled Pittsburgh Compound-B or florbetapir F 18 brain scan results. Of 109 patients referred for evaluation of language symptoms who underwent amyloid brain imaging, 3 were excluded because of incomplete language evaluations, 5 for absence of significant aphasia, and 12 for presenting with significant initial symptoms outside of the language domain, leaving a cohort of 89 patients with PPA.

Main Outcomes and Measures

Clinical, cognitive, neuroimaging, and pathology results.

Results

Twenty-eight cases were classified as imaging-supported semantic variant PPA (11 women [39.3%]; mean [SD] age, 64 [7] years), 31 nonfluent/agrammatic variant PPA (22 women [71.0%]; mean [SD] age, 68 [7] years), 26 logopenic variant PPA (17 women [65.4%]; mean [SD] age, 63 [8] years), and 4 mixed PPA cases. Twenty-four of 28 patients with semantic variant PPA (86%) and 28 of 31 patients with nonfluent/agrammatic variant PPA (90%) had negative amyloid PET scan results, while 25 of 26 patients with logopenic variant PPA (96%) and 3 of 4 mixed PPA cases (75%) had positive scan results. The amyloid positive semantic variant PPA and nonfluent/agrammatic variant PPA cases with available autopsy data (2 of 4 and 2 of 3, respectively) all had a primary frontotemporal lobar degeneration and secondary Alzheimer disease pathologic diagnoses, whereas autopsy of 2 patients with amyloid PET-positive logopenic variant PPA confirmed Alzheimer disease. One mixed PPA patient with a negative amyloid PET scan had Pick disease at autopsy.

Conclusions and Relevance

Primary progressive aphasia variant diagnosis according to the current classification scheme is associated with Alzheimer disease biomarker status, with the logopenic variant being associated with carbon 11-labeled Pittsburgh Compound-B positivity in more than 95% of cases. Furthermore, in the presence of a clinical syndrome highly predictive of frontotemporal lobar degeneration pathology, biomarker positivity for Alzheimer disease may be associated more with mixed pathology rather than primary Alzheimer disease.

Nanoclusters of crystallographically aligned nanoparticles for magnetic thermotherapy: aqueous ferrofluid, agarose phantoms and ex vivo melanoma tumour assessment

Magnetic hyperthermia is an oncological therapy where magnetic nanostructures, under a radiofrequency field, act as heat transducers increasing tumour temperature and killing cancerous cells. Nanostructure heating efficiency depends both on the field conditions and on the nanostructure properties and mobility inside the tumour. Such nanostructures are often incorrectly bench-marketed in the colloidal state and using field settings far off from the recommended therapeutic values. Here, we prepared nanoclusters composed of iron oxide magnetite nanoparticles crystallographically aligned and their specific absorption rate (SAR) values were calorimetrically determined in physiological fluids, agarose-gel-phantoms and ex vivo tumours extracted from mice challenged with B16-F0 melanoma cells. A portable, multipurpose applicator using medical field settings; 100 kHz and 9.3 kA m^-1, was developed and the results were fully analysed in terms of nanoclusters' structural and magnetic properties. A careful evaluation of the nanoclusters' heating capacity in the three milieus clearly indicates that the SAR values of fluid suspensions or agarose-gel-phantoms are not adequate to predict the real tissue temperature increase or the dosage needed to heat a tumour. Our results show that besides nanostructure mobility, perfusion and local thermoregulation, the nanostructure distribution inside the tumour plays a key role in effective heating. A suppression of the magnetic material effective heating efficiency appears in tumour tissue. In fact, dosage had to be increased considerably, from the SAR values predicted from fluid or agarose, to achieve the desired temperature increase. These results represent an important contribution towards the design of more efficient nanostructures and towards the clinical translation of hyperthermia.

Selective anti-leukaemic activity of low-dose histone deacetylase inhibitor ITF2357 on AML1/ETO-positive cells

We analysed the in vitro effects of a new hydroxamate derivative, ITF2357, on AML cells. ITF2357 potently induced histone acetylation. ITF2357 0.1 microM blocked proliferation and induced apoptosis in AML1/ETO-positive Kasumi-1 cells, while AML1/ETO-negative HL60, THP1 and NB4 cell lines were sensitive only to 1 microM ITF2357. Apoptosis was induced by 0.1 microM ITF2357 in AML1/ETO-positive primary blasts and U937-A/E cells induced to express AML1/ETO, but not in U937-A/E cells non-expressing AML1/ETO. In Kasumi-1 cells 0.1 microM ITF2357 induced AML1/ETO degradation through a caspase-dependent mechanism. ITF2357 0.1 microM also determined DNMT1 efflux from, and p300 influx to, the nucleus. Moreover, 0.1 microM ITF2357 determined local H4 acetylation and release of DNMT1, HDAC1 and AML1/ETO, paralleled by recruitment of p300 to the IL-3 gene promoter. ITF2357 treatment, however, did not induce re-expression of IL-3 gene. Accordingly, the methylation level of IL-3 promoter, as well as of several other genes, was unmodified. In conclusion, ITF2357 emerged as an anti-leukaemic agent very potent on AML cells, and on AML1/ETO-positive cells in particular. More relevantly, clearly emerged from our results that ITF2357 could be an ideal agent to treat AML subtypes presenting AML1/ETO fusion protein which determine HDAC involvement in leukaemogenesis.

Considerations about the complete resection in NSCLC surgery. Review

The complete resection for NSCLC is analyzed through the study of a series of retrospective surgical reports upon the incomplete resection, due to a microscopic residual tumor at the resection margin. Following Shields' statement in 1974, the incomplete resection represents, in fact, the basic study protocol for the local recurrence following the resection of primary NSCLC. First of all, the obligation for a careful intraoperative pathologic assessment upon the resection margins, clearly emerges from this study. Secondly, two main aspects featuring the incomplete resection have also been pointed out. The first is represented by the historical microscopic residual tumor at the bronchial resection margin, while the second, more recently recognized, is represented by the critical resection margin within the involved ipsilateral mediastinal lymphatic area. The analysis of such different figures leads to different considerations when dealing with the basic matter of the local-regional completeness of resection and the oncological result in terms of cure. In fact, while the problem of the bronchial remnant appears amenable to further improvement by activating the surgical attention, the second, instead, is to be considered unmodifiable by the surgery alone. It basically depends on the extended microvascularity of the large lymphatic mediastinal network which appears to be the crucial factor of risk for such a "lymphatic" resection margin. In conclusion, the matter of complete resection is still open to further research provided that the design is strictly prospective. As a matter of fact, so far the expectation for cure in any apparently completely resected NSCLC is ruled by other well-known factors of prognosis which do not consider the quality of the resected margin at all.

Listening to our clients: a dangerous proposal

Although therapeutic thinking and practice have entered their second century, most practitioners remain largely uncertain as to what data to trust, including "what works" and, "why it works." If anything, practitioners' reliance on ever-increasing numbers of theoretical models and either vague or contradictory research findings as primary guidelines to their practice has added to the confusion. What can the practitioner trust? This paper puts forward the "dangerous proposal" that it is of primary value for clinical professionals to place their trust on an often overlooked variable: the clients' statements about their therapy and their relationship to and with their therapist. It is argued that through the clarification of this variable will emerge a better understanding of the nonspecific variables of the therapeutic relationship itself and, as significantly, of the encompassing interrelational realms of discourse evident in all therapeutic models.

Propagation velocity measurement: autocorrelation technique applied to the electromyogram

Muscle fibre conduction velocity is an important measurement in electrophysiology, both in the research laboratory and in clinical practice. It is usually measured by placing electrodes spaced at known distances and estimating the transit time of the action potential. The problem, common to all methods, is the estimation of this time delay. Several measurement procedures, in the time and frequency domains, have been proposed. Time-domain strategies usually require two acquisition channels, whereas some frequency-domain methods can be implemented using a single one. The method described operates in the time domain, making use of the autocorrelation function of the difference signal obtained from two needle electrodes and only one acquisition channel. Experimental results were obtained from the electromyogram of two biceps muscles (two adult male subjects, nine records each) under voluntary contraction, yielding an average of 3.58 m s(-1) (SD=0.04 m s(-1)) and 3.37m s(-1) (SD=0.03 m s(-1)), respectively. Several tests showed that the proposed method works properly with electromyogram records as short as 0.3 s.

The "Will Rogers effect" on stage grading

Will Rogers phenomenon affects survival statistics applied to clinical research and could determine a misreading of results. Stage migration due to new methods of diagnostic imaging and staging invasive procedures could improve actuarial survival in each stage. TNM System is impaired when survival rates come from different inhomogeneous countries, regions and eras. Randomized trials suffer this fallacious phenomenon when staging depends on the different treatments which are to be evaluated.

The new international staging system for lung cancer. Evolution of the system and concerned remarks

The rationale of the Staging System of Lung Cancer is discussed from his presentation (Mountain, 1985) to the recent revision and proposals of new classifications. Survival rates offered a strong statistical support to the latest revision in 1997. Stage Group have become 7 out of Stage 0 (Tis). In the New Lymph Node Map, station 4 is confirmed as mediastinal (N2). The improved definition of Stage Grouping requires a golden standard of staging and a worldwide consensus on the surgical approach to mediastinal lymphadenectomy. IASLC, the International Association for the Study of Lung Cancer, is now moving to collect a new largest database with the aim to offer the next expected Revision.

Considerations about tumor size as a factor of prognosis in NSCLC

A literature review of the initial attempt to correlate tumor size in NSCLC with the expectancy of survival is presented starting from the 60s. The larger size was connected with an increased risk of metastatic diffusion. In the 70s resulted evident the relationship between tumor size and lymph node involvement so affecting survival. In the context of the TNM Staging System (Mountain 1986) size appeared a well assessed factor of prognosis and is recognised to play a major role in Stage I where the subsets T1N0 and T2N0 showed a consistent difference in survival across the 3 cm cut-off. The peculiar relation between largest size and mediastinal lymph node metastases is discussed as well as the proposal to allocate T2 descriptor within the range 3-5 cm. Finally, series of clinical observations from Japanese experience about small sized T1N0 tumors are presented and discussed.

The invasive staging and the role of complete resection in the surgical treatment of NSCLC

Years of debates couldn't solve the discussion between the NSCLC assessment founded on CT scan and mediastinoscopy as in the Western countries and the refined extensive bronchoscopy, CT imaging and exploratory thoracotomy as practiced in Japan. Recently, the clinical onset of combined therapy protocols, the recognised value of the intrathoracic staging (also in the West) and survival rates in the earlier N2 disease moved towards change this steady situation. The role of complete resection in N2 NSCLC is therefore debated from the preoperative assessment to survival results in resected cases. Accuracy of CT scan and cervical mediastinoscopy is discussed also in the light of neoadjuvant therapy. The clinical value of intrathoracic staging is improved by Japanese experiences while a rationale assessment of Complete/Incomplete Resections is defined. Moreover, technical details of intraoperative recognition are cleared.

[Decubitus lesions in patients referred to acute and post-acute home nursing care for the elderly in Genova]

The Elderly Services of USL 3 "Genovese" together with the team for Continuing Education designed and implemented a survey on the elderly clients referred to the home care and nursing home services. The aim of the study was to describe the frequency, distribution and severity of pressure ulcers. The data were collected during a period of seven months: from 1st November 1997 to 31st May 1998. One thousand seven hundred and twenty nine clients were observed; 705 (41%) had single or multiple pressure ulcers. Patients with multiple pressure ulcers accounted for 42% of the total. The sacrum was the most affected site (43% of the patients with a single ulcer and 33% with multiple ulcers). Patients with severe pressure ulcers (stages 3 degrees and 4 degrees NPUAP classification) accounted for 42% of the total. Pressure sores were observed in 15% of "at no risk" patients and in 40% of those at low risk (Norton Scale score). The study highlighted a lack of documentation (90% patients) on treatments performed in the hospital and prescribed at discharge for the pressure sores. These findings reflects possibly the fact that this aspect of care is unduly disregarded by nursing personnel, and that a goal-oriented retraining, underlining also the need of appropriate documentation, is warranted.

[Adrenalectomy in metastasis of primary pulmonary carcinoma: an emerging issue]

Such a novel surgical project is supported by a large basic knowledge on molecular biology of solid tumours progression as well as the already assessed clinical experience in the parallel field of surgery for lung, brain and liver metastases. While pathology and the clinical work up have for a long time pointed out the steady rate of adrenal metastatic involvement from lung cancer (from 25 to 28% of all cases at the autopsy and, on clinical grounds, the most important site of extrapulmonary tumour spread just after the first one represented by the mediastinal lymphatic groups), the surgical approach to the problem is still very limited and the few operated cases previously reported in world literature (summing up to a total of 21) are not truly homogeneous and even largely scattered in time. The Authors report on their personal contribution in this field with four consecutive cases who underwent surgery during the last five years. The most important clinical features together with the initial remarkable result obtained in one patient who is still free of disease more than 3 years after the sequential radical resection of the primary lung tumour and the metastatic ipsilateral adrenal gland, are presented. In the light of this preliminary positive experience, the Authors are planning a sound clinical research based on the combined resection of those NSC Lung Cancers which appear surgically resectable but already included in an unresectable Stage IV Disease only because of the contemporary adrenal metastases (M1). An adjuvant chemotherapy in usually added.

Resection for peripheral higher stage lung tumor. A compared Italian cumulative experience

Preceded by an international overview on the surgical approach to the peripheral higher stage NSCLC, the cumulative clinical experience from ten Italian University Departments and Teaching Hospitals, is analyzed in the light of the corresponding international contributions. Accordingly, the clinical records of 470 patients affected by such Stage III tumors and surgically treated, were collected and retrospectively reviewed. 43 out of 120 patients belonging to the group of apical invasive Pancoast's tumour underwent an en-bloc chest-wall resection, while an extrapleural dissection was performed in the remaining 77. Combined segmentectomy was prevalent (54%), while lobectomy/bilobectomy was performed in 38%, wedge resection in 5% and pneumonectomy in 3% of all cases respectively. Preoperative high-voltage radiation was given in 70% of them; while adjuvant RT was requested in 17% of cases, mainly because of N1-2 status. Actuarial 5-year survival was 14% with a range of 0% in N2 cases to 21% in NO-1 ones. When considering surgical modes, the en-bloc chest-wall resection had a 5-year survival of 20% while the more limited extrapleural dissection yield only a 9% survival. Compared with the international experience the 14% 5-year survival is standing at the bottom of the scale. On the other hand, 350 patients belong to the other two main groups of peripheral tumors taken in consideration: the ones which, even apical, are yet lying anteriorly far enough from the costo-vertebral angle (apical non Pancoast tumor), and the other ones which are lower placed along the thoracic cage. The majority of these patients (213) were treated by an extrapleural dissection, while the remaining minority (123) received an en-bloc chest-wall resection with 1-2 ribs resected in 46%, 3 ribs in 38% and 4 ribs or more in 16%, respectively. Combined lobectomy/bilobectomy was prevalent (64%), while pneumonectomy was performed in 16%, more limited resections in 16% and exploration alone in 4% respectively. 5-year survival was 18% ranging from 0% in N2 patients to 23% in the NO-1 ones. The extrapleural dissection had a 5-year survival rate of 24.5%, while the en-bloc chest-wall resection yield a lower rate of 15.6%. This overall survival can be indeed considered nearer the international one, even if both surgical approach and the related 5-year survival rates are in full discordance with the compared international references.

[TNM staging system of lung carcinoma: historical notes, limitations and controversies]

The TNM System as originally proposed by Denoix in 1946, provides a consistent, reproducible description of the anatomic extent of disease in cancer patients at a specific time in the life history of the cancer. C.F. Mountain first adapted this classification to lung cancer in 1973 on behalf of AJCC. In 1986 he presented the "New Intl. Staging System for Lung Cancers" mainly based on a 13 yr experience of the previous one, which was accepted world-wide through a round of international consensus meetings held in 1985. Clinical Staging is the best estimate of disease extent made prior to the institution of any therapy; Surgical-pathological Staging is the classification of disease extent as determined from pathological examination of resected specimens. Accordingly, once the diagnosis is made, it is necessary to stage accurately the tumour determining the size and location of the tumour (T status), the presence or absence of lymphnode involvement (N status), and whether the tumour is metastatic to distant sites (M status). Moreover the uniform staging criteria for lung cancer will assure for each patient the better selection of treatment, the evaluation of operability, the need for adjuvant therapy, as well as the estimation of prognosis. Equally important is the resultant ability to compare the outcome of treatment protocols from different centres. More recently C.F. Mountain has added to the Staging System a new standard logic or "convention" for classifying infrequently observed presentations of lung cancer with which the standard rules of Staging System itself don't fit. These conventions are based on empiric expectation for treatment selection and survival that are similar to those for the Staging definitions, which are based on actuarialsurvival data. Many different types of tumour such as multiple masses, synchronous multiple primitives, discontinuous tumour foci in visceral or parietal pleura as well neoplastic involvement of various mediastinal structures, could be now staged with a major benefit for their treatment protocols. In conclusion the Staging System represents today a standard clinical methodology which basically helps in a better clinical approach to lung cancer even if it cannot fully cover and consider all the innumerable manifestations of the tumor. Therefore, if it is true that in the near future the new molecular predictors of prognosis are expected to measure more deeply the extent of disease, for the present time the International Staging System still continues to act as the best common method for measuring prognosis.

[Lobar bronchoplasty for tumor. Surgical technique and long-term results]

Between 1978 and 1994, 55 patients (53 men and 2 women) with a mean age of 62 years underwent an extended lobectomy to the main bronchus, with bronchial re-anastomosis, for bronchogenic tumours located around the lobar orifice. There were 32 upper sleeve lobectomies (58%) with a wedge resection of carina in one instance, 7 lower mono/bilobectomies with an upper lobe "turn up" re-anastomosis (13%) and 16 upper wedge lobectomies (29%). Squamous cell carcinoma was predominant (32 patients, 58%), while the adenocarcinoma was present in 16%, adenosquamous in 5%, microcitoma in 9%, carcinoid in 4% and a well differentiated neuro-endocrine carcinoma in 2%. The indication for the bronchoplastic procedure was judged to be when the FEV, value was about -25% of the normal; in a few patients still in good respiratory condition, an elective indication was also admitted. Postoperative staging was: Stage 0 in 1 patient, Stage I in 7 patients; Stage II in 10 patients; Stage III A in 31 patients; Stage III B in 5 patients and Stage IV in 1 patient. Follow-up was completed with a mean extension of 40 months (range 3 months-16 years). There was no operative mortality in Stages I and II as well as in Stages III B and IV, while it was 9% in Stage III A patients. Survival rates according to the stage were as following: 66% 5 and 10 year for Stage I disease; 56% 5 year and 45% 10 year for Stage II disease; 7% 4 year for Stage III A. None of 5 patients belonging to Stage III B has survived for more than 18 months (mean 7). Some single survivals are mentioned because of their special clinical features. Besides stressing the absolute value of survival rates obtained in Stage I and II disease, the Author also point out the clinical role of these advanced surgical techniques in improving both the survival length and the quality of life, when applied for the treatment of more advanced Stage III A.

[Artificial blood. Experimental studies on fluorocarbons as chemical blood substitutes]

Fluorocarbonates are organic compounds capable of carrying oxygen and surrendering it to tissues by means of biological sound modalities. Experimentation of an emulsion consisting of perfluorotripropylamine and perfluorodecaline (Fluosol DA 20%) as a blood substitute is reported. Acute (Ht less than 1%) and chronic morphological (Ht = 15%) studies were performed on rats, and a semi-acute biochemical and morphological protocol (Ht = 21%) was experimented in pigs. The first signs of altered cerebral electrical activity occurred at Ht = 2% in the acute experiments, and death due to respiratory arrest took pace at Ht = 0.5%. In the semiacute and chronic experiments, widespread infiltration of fluorocarbonic micelles was noted on histological and electron microscope lung and liver preparations.

Morphological evaluation of the human umbilical vein graft. An experimental study

23 human umbilical vein segments (5 mm X 4-5 cm) were implanted into the carotid and iliac arteries of 15 dogs, removed at intervals ranging from 10 to 360 days after surgery and analyzed by light and scanning electron microscopy. 10 days after implantation, a thin layer of fibrin covered the central areas of the grafts, while thick platelet aggregates were found near the anastomoses. After 30 days, the progressive connective tissue ingrowth led to the organization of a thin fibrous inner layer on which endothelial-like cells grew, spreading from both anastomoses. The endothelialization process appeared to be almost complete at 120 days after implantation, while at 360 days the flow surface was totally lined.

Scanning electron microscopy evaluation of porous and nonporous arterial substitutes

The fate of two different kinds of new small arterial substitutes, porous and nonporous, has been compared, particularly with regard to the structure of the luminal surface. Twenty-eight weavenit Dacron pyrolytic carbon coated grafts and 28 glutaraldehyde-tanned human umbilical vein segments were implanted into the carotid arteries of dogs. Grafts were removed at intervals, from ten to 120 days after implantation, and examined by scanning electron microscopy. The cumulative patency rate was 96.4 per cent for Dacron and 85.7 per cent for umbilical vein grafts. Ten days after implantation, the Dacron grafts were uniformly covered by a thin thrombus layer, while the umbilical vein grafts showed a thin network of fibrin on the central portion of the luminal surface of the graft and thrombotic deposits at the anastomoses. Thirty days after implantation, both types of prostheses showed the development of a thin fibrous tissue layer on the inner surface. Finally, at 120 days, an endothelial lining was observed.

[Experimental research on the use of fluorocarbon compounds (FC 43) as blood substitutes]

The authors have experimented a fluorocarbon compound (FC 43) in form of a stable emulsion (20%), in the presence of a suitable surfactant agent (Pluronic F 68: 2,5%), as an hematic substitute. The animals (fifteen rabbits) underwent substitution of 50% of the total hematic volume with same volumes of the emulsion and thereafter have been examined for a period of twenty-four hours. During the time of observation there were no changes on: 1) acid-base equilibrium; 2) respiratory homeostasis and 3) major circulatory parameters.

[An experimental investigation of the use of a fluorocarbon (FC 43) as blood substitute]

A fluorocarbonate emulsion was infused into 30 rabbits after the removal of varying amounts of blood. Parameters relating to the transport of respiratory gases and the fundamental features of the macrocirculation were monitored. The animals were sacrificed after 6 or 24 hr and the histological changes in the main parenchymas were assessed. The material injected displayed low toxicity, a good ability to act as a vehicle for oxygen and carbon dioxide, and no tendency to alter the macrocirculation. Numerous problems remain, however, with regard to the stability of fluorocarbonates over the course of time and the effect of their uptake by tissues.

[Parenchymal morphology after oxygenated alveolar lavage (L.A.O.) with liquid fluorocarbons]

A series of experiments was carried out to determine histological damages in rabbit's lung, liver, kidney and brain after oxygenated alveolar lavage (L.A.O.).

[Mixed aorta-popliteal by-pass: a new proposal for the treatment of extensive ilio-femoral obstruction]

The nosological polymorphism of peripheral arterial obstruction (A.O.P.) continuously requires new surgical techniques of vascular repair. This led the AA. to develop a new composed aorto-popliteal by-pass. It consists of a proximal (aorto-femoral) synthetic segment (Dacron D.V.) which is distally anastomozed to a biological (Meadox-Dardik Biograft) femoral-popliteal segment. Indications for aorto-popliteal by-pass, technical problems, patient selection and results are here discussed.

[Oxygenating intra-alveolar lavage (OAL) with the use of some new fluorinated compounds]

Certain fluorinated carbonate compounds can carry O2 and CO2 in a physiological manner. This faculty was exploited in the elaboration of an experimental intra-alveolar oxygenating washing protocol employing such compounds as intrapulmonary oxygenating liquids conveyed by transtracheal flooding of the alveoli in 20 rabbits. AP, PaP, CVP and EP were monitored in accordance with a 35' protocol, during which the positive oxygenation and negative emptying phases of the washing process were repeated at an average 2 cycles/min. A respiratory exchange capable of keeping all the animals alive until the recommencement of spontaneous ventilation was noted, along with only slight changes in lung structure. Once an in-depth study is made of certain fundamental phenomena related to structure and lung function, it is felt that this washing method can be used clinically for the treatment of hypoxaemic situations in which normal alveocapillary exchange is impeded by extraneous material, as in desquamative interstitial pneumonia, pulmonary alveolar proteinosis, etc.