Radiofrequency ablation for single lung tumours not suitable for surgery: seven years' experience.

PURPOSE: This study was done to review recurrence patterns in patients with lung cancer (primary or secondary) treated with percutaneous image-guided radiofrequency (RF) ablation. MATERIALS AND METHODS: From January 2003 to August 2010, 32 patients (24 with primary non-small-cell lung cancer and eight with metastases) with single lung cancer were treated with RF ablation. Post-treatment imaging results were available for each patient. Follow-up was performed using computed tomography (CT) scans at 1, 3, 6, 12, 18 and 24 months after the procedure and annually thereafter. Patterns of recurrence were classified as local, intrapulmonary, nodal, mixed and distant. We evaluated overall survival after RF ablation and the factors associated with recurrence. RESULTS: Seventeen (53.1%) patients showed no evidence of recurrence at follow-up imaging (range 12-72 months; mean, 32.5 months). Recurrence was seen in 15 (46.9 %) patients (range 6-36 months; mean 14.8 months). Local recurrence (40%) after RF ablation was the most frequent. Median disease-free survival was 20 months. Sex, tumour location, tumour size and tumour stage were not associated with a risk of recurrence. Patient age was related to the risk of recurrence (p<0.05). CONCLUSIONS: Local recurrence is the most common pattern in our series. A more aggressive initial RF ablation might offer improvement in outcomes, but this hypothesis needs to be confirmed by larger studies involving a larger number of patients.

Suprarenal inferior vena cava filter implantation.

PURPOSE: This study evaluated the feasibility, safety, and efficacy of the suprarenal implantation of a retrievable filter in patients with renal cell carcinoma (RCC) and renal vein thrombosis (RVT) [extending or not extending to the inferior vena cava (IVC)] undergoing surgery. MATERIALS AND METHODS: Between March 2005 and May 2010, 13 patients (eight men and five women; mean age 67.08 years, range 38-95) with RCC and RVT associated or not with IVC thrombosis underwent implantation of a retrievable suprarenal IVC filter. All patients underwent computed tomography angiography (CTA), which documented RVT and in some cases its extension to the IVC. The level of IVC involvement by the neoplastic thrombus was evaluated on the basis of the Oto classification. Cavography was performed before and after filter implantation. Surgical resection of RCC was performed in all patients. A CTA scan was performed 1 week before filter removal. RESULTS: The procedure had 100% feasibility. All filters were correctly deployed in the suprarenal tract of the IVC. There was no evidence of peri-or postprocedural complications. All patients were monitored for clinical symptoms of pulmonary embolism (PE). There was no evidence of PE in the 30 days after the procedure. All suprarenal IVC filters were removed from 30 to 60 days after surgery. CONCLUSIONS: Implantation of a temporary suprarenal IVC filter is an additional and feasible procedure that can prevent immediate and perioperative PE.

Upper urinary tract biopsy: an old device for a new approach.

PURPOSE: The authors sought to evaluate the feasibility, diagnostic accuracy and safety of urological biopsy performed using a flexible alligator forceps. MATERIALS AND METHODS: Twenty-seven patients with suspected urothelial malignancy underwent retrograde biopsy using a 7-F biopsy forceps (Cordis, Miami, FL, USA). Mild sedation was guaranteed by an anaesthesiologist. The final diagnosis was confirmed by cytohistological data and subsequently by pathology findings at surgery. Lesions with benign histopathology were closely monitored for at least 12 months. RESULTS: The technical success rate was 92.6%. The high diagnostic accuracy was related to the positive correspondence between histological outcomes and surgical results or follow-up observations. As regards sample site, the procedure was less successful in calyceal lesions than in lesions located in the upper urinary tract, with a technical success of 71.43%. Twenty patients had asymptomatic haematuria in the early hours after the procedure; ten of them had mild dysuria. No one require medication, and no major complications occurred. CONCLUSIONS: Urological forceps biopsy is a safe and easy procedure. It provides a relatively high level of accuracy in the diagnosis of lesions of the upper urinary tract.

Endovascular treatment of ruptured abdominal aortic aneurysms: aorto-uni-iliac or bifurcated endograft?

PURPOSE: This study evaluated the safety and technical and clinical success rates of positioning endovascular endografts (EG) in ruptured abdominal aneurysms. MATERIALS AND METHODS: Patients with a ruptured abdominal aortic aneurysm confirmed by contrast-enhanced computed tomography angiography (CTA) were eligible for the analysis. Of 67 patients, 42 (62.7%) were treated with EG. Thirteen patients (30.9%) received an aorto-uni-iliac EG (group A) and 29 a bifurcated EG (group B). Patients were divided for comparative analysis according to the configuration of the EG implanted. RESULTS: The primary technical success rate was 100%; the primary clinical success rate was 95% (40/42). There were two intraoperative deaths (4.7%) related to intractable shock. No patient required conversion to open repair. Overall, 12 patients (28.5%) died within 30 days. The in-hospital death rate was 30.9% (13/42). Hospital mortality rate was statistically higher in group A; the type of EG and intensive care unit admission were the only independent predictors of hospital mortality. CONCLUSIONS: In our experience, a higher mortality rate was observed for the aorto-uni-iliac configuration; shock at admission was confirmed as the most important factor for postoperative survival.

Complications of microwave and radiofrequency lung ablation: personal experience and review of the literature.

PURPOSE: Complications correlated with percutaneous radiofrequency ablation (RFA) and microwave ablation (MWA) of lung tumours were retrospectively reviewed to compare them with data from the literature and to assess risk factors related with the procedures. MATERIALS AND METHODS: From January 2003 to January 2009, 29 patients (36 lung lesions) were treated with RFA; from January 2007 to January 2009, 16 patients (17 lung lesions) were treated with MWA. Complications recorded at our institution are reported following the Society of Interventional Radiology guidelines. A systematic review of the literature was performed. RESULTS: Any major complication of RFA or MWA was recorded. In agreement with the literature, pneumothorax was the most frequent complication, even though the incidence in our series was lower than reported in the literature (3.5% vs. 4.3-18%). Other complications of RFA were pleural effusion and subcutaneous emphysema. No massive haemorrhages, haemoptysis, abscesses, pneumonia, infections or tumour seeding were recorded in our series. The most common complication of MWA was pneumothorax (25% vs. 39% reported in the literature). Pleural effusion was a common reaction, but therapeutic drainage was never required. CONCLUSIONS: Pneumothorax is the most common complication of both techniques. RFA and MWA are both excellent choices in terms of safety and tolerance.

Effects of paracetamol and propacetamol on gastric mucosal damage and gastric lipid peroxidation caused by acetylsalicylic acid (ASA) in rats.

We have studied the effect of paracetamol and its pro-drug propacetamol on gastric mucosal damage induced by acetylsalicylic acid (ASA) and its possible relation to changes in gastric lipid peroxidation status in rats. Paracetamol or propacetamol were administered intragastrically 1h before ASA (300 mg kg(-1)) in the following equivalent doses: 62.5, 125.0 and 250.0 mg kg(-1) or 125.0, 250.0 and 500.0 mg kg(-1), respectively. The effects of the tested agents were compared to that of prostaglandin E2 (PGE2) 15, 30 and 60 mg kg(-1). Gastric ulcer formation was estimated morphometrically 4h after ASA administration. Malondialdehyde (MDA), glutathione (reduced, GSH, and oxidized, GSSG) and uric acid (UA) were determined in gastric mucosa and blood plasma and used as biochemical markers of the oxidative status. The results showed that paracetamol (250, 125, 62.5 mg kg(-1)) and propacetamol (500, 250, 125 mg kg(-1)) diminished the area of ASA-induced gastric lesions. The effect of propacetamol was more pronounced than that of paracetamol and similar to that of PGE2. Gastric MDA increased 3-fold in the ASA-group. The tested agents reduced it by a range of 30-70%. In all pretreated groups gastric glutathione and UA levels were found higher than that of control group and lower than that of ASA-group. Paracetamol and propacetamol, as well as PGE2, diminished the lipid peroxidation in plasma to a lesser extent than in gastric mucosa, but maintained elevated levels of the selective plasma antioxidant UA. These results show that the ASA-induced gastric mucosal damage is accompanied by the development of oxidative stress, evidenced by the accumulation of MDA, and concomitant initial activation of cell antioxidant defences. As paracetamol and propacetamol tend to decrease gastric lesions caused by ASA and alter gastric mucosal MDA, glutathione and UA values in a favorable manner, it could be suggested that their effects on the gastric mucosa could be related to interference with oxidative stress development.

Biphasic waveforms for automatic external defibrillation in human: a review.

Ventricular fibrillation is the principal cause of sudden cardiac arrest and the electrical defibrillation is often the only effective therapy. A very interesting question is represented by the electric parameters of defibrillation shock. Today, monophasic waveform is widely used in Europe and in the United States, but, recently, the Food and Drug Administration grants approval for an automatic external defibrillator (AED) producing a biphasic pulse. In this review we discuss about the effectiveness and the safety of biphasic waveform, by examining a series of human studies between 1982 and 1999. We have found that available data are often incomplete, unclear, dishomogeneous and, consequently, difficult to compare. Furthermore, among the authors there is no concordance about the meaning of "safety", "effectiveness", "success", "equivalence" and "superiority" of biphasic versus monophasic shock: however, biphasic shock, that uses a lower energy level, seems to reduce post-defibrillation heart damage. Due to the lack of homogeneous studies it is not possible to state which kind of signal is more reliable, even if some clinical reports and experimental data seem to tribute to the biphasic waveform a better therapeutic effectiveness and safety. By examining the current scientific literature, we conclude that further studies have to be performed to definitively validate the use of biphasic shock.

Ketorolac for paediatric postoperative pain. A review.

Ketorolac, a nonsteroidal anti-inflammatory drug (NSAID) largely used in adults, deserves particular attention for postoperative pain therapy in children, even if it is not officially approved for paediatric use. We have examined a lot of studies about the use of ketorolac for paediatric postoperative pain, pointing out pharmacological and pharmacokinetic properties and side effects. There are significant differences in pharmacokinetic parameters, doses, routes of administration, length of treatment, side effects, usage precautions and pharmacological interactions between children and adults. Amongst the many drugs available, ketorolac seems to be particularly efficient for postoperative pain therapy in children too.

Gastroprotective effect of propacetamol against cold/restraint stress ulcers in rats.

BACKGROUND: Comparative evaluation of propacetamol and morphine on the cold restraint stress ulcers in rats. METHODS: The present study compared the effects of propacetamol hydrochloride (250 and 500 mg.kg-1 i.p.) and morphine hydrochloride (10 mg.kg-1 i.p.) against gastric mucosal damage induced by cold/restraint stress (4 degrees C for 3 h) in rats. Morphometrical and histomorphological studies were carried out. Mean ulcer number and length were calculated. RESULTS: The results show that propacetamol in the lower dose tested decreases the ulcer number and length by 56.4% (p > 0.05) and by 68.94% (p < 0.01). After propacetamol 500 mg.kg-1 the ulcer number and length were found significantly decreased by 74.83% and 83.5%. Marked decrease was found in morphine-pretreated group (-77.03% and -85.09%). The morphometrical results have been confirmed histomorphologically. CONCLUSIONS: It might be concluded that morphine (10 mg.kg-1) and propacetamol (500 mg.kg-1) are equipotent in their ability to prevent the stress ulceration in rats.

Electric nerve stimulation: analysis of two clinical cases of failed nerve electrolocation by using sheathed needles.

The aim of this work was to explain the reasons of two unsuccessful blocks of sciatic nerve even if anaesthetic solution was injected through insulated needle on elicited twitch. The clinical cases were two outpatients undergoing diagnostic arthroscopy of knee under anaesthetic block of sciatic and femoral nerves. In both patients, the muscular twitch appeared when the ischiatic bone was kept in unexpected touch with needle tip. In spite of the attempt to locate correctly the needle (the touch with bone means that the nerve is not in front of the needle tip), the injection of anaesthetic solution was unsuccessful. In clinical environment, when electroinsulated needles gathered total amount of administered current on the needle tip, it was not possible to elicit a twitch just at the moment of touch of the needle with the bone. Referred events disagree with some experimental works performed out of clinical environment, which found that total amount of administered current through an insulated needle gathers always in front of the tip. Our clinical observations seems to confirm an electrolocation mistake called "electrical shadow". The ability of sheathed needles to work as occasional capacitor due to the alternation of two conductor layers (needle shaft and tissue) and of a dielectric (coating material) can explain some missing electrolocations, as the appearance of electric fields within dielectric needle sheathing.

Electric nerve stimulation (ENS): 70 clinical cases of bi-block aided by an electric bipolar signal.

INTRODUCTION: The practice of local anaesthesia aided by ENS, among other things, is based on the use of available electric signals searching peripheral nerves. Most electric generators produce a square monopolar signal that is potentially dangerous because it exists a risk of hyperpolarization damage with neural lesions by galvanic effect. AIM: To inform about the use of a bipolar signal, different than the usual square monophasic signal. In theory a bipolar signal prevents the risk of hyperpolarization by lessening average intensity of current crossing the tissues. METHODS: Our experience is based on 70 clinical cases of bi-block performed by searching the nerve by using an electric bipolar signal to locate a peripheral nerve. RESULTS: Local anaesthesia can be successfully performed by using bipolar electric signals not currently employed. In 2/70 patients it was needed to perform surgery under general anesthesia. The rate of successful blocks was similar to the results of current literature. DISCUSSION AND CONCLUSIONS: Most authors search peripheral nerves by square monophasic signals. It arrives because it's widely believed that a square signal is advantageous because of high ratio di/dt (intensity/time). Today, it's not assessed in clinical practice that an electric signal is deeply modified in its parameters and its form by capacitive and resistive properties of the human body.

Respiratory dysfunction related to diaphragmatic shoulder pain after abdominal and pelvic laparoscopy.

Many recent studies registered respiratory dysfunction after laparoscopic surgery; it is well known that the stimulation of the diaphragmatic tendon centre produces a typical shoulder pain. We hypothesize that diaphragmatic tendon centre stress causes postlaparoscopic ventilatory alterations; the aim of this study was to verify whether clinically respiratory dysfunction and shoulder pain relationship exists, after laparascopy with or without contemporaneous stimulation of gallbladder area. So we evaluated, preoperatively and 24 hours after the operation, 20 patients undergoing laparoscopic cholecystectomy (CP), 20 gynaecological patients undergoing laparoscopic ovarian surgery (GP) and 20 control patients undergoing orthopaedic limbs operations (OP) by pulmonary function tests, using computerized spirometry. Diaphragm referred pain was assessed for location and intensity. No orthopaedic patient showed postoperatively pain or pulmonary dysfunction demonstrating that the typical postlaparoscopic restrictive pattern is independent of general anaesthesia. In the CP and GP groups postoperative pulmonary functions were significantly reduced if compared with the orthopaedic control group but not significantly different between them. Moreover, 8 patients from the CP group and 13 from the GP group referred diaphragmatic pain: they showed significantly greater reduction of pulmonary function in comparison with the patients without pain in the respective groups. We conclude that diaphragmatic dysfunction after pneumoperitoneum, and not gallbladder area stimulation, seems to play the most important role in the pathogenesis of both shoulder pain and respiratory restrictive abnormalities after laparoscopy.

[A method of image enhancement in the use of hydrosoluble uro-angiographic contrast media]. / Un metodo di ottimizzazione dell'immagine nell'impiego di mezzi di contrasto idrosolubili uro-angiografici.

The radiographic contrast, when using hydrosoluble uro-angiographic contrast media, depends on several factors. A phantom and a new method are proposed to assess and optimize the contrast. The phantom allows to simulate three pseudovessels with diameter of 2 mm, 5 mm, and 10 mm, placed in a water-equivalent layer of 20/cm thickness. The phantom is exposed to a photon beam produced by a conventional X ray tube, and the images are obtained using conventional screen film system. The aim of the study is to assess the radiographic contrast between the vessel and the background when modifying the optical density of the radiograph (by different settings of the mAs switching), the X-ray tube high voltage and the diameter of the vessels; the contrast was studied with four different contrast media (Uromiro 24%, Conray 36%, Iopamiro 300 and Iomeron 400) and three X-ray tube high voltages (60 kV, 80 kV, 100 kV). The curve fitting the contrast as a function of the optical density of the background (in each condition of high voltage, diameter of the vessel and contrast media used) is a parabola. A quite narrow distribution of abscissas of the maxima of the parabolas was found, ranging from the minimum optical density 1.21 in the case of 100 kV high voltage and 2 mm diameter to the maximum optical density 1.58 in the case 60 kV and 10 mm. The mean value (1.40) is proposed as the optical density of the background optimizing the contrast according to the screen-film system used. In conclusion, the authors suggest to optimize the use of contrast media, trying to obtain radiographs with an optical density approaching the optimal value in any clinical situation. Therefore tables of the settings of the X-ray tube and generator are required; the tables must take into account the main parameters influencing the settings, such as the source-film distance, the water-equivalent thickness of the patient and the film-screen system used.

Electromyographic signal frequency analysis in evaluating muscle fatigue of patients with peripheral arterial disease.

Peripheral arterial disease (PAD) patients are commonly classified on the basis of subjective evaluations of pain and fatigue. Surface electromyography (EMG) is an objective method for studying peripheral muscle fatigue. Fifteen patients with PAD and 15 healthy volunteers matched for age and sex were studied. Surface EMG was recorded over the medial gastrocnemius during 100 seconds at 60% of maximal effort. EMG traces were analyzed off-line to obtain the power spectrum. The median frequency was calculated in the first 30 seconds (T0) and between 70 and 100 seconds (T1). Significantly lower T1 values, compared with T0, were found in both the PAD and the control groups (p < .005; p < .05). T0 values were not different between group, whereas T1 values were significantly lower in PAD patients (p < .01). EMG frequency analysis can be considered an easy, painless method providing objective information on muscular performance and fatigue in PAD patients.

[Rationalization of transfusional therapy in elective surgery. Our experience]. / Razionalizzazione della terapia trasfusionale nella chirurgia di elezione. Nostra esperienza.

The paper reports the authors' experience regarding the rationalisation of transfusional therapy. The high risks of infection or damage to the immune system have highlighted the need to review the approach used by the anesthetist, surgeon or hematologist resulting in major cultural changes and the development of methods for the use of autologous blood. The study was carried out by comparing 2 similar periods of surgical activity in which the sole variant was the different attitude of the anesthetist who utilised blood transfusion on the basis of pre, intra and postoperative hematocrit values; in addition, the Authors report the results obtained in a group of patients enrolled for EIN. They observed that by using simple rationalisation a 30% saving, equivalent to 101 blood units, was achieved; EIN was performed in 20 patients out of the 32 enrolled with an effective 20% saving equivalent to 40 units; calculating the theoretical saving which could be obtained by total EIN and rationalisation, a saving of as much as 58% equivalent to 198 units could be achieved. Even if many aspects still require definition, good rationalisation, even using simple techniques, coupled with the availability of autologous blood certainly makes blood transfusion safer and less expensive.

[Chronic progressive obliterating arteriopathy and muscle fatigue: the role of frequency analysis of the electromyographic signal]. / Arteriopatia obliterante cronica progressiva e fatica muscolare: ruolo dell'analisi in frequenza del segnale elettromiografico.

Clinical evaluation of patients with peripheral arterial disease (PAD) is mainly based on Fontaine's classification, in which pain is the most important element. The use of objective techniques can allow a more precise evaluation, since pain is always subjective. In PAD patients, pain is frequently associated with early fatigue. Peripheral muscle fatigue can be easily assessed by a particular electromyographical method, based on the frequency analysis of the signal. In PAD patients, this method can provide objective information on muscular performance, with possible uses in medicine, surgery, rehabilitation and occupational medicine.