Interventional management of recurrent malignant pleural effusion: state of the art in 2021.

OBJECTIVE: This narrative review aims to describe and compare different interventional methods for the management of recurrent malignant pleural effusion and offers perspectives for the future era. BACKGROUND: Dyspnea as a result of the recurrent malignant pleural effusion is one of the main factors decreasing the quality of life in patients with oncologic diseases. To date, there is no strict guideline for the management of malignant pleural effusions. RESULTS: Several different techniques are available to prevent production of the effusion or to provide intermittent drainage, however, the principle of these methods remains palliative. The choice of treatment in any patient depends mainly on the preferences of the patient, speed of the fluid production, expandability of the lung, and predicted survival of the patients. The interventional methods of managing malignant pleural effusions are described in detail, including thoracocentesis, chemical pleurodesis, talc poudrage pleurodesis, slurry pleurodesis, thoracoscopic procedures, indwelling pleural catheters, implantable pleural ports, and pleuroperitoneal shunting. CONCLUSION: Pleurodesis and fully implantable devices such as pleural ports may become the most useful techniques in the future, mainly because of better comfort for the patients and no need for repeated pleural punctures (Ref. 55).

Association of apelin and AF in patients with implanted loop recorders undergoing catheter ablation.

BACKGROUND: Previous studies showed an association between apelin and atrial fibrillation (AF). The aim of this study was to analyse the effect of pulmonary vein isolation (PVI) in patients with paroxysmal AF on plasmatic apelin concentrations. METHODS: Nine consecutive patients (aged from 43 to 69 years, 3 females and 6 males) with documented paroxysmal atrial fibrillation and implanted loop recorders (ILR) for continuous ECG monitoring were included in this study. All the patients underwent a radiofrequency catheter ablation with PVI. RESULTS: The plasmatic concentration of apelin increased after PVI. The average plasmatic concentration of apelin before PVI was 0.299 ng/ml (±0.16), 3 months after PVI 0.462 ng/ml (±0.10) and 9 months after PVI 0.565 ng/ml (±0.146). There was an increase in the concentration of apelin 3 months and 9 months after the PVI by 0.163 ng/ml (p=0.07) and by 0.266 ng/ml (p=0.01), respectively. The concentration of apelin inversely correlated with the AF burden (r=-0.44, p=0.03). CONCLUSIONS: Our study showed a significant increase in apelin levels after the reduction of AF burden via PVI and an inverse correlation with AF burden. Apelin might be a promising marker of AF (Tab. 2, Fig. 2, Ref. 28).

Surgical conditions with rocuronium versus suxamethonium in cesarean section: a randomized trial.

BACKGROUND: Onset times and conditions for intubation after rocuronium versus suxamethonium at cesarean section have been evaluated, but no study thus far has examined the influence of these neuromuscular blocking drugs on the surgical conditions or their effect on the duration of surgery and the ease of fetal delivery. We aimed to compare the surgical conditions for delivery in parturients who received deep neuromuscular block with rocuronium with those who had induction with suxamethonium. METHODS: Ninety patients undergoing cesarean section under general anesthesia were randomized to receive either rocuronium 0.6 mg/kg or suxamethonium 1 mg/kg for tracheal intubation and delivery. Times to delivery and the quality of surgical conditions, using a five-point Surgical Rating Scale for Delivery (SRSD) ranging from 1 (poor) to 5 (excellent), were evaluated. RESULTS: The median SRSD (range) was found to be significantly better in the rocuronium group [4 (3-5) points vs 3 (2-4) points with suxamethonium (P <0.001)]. Whereas the mean (SD) induction-to-intubation interval was longer with rocuronium [106 (34) s vs 68 (32) s with suxamethonium (95% CI of the difference 24 to 52 s, P <0.001)], the incision-to-delivery interval was shorter in the rocuronium group [147 (68) s vs 196 (51) s with suxamethonium (95% CI of the difference -75 to -24 s, P <0.001)]. The mean induction-to-delivery intervals were similar [268 (73) s vs 276 (63) s, respectively]. CONCLUSIONS: Whereas the induction-to-delivery intervals were comparable, we found rocuronium superior to suxamethonium in allowing better surgical conditions for fetal delivery, which enabled an easier delivery and a shorter incision-to-delivery interval.

Analysis of hemocoagulation tests for prediction of venom-induced consumption coagulopathy development after Viperidae bite.

OBJECTIVE: Viperidae snakes are responsible for 95 % of the bites caused by exotic-bred snakes in our country. Their envenoming may be associated with a severe acute coagulation disorder - venom-induced consumption coagulopathy (VICC). Thus, its early prediction is vital for an adequate therapy including antivenom delivery. MATERIAL AND METHODS: Laboratory coagulation tests of 14 patients suffering from VICC were processed and statistically analyzed to evaluate the importance of individual parameters in the time after the bite. RESULTS: The pathological values of D-dimer (D-dim) and fibrinogen (FBG) were found to be the first indicators of VICC development, with a median time of 4.55 hours since the bite, while median values for prothrombin time and international normalized ratio (PT/INR), activated partial thromboplastin time (APTT), and thrombin time (TT) were 5.9 h, 8.15 h, and 5.5 h, respectively. In the first samples, the values of D-dim were found to be pathologically increased in all 14 patients, while pathological levels of FBG were seen only in 11 cases. PT/INR and APTT were prolonged in 8 and 6 cases, respectively. CONCLUSION: An increase in D-dim values was found to be the first parameter signaling developing VICC in all analyzed cases (Tab. 2, Ref. 12).

[Identifying the Importance of MT-3 Expression for Neuroblastoma Cells]. / Identifikace významu exprese MT-3 pro bunky neuroblastomu.

BACKGROUND: Resistance of cancer cells to cytostatics is caused by a number of mechanisms that are often combined. These include reduced cell entry or increased efflux, increased DNA repair, defects of, apoptotic pathways, increased cytostatic degradation as well as elevated levels of intracellular thiols of glutathione and metallothioneins (MT). It has been reported that high concentrations of thiol groups in the cytoplasm bind platinum alkylation derivatives and chemorezistence is due to the transfer of platinum from the cytostatic to MT, which inactivates them. Because we have shown an increase in MT levels in resistant neuroblastoma (NB) lines, but not in sensitive lines after incubation with platinum cytostatics, we have considered MT-3 for NB cells in our previous studies. METHOD: SiMa NB cell lines transfected with vector containing human MT-3 and GFP or GFP only (control). Expression Microarray Human Cancer 3711 ElectraSense medium density 4 × 2k array slides with 1,609 DNA probes (Custom Array, Bothell, WA, USA), MT-3 expression and most expressed genes validated by real-time polymerase chain reaction. Sensitivity to CDDP (cisplatin) - MTT assay, clonogenicity test, Western blott caspase cleavage and free oxygen radicals fluorescence microscopy after CellROX Deep Red Reagent staining. Levels of MT-3 mRNA in 23 samples of high-risk NB, normal human cortex and bovine adrenal glands were investigated by reverse transcription polymerase chain reaction. RESULTS: Expression microarray showed downregulation 3 and overexpression of 19 genes in MT-3 transfected NB cells. Using gene ontology, over-expressed genes have been shown to drive senescence-induced oncogenes (CDKN2B and ANAPC5), and the genes of glutathione S-transferase M3, caspase 4 and DNAJB6 (chaperone neuronal proteins) were also expressed. We have demonstrated a reduced sensitivity of MT-3 transfected cells to CDDP (24h IC50 of 7.48 ± 0.97 and 19.81 ± 1.2 µg/ml), a higher number of colonies after incubation with CDDP, reduced caspase 3 after incubation with CDDP and lower free oxygen radicals after induction of CDDP. High-grade NB cells expressed MT-3 significantly more than non-tumoral adrenal cells but failed to show a clear relationship to disease course. CONCLUSION: We have demonstrated the relationship between MT-3 and senescence-induced oncogene genes and some other genes relevant to cell fate (glutathione S-transferase M3, caspase 4 and DNAJB6) and a significant proportion of MT-3 on CDDP resistance. High levels of MT-3 in high-risk NB could be one of the causes of frequent relapses in this tumor.Key words: neuroblastoma - metallothionein 3 - chemoresistance The authors declare they have no potential conflicts of interest concerning drugs, products, or services used in the study. The Editorial Board declares that the manuscript met the ICMJE recommendation for biomedical papers.This work was supported by AZV CR grant 15- 28334A. Submitted: 17. 2. 2018Accepted: 16. 4. 2018.

[Management of acute postoperative pain following thoracotomy - state of the art]. / Lécba akutní pooperacní bolesti po torakotomii - soucasné moznosti.

UNLABELLED: Postoperative pain management is an important part of complex perioperative care in patients undergoing thoracotomy, irrespective of the procedure type. Adequate pain relief leads to early mobilisation, improves respiratory functions and decreases global stress response. Thus, good perioperative pain management significantly reduces postoperative complications. Currently, numerous analgesic methods are available for the management of acute postthoracotomy pain including patient- or nurse-controlled systemic administration of analgesics, infiltration with local anaesthetics, intrapleural or intercostal nerve blockades and neuroaxial blocks (paravertebral, intrathecal, epidural). The aim of this review is to analyze the currently used methods in postthoracotomy pain management, their benefits in the light of current guidelines, and potential risks. KEY WORDS: thoracotomy - chest surgery analgesia.

Blockade of the ganglion impar (walther), using ultrasound and a loss of resistance technique.

The ganglion impar is an unpaired sympathetic structure located at the level of the sacrococcygeal joint. Blockade of this structure has been utilised to treat chronic perineal pain. Methods to achieve this block often involve the use of fluoroscopy which is associated with radiation exposure of staff involved in providing these procedures. We report a combined loss of resistance injection technique in association with ultrasound guidance to achieve the block. Ultrasound was used to identify the sacrococcygeal joint and a needle was shown to enter this region. Loss of resistance was then used to demonstrate that the needle tip lies in a presacral space. The implication being that any injectate would be located in an adequate position. The potential exception would be a neurodestructive procedure as radiographic control of needle tip in relation to the rectum should be performed and recorded. However when aiming for a diagnostic or local anaesthetic based treatment option we feel that this may become an accepted method.

Pulsed radiofrequency therapy versus greater occipital nerve block in the management of refractory cervicogenic headache - a pilot study.

The aim of this pilot study was to compare the efficacy of pulsed radiofrequency to the greater occipital nerve versus a greater occipital nerve block with a mixture of local anaesthetic and steroid in the management of refractory cervicogenic headache. We enrolled 30 patients suffering from refractory cervicogenic headache. Patients were randomly allocated into two groups of fifteen. A greater occipital nerve block with steroid was utilised in group A, while a pulsed radiofrequency treatment was employed in group B. Success of both procedures was evaluated by comparing pre and post intervention Visual Analogue Scale of pain, Medication Quantification Scale - III. and Global Perceived Effect at three and 9 months after the procedures. At three months post therapy a significant decrease in Visual Analogue Scale (p<0.001) was identified (3.2 points in group A, 3.3 points in group B respectively). In group B pain remained reduced even after 9 months (p<0.001) when compared to pre treatment scores. The consumption of analgesic medication was reduced significantly in both groups at three months (p<0.001) and 9 months (p<0.01), respectively. No serious complication was noted. Greater occipital nerve block is a safe, efficient technique in the management of cervicogenic headaches. Despite the lack of high quality scientific evidence (level III or IV) in the literature, we have extensive experience with steroid application and pulsed radiofrequency to the greater occipital nerve and report the beneficial results in our study.

Effect of pulsed radiofrequency therapy on the suprascapular nerve in shoulder pain of various aetiology.

BACKGROUND: Pulsed radiofrequency treatment (PRF) applied to the suprascapular nerve may provide pain relief for patients suffering from shoulder pain as described in three case series. AIMS: The effect of PRF to the suprascapular nerve was retrospectively analysed on 28 patients with shoulder pain lasting longer than 1 month, with a 6-month follow-up. Group A was treated with PRF and local anaesthetics only while group B was treated with PRF, local anaesthetic and steroid. Pain scores were evaluated before and after the procedure and at 1, 3 and 6 months. RESULTS: More than 50% of patients in both groups had significant pain relief after 3 months. No major, but only one minor complication occurred. CONCLUSIONS: Our results suggest that the analgesic effects of PRF last more than 3 months in the majority of patients. The addition of steroid to the PRF treatment appears to have no benefit.

The use of an i-gel supraglottic airway for the airway management of a patient with subglottic stenosis: a case report.

The airway management of patients with subglottic stenosis poses many challenges for the anesthesiologist. Although many anesthesiologists would prefer the use of a narrow endotracheal tube in this patient population, the use of laryngeal mask airways has also been described. We report the case of a patient who was managed using an i-gel supraglottic airway due to a difficulty with inserting an endotracheal tube during a previous procedure. A 47-year old woman with an ASA (American Society of Anesthesiologists) score of I was scheduled to undergo a laparoscopic cholecystectomy. An i-gel supraglottic airway was inserted without difficulty, provided a good seal, and allowed for controlled ventilation with acceptable peak pressures throughout the operation, including during pneumoperitoneum. Furthermore, the vocal cords were successfully visualized using a fiberscope, allowing the possibility of eventual fiberoptic intubation, if it had been necessary. The presence of subglottic stenosis was also confirmed using the fiberscope. Thus, the i-gel airway device has multiple features that makes it suitable for use in situations where a narrow endotracheal tube is inadvisable or too difficult to use.

A comparison of the I-gel supraglottic airway as a conduit for tracheal intubation with the intubating laryngeal mask airway: a manikin study.

BACKGROUND: Insertion of a supraglottic airway and tracheal intubation through it may be indicated in resuscitation scenarios where conventional laryngoscopy fails. Various supraglottic devices have been used as conduits for tracheal intubation, including the intubating laryngeal mask airway (ILMA), the Ctrach laryngeal mask and the I-gel supraglottic airway. METHODS: A prospective study with 25 participants evaluated the success rate of blind intubation (using a gum-elastic bougie, an Aintree intubating catheter (AIC) and designated tracheal tube) and fibrescope-guided tracheal intubation (through the intubating laryngeal mask airway and the I-gel supraglottic airway) on three different airway manikins. RESULTS: Twenty-five anaesthetists performed three intubations with each method on each of three manikins. The success rate of the fibrescope-guided technique was significantly higher than blind attempts (P<0.0001) with both devices. For fibreoptic techniques, there was no difference found between the ILMA and I-gel (P>0.05). All blind techniques were significantly more successful in the ILMA group compared to the I-gel (P<0.0001 for bougie, Aintree catheter and tracheal tube, respectively). CONCLUSIONS: The results of this study show that, in manikins, fibreoptic intubation through both ILMA and I-gel is a highly successful technique. Blind intubation through the I-gel showed a low success rate and should not be attempted.

Regional anaesthesia for carotid endarterectomy: an audit over 10 years.

BACKGROUND: The aim of this retrospective study was to compare the failure rates and the frequency of anaesthesia-related complications of two different methods of regional anaesthesia used for carotid endarterectomy--cervical epidural (CE) anaesthesia and cervical plexus block (CPB). METHODS: The study included 1828 carotid endarterectomies performed in 1455 patients between 1996 and 2006. A combination of deep and superficial CPB was used for 1166 procedures, whereas in 662 cases surgery was performed under CE anaesthesia. RESULTS: The failure rate of CPB was 3% compared with 6.9% for CE anaesthesia (P < 0.0001). The reasons for failure of the anaesthetic techniques were (1) technical failure, (2) insufficient analgesia, (3) non-compliant patients, and (4) anaesthetic complications. The incidence of complications resulting from CE anaesthesia was significantly higher than with CPB; life-threatening complications--2% compared with 0.3% (P < 0.0001); other anaesthesia-related complications 5.7 vs 4.7%. Serious complications included inadvertant injection into the subarachnoid space or vertebral artery. The frequency of shunt insertion, perioperative stroke, and death from any cause was similar in both groups of patients. CONCLUSIONS: Both methods of regional anaesthesia are acceptable for carotid artery surgery. CPB is associated with a significantly lower frequency of anaesthesia-related complications and should therefore be considered the anaesthetic of choice. CE anaesthesia should not be performed except in extenuating circumstances such as variant anatomy or the requirement for more extensive surgery.

[Bacterial aortitis]. / Aortitis bacterialis.

A cohort of 14 patients with bacterial destruction of various segments of the aortic wall is presented. The Salmonella enteritidis strain was predominantly responsible. Most patients had typical history of symptomatic trias of sepsis, abdominal and/or back pain and positive blood cultures. CT scan showed pseudoaneurysm within the thoracic, subphrenic or subrenal aorta as well as acute hemorrhage in three patients. One of these was excluded from invasive treatment due to hopeless prognosis. In one patient primary aortoduodenal phistula was responsible for GI bleeding. Five patients were operated and prosthetic replacement of subrenal or iuxtarenal aortic portion together with aortorenal bypass in a couple of cases was performed. In eight patients stentgrafts (SG) of various types were deployed completed with femorofemoral crossover bypass when necessary. All patients were subject to long-standing antibiotic therapy. Two patients expired following SG insertion, all operated patients survived. Average follow-up has been 1 year (1-22 months) so far. A groin abscess was later drained in one patient. Neither CT nor isotope scanning showed persistent or recurrent infectious or hemorrhagic foci in any survivors whatsoever. The authors review and consider the doubtful indication of aortic SG deployment into the septic terrain in selected cases. Midterm results might justify its use in overly debilitated patients otherwise not eligible for radical operation due to its prohibitive risk.

[Minilaparotomy as an access route to vascular reconstruction procedures in the aortoiliac region]. / Minilaparotomie jako prístup k cévním rekonstrukcím v aortoilické oblasti.

Following the example of general surgical procedures, also vascular surgery gradually minimizes the size of its surgical entrances. Miniinvasive surgical procedures significantly reduce postoperative complaints and shorten the patients recovery rates. Minilaparotomy, either a hand-assisted or a laparoscopy-assisted procedure, a procedure conducted fully via laparoscopy or thoracoscopy and a robot-assisted procedure, all of the above are contemporary options for miniinvasive procedures in the vascular surgery. The authors introduce their initial experience with the use of minilaparotomy in the aortoiliac region. From November 2002 to April 2004, 29 procedures were performed for the abdominal aortic aneurysm repair or for aortoiliac occlusive disease. In 15 cases the abdominal aortic aneurysm was managed and in 14 cases the aortoiliac occlusive disease was managed.