Development of cadaver perfusion models for surgical training: an experimental study.

PURPOSE: Perfusion techniques on cadavers are heterogeneous and imperfect. The objective of this study was to improve the existing circulation model for surgical simulation on cadavers. METHODS: We used a three-step experimental approach. The first part of the experiment tested two variables: the type of circuit and the use of a heater for perfusion. The second approach evaluated two parameters: the injection fluid and the type of body conditioning (embalmed or freshly dead prepared using different washing techniques). The third one was an improvement on the best circulation obtained, which focused on the injection fluid. To compare the realism of these different techniques, we constructed a score with realism parameters: the volume of return flow, the presence of peripheral venous return and the perfusion of abdominal arteries. RESULTS: We found that the use of a heater seemed to improve the perfusion, while performing an arteriovenous bypass did not seem very effective. A correlation rate of 0.84 was found between the realism score and the injected fluid chosen. The best score (4/6) was found for a non-embalmed body with a low-pressure washing technique using a gelatin-based liquid at a concentration of 4 g/L for circulation. Scores obtained using embalmed bodies for both injection fluids for high-pressure washing or for 8-g/L gelatin injection fluid did not exceed 3/6. CONCLUSIONS: We showed that using a non-embalmed body with low-pressure washing and a 4-g/L gelatin-based fluid was the most effective technique for cadaver perfusion.

Lactated Ringer' Solution may be Superior to Saline-Based 6% Hydroxyethyl Starch 130/0.4 for Early Resuscitation within 12 hours from Hemorrhagic Shock.

Purpose: To compare the effects of fluid resuscitation with lactated Ringer's solution (LR) and saline-based 6% hydroxyethyl starch 130/0.4 (HES) on the inflammatory response and oxidative stress in the small intestine as well as on bacterial translocation to the liver. Methods: Sprague-Dawley rats were subjected to blood pressure-controlled hemorrhagic shock and then resuscitated with LR or HES. At 1, 3, 6, 12, and 24 hr after resuscitation, liver tissues were collected to count the bacterial colonies, and small intestines were harvested to analyze the levels of inflammatory (TNF-α and HO-1) and oxidative stress (MPO) mediators as well as the intestinal injury by immunohistochemistry, colorimetry and hematoxylin & eosin staining, respectively. Results: The expression level of TNF-α in the LR group was stable from 1 to 6 hr but decreased at 12 hr and then abruptly increased at 24 hr. The expression level of TNF-α in the LR group was significantly lower than that in the HES group, especially during the first 12 hr post-fluid infusion. MPO activity decreased to its lowest level at 3 hr but increased from 6 to 12 hr, with no difference at 24 hr between the two groups. Although a decreasing tendency was observed from 6 hr, HO-1 expression levels remained higher in the LR group than in the HES group at 12 and 24 hr, particularly at 12 hr. During the initial 12 hr, the LR group exhibited significantly lower colony-forming units in the liver tissues than the HES group. Chiu's score in the intestine decreased regardless of which resuscitative fluids were used. Conclusions: During early resuscitation (within 12 hr), LR may be superior to HES in reducing intestinal injuries by suppressing inflammatory and oxidative mediators.

Efficacy and safety of SIC-8000 (Eleview®) for submucosal injection for endoscopic mucosal resection and endoscopic submucosal dissection in an in vivo porcine model.

BACKGROUND: Submucosal injection is generally required for both endoscopic-mucosal resection (EMR) and submucosal dissection (ESD). SIC-8000 (Eleview™) is a new FDA 510(k) cleared and CE marked liquid composition for submucosal injection, containing a biocompatible polymer as a cushioning agent. AIMS: The aim of this randomized study was to compare Eleview with saline solution when performing upper- and lower-GI EMR/ESD in a porcine model. METHODS: EMR/ESD procedures were performed in a total of 10 white domestic pigs comparing Eleview vs. NaCl 0.9% containing methylene blue at 0.001% (control solution) as submucosal solution to be injected. Animals were randomized between EMR (22 procedures) and ESD (22 procedures) and between upper- (8 animals) and lower-(2 animals) GI procedures. All procedures were performed aiming for a resection size of 1 cm × 1 cm for EMR and 2 cm × 2 cm for ESD. Volume of injected fluid, number of injections, time of resection, technical success, en-bloc resection, and adverse events were collected. Endoscopic surveillance was conducted each week for 4 weeks after the EMR/ESD, including biopsies on the margins of resection sites at week-1 of follow-up. After four weeks, pigs were sacrificed and necropsy performed. RESULTS: Overall, 22 EMR and 22 ESD were performed in 10 live pigs. The average total volume needed for EMR and ESD was statistically significantly lower with Eleview as compared with control solution for both of the techniques (EMR: 5.6 ±â€¯3.4 ml vs. 11.5 ±â€¯6.7 ml; p = 0.02; ESD: 19.0 ±â€¯10.0 ml vs. 36.3 ±â€¯16.9 ml; p = 0.02). The rate of adverse events was statistically significantly lower in the Eleview than in the control group (2/26, 7.7% vs. 6/18, 33.3%; p = 0.03), but most of them were minor. No difference between Eleview and control solution was found in the rate of technical success (EMR: 11/13, 84.6% vs. 7/9, 77.8%; p = 0.7; ESD: 13/13, 100% vs. 9/9, 100%; p = 1), en-bloc resection (EMR: 6/13, 46.2% vs. NaCl: 5/9, 55.6%; p = 0.06; ESD: 12/13, 92.3% vs. 8/9, 88.9%; p = 0.8), and time of resection (EMR: 9.1 ±â€¯7.75 min vs. 9.4 ±â€¯9.6 min; p = NS; ESD: 38.4 ±â€¯17.2 min vs. 40.2 ±â€¯19.1 min; p = NS). At endoscopic follow up and necropsy, no difference in the process of healing of post-endoscopic ulcer and in the histological inflammation at the site of resection was shown between the two groups. CONCLUSIONS: The new submucosal injection composition Eleview appeared to be an effective alternative to saline solution for submucosal injection for EMR/ESD, resulting in a substantial reduction of the volume administered to achieve an adequate lifting. No signs of adverse local or distant tissue reaction to Eleview were found at long-term follow up.

Saline irrigation for chronic rhinosinusitis.

BACKGROUND: This review is one of six looking at the primary medical management options for patients with chronic rhinosinusitis.Chronic rhinosinusitis is common and is characterised by inflammation of the lining of the nose and paranasal sinuses leading to nasal blockage, nasal discharge, facial pressure/pain and loss of sense of smell. The condition can occur with or without nasal polyps. Nasal saline irrigation is commonly used to improve patient symptoms. OBJECTIVES: To evaluate the effects of saline irrigation in patients with chronic rhinosinusitis. SEARCH METHODS: The Cochrane ENT Information Specialist searched the ENT Trials Register; Central Register of Controlled Trials (CENTRAL 2015, Issue 9); MEDLINE; EMBASE; ClinicalTrials.gov; ICTRP and additional sources for published and unpublished trials. The date of the search was 30 October 2015. SELECTION CRITERIA: Randomised controlled trials (RCTs) with a follow-up period of at least three months comparing saline delivered to the nose by any means (douche, irrigation, drops, spray or nebuliser) with (a) placebo, (b) no treatment or (c) other pharmacological interventions. DATA COLLECTION AND ANALYSIS: We used the standard methodological procedures expected by Cochrane. Our primary outcomes were disease-specific health-related quality of life (HRQL), patient-reported disease severity and the commonest adverse event - epistaxis. Secondary outcomes included general HRQL, endoscopic nasal polyp score, computerised tomography (CT) scan score and the adverse events of local irritation and discomfort. We used GRADE to assess the quality of the evidence for each outcome; this is indicated in italics. MAIN RESULTS: We included two RCTs (116 adult participants). One compared large-volume (150 ml) hypertonic (2%) saline irrigation with usual treatment over a six-month period; the other compared 5 ml nebulised saline twice a day with intranasal corticosteroids, treating participants for three months and evaluating them on completion of treatment and three months later. Large-volume, hypertonic nasal saline versus usual care One trial included 76 adult participants (52 intervention, 24 control) with or without polyps.Disease-specific HRQL was reported using the Rhinosinusitis Disability Index (RSDI; 0 to 100, 100 = best quality of life). At the end of three months of treatment, patients in the saline group were better than those in the placebo group (mean difference (MD) 6.3 points, 95% confidence interval (CI) 0.89 to 11.71) and at six months there was a greater effect (MD 13.5 points, 95% CI 9.63 to 17.37). We assessed the evidence to be of low quality for the three months follow-up and very low quality for the six months follow-up. Patient-reported disease severity was evaluated using a "single-item sinus symptom severity assessment" but the range of scores is not stated, making it impossible for us to determine the meaning of the data presented.No adverse effects data were collected in the control group but 23% of participants in the saline group experienced side effects including epistaxis. General HRQL was measured using SF-12 (0 to 100, 100 = best quality of life). No difference was found after three months of treatment (low quality evidence) but at six months there was a small difference favouring the saline group, which may not be of clinical significance and has high uncertainty (MD 10.5 points, 95% CI 0.66 to 20.34) (very low quality evidence). Low-volume, nebulised saline versus intranasal corticosteroids One trial included 40 adult participants with polyps. Our primary outcome of disease-specific HRQL was not reported. At the end of treatment (three months) the patients who had intranasal corticosteroids had less severe symptoms (MD -13.50, 95% CI -14.44 to -12.56); this corresponds to a large effect size. We assessed the evidence to be of very low quality. AUTHORS' CONCLUSIONS: The two studies were very different in terms of included populations, interventions and comparisons and so it is therefore difficult to draw conclusions for practice. The evidence suggests that there is no benefit of a low-volume (5 ml) nebulised saline spray over intranasal steroids. There is some benefit of daily, large-volume (150 ml) saline irrigation with a hypertonic solution when compared with placebo, but the quality of the evidence is low for three months and very low for six months of treatment.

Height-, extent-, length-, and pupil-based (HELP) algorithm to manage post-phacoemulsification Descemet membrane detachment.

PURPOSE: To analyze the functional and anatomic outcomes of management of Descemet membrane detachment after phacoemulsification using a protocol based on the detachment's height, extent, and chord length and its relation to the pupil. SETTING: Dr. Agarwal's Eye Hospital and Eye Research Centre, Chennai, India. DESIGN: Prospective comparative case series. METHODS: Eyes with post-phacoemulsification Descemet membrane detachment were managed surgically or medically based on the detachment's height, extent, length (chord), and relation to the pupil (HELP protocol). Central corneal thickness (CCT), chord length, and detachment height were determined by anterior segment optical coherence tomography (AS-OCT) (Visante). RESULTS: Of 161 eyes, 96 were treated surgically (Group 1) and 65 medically (Group 2). The mean length and mean height of Descemet membrane detachment were 2.4 mm ± 1.4 (SD) and 266 ± 189.8 µm, respectively, in Group 1 and 1.03 ± 0.4 mm and 153.3 ± 60.8 µm, respectively, in Group 2. The complete reattachment rate was 95.8% in Group 1 and 96.9% in Group 2. The corrected distance visual acuity (CDVA) was 20/40 or better in 83.3% of eyes in Group 1 and 92.3% of eyes in Group 2. No eye lost CDVA as a result of a Descemet membrane scar in the central 5.0 mm of the cornea. The AS-OCT allowed visualization of the detachment in all eyes with a CCT of more than 800 µm. There was no difference in the final CDVA between Group 1 and Group 2. CONCLUSIONS: The AS-OCT-based algorithm was effective for managing post-surgical Descemet membrane detachment in eyes with dense corneal edema. Early surgical intervention for detachments in the central cornea can reduce scarring-induced visual loss. FINANCIAL DISCLOSURE: No author has a financial or proprietary interest in any material or method mentioned.

Randomized controlled trial comparing Moviprep® and Phosphoral® as bowel cleansing agents in patients undergoing colonoscopy.

BACKGROUND: Introducing colonoscopy as part of colorectal cancer screening on a national level, we aimed at evaluating the efficacy of the two most common bowel cleansing agents, Moviprep(®) and Phosphoral(®). Secondly, we evaluated the benefit for the patient and society in terms of sick leave and discomfort. METHODS: In a single-blinded randomized equivalence trial, Phosphoral(®) (NaP) was compared with Moviprep(®) (2 l polyethylene glycol + ascorbic acid) in patients undergoing colonoscopy due to suspicion of cancer. Patients filled out questionnaires concerning stool consistency, discomfort and number of sick days due to bowel cleansing. Blinded colonoscopists estimated the efficiency of the cleansing using the validated Harefield Cleansing Scale. RESULTS: Two hundred and sixty-six patients were included 250 of whom underwent full colonoscopy. There was no difference in the percentage of acceptable bowel cleansings in the two groups; however, a significantly higher number of A scores were observed in the Moviprep(®) group (p = 0.028). We found no correlation between stool consistency and outcome of the cleansing and no difference in subjective discomfort during cleansing. Vomiting during cleansing occurred more often in the Phosphoral(®) group (p = 0.002). There was a trend toward a smaller number of sick days in patients who used Moviprep(®) compared with Phosphoral(®). CONCLUSIONS: Moviprep(®) and Phosphoral(®) provided equally efficient bowel cleansing in 90 % of patients, but Moviprep(®) provided a higher quality of cleansings graded as successful. The two agents were equally tolerated, and no difference was found in the related number of sick days.

[Effects of hyperoncotic cardiopulmonary bypass prime on extravascular lung water and cardiopulmonary function in patients undergoing coronary artery bypass surgery].

OBJECTIVE: To investigated the effect of a hyperoncotic CPB-prime with hydroxyethyl starch (HES) 6% (130/0.4) on extravascular lung water (EVLW) and post-pump cardiac and pulmonary functions. METHODS: This study plan approved by the hospital ethics committee review. In 40 randomized patients undergoing elective coronary artery bypass graft surgery (CABG), a colloid prime (COP:42.5 mmHg, HES-group, n = 20) and a crystalloid prime (Ringer's lactate, crystalloid group, n = 20) of equal volume were compared with respect to the effects on cardiopulmonary function. Cardiac index (CI), mean arterial pressure (MAP), pulmonary capillary wedge pressure (PCWP), systemic vascular resistance index (SVRI), pulmonary artery pressure (PAP), pulmonary vascular resistance index (PVRI), alveolo-arterial oxygen difference (AaDO2), pulmonary shunt fraction (Qs/QT), extravascular lung water (EVLW), COP, fluid balance and body weight were evaluated peri-operatively. RESULTS: Pre-operative demographic and clinical data, CPB-time, crossclamp time and the number of anastomoses were comparable for both groups. During CPB, COP was reduced by 22% in the HES-group [(16.7 ± 3.9) vs (21.5 ± 2.2) mmHg, P < 0.05] while it was reduced by more than 50% of the pre-CPB value [10.7 ± 2.0 vs (22.7 ± 1.9) mmHg, P < 0.05] in the crystalloid group (P < 0.05 HES-group vs. crystalloid group). Post-CPB EVLW was unchanged in the HES-group but it was elevated by 21% in the crystalloid group (P < 0.05 HES-group vs crystalloid group), CI was higher in the HES-group [(3.3 ± 0.3) vs (2.7 ± 0.7) L/min, P < 0.05]. Fluid balance was less in the HES-group (715 ± 544 vs 1 951 ± 487, P < 0.05). Post-operative weight gain could be prevented in the HES-group but not in the crystalloid group (1.4 ± 1.1 vs -0.3 ± 1.3, P < 0.05). No significant differences were seen for MAP, PAP, PCWP, SVRI, PVRI, AaDO2 and (Qs/QT) between the two groups at any time. CONCLUSIONS: Hyperoncotic CPB-prime using HES 6% improves CI and prevents EVLW accumulation in the early post-pump period, while pulmonary function is unchanged.

Inhaled hyperosmolar agents for bronchiectasis.

BACKGROUND: Mucus retention in the lungs is a prominent feature of bronchiectasis. The stagnant mucus becomes chronically colonised with bacteria, which elicit a host neutrophilic response. This fails to eliminate the bacteria, and the large concentration of host-derived protease may contribute to the airway damage. The sensation of retained mucus is itself a cause of suffering, and the failure to maintain airway sterility probably contributes to the frequent respiratory infections experienced by many patients.Hypertonic saline inhalation is known to accelerate tracheobronchial clearance in many conditions, probably by inducing a liquid flux into the airway surface, which alters mucus rheology in a way favourable to mucociliary clearance. Inhaled dry powder mannitol has a similar effect. Such agents are an attractive approach to the problem of mucostasis, and deserve further clinical evaluation. OBJECTIVES: To determine whether inhaled hyperosmolar substances are effective in the treatment of bronchiectasis. SEARCH METHODS: We searched the Cochrane Airways Group Specialised Register, trials registries, and the reference lists of included studies and review articles. Searches are current up to April 2014. SELECTION CRITERIA: Any randomised controlled trial (RCT) using hyperosmolar inhalation in patients with bronchiectasis not caused by cystic fibrosis. DATA COLLECTION AND ANALYSIS: Two review authors assessed studies for suitability. We used standard methods recommended by The Cochrane Collaboration. MAIN RESULTS: Eleven studies met the inclusion criteria of the review (1021 participants).Five studies on 833 participants compared inhaled mannitol with placebo but poor outcome reporting meant we could pool very little data and most outcomes were reported by only one study. One 12-month trial on 461 participants provided results for exacerbations and demonstrated an advantage for mannitol in terms of time to first exacerbation (median time to exacerbation 165 versus 124 days for mannitol and placebo respectively (hazard ratio (HR) 0.78, 95% confidence interval (CI) 0.63 to 0.96, P = 0.022) and number of days on antibiotics for bronchiectasis exacerbations was significantly better with mannitol (risk ratio (RR) 0.76, 95%CI 0.58 to 1.00, P = 0.0496). However, exacerbation rate per year was not significantly different between mannitol and placebo (RR 0.92 95% CI 0.78 to 1.08). The quality of this evidence was rated as moderate. There was also an indication, from only three trials, again based on moderate quality evidence, that mannitol improves health-related quality of life (mean difference (MD) -2.05; 95% CI -3.69 to -0.40). An analysis of adverse events data, also based on moderate quality evidence, revealed no difference between mannitol and placebo (OR 0.96; 95% CI 0.61 to 1.51). Two additional small trials on 25 participants compared mannitol versus no treatment and the data from these studies were inconclusive.Four studies (combined N = 113) compared hypertonic saline versus isotonic saline. On most outcomes there were conflicting results and the opportunities for the statistical aggregation of data from studies was very limited. It is not possible to draw robust conclusions for this comparison and judgments should be reserved until further data are available. AUTHORS' CONCLUSIONS: There is an indication from a single, large, unpublished study that inhaled mannitol increases time to first exacerbation in patients with bronchiectasis. In patients with near normal lung function, spirometry does not change dramatically with mannitol and adverse events are not more frequent than placebo. Further investigation is required in a patient population with impaired lung function.It is not possible to draw firm conclusions regarding the effect of nebulised hypertonic saline due to significant differences in the methodology, patient groups, and findings amongst the limited data available. The data suggest that it is unlikely to have benefit over isotonic saline in patients with milder disease, and hence future studies should test its use in those with more severe disease.

Imaging findings post colorectal endoscopic mucosal resection.

Endoscopic mucosal resection is commonly the treatment regime of choice for large sessile colonic polyps. We describe the computed tomography findings of a 51 year old female who presented with transient severe abdominal pain without systemic upset post endoscopic mucosal polyp resection, which resolved with conservative management. This is the second case in the literature that demonstrates 'normal' appearances post endoscopic mucosal resection. The clinical team and radiologist need to be aware of these findings when making management decisions in patients who present with acute pain post endoscopic mucosal resection.

Out-of-hospital hypertonic resuscitation after traumatic hypovolemic shock: a randomized, placebo controlled trial.

OBJECTIVE: To determine whether out-of-hospital administration of hypertonic fluids would improve survival after severe injury with hemorrhagic shock. BACKGROUND: Hypertonic fluids have potential benefit in the resuscitation of severely injured patients because of rapid restoration of tissue perfusion, with a smaller volume, and modulation of the inflammatory response, to reduce subsequent organ injury. METHODS: Multicenter, randomized, blinded clinical trial, May 2006 to August 2008, 114 emergency medical services agencies in North America within the Resuscitation Outcomes Consortium. INCLUSION CRITERIA: injured patients, age ≥ 15 years with hypovolemic shock (systolic blood pressure ≤ 70 mm Hg or systolic blood pressure 71-90 mm Hg with heart rate ≥ 108 beats per minute). Initial resuscitation fluid, 250 mL of either 7.5% saline per 6% dextran 70 (hypertonic saline/dextran, HSD), 7.5% saline (hypertonic saline, HS), or 0.9% saline (normal saline, NS) administered by out-of-hospital providers. Primary outcome was 28-day survival. On the recommendation of the data and safety monitoring board, the study was stopped early (23% of proposed sample size) for futility and potential safety concern. RESULTS: : A total of 853 treated patients were enrolled, among whom 62% were with blunt trauma, 38% with penetrating. There was no difference in 28-day survival-HSD: 74.5% (0.1; 95% confidence interval [CI], -7.5 to 7.8); HS: 73.0% (-1.4; 95% CI, -8.7-6.0); and NS: 74.4%, P = 0.91. There was a higher mortality for the postrandomization subgroup of patients who did not receive blood transfusions in the first 24 hours, who received hypertonic fluids compared to NS [28-day mortality-HSD: 10% (5.2; 95% CI, 0.4-10.1); HS: 12.2% (7.4; 95% CI, 2.5-12.2); and NS: 4.8%, P < 0.01]. CONCLUSION: Among injured patients with hypovolemic shock, initial resuscitation fluid treatment with either HS or HSD compared with NS, did not result in superior 28-day survival. However, interpretation of these findings is limited by the early stopping of the trial. CLINICAL TRIAL REGISTRATION: Clinical Trials.gov, NCT00316017.

Curso de Atualização em Emergências Médicas: aula 19: reposição volêmica / Course of Updating in Medical Emergencies: class 19: volemic replacement

Hipovolemia em pacientes agudamente enfermos é um evento relativamente comum, e com importância clínica para o paciente, sendo a rápida e vigorosa reposição volêmica capaz de diminuir o risco de morte inicialmente e de evolução para falência renal na sequência. Neste artigo revisaremos os diferentes tipos de expansores, suas propriedades, vantagens e desvantagens. Os cristaloides se mantêm como preferência pela segurança, eficácia e baixo custo, com a desvantagem da importante formação de edema. As soluções hipertônicas têm indicação no atendimento pré-hospitalar por ser eficaz, porém com estabilização hemodinâmica de caráter efêmero, e pela possibilidade de distúrbios eletrolíticos. Estudos clínicos randomizados não demonstraram superioridade da albumina aos cristalóides e assim como são de custo alto ficam como segunda alternativa ou casos selecionados.

Hypovolemia in critically ill patients is a common event in intensive care patients, and it is clinically relevant for the patient. The fluid replacement is used to try to reduce risk of death and evolution to renal failure. In this article we review different types of expansors, their properties, advantages and disadvantages. Crystalloids are indicated for the safety, efficacy and low cost, the only disadvantage is oedema formation. Hypertonic crystalloid are indicated only in prehospitalar fluid resuscitation, because of your efficacy, but for a short period of time, and the possibility of hydroeletrolitic derangements. There is no evidence that colloids are more effective than crystalloids in reducing mortality in people who are critically ill or injured, and the high cost, turn them the second choice.

Comparative performance of novel solutions for submucosal injection in porcine stomachs: An ex vivo study.

BACKGROUND: Submucosal injection of normal saline (NS) is commonly used during endoscopic mucosal resection (EMR) and endoscopic submucosal dissection (ESD) but is quickly absorbed. Sodium hyaluronate (SH) produces longer lasting mucosal elevation but is expensive. AIMS: To evaluate the performance of novel solutions for submucosal injection in comparison with NS and SH. METHODS: One ml of the following solutions was injected in the submucosa of fresh specimens of porcine stomachs: NaCl 0.9%, SH 0.4%, human albumin 25%, two artificial tears solutions, namely, hydroxypropyl methylcellulose (HPMC) 0.3%/dextran 70.1% and polyvinyl alcohol (PVA) 1.4%, hydroxyethyl starch (HES) 6% and polyethylene glycol (PEG) 50%. The time until the disappearance of the mucosal elevation was recorded in a blind manner. RESULTS: The median duration of mucosal elevation was significantly longer with HPMC/dextran, PVA, HES, PEG and SH (29, 26, 38, 31.5, and 41.5min, respectively) compared with NS (12min) (p<0.05 for each comparison). There were no significant time differences between SH and HPMC/dextran, HES and PEG (p>0.05). CONCLUSIONS: Novel viscous or hypertonic solutions for submucosal injection, perform better than normal saline and equally well as sodium hyaluronate in porcine stomachs in vitro.

Pharmacological treatment options for bronchiectasis: focus on antimicrobial and anti-inflammatory agents.

Patients with bronchiectasis experience tenacious mucus, recurrent infectious exacerbations, and progressive worsening of symptoms and obstruction over time. Treatment is aimed at trying to break the cycle of infection and progressive airway destruction. Antibacterial treatment is targeted towards likely organisms or tailored to the results of sputum culture. Inhaled antibacterial therapy may offer the advantage of increased local concentration of medication, while minimizing systemic adverse effects; however, to date, studies have been equivocal in this disorder. Macrolides, in addition to their antibacterial properties, have unique anti-inflammatory properties, which may make them useful in this disorder. Other mucoactive and anti-inflammatory agents, such as inhaled corticosteroids, mannitol and hypertonic saline, may also prove useful in this disease, but further studies are needed.

Treatment of multiple primary hydatid cysts.

Hydatid disease, which is caused by the parasite Echinococcus granulosis, is endemic in certain parts of the world in which humans and sheep live in proximity. Hydatid cysts occur most often in the liver, and affliction with multiple cysts is rare. We present the case of a 48-year-old woman with 55 hydatid cysts (47 in the liver, 5 in the right lung, and 3 in the left lung). The cysts in the right lung were intact, and those in the left lung had ruptured. A partial cystectomy was performed to excise 34 cysts through a right thoracoabdominal incision. The remaining deeply seated cysts were treated by needle aspiration and the ultrasonographically guided injection of hypertonic saline. This case report indicates that open surgery accompanied by ultrasonographically guided aspiration can effectively treat multiple hydatid cysts in a single laparotomy session.

Perioperative complications of blood brain barrier disruption under general anesthesia: a retrospective review.

Blood brain barrier disruption enhances drug delivery in primary central nervous system lymphoma. In this study, we report adverse events that were encountered intraoperatively and in the postoperative period in these patients. A retrospective analysis of 17 patients documenting demographic data, preprocedure medical history, intraoperative, and postoperative anesthetic complications was conducted between January 2002 and December 2004. Seventeen patients underwent 210 treatments under general anesthesia with a mean of 12.4+/-7.2 treatments per patient. Focal seizures occurred in 13% of patients. Generalized motor seizures occurred in 4 treatment sessions in 2 different patients. The incidence of seizures was significantly higher when the internal carotid artery was used for injection, as opposed to the vertebral artery (20.8% and 6.02%, respectively, P=0.0034). Tachycardia associated with ST segment depression occurred 9 times (4.3%) in 3 patients. One patient had significant ST segment elevation (more than 1.5 mm). Transient cerebral vasospasm after methotrexate injection occurred in 9% of patients. Postoperative nausea and vomiting were observed in 11.9% of patients. After emergence, lethargy and obtundation occurred in 7.6% of the cases. The incidence of postoperative headache and reversible motor deficits was 6% and 3.8%, respectively. Our review highlights the problems that were encountered during blood brain barrier disruption under anesthesia and in the postoperative period. Further prospective studies are required for comprehensive evaluation of intraprocedure and postprocedure complications that will allow development of an optimal anesthetic plan and will improve patient outcome by preventing potential complications.

Hypertonic hydroxyethyl starch solution for hypovolaemia correction following heart surgery.

BACKGROUND: The aim of the study was to evaluate the effect of hypertonic NaCl hydroxyethyl starch solution on haemodynamics and cardiovascular parameters in the early postoperative period in patients for correction of hypovolaemia after heart surgery. METHODS: Eighty patients undergoing myocardial revascularisation at the Clinic of Cardiac Surgery of the Heart Centre (Kaunas University of Medicine) were randomly divided into two groups. The HyperHaes group (n = 40) received 250ml 7.2% NaCl/6% HES solution and the control Ringer's acetate group (n = 40) received placebo (500 ml Ringer's acetate solution) for volume correction after the surgery. RESULTS: After infusion of HyperHaes solution, cardiac index increased from 2.69 (0.7) to 3.52 (0.8) l/min/m2, systemic vascular resistance index, pulmonary vascular resistance index and the gradient between central and peripheral temperature decreased, and oxygen transport parameters improved. Ringer's group patients needed more intensive infusion therapy (4050.0 (1102.2) ml in the Ringer's group, 3513.7(762.5) ml in the HyperHaes group). During the first 24 hours postoperatively, diuresis was significantly higher in the HyperHaes group (3640.0 (1122.9) ml and 2736.0 (900.7) ml), total fluid balance was lower in HyperHaes group (1405.6 (1519.0) ml and 2718.3 (1508.0)ml, respectively). After the infusion of HyperHaes solution, no adverse events were noted. CONCLUSIONS: HyperHaes solution had a positive effect on haemodynamic parameters and microcirculation. Oxygen transport was more effective after HyperHaes solution infusion. Higher diuresis, lower need for the infusion therapy for the first 24 hours and lower total fluid balance were determined in the HyperHaes group. No adverse effects were observed after HyperHaes solution infusion.

Cystic echinococcosis in immigrant from Peru: first case treated with percutaneous treatment in Japan.

We report a case of cystic echinococcosis (CE) caused by Echinococcusgranulosus, for which a modified percutaneous evacuation (PEVAC) treatment was applied. The patient had immigrated from Peru to Japan and had 2 hydatid cystic masses, 1 located in segment (S)5 of the liver and the other in S3 (5.3 and 3.5 cm in diameter, respectively), both of which were visualized as pseudotumors by ultrasound (US) examinations. Albendazole treatment showed no effects and surgical treatment was refused. After punctuation of the S5 cyst under US guidance and S3 with CT guidance, 10- and 12-French gauge catheters, respectively, with multiple side holes were inserted. About 60 ml of the cyst contents was drawn out from the S5 lesion and 2 ml from the S3 lesion. Using repetitive manual injections and aspiration of small amounts of hypertonic saline, the remaining cyst content was removed as much as possible, after which 20 and 10 ml of 98% ethanol was injected into the S5 and S3 lesions, respectively. A short-term evaluation during the 4 month-period following the procedure using US revealed nearly complete evacuation of the S5 lesion, whereas that at S3 remained as a pseudo-solid mass. We consider that percutaneous treatment is a safe therapeutic modality for hydatid cysts. This is the first case report of CE treated percutaneously in Japan.

Evaluation of dextrose 50 % as a medium for injection-assisted polypectomy.

BACKGROUND AND STUDY AIMS: Injection-assisted polypectomy (IAP) is traditionally carried out by using normal saline as the submucosal fluid cushion. However, normal saline, being isotonic, does not maintain the elevation of the mucosa for prolonged periods. It was hypothesized that dextrose 50 %, as a hypertonic solution, might be an ideal medium for IAP. This study evaluated the efficacy and safety of dextrose 50 % for performing IAP. PATIENTS AND METHODS: All patients undergoing IAP during gastroscopy or colonoscopy were randomly assigned on a prospective basis to receive either normal saline or dextrose 50 % as the submucosal fluid cushion. The endoscopist was blinded to the type of solution injected. The volume of solution and number of sites injected to elevate the lesion, the number of times IAP was interrupted to inject more fluid to maintain elevation, the rates of en bloc and complete resections, and the complication rates were compared in the two groups. The mean follow-up period was 10 months. RESULTS: Fifty-two sessile lesions were removed in 50 patients. In comparison with normal saline, smaller volumes (median 7 ml vs. 5 ml; P = 0.02) and fewer injections (median 2 vs. 1; P = 0.003) were required to perform IAP when dextrose 50 % was used. The en bloc resection rate was higher with dextrose 50 % than with normal saline (82 % vs. 44 %; P = 0.01). Elevation of the submucosal area persisted even after completion of IAP in 96 % of the patients randomly assigned to dextrose 50 %, compared with 20 % of those receiving normal saline ( P < 0.001). There were no significant differences in the rates of complete resection or complications between the two groups. CONCLUSIONS: Dextrose 50 % is superior to normal saline as a submucosal fluid cushion, as it allows better en bloc resection during injection-associated polypectomy.