Effect of intraoperative hyperthermic intrathoracic chemotherapy after pleurectomy decortication for treatment of malignant pleural mesothelioma: a comparative study.

Malignant pleural mesothelioma (MPM) is an aggressive malignancy with few long-term survivors. Despite the dismal prognosis, hyperthermic intrathoracic chemoperfusion (HITOC) was shown to improve survival in a selective group of patients. We analyzed the influence of HITOC following pleurectomy and decortication on postoperative morbidity and overall survival for patients suffering from localized mesothelioma. From March 2017 until August 2023, 55 patients with localized pleural mesothelioma underwent pleurectomy and decortication. Thirty patients performed only surgery while 25 consecutive patients had surgery followed by HITOC with cisplatin (125 mg/m2) infused for 70 min at a temp of 40-43 °C. We analyzed postoperative morbidity, HITOC-related complications, and the influence of HITOC on survival. The trial was registered on 19/08/2022 as NCT05508555. The HITOC group had a mean age of 53.1 ± 8.2 years while the surgery group (non-HITOC) had a mean age of 52.1 ± 8.6 years. The HITOC group had 17 (68%) men, whereas the surgery group included 18 (60%) males. The 30-day mortality in the HITOC group was 0% vs 1 case (3.3%) in the surgery group. HITOC-related transient complications occurred in 4/25 (16%) of the HITOC group (atrial fibrillation, renal impairment and transient hypotension). Progression-free survival in the HITOC group was 8 months (95% CI 4.3-11.6) vs 6 months (95% CI 2.5-9.9) in the surgery-only group (p = 0.79). The overall survival time in the HITOC group was 28 months (95% CI 21.5-34.5) vs 22 months (95% CI 17.5-26.5) in the surgery-only group (p = 0.75). Risk factors analysis for recurrence in the HITOC group confirmed a significant role for early stages (p = 0.03). HITOC following pleurectomy and decortication is a safe therapeutic option that may improve survival for selected patients with localized epithelial pleural mesothelioma. Patients with earlier-stage mesothelioma are more likely to benefit from radical surgery and HITOC.

Protective effect of Galectin-3 inhibitor against cardiac remodelling in an isoprenaline-induced myocardial infarction in type 2 diabetes.

Type 2 Diabetes mellitus (T2DM) has the potential to impair cardiac function and cause heart failure. We aimed to study the cardioprotective influence of Galactin-3 (Gal-3) inhibitor; modified citrus pectin (MCP) in isoprenaline induced myocardial infarction (MI) in T2DM rats. Forty rats were allocated into 4 groups; groups I and II served as control. T2DM was provoked in groups III and IV by serving them high fat diet followed by a single low dose of Streptozotocin (STZ), then group IV were administered MCP in drinking water for 6 weeks. Groups III and IV were then subcutaneously injected isoprenaline hydrochloride once daily on the last 2 successive days to induce MI. MCP restored echocardiographic parameters with significant decline in Gal-3 area % in cardiac tissue alongside protection against cardiac remodelling. our data showed that there is a protective potential for Gal-3 inhibitor (MCP) against cardiac injury in isoprenaline induced MI in T2DM.

Type 2 Diabetes mellitus (T2DM) has the potential to impair cardiac function and cause heart failure (HF).Gal-3 inhibition with MCP for 6 weeks caused effective protection against cardiac fibrosis, LV dysfunction, and ensuing heart failure progress in type 2 diabetic rats with an isoprenaline-induced myocardial infarction.The defending effect of Gal-3 inhibitor; MCP seems to be exerted by modulating cardiac cell response to injury, through decreasing incidence of cardiac inflammation, oxidative stress, apoptosis and decreased cardiac Gal-3 immuno-reactivity.

Pleural manometry during thoracocentesis in patients with malignant pleural effusion: A randomized controlled trial.

Background: Large-volume therapeutic thoracocentesis may be associated with pulmonary congestion or a more serious complication; re-expansion pulmonary edema (RPE). We investigated whether monitoring pleural pressure with manometry during thoracocentesis would prevent these pulmonary symptoms/RPE and allow larger volume drainage. Methods: We did a randomized controlled trial involving 110 patients with large malignant pleural effusions. Patients were randomly allocated to obtain thoracocentesis with or without pleural manometry. We measured the incidence of pulmonary congestion symptoms, total fluid aspirated, and pleural pressures in both groups. This trial is listed on ClinicalTrials.gov as NCT04420663. Results: The mean amount of total thoracocentesis fluid withdrawn from the control group was 945.4±78.9 (mL) and 1690.9±681.0 (mL) from the intervention group (P<0.001). Clinical symptoms of pulmonary congestion appeared in (n=20) (36.3%) of patients in the intervention group while no symptoms appeared in controls (P<0.001). The difference between opening and closing pressures between the non-symptomatic cluster and the symptomatic cluster was (32.8±15.6 versus 42.2±13) respectively (P=0.02). Total fluid withdrawn from the non-symptomatic cluster was 1828.5±505 mL in comparison to 1,450±875 mL in the symptomatic cluster (P=0.04). Conclusion: Pleural manometry can be used to increase the volume of fluid removed on each occasion in patients with malignant pleural effusion. In our study, pleural manometry was associated with a larger number of pulmonary congestion symptoms/RPE. We believe that manometry may be a useful tool to not exceed a 17 cm H2O gradient in pleural pressure which should be avoided to prevent pulmonary congestion symptoms or RPE. Pulmonary congestion symptoms/RPE are not related to the amount of volume withdrawn but to the gradient of pleural pressure drop. Our conclusion does support the adoption of pleural manometry whenever large-volume thoracocentesis is intended.

The efficacy of oral corticosteroids for treatment of Tietze syndrome: A pragmatic randomized controlled trial.

WHAT IS KNOWN AND OBJECTIVE: Tietze syndrome is a rare form of chest wall costochondritis with joint swelling which can cause significant chest pain and decline in ability of daily activities. There is no standardized treatment protocol. The aim of this study was to assess the efficacy of adding oral steroids in addition to other non- steroidal treatment in improvement of pain and quality of life (QOL) in patients with Tietze syndrome. METHODS: Forty patients with Tietze syndrome were randomly divided into two treatment groups: (1) One week of prednisolone 40 mg daily followed by 1 week of prednisolone 20 mg daily followed by 1 week of 10 mg with 3 weeks of non-steroidal anti-inflammatory drug (NSAID) treatment (n = 20); (2) three weeks of NSAID treatment only (n = 20). A symptom questionnaire was used to rate the major symptoms of Tietze syndrome and costochondritis: Numeric rating scale (NRS) for pain on a scale of 0 (no pain) to 10 (severest pain); the resulting global symptom score was used to evaluate the efficacy of treatment with assessment of joint swelling resolution. The EQ-5D-5L instrument for measurement of QOL was used. Assessments were made on intention to treat basis at baseline and at 1, 2 and 3 weeks followed by a medium term follow period after treatment cessation. The trial was registered at www.isrctn.com ISRCTN11877533. RESULTS AND DISCUSSION: There was a significant drop in mean NRS pain scores between the groups at 1, 2 and 3 weeks in favour of the steroid group (46.8% vs. 17.7%; p < 0.001, 56.3% vs. 35.8% p < 0.001 and 65.4% vs. 46.7% p < 0.001 respectively). There was a 25.8% (95% CI 13.2-38.8) difference in mean NRS score drop at a median of 6.5 months after treatment cessation in favour of the steroid group over the NSAID only group. Only three cases of mild GIT upset in the steroid group and two cases of mild nausea were reported in the NSAID group. There was an improvement in QOL using the median EQ-5D-5L scoring at 3 weeks in favour of the steroid group 7 (7, 8) versus 10 (8.5-11), (p < 0.001). The improvement in pain scoring and QOL did not correlate with improvement in joint swelling at 3 weeks after treatment with 2/20 (10%) in the steroid arm versus 1/20 (5%) in NSAID arm having an obvious improvement (p = 0.393). WHAT IS NEW AND CONCLUSION: In this study, addition of short-term oral corticosteroids showed a clear benefit for use at 1, 2 and 3 weeks in improvement of pain and QOL in patients with Tietze syndrome. This difference was maintained at mid-term follow up after treatment cessation. This facilitates the advantage of using steroids as well as excluding their side effects for an accepted timeframe.

Is hormonal manipulation after surgical treatment of catamenial pneumothorax effective in reducing the rate of recurrence? A systematic review and meta-analysis.

OBJECTIVES: Catamenial pneumothorax CP is a rare form of spontaneous pneumothorax in females forming part of thoracic endometriosis syndrome. Studies have suggested possible benefit from postoperative hormonal administration. As this treatment is inconsistent, we aimed at performing the first meta-analysis to study the efficacy of adding hormonal treatment after surgery to reduce the chances of recurrent catamenial pneumothorax. METHODS: CENTRAL, MEDLINE/PubMed, Cochrane Library, and Scopus were systematically searched from inception up to December 15, 2021. Studies reporting five or more patients with end point outcome were included. The main outcome assessed was postoperative recurrence of CP after hormonal manipulation. Baseline, procedural, outcome, and validity data were systematically appraised and pooled with random-effect methods. meta- regression for the effect of patient age and follow up period were tested. Publication bias was examined. This trial was registered with PROSPERO under registration number CRD42022325377. RESULTS: Our electronic search retrieved 644 citations, 48 of which were selected for full-text review. Eleven studies with a combined population of 111 patients fulfilled the inclusion criteria. All patients reached an endpoint of follow up for postoperative recurrence of catamenial pneumothorax after receiving hormonal treatment. Overall study validity was acceptable, with a median score of 6 on the Newcastle Ottawa scale NOS appraising the quality of observational studies. CP is almost always a right-side disease (107/111 = 96.3 %). The risk of postoperative recurrence with hormonal treatment was 17.3 % (8.9 - 25.8 %) with moderate non-significant heterogeneity (I2 = 40.85 %; P = 0.076). The cumulative risk of recurrence for all patients not receiving postoperative hormonal therapy included in our study was 54.2 % (19/35 patients). Meta regression showed age to be a significant predictor of postoperative recurrence (p = 0.03). As the age increases one year, the risk of recurrence decreases by 6 % (0.2 - 3 %). Publication bias was detected by visualizing the funnel plot of standard error, Egger's test with p < 0.01 and Begg & Mazumdar test with p < 0.01. CONCLUSION: The study included the largest number of CP patients with outcome findings of postoperative recurrence with hormonal treatment despite the small number of studies, non-randomised fashion and publication bias. Our findings recommend the use of hormonal manipulation after thoracic surgical intervention for catamenial pneumothorax unless evident contraindications. Younger patients are at a higher risk of recurrence after surgery.

Thoracic surgery in Egypt.

General thoracic surgery operations in Egypt are performed mainly by cardiothoracic surgeons and less oftenly by dedicated thoracic surgeons and general surgeons. This is mainly due to the relatively small number of thoracic surgeons in relation to population as only 210 cardiothoracic surgery specialists and 458 consultants are registered with the Egyptian Medical Syndicate (EMS) in a country with a population of more than 100 million people. Thoracic surgeons in Egypt are faced with a number of burdens, including the need to propagate the service to advanced technology infront of the obstacle of limited resources. Other burdens include higher incidence of TB, trauma and foreign body inhalation related to cultural backgrounds. More centres now are major video-assisted thoracic surgery (VATS) providing centres and others are specialized in more complex surgeries like complicated airway procedures and radical surgery for mesothelioma. As part of the international community, the COVID-19 pandemic has put more burdens on the thoracic surgery service as most centres have reduced their elective surgery workload to less than half of usual. Interestingly, the pandemic has allowed a self-referral screening programme with widespread Computed Tomography (CT) chest being performed among the population allowing thoracic surgeons to operate more on early stage lung cancer. The academic challenges for thoracic surgeons are even more with need for developing national databases. Nevertheless, thoracic surgeons in Egypt are optimistic regarding the future. The rising interest among the younger population will push training programs to meet the interests of enthusiastic junior surgeons. While the ancient history of thoracic surgery in Egypt seems to be extraordinary, the future perspectives promise to be more rewarding.

Variation in outcome of invasive mechanical ventilation between different countries for patients with severe COVID-19: A systematic review and meta-analysis.

BACKGROUND: COVID 19 is the most recent cause of Adult respiratory distress syndrome ARDS. Invasive mechanical ventilation IMV can support gas exchange in patients failing non-invasive ventilation, but its reported outcome is highly variable between countries. We conducted a systematic review and meta-analysis on IMV for COVID-associated ARDS to study its outcome among different countries. METHODS: CENTRAL, MEDLINE/PubMed, Cochrane Library, and Scopus were systematically searched up to August 8, 2020. Studies reporting five or more patients with end point outcome for severe COVID 19 infection treated with IMV were included. The main outcome assessed was mortality. Baseline, procedural, outcome, and validity data were systematically appraised and pooled with random-effect methods. Subgroup analysis for different countries was performed. Meta-regression for the effect of study timing and patient age and were tested. Publication bias was examined. This trial was registered with PROSPERO under registration number CRD42020190365. FINDINGS: Our electronic search retrieved 4770 citations, 103 of which were selected for full-text review. Twenty-one studies with a combined population of 37359 patients with COVID-19 fulfilled the inclusion criteria. From this population, 5800 patients were treated by invasive mechanical ventilation. Out of those, 3301 patients reached an endpoint of ICU discharge or death after invasive mechanical ventilation while the rest were still in the ICU. Mortality from IMV was highly variable among the included studies ranging between 21% and 100%. Random-effect pooled estimates suggested an overall in-hospital mortality risk ratio of 0.70 (95% confidence interval 0.608 to 0.797; I2 = 98%). Subgroup analysis according to country of origin showed homogeneity in the 8 Chinese studies with high pooled mortality risk ratio of 0.97 (I2 = 24%, p = 0.23) (95% CI = 0.94-1.00), similar to Italy with a low pooled mortality risk ratio of 0.26 (95% CI 0.08-0.43) with homogeneity (p = 0.86) while the later larger studies coming from the USA showed pooled estimate mortality risk ratio of 0.60 (95% CI 0.43-0.76) with persistent heterogeneity (I2 = 98%, p<0.001). Meta-regression showed that outcome from IMV improved with time (p<0.001). Age had no statistically significant effect on mortality (p = 0.102). Publication bias was excluded by visualizing the funnel plot of standard error, Egger's test with p = 0.714 and Begg&Mazumdar test with p = 0.334. INTERPRETATION: The study included the largest number of patients with outcome findings of IMV in this current pandemic. Our findings showed that the use of IMV for selected COVID 19 patients with severe ARDS carries a high mortality, but outcome has improved over the last few months and in more recent studies. The results should encourage physicians to use this facility when indicated for severely ill COVID-19 patients.

Multi-disciplinary approach for the management of non-metastatic non-small cell lung cancer in the Middle East and Africa: Expert panel recommendations.

The Middle East and Africa (MEA) region, a large geographical area, lies at the confluence of Asian, Caucasian and African races and comprises of a population with several distinct ethnicities. The course of management of non-small cell lung cancer (NSCLC) differs as per patients' performance status as well as stage of disease, requiring personalized therapy decisions. Although management of NSCLC has received a significant impetus in the form of molecularly targeted therapies and immune therapies in last few years, surgery remains gold standard for patients with early-stage disease. In case of unresectable disease, radiotherapy and chemotherapy are the primary management modalities. With newer therapies being approved for treatment of early stage disease, use of multi-disciplinary team (MDT) for comprehensive management of NSCLC is of prime importance. A group of experts with interest in thoracic oncology, deliberated and arrived at a consensus statement for the community oncologists treating patients with NSCLC in the MEA region. The deliberation was based on the review of the published evidence including literature and global and local guidelines, subject expertise of the participating panellists and experience in real-life management of patients with NSCLC. We present the proposed regional adaptations of international guidelines and recommends the MDT approach for management of NSCLC in MEA.

Does the Nuss procedure for treating pectus excavatum compromise the long term internal mammary artery flow? A systematic review.

INTRODUCTION: The Nuss procedure is the most common procedure used to treat patients with pectus excavatum. The effect of the Nuss bars on the long-term internal mammary artery flow (IMA) is not well studied. This could have an impact on patients requiring a coronary artery bypass grafting surgery after the Nuss procedure. We performed a systematic review to study the impact of the Nuss bars on the IMA long term flow. METHODS: A Medline search from January 1990 to August 2020 was performed using [Nuss OR thoracoscopic pectus OR minimally invasive pectus] AND [Internal mammary OR Internal thoracic OR IMA OR ITA]. English language papers only were included. This trial was registered with PROSPERO under registration number CRD42021234010. RESULTS: A total of 48 papers were identified using the reported search, of which three represented the best evidence to answer the clinical question. One study looked at the IMA flow via computed tomography (CT)-angiography on the 10th postoperative day after the Nuss procedure and found 15 out of 34 patients (44%) to have abnormal IMA blood flow but with no clinical consequences. Two studies looked at the IMA flow after removal of the Nuss-bar. The first study utilized CT-angiography on the 5th postoperative day after Nuss-bar removal and found four out of the six patients studied (67%) to have abnormal flow. The last study was composed of 19 patients and looked at IMA flow during the presence of the Nuss-bars and after its removal utilizing Doppler-angiography. It found 11 out of 19 patients (58%) to have abnormal blood flow with the bars in place. After removal of the bars, only two patients (10%) were found to have unilateral IMA obstructed flow. CONCLUSION: In patients undergoing the Nuss procedure for management of pectus excavatum, the internal mammary artery flow is compromised in 44%-58% of patients with the bar in situ. When these patients are assessed 10 days following removal of the bar, some reversal of compromised IMA flow is evident. However, in up to 67% of patients, abnormal IMA flow remains. Further studies are required to determine whether this abnormal flow is permanent, which will require examining patients at longer follow-up intervals. Patients undergoing coronary artery bypass grafting who have a history of a Nuss procedure should receive preoperative IMA imaging.

Airway Surgery for Laryngotracheal Stenosis During the COVID-19 Pandemic: Institutional Guidelines.

OBJECTIVE: The management of laryngotracheal stenosis is challenging, as patients usually require in-time interventions. The current coronavirus disease 2019 (COVID-19) pandemic has added unique challenges to this procedure. The presence of the virus in high concentrations in the aerodigestive tract and the need for an open airway during surgery can increase the risk of aerosolization of the virus and subsequent infection of the surgical, anesthetic, and operating room (OR) personnel. DESIGN: Retrospective cohort study. SETTING: University hospital. PARTICIPANTS: Patients who underwent airway interventions between March and October 2020. INTERVENTIONS: A protocolized strategy was initiated during the COVID-19 pandemic to facilitate the consistent management of all patients undergoing airway interventions. MEASUREMENTS AND MAIN RESULTS: During a seven-month period, 34 patients were managed with this policy. All threatened airways were managed successfully and no healthcare workers dealing with such procedures were infected. Priorities during the current novel coronavirus pandemic are ensuring the safety of healthcare professionals and offering urgent bronchoscopic and surgical airway interventions for patients with progressive symptoms and threatened airways. CONCLUSIONS: Surgical and bronchoscopic management of laryngotracheal stenosis presents a unique challenge during the COVID-19 pandemic, requiring careful consideration of patient triage and the development of protocols that minimize risk to patients and healthcare professionals. Close collaboration between thoracic surgeons and anesthesiology teams is essential to safely navigate and handle these threatened airways while mitigating the risk of viral aerosolization.

Tailored anaesthesia for thoracoscopic surgery promoting enhanced recovery: The state of the art.

PURPOSE OF THE REVIEW: The current review focuses on precise anaesthesia for video-assisted thoracoscopic surgery (VATS) with the goal of enhanced recovery. The main aim of an enhanced recovery program after thoracic surgery is to reduce postoperative stress response, protect from postoperative pulmonary complications, give hospitals a better financial option and improve overall patient outcome. This can ultimately reduce hospital stay and increase patient satisfaction. With advances in endoscopic, robotic and endovascular techniques, video-assisted thoracoscopic surgery (VATS) can be performed in a minimally invasive way in managing most pulmonary, pleural and mediastinal diseases. As a minimally invasive technique, video-assisted thoracoscopic surgery (VATS) represents an important element of enhanced recovery program in thoracic surgery as it can achieve most of its goals. Anaesthetic management during preoperative, intraoperative and postoperative period is essential for the establishment of a successful enhanced recovery program. In the era of enhanced recovery protocols, non-intubated thoracoscopic procedures present a step forward. This article focuses on the key anaesthetic elements of the enhanced recovery program during all phases of thoracoscopic surgery. Having reviewed recent literature, a systematic review of literature will highlight successful ERAS protocols published for thoracoscopic surgery.

Recurrence of mesothelioma after a macroscopic complete resection procedure: is a second radical surgery justified?

A best evidence topic was written according to a structured protocol. The question addressed was: In patients with mesothelioma who develop a local recurrence after macroscopic complete resection (MCR) surgery, does performing a second radical surgery lead to improvement in survival? A total of 2076 papers were identified using the reported search, of which 3 represented the best evidence to answer the clinical question. The authors, date, journal, country, study type, population, outcomes and key results are tabulated. The 2 largest studies included 16 patients each who underwent a second surgery for radical resection of recurrence after MCR for mesothelioma. One study (with 16 chest wall resections) had no in-hospital mortality, whereas the other study showed 2/16 (12.5%) patients dying in the hospital, both of whom had a contralateral pleurectomy. One study correlated the median survival after the second surgery with the time to recurrence and epithelioid pathology. The other study showed better post-recurrence survival after a second surgery, with patients having a significantly longer median post-recurrence survival (16 months) compared with those who received other types of second-line therapy (9 months) and those who received no therapy at all (2 months) (P < 0.0005), although selection bias is a possibility. The last study included 8 patients who underwent a second surgery for radical intent after MCR for mesothelioma. The median time to recurrence was 29 months and the survival after second surgery was 14.5 months with no correlation to disease-free interval (expected due to the small number of patients). In patients presenting with recurrence of mesothelioma after an MCR procedure, radical surgery to resect the recurrent tumour could have a role in improvement of survival in selected patients. Positive prognostic factors include epithelioid pathology and a longer disease-free interval after the first procedure.

Extracorporeal membrane oxygenation (ECMO) in patients with severe COVID-19 adult respiratory distress syndrome: a systematic review and meta-analysis.

Background: COVID 19 is the most recent cause of adult respiratory distress syndrome (ARDS). Extracorporeal membrane oxygenation (ECMO) can support gas exchange in patients failing conventional mechanical ventilation, but its role is still controversial. We conducted a systematic review and meta-analysis on ECMO for COVID-associated ARDS to study its outcome. Main body: CENTRAL, MEDLINE/PubMed, Cochrane Library, and Scopus were systematically searched from inception to May 28, 2020. Studies reporting five or more patients with COVID-19 infection treated venovenous with ECMO were included. The main outcome assessed was mortality and ICU/hospital discharge. Baseline, procedural, outcome, and validity data were systematically appraised and pooled with random-effect methods. The validity of all the included observational studies was appraised with the Newcastle Ottawa scale. Meta-regression and publication bias were tested. This trial was registered with PROSPERO under registration number CRD42020183861.From 1647 initial citations, 34 full-text articles were analyzed and 12 studies were selected, including 194 patients with confirmed COVID-19 infection requiring ICU admission and venovenous ECMO treatment. Median Newcastle-Ottawa scale was 6 indicating acceptable study validity. One hundred thirty-six patients reached an endpoint of weaning from ECMO with ICU/hospital discharge or death while the rest were still on ECMO or in the ICU. The median Berlin score for ARDS prior to starting ECMO was III. Patients received mechanical ventilation before ECMO implementation for a median of 4 days and ECMO was maintained for a median of 13 days. In hospital and short-term mortality were highly variable among the included studies ranging between 0 and 100%. Random-effect pooled estimates suggested an overall in-hospital mortality risk ratio of 0.49 (95% confidence interval 0.259 to 0.721; I2 = 94%). Subgroup analysis according to country of origin showed persistent heterogeneity only in the 7 Chinese studies with pooled estimate mortality risk ratio of 0.66 (I2 = 87%) (95% CI = 0.39-0.93), while the later larger studies coming from the USA showed pooled estimate mortality risk ratio of 0.41 (95% CI 0.28-0.53) with homogeneity (p=0.67) similar to France with a pooled mortality risk ratio of 0.26 (95% CI 0.08-0.43) with homogeneity (p=0.86). Meta-regression showed only younger age as a predictor of mortality (p=0.02). Publication bias was excluded by visualizing the funnel plot of standard error, Egger's test with p=0.566, and Begg and Mazumdar test with p=0.373. Conclusion: The study included the largest number of patients with outcome findings of ECMO in this current pandemic. Our findings showed that the use of venovenous ECMO at high-volume ECMO centers may be beneficial for selected COVID 19 patients with severe ARDS. However, none of the included studies involve prospective randomized analyses; and therefore, all the included studies were of low or moderate quality according to the Newcastle-Ottawa scale. In the current era and environment of the pandemic, it will likely be very challenging to conduct a prospective randomized trial of ECMO versus no-ECMO for COVID-19. Therefore, the information contained in this systematic review of the literature is valuable and provides important guidance. Trial registration: The study protocol link is at www.crd.yorl.ac.uk/PROSPERO under registration number CRD42020183861.

Venous pectoralis minor syndrome: a rare subdivision of the thoracic outlet syndrome.

We analysed data of all patients who had received surgery for rare, isolated venous pectoralis minor syndrome at our tertiary institution from January 2015 to December 2018. Venous duplex scan was the preferred mode of diagnosis in all our patients. We operated on patients via a 5-6 cm deltopectoral groove incision. Ten procedures were performed on 6 patients, of whom 5 were female. The median age was 23 years (range 17-33 years). Three patients (2 female, 1 male) with bilateral pectoralis minor syndrome had separate procedures performed over a course of a few weeks. The median operating time was 22 min (range 15-95 min). Median blood loss was 20 ml (range 5-410 ml). The median hospital stay was 2 days (range 1-5 days). There was one complication in the form of a recurrence on the right side in a patient who had bilateral pectoralis minor syndrome. No other morbidities were recorded. Nine of 10 procedures (90%) were classified by patients as being satisfactory, where symptoms had partially or completely resolved. Our experience emphasizes the need for a systematic search and to maintain a high index of suspicion for venous pectoralis minor syndrome in all patients complaining of painful symptoms related to thoracic outlet syndrome. The deltopectoral groove approach is a simple and straightforward incision with a gentle learning curve.

Conventional intensive versus LED intensive phototherapy oxidative stress burden in neonatal hyperbilirubinaemia of haemolytic origin.

Background: Phototherapy causes oxidative stress which is of particular importance in neonates because of the increased susceptibility of neonatal red blood cell membranes to oxidative damage.Aim: To evaluate the oxidant/antioxidant status in neonates with haemolytic hyperbilirubinaemia before and after exposure to two different intensive phototherapy light sources.Patients and Methods: A randomised controlled study was undertaken in 54 full-term neonates with indirect haemolytic hyperbilirubinaemia admitted to a neonatal intensive care unit in the first week of life. They were randomly divided into two equal groups. Group 1 infants were exposed to intensive conventional phototherapy (Bilisphere 360) and Group 2 were exposed to an intensive light-emitting diode (LED) phototherapy device (Bilitron bed 3600). Total serum bilirubin (TSB), total oxidative stress (TOS), total antioxidant capacity (TAC) and the oxidative stress index (OSI) were measured before and 48 hours after initiation of phototherapy.Results: There was a significant decrease in TSB after phototherapy in both groups (p < 0.001). The TOS and OSI were significantly increased after phototherapy in both groups (p < 0.001) but more so in Group 1 with conventional phototherapy (p = 0.05 and 0.01, respectively). TAC was significantly decreased after phototherapy in both groups (p < 0.00) but more so in Group 1 (p = 0.03).There were significant increases in the incidence of dehydration, hyperthermia and skin rash in the conventional compared with the LED phototherapy group (p = 0.02, 0.01 and 0.02, respectively). However, there was a significant increase in the incidence of hypothermia in the LED compared with the conventional phototherapy group (p = 0.001).Conclusion: Both intensive conventional and LED phototherapy are equally effective in decreasing TSB, but intensive LED phototherapy is safer than intensive conventional phototherapy with regard to oxidative stress and oxidant/antioxidant imbalance.Abbreviations: DSB: direct serum bilirubin; G6PD: glucose-6-phosphate dehydrogenase enzyme; LED: light-emitting diode; OSI: oxidative stress index; TAC: total antioxidant capacity; TOS: total oxidative stresses; TSB: total serum bilirubin.

Thoracoscopic management of early stages of empyema: is this the golden standard?

BACKGROUND: Empyema is a well-known disease that significantly increases the morbidity and mortality associated with pneumonia. There are a number of treatment modalities available but recently video assisted thoracoscopic surgery (VATS) has been suggested as a reliable tool in management of empyema; particularly in early stages. The aim of this study is to assess the safety and effectiveness of using initial VATS for all surgically fit patients with early stages of empyema. METHODS: Sixty-six patients with early stage empyema were prospectively studied between December 2013 and March 2016. Patients were divided into two groups: group A (28 patients) were managed conservatively without surgery for stage I (exudative) phase empyema by the chest physicians; and group B (38 patients) were managed by the thoracic surgeons by VATS for stage I (exudative) and stage II (fibrino-purulent) empyema. Comparison was made between both groups. RESULTS: There was no statistically significant difference between the groups from the point of view of age, sex or pre-intervention comorbidities (P>0.05). Average hospital stay in group A was 22 days (7-131 days), it was 4.1 days (2-14 days) in group B (P=0.004; 95% CI: 10.3-25.5) with a resultant lower cost. Three patients (10.7%) in group A suffered from major morbidity during treatment while none in group B suffered a major postoperative morbidity (P=0.039). There were 2 mortalities (7.1%) in group A and no deaths in group B (P=0.094). During a mean follow up period of 8 months [6-14] in group A 14.3% of the patients underwent open decortication, whereas in group B, 5.3% of the patients underwent the same procedure (P=0.047). CONCLUSIONS: Thoracoscopic management of early stages of empyema should be the golden standard of management in surgically fit patients; particularly in the fibro-exudative phase of empyema. It is an effective and safe technique that reduces hospital stay, cost, complications and avoids the need for a decortication via a thoracotomy in most cases.

Optimization of a novel programmable data-flow crypto processor using NSGA-II algorithm.

The optimization of a novel programmable data-flow crypto processor dedicated to security applications is considered. An architecture based on assigning basic functional units to four synchronous regions was proposed in a previous work. In this paper, the problem of selecting the number of synchronous regions and the distribution of functional units among these regions is formulated as a combinatorial multi-objective optimization problem. The objective functions are chosen as: the implementation area, the execution delay, and the consumed energy when running the well-known AES algorithm. To solve this problem, a modified version of the Genetic Algorithm - known as NSGA-II - linked to a component database and a processor emulator, has been invoked. It is found that the performance improvement introduced by operating the processor regions at different clocks is offset by the necessary delay introduced by wrappers needed to communicate between the asynchronous regions. With a two clock-periods delay, the minimum processor delay of the asynchronous case is 311% of the delay obtained in the synchronous case, and the minimum consumed energy is 308% more in the asynchronous design when compared to its synchronous counterpart. This research also identifies the Instruction Region as the main design bottleneck. For the synchronous case, the Pareto front contains solutions with 4 regions that minimize delay and solutions with 7 regions that minimize area or energy. A minimum-delay design is selected for hardware implementation, and the FPGA version of the optimized processor is tested and correct operation is verified for AES and RC6 encryption/decryption algorithms.

Medium term results of total knee arthroplasty as a primary treatment for knee fractures.

INTRODUCTION: Successful treatment of knee comminuted periarticular fractures associated with osteoporosis and pre-existing arthritis is a challenging task. METHODS: This is a prospective study on 27 patients who had comminuted intra and periarticular knee fractures and pre-existing arthritis. Fractures were classified according to Muller's AO classification. Primary knee arthroplasty was performed ± internal fixation following 4 weeks of splinting. A stem was added to the tibial tray and Legacy Constrained Condylar Knee (LCCK) or Rotating Hinge (RH) prosthesis were used depending on the level of ligament damage and bone defects. The Knee Society Score (KSS) and radiological evaluation were performed at 3, 6 and 12 months then annually thereafter. RESULTS: The average age of this group of patients was 63 years (range 59-74). Sixteen knees received primary femoral component and Posterior Stabilized insert, while 8 had LCCK. RH implants were chosen in 2 and distal femoral replacement was necessary in one knee. Twenty five patients were available for the final review at an average 6 years in whom the KSS was 80 (range 75-89) points. All patients achieved full knee extension and average knee flexion of 110° (range 90-135°). One knee needed re-admission for early Debridement Antibiotic Irrigation and Retention (DAIR) but none of the knees was revised or awaiting revision. CONCLUSION: Knee arthroplasty achieves highly successful outcome when performed as a primary treatment for comminuted intra and periarticular knee fractures in elderly patients. Survival of implants and functional range of movement at midterm are excellent.