Initial size of unilateral pleural effusion determines impact of thoracocentesis on oxygenation.

BACKGROUND: There have been contradicting reports in the literature regarding the impact of pleural fluid aspiration on patients' oxygenation. The aim of this study was to assess the role of the initial size of effusion on post-drainage oxygenation. METHODS: We studied 122 patients, aged (mean±SD) 61.2±16.8 years, with unilateral pleural effusion and no remarkable parenchymal lesion, by determining PaO2, PaCO2 and [A-a] PaO2 just before thoracocentesis (T1), 30 min after its completion (T2) and 48 hours after the procedure (T3). Patients were divided into group A (75 patients) with small and moderate sized effusions and group B (47 patients) with large and massive effusions. The position of the meniscus line on the posteroanterior film, being arbitrarily set at just above the upper costal margin of the sixth anterior rib, was used to divide the two groups. Patients were studied at rest, breathing room air in the sitting position. Repeated measures ANOVA (related samples) and the Friedman test when the normality assumption was violated were used. RESULTS: In group A, at T3, PaO2(mm Hg) showed a statistically significant increase versus T1 (p<0.001) and T2 (p=0.002), while [A-a] PaO2 displayed a statistically significant decrease compared with T1 (p<0.001) and T2 (p=0.001). In group B, at T2, PaO2 presented significant decrease versus T1 (p<0.001) and T3 (p<0.001), while [A-a] PO2 was found to be significantly increased compared with both T1 and T3 (p<0.001). CONCLUSION: Patients with smaller effusions showed a small improvement in their oxygenation 48 hours post-thoracocentesis (T3). Patients with larger effusions exhibited a transient reduction in their oxygenation immediately after fluid removal (T2).

Temporal evolution of thoracocentesis-induced changes in spirometry and respiratory muscle pressures.

BACKGROUND: Several studies investigated the effects of thoracocentesis on aspects of respiratory function without generally ensuring absence of coexistent lung pathology or homogeneity in initial size of the effusion. METHODS: We studied 90 patients aged 61.6±15.9 years (mean±SD) separated into a group A with small-sized or medium-sized effusion (A=56 patients) and a group B with large and massive one (B=34 patients). There was no significant lung lesion or cardiovascular pathology. The basic spirometric parameters and maximal respiratory pressures were recorded on three instances: just before thoracocentesis (T1), 30 min after completion of the procedure (T2) and after 48 hours (T3). RESULTS: At T2 vs T1, groups A and B respectively presented significant change (mean±SD) (increase) in forced vital capacity (FVC) of 0.071±0.232 and 0.139±0.224 L, in forced expiratory volume in 1 s (FEV1) of 0.127±0.231 and 0.201±0.192 L, in FEV1/FVC of 2.8% and 4.9%, in peak expiratory flow rate (PEFR) of 0.342±0.482 and 0.383±0.425 L/s, in maximal expiratory pressure (MEP) of 0.049±0.037 and 0.049±0.039 kPa and in maximal inspiratory pressure (MIP) of 0.040±0.041 kPa only in group A while decrease in MIP with significant change of 0.055±0.051 kPa in group B. At T3 vs T2 in groups A and B, there was significant change (decrease) in FEV1/FVC of 2.7% and 4.6% as well as significant change (increase) in MIP of 0.036±0.046 and 0.115±0.060 and in MEP of 0.049±0.043 and 0.070±0.048 kPa. CONCLUSIONS: Thoracocentesis is associated with progressive-small relative to the volume of fluid removed-increases in lung volumes. In larger effusions at T2, a transient decrease in MIP is observed presumably due to temporary geometric distortion of the diaphragm immediately after fluid removal.

Management and postoperative outcome in primary lung cancer and heart disease co-morbidity: a systematic review and meta-analysis.

BACKGROUND: Co-morbidity of primary lung cancer (LC) and heart disease (HD), both requiring surgical therapy, characterizes a high risk group of patients necessitating prompt diagnosis and treatment. The aim of this study is the review of available evidence guiding the management of these patients. METHODS: Postoperative outcome of patients operated for primary LC (first meta-analysis) and for both primary LC and HD co-morbidity (second meta-analysis), were studied. Parameters examined in both meta-analyses were thirty-day postoperative mortality, postoperative complications, three- and five-year survival probabilities. The last 36 years were reviewed by using the PubMed data base. Thirty-seven studies were qualified for both meta-analyses. RESULTS: The pooled 30-day mortality percentages (%) were 4.16% [95% confidence interval (CI): 2.68-5.95] (first meta-analysis) and 5.26% (95% CI: 3.47-7.62) (second meta-analysis). Higher percentages of squamous histology and lobectomy, were significantly associated with increased (P=0.001) and decreased (P<0.001) thirty-day postoperative mortality, respectively (first meta-analysis). The pooled percentages for postoperative complications were 34.32% (95% CI: 24.59-44.75) (first meta-analysis) and 45.59% (95% CI: 35.62-55.74) (second meta-analysis). Higher percentages of squamous histology (P=0.001), lobectomy (P=0.002) and p-T1 or p-T2 (P=0.034) were associated with higher proportions of postoperative complications (second meta-analysis). The pooled three- and five- year survival probabilities were 68.25% (95% CI: 45.93-86.86) and 52.03% (95% CI: 34.71-69.11), respectively. Higher mean age (P=0.046) and percentage lobectomy (P=0.009) significantly reduced the five-year survival probability. CONCLUSIONS: Lobectomy and age were both accompanied by reduced five-year survival rate. Also, combined aorto-coronary bypass grafting (CABG) with lobectomy for squamous pT1 or pT2 LC displayed a higher risk of postoperative complications. Moreover, medical decision between combined or staged surgery is suggested to be individualized based on adequacy of coronary arterial perfusion, age, patient's preoperative performance status (taking into account possible co-morbidities per patient), tumor's staging and extent of lung resection.

Comparative changes in tissue oxygenation between laparoscopic and open cholecystectomy.

BACKGROUND: Previous studies examined the effect of laparoscopic cholecystectomy (LC) versus open cholecystectomy (OC) on physiological variables of the respiratory system. In this study we compared changes in arterial blood gases-related parameters between LC and OC to assess their comparative influence on gas exchange. METHODS: We studied 28 patients, operated under identical anesthetic protocol (LC: 18 patients, OC: 10 patients). Measurements were made on the morning before surgery (BS), the second (AS2) and the eighth (AS8) postoperative day. Studied parameters, including alveolar-arterial difference in PO2 ((A-a)DO2) and oxygen content (Oct in vol%), were statistically compared. RESULTS: On AS2 a greater increase was found in ((A-a)DO2) for the OC compared to LC (4.673 ± 0.966 kPa versus 3.773 ± 1.357 kPa, respectively). Between BS and AS2, Oct in vol% decreased from 17.55 ± 1.90 to 15.69 ± 1.88 in the LC and from 16.99 ± 2.37 to 14.62 ± 2.23 in the OC, whilst a reduction (P = 0.093) between AS2 and AS8 was also found for the open method. Besides, on AS2, SaO2% decrease was greater in OC compared to LC (P = 0.096). CONCLUSIONS: On AS2, the greater increase in OC-((A-a)DO2) associated with Oct in vol% and SaO2% findings also in OC group suggest that LC might be associated with lower risk for impaired tissue oxygenation.

Effects of laparoscopic cholecystectomy on lung function: a systematic review.

AIM: To present and integrate findings of studies investigating the effects of laparoscopic cholecystectomy on various aspects of lung function. METHODS: We extensively reviewed literature of the past 24 years concerning the effects of laparoscopic cholecystectomy in comparison to the open procedure on many aspects of lung function including spirometric values, arterial blood gases, respiratory muscle performance and aspects of breathing control, by critically analyzing physiopathologic interpretations and clinically important conclusions. A total of thirty-four articles were used to extract information for the meta-analysis concerning the impact of the laparoscopic procedure on lung function and respiratory physiopathology. The quality of the literature reviewed was evaluated by the number of their citations and the total impact factor of the corresponding journals. A fixed and random effect meta-analysis was used to estimate the pooled standardized mean difference of studied parameters for laparoscopic (LC) and open (OC) procedures. A crude comparison of the two methods using all available information was performed testing the postoperative values expressed as percentages of the preoperative ones using the Mann-Whitney two-sample test. RESULTS: Most of the relevant studies have investigated and compared changes in spirometric parameters.The median percentage and interquartile range (IQR) of preoperative values in forced vital capacity (FVC), forced expiratory volume in 1 s and forced expiratory flow (FEF) at 25%-75% of FVC (FEF25%-75%) expressed as percentage of their preoperative values 24 h after LC and OC were respectively as follows: [77.6 (73.0, 80.0) L vs 55.4 (50.0, 64.0) L, P < 0.001; 76.0 (72.3, 81.0) L vs 52.5 (50.0, 56.7) L, P < 0.001; and 78.8 (68.8, 80.9) L/s vs 60.0 (36.1, 66.1) L/s, P = 0.005]. Concerning arterial blood gases, partial pressure of oxygen [PaO2 (kPa)] at 24 or 48 h after surgical treatment showed reductions that were significantly greater in OC compared with LC [LC median 1.0, IQR (0.6, 1.3); OC median 2.4, IQR (1.2, 2.6), P = 0.019]. Fewer studies have investigated the effect of LC on respiratory muscle performance showing less impact of this surgical method on maximal respiratory pressures (P < 0.01); and changes in the control of breathing after LC evidenced by increase in mean inspiratory impedance (P < 0.001) and minimal reduction of duty cycle (P = 0.01) compared with preoperative data. CONCLUSION: Laparoscopic cholecystectomy seems to be associated with less postoperative derangement of lung function compared to the open procedure.

The role of neurotrophins in axonal growth, guidance, and regeneration.

Neurotrophins are proteins that regulate neuronal survival, axonal growth, synaptic plasticity and neurotransmission. They are members of the neurotrophic factors family and include factors such as the nerve growth factor (NGF), the brain derived neurotrophic factor (BDNF), the neurotrophin-3 (NT-3), and the neurotrophin-4/5 (NT-4/5). These molecules bind to two types of receptors: i) tyrosine kinase receptors (TrkA, TrkB, TrkC) and ii) a common neurotrophin receptor (p75NTR). The two receptor types can either suppress or enhance each other's actions. Neurotrophins have a multifunctional role both in the central and peripheral nervous system. They have been suggested as axonal guidance molecules during the growth and regeneration of nerves. It has also been proven that they stimulate axonal growth by mediating the polymerization and accumulation of F-actin in growth cones and axon shafts. Neurotrophins, as other neurotrophic factors, have been shown that they reduce neuronal injury by exposure to excitotoxins, glucose deprivation, or ischemia. Furthermore, the nerve regeneration promoting effect of these growth factors is well documented for many different models of central or peripheral nervous system injury. Several studies have shown that exogenous administration of these factors has protective properties for injured neurons and stimulates axonal regeneration. Based on these properties, these molecules may be used as therapeutic agents for treating degenerative diseases and traumatic injuries of both the central and peripheral nervous system.

Ectopic modified sebaceous glands in human penis.

The balanopreputial sulcus is believed to be the most frequent site of the so-called Tyson's glands. The intriguing feature of these anatomical structures is their mere existence, which has been doubted. Herein, the authors present a case of a 24-year-old man who underwent surgical treatment of his phimosis. On microscopic examination of the specimen, glands with morphological features similar to those described by Tyson were noted.

Pericardial involvement as an atypical manifestation of giant cell arteritis: report of a clinical case and literature review.

PURPOSE: Pericardial effusion has been known to be a rare manifestation of giant cell arteritis. During the last six decades, only 24 cases have been cited in the literature. In this report, we describe the case of a patient presenting with nonspecific symptoms and development of pericardial effusion. PROCEDURES AND FINDINGS: A 71-year-old woman was admitted to the hospital with low-grade fever, exertion breathlessness, atypical diffuse muscular pain, and weight loss over a period of about 5 weeks. Pericardial effusion and giant cell arteritis were diagnosed by echocardiography and left temporal artery biopsy, respectively. Treatment with corticosteroids resulted in remarkable improvement of symptoms and complete remission of pericardial effusion. One year after admission, the patient remained in a stable good condition, under low steroid maintenance dosage. CONCLUSIONS: The diversity of clinical manifestations (such as pericardial effusion) in such a potentially severe disease should alert the physician to prompt diagnosis and treatment in view of impending irreparable vascular damages, even in cases in which the initial presentation is quite uncommon.

Penile erection during transurethral surgery.

Intraoperative penile erection during endoscopic surgery, although an infrequent occurrence, is a troublesome complication and a challenge to the urologist. It is difficult to perform the procedure during penile erection, because various complications may occur. The etiology is unclear, and a number of pharmacological remedies have been discussed in the literature. Herein, we describe the treatment and outcomes for 3 patients with intraoperative penile erection and provide a brief review of the associated literature. Intraoperative penile erection is a rare event during transurethral procedures, with a frequency of approximately 0.1% in our institution. To our knowledge, no generally accepted protocols for the prevention or treatment of this phenomenon have been reported in the literature. We recommend intracorporeal injection of 250 microg of phenylephrine: detumescence occurred rapidly in all patients after a single injection. The mode of administration is simple, and no complications have been reported.

Changes in breathing control and mechanics after laparoscopic vs open cholecystectomy.

HYPOTHESIS: We hypothesized that there might be different effects on breathing control and respiratory mechanics after laparoscopic vs open cholecystectomy. DESIGN: Randomized clinical trial. SETTING: A general hospital in Greece. PATIENTS: Of 53 patients assessed for eligibility, 18 and 10 were randomly allocated to the laparoscopic and open cholecystectomy groups, respectively. These 28 patients had normal spirometry measurements and American Society of Anesthesiologists' class I physical status. MAIN OUTCOME MEASURES: Measurements of breathing control and mechanics variables. Tidal volume, inspiratory time, breathing frequency, mean inspiratory flow, duty cycle, central respiratory drive, and mean inspiratory impedance were recorded before surgery on the second and eighth postoperative days. Airway resistance was recorded before surgery and on the eighth postoperative day, with all measurements being performed under no influence of analgesia. RESULTS: Two days after surgery, inspiratory time, breathing frequency, and central respiratory drive were significantly changed compared with preoperative values for both methods, whereas mean inspiratory impedance was significantly increased (P<.001) for the laparoscopic procedure. Eight days after surgery, changes were seen only for the laparoscopic group: duty cycle and airway resistance were significantly reduced (P = .01) and increased (P = .04), respectively, compared with preoperative data. CONCLUSION: Laparoscopic cholecystectomy seems to be associated with small but sustained alterations in the control of breathing and mechanics, which might have an unfavorable clinical impact on patients with compromised lung function.

The art of science: transitional cell carcinoma of the bladder and Golconda.

Science and art are, surprisingly, intimately linked to each other. Over the centuries, artists used their talent in order to depict with the greatest detail possible the human anatomy and later the histology of tissues, helping scientists comprehend better the world and human nature. From the opposite perspective, scientific images coming from observation or experimentation can constitute art since they can have form and beauty. An example is mitotic figures, particularly the atypical ones observed in cancer. The affinity between art and science is demonstrated herein, by their harmonic coexistence in one figure, and also by the ease and naturalness by which the phrases used by Magritte in order to describe one of his paintings, the famous "Golconda" can be paraphrased to describe a neoplasm, a transitional cell carcinoma of the bladder.