Nerve changes associated with post thoracotomy pain syndrome.

BACKGROUND: Chronic post-thoracotomy pain (PTPS) is a frequent complication of thoracic operations. Sometimes the pain is excruciating enough to impair activities of daily living (ADL). All thoracic procedures have the potential to cause trauma to the intercostal nerves due to retractor use, chest closure techniques, and or wound healing. In our study, we analyzed the microscopic aspects of the nerves involved in the healing process, to better understand the histopathology of chronic pain. MATERIAL AND METHODS: 29 patients with PTPS underwent intercostal neurectomy to alleviate the symptoms. Microscopic specimens harvested during the surgeries were sent to our pathology unit for evaluation. The following data regarding the surgical procedures was collected: surgical approach, chest closure type, number of excised nerves, and time interval from previous surgery to neurectomy. RESULTS: A mean of 2.34±1.11 nerves were excised. Microscopy of the specimens revealed: fibrosis, hyalinization of the epineurium and perineurium, intense hyperemia of the blood capillaries, and interstitial edema. 7 cases presented with myxoid degeneration of epineurium and perineurium. In all the cases, endoneurium, myelin sheaths, and axons were interrupted. The endoneurium showed the presence of hyperemic dilated capillaries. The segmental cytoplasmic vacuolization of Schwann's cells with the total disappearance of axons was also noted. 60% of the examined specimens had intraneural myxoid degeneration, with highly dense irregular connective tissue around nerve fibers. CONCLUSIONS: The pathologic findings in the structure of the intercostal nerves obtained from the patients are indicative of the involvement of the wound healing mechanisms in PTPS. The negative impact of wound healing could be considered a key component in the development of intense chronic pain.

New Thoracotomy Closure, a Simple Way to Decrease Chronic Post-Operative Pain in Selected Patients-Blinded Prospective Study.

BACKGROUND AND OBJECTIVES: Chronic post-thoracotomy pain syndrome (PTPS) is a very common and uncomfortable complication, occurring frequently after thoracic operations, leading to the necessity of further medication and hospitalizations. One important risk factor in developing chronic pain is the chest closure technique, which can lead to chronic intercostal nerve damage. This study proposes an alternative nerve-sparring closure technique to standard peri-costal sutures, aimed toward minimizing the risk of chronic pain in selected patients. MATERIALS AND METHODS: We performed a prospective randomized study on 311 patients operated for various thoracic pathology over a period of 12 months, evaluating incision types, chest closure technique, and number of drains with drainage duration. The patients were divided into three groups: peri-costal (PC), proposed extra-costal (EC), and simple (SC) suture, respectively. Pain was measured on day 1, 2, 5, 7, and at 6 months post-operatively using the Visual Analogic Scale. RESULTS: No significant differences in pain level were recorded in the first two post-operative days between the PC and EC groups. However, a significant decrease in pain level was observed on day 5 and at 6 months post-operatively, with a mean level of 3.5 ± 1.8, 1.2 ± 1 for the EC group compared to a mean value of 5.3 ± 1.6, 3.2 ± 1.5, respectively. No significant differences were observed regarding other evaluated variables. CONCLUSIONS: The lower recorded pain scores in patients with extra-costal chest closure are a strong argument to use this technique. Its ease of use is similar to the classic peri-costal closure, and the time needed to perform it is not significantly increased. The association of this technique with less invasive procedures and short drainage duration limits chronic post-operative pain. This procedure may represent an option for decreasing healthcare costs associated with the management of PTPS.

Metformin alleviates monoamine oxidase-related vascular oxidative stress and endothelial dysfunction in rats with diet-induced obesity.

In the past decade, monoamine oxidase (MAO) with 2 isoforms, MAO-A and B, has emerged as an important source of mitochondrial reactive oxygen species (ROS) in cardio-metabolic pathologies. We have previously reported that MAO-related oxidative stress mediates endothelial dysfunction in rodent models of diabetes and diabetic patients; however, the role of MAO in the vascular impairment associated to obesity has not been investigated so far. Metformin (METF), the first-line drug in the therapy of type 2 diabetes mellitus, has been reported to elicit vasculoprotective effects via partially elucidated mechanisms. The present study was purported to assess the effects of METF on MAO expression, ROS production and vasomotor function of aortas isolated from rats with diet-induced obesity. After 24 weeks of high calorie junk food (HCJF) diet, isolated aortic rings were prepared and treated with METF (10 µM, 12 h incubation). Measurements of MAO expression (quantitative PCR and immune histochemistry), ROS production (spectrometry and immune-fluorescence) and vascular reactivity (myograph studies) were performed in rat aortic rings. MAO expression was upregulated in aortic rings isolated from obese rats together with an increase in ROS production and an impairment of vascular reactivity. METF decreased MAO expression and ROS generation, reduced vascular contractility and improved the endothelium-dependent relaxation in the diseased vascular preparations. In conclusion, METF elicited vascular protective effects via the mitigation of MAO-related oxidative stress in the rat model of diet-induced obesity.

Improvement of Platelet Respiration by Cell-Permeable Succinate in Diabetic Patients Treated with Statins.

Diabetes mellitus (DM) is the most severe metabolic disease that reached the level of a global pandemic and is associated with high cardiovascular morbidity. Statins are the first-line lipid-lowering therapy in diabetic patients with or without a history of atherosclerotic disease. Although well tolerated, chronic treatment may result in side effects that lead to treatment interruption. Mitochondrial dysfunction has emerged as a central pathomechanism in DM- and statin-induced side effects. Assessment of mitochondrial respiration in peripheral platelets has been increasingly used as a mirror of organ mitochondrial dysfunction. The present study aimed to assess the: (i) changes in mitochondrial respiration elicited by statins in patients with type 2 DM and (ii) the effects of cell-permeable succinate (NV118) on respiratory parameters in platelets harvested from these patients. No significant changes were found in global mitochondrial respiration of intact platelets isolated from diabetic patients treated with either atorvastatin or rosuvastatin. Similarly, no significant changes in mitochondrial respiration of permeabilized platelets were found between diabetic patients treated with atorvastatin and healthy controls. Acute ex vivo administration of NV118 significantly improved respiration in isolated platelets. These results prompt further research on the role of permeable succinate as a therapeutic alternative for improving mitochondrial function in metabolic pathologies and point to the role of peripheral platelets as a potential biomarker of treatment response.

Fortuitous discovery of melanomas in the ENT Department - a histopathological and immunohistochemical study.

The melanoma, having its origin in the melanocyte cells, is one of the most aggressive forms of skin cancer in the world with one of the highest rates of brain metastasis. The incidence of cutaneous melanoma in the Mediterranean countries varies from three to five cases∕100 000 people∕year. Its prognosis is based on an early diagnosis. Sinonasal mucosal melanoma (SNMM) is an extremely rare tumor, accounting for 0.3-2% of all melanomas. The non-specific symptomatology is often delaying the presentation of the patient at the hospital and therefore the diagnosis. The SNMM is a highly aggressive tumor, and the presence of metastasis at the diagnosis usually implies a poor prognosis. The management of the melanomas requires a precise pre-therapeutic assessment and a multidisciplinary approach for the diagnosis, with surgical treatment or radiotherapy required in order to ensure a better a quality of life. In this paper, we retrospectively analyzed two cases of mucosal melanoma and one case of cutaneous melanoma of the nose.

Primary tonsillar tuberculosis - case report.

We report the case of a 44-year-old male patient with tonsillar tuberculosis (TB) diagnosed in the Department of Ear, Nose & Throat (ENT), "Victor Babes" University of Medicine and Pharmacy, Timisoara, Romania. The patient addressed to our Clinic with intense odynophagia, referred otalgia, sore throat, fever periods and weight loss. During the ENT clinical exam, we identified an enlarged left tonsil, partially covered with yellowish-white plaque, with ulceration and bleeding spots localized on tonsillar inferior pole. A high suspicion of tonsillar malignancy was raised, and a biopsy was performed revealing extrapulmonary TB. Taking into consideration the normal chest X-ray, a primary tonsillar TB diagnosis was established. The patient was addressed to Department of Pneumophthisiology for anti-tuberculous therapy for six months. At the end of the treatment, the patient was symptoms-free.

Type II pleuropulmonary blastoma in a 2-year-old girl: a case report.

Pleuropulmonary blastoma (PPB) is a very rare, malignant aggressive primary lung tumor, which occurs mainly in children less than 5 years old. Due to its poor prognosis, it is aggressively treated with multimodal therapy including surgery and chemotherapy. We present a case of PPB in a 2-year-old girl who was brought to the pediatric clinic for fever, cough and respiratory distress. Imaging studies showed a heterogeneous solid-cystic mass (12∕9∕11 cm) in the upper right pulmonary lobe. Through right thoracotomy, a specimen was obtained, the histopathological and immunohistochemical features of the specimen being suggestive for type II PPB. Aggressive chemotherapy and right pneumonectomy resulted in control of disease, the patient being currently in complete remission four years after the diagnosis.

The reciprocal relationship between coping mechanisms and lung cancer diagnosis: findings of a prospective study.

BACKGROUND/PURPOSE: Lung cancer is a major stress factor for the affected individual, leading to psychological distress in over 50% of the diagnosed patients. Since coping styles describe different patterns in approaching serious problems, our study aimed at ascertaining if the diagnosis of lung cancer has an impact on the patient's coping styles and if there is a difference in psychical response among patients with different coping styles, as assessed by variance of anxiety and depression scores after diagnosis. PATIENTS AND METHODS: In this prospective study, a cohort of 50 patients were evaluated using the COPE scale, Generalized Anxiety Disorder Questionnaire 7 (GAD-7), and Patient Health Questionnaire-9 (PHQ-9), both prior to and 1 month after learning about their lung cancer diagnosis. The baseline and the final parameters were compared and stratified with respect to coping styles. RESULTS: We observed that 1 month after learning the diagnosis, the patients had a significantly higher GAD-7 score (median score 12 vs 4 points; p<0.001). At the same time, the PHQ-9 score was significantly higher at the 1 month follow-up time-point (median score 16 vs 7; p=0.002). The increases in the anxiety scores were significant in patients with initial social support (13 vs 3; p=0.014) and avoidance coping style (14 vs 6; p=0.003). Regarding the depression scores, after the diagnosis, the only significant increase was observed in patients with initial avoidance coping style (18 vs 5; p=0.014). CONCLUSION: Our study demonstrates that patients who receive the diagnosis for cancer show a significant increase in anxiety and depression intensity. The most adaptive coping style turned out to be the problem-focused one while the least adaptive one was the avoidant style.

Costal Cartilages Do Not Overgrow in Patients with Pectus Excavatum.

OBJECTIVE: The purpose of this study was to determine whether or not patients with pectus excavatum (PE) exhibit costal cartilage overgrowth compared to normal subjects. MATERIALS AND METHODS: The computed tomography acquisitions of 32 patients with PE and 35 normal controls were analyzed. On axial images the length of the 4th-7th costal cartilages was measured to calculate the Haller index. The ratio between the length of the cartilages and the median of the transverse and longitudinal thorax diameters were recorded to account for anatomical variability. The length of the cartilages was compared between the PE and control subjects using the independent-samples t test. For patients with asymmetric PE the length of the 4th-7th costal cartilages was compared between the rotated and nonrotated sides. RESULTS: The mean transverse and coronal thorax diameters were 233.29 ± 24.47 and 231.69 ± 22.47 mm for PE patients and 252.67 ± 37.25 and 238.64 ± 27.40 mm for controls, respectively, with no significant differences between the two groups (p = 0.816 and 0.145). The mean sagittal diameter (59.30 ± 14.21 mm) and Haller index (4.02 ± 1.34) in the PE group were significantly different from the controls (107.34 ± 19.59 and 2.2 ± 0.54 mm, respectively; p = 0.00). Actual and relative lengths of costal cartilages were similar in both PE subjects and controls for all 4 costal cartilages measured. In subjects with asymmetric PE, both relative and absolute costal cartilage lengths were similar on the rotated and nonrotated side. CONCLUSIONS: The length of the 4th, 5th, 6th and 7th costal cartilages was similar in PE patients and the control subjects. These was also similar between the rotated and nonrotated sides of the sternum in patients with asymmetric PE.

The role of surgery in the management of pleuropulmonary tuberculosis - seven years' experience at a single institution.

Pleuropulmonary tuberculosis (TB) is a relatively frequent condition (the incidence of (TB) was 176/100,000 in our county in 2004) and some of these patients with TB are undergoing surgical interventions. The authors share their experience in surgical treatment of pleuropulmonary tuberculosis, based on minimal invasive techniques such as VATS and filling the residual cavities with muscle or skin-muscle grafts. The authors are retrospectively revising 144 patients between 1 January 2001 and 31 December 2007 who underwent surgical treatment for tuberculosis in this period. Two hundred and thirteen surgical procedures were performed for pleuropulmonary tuberculosis, representing 4% of all the procedures done in the department. For most of the patients the etiological diagnosis was not established until the operations, all the patients were sputum-negative. The diagnoses at the admittance were: pulmonary nodules or tumors (42 patients), pleural collections (46), pleural thickening and post-tuberculosis syndromes (46), fibrocavitary tuberculosis (6), and tuberculous pericarditis (4). Of all the procedures applied, 14 were pulmonary resections, 50 atypical (wedge) resections, 70 video-assisted thoracic surgery (VATS) procedures, and nine patients needed muscle or skin-musle flap for residual pleural cavities. Eleven patients (7.6%) had to undergo secondary surgery due to complications. No in-hospital mortality was registered. The mean hospitalisation period was 10.1+/-4.2 (S.D.) days.

[An improved approach in the diagnosis of mediastinal/pulmonary masses through the CT-guided transthoracic fine needle aspiration]. / O abordare eficientizata economic a diagnosticului formatiunilor mediastinopulmonare prin punctie transtoracica ghidata CT.

AIM: In our clinic we have gathered more than 750 cases of CT-guided transthoracic fine needle aspiration (FNA). This procedure is very useful for the diagnosis of mediastinal/pulmonary tumor masses. Because of the relatively high cost of this procedure, we tried to find out a less expensive but still reliable way to get the diagnosis for these tumors, and for this reason we figure out an original approach. METHODS: The study population consisted of 160 patients divided in two groups. To first group we applied the classic method using the conventional needles and the Papanicolaou stain. For the second group we used the spinal anesthetic needle and an original stain (blue--polychrome--tanine--Dragan). The chi2 test was used to match the results and complications between the two groups. RESULTS: This study prove that this original method is as reliable as the classic one but with a ten-fold reduction of costs: 1,198 euro versus 128 euro per 100 smears. CONCLUSIONS: Choosing of this original method for the diagnosis of mediastinal/pulmonary tumors through transthoracic FNA is justified by the low cost, simple technique and the same reliability as the classic method.