[Malignant pleural mesothelioma: The role of surgery]. / Mésothéliome pleural malin : place de la chirurgie.

INTRODUCTION: Malignant pleural mesothelioma (MPM) is a rare and highly aggressive disease, whose incidence is increasing. Asbestos is the primary causal agent. STATE OF KNOWLEDGE: Knowledge about MPM has evolved. Thoracoscopy is essential for diagnosis of MPM. It allows performing pleural biopsies, to study the extent of the disease and to relieve dyspnea. The pathological diagnosis is also better codified with immunohistochemistry and with analysis by expert of Mesopath group. Curative surgical treatments are pleurectomy decortication and extended pneumonectomy in combination with chemotherapy and/or radiotherapy. Those heavy treatments improve survival in highly selected patients. For the other patients, supportive measures will be considered to reduce pain and dyspnea. PROSPECT: Radical surgical treatment is only offered in therapeutic trials or multimodal treatment. Its place is not formally established. New therapies associated to surgical treatment are being studied. CONCLUSIONS: Surgical management of MPM has to be operated in specialized teams where the survival benefit and quality of life is discussed case by case.

Late costal osteomyelitis with a cutaneous fistula after flame burns: a case report.

Chest wall defects are an unusual complication of burn injury, generally seen after high-voltage electrical burns. Here we report the case of a 57-year-old man who developed costal chondritis and osteomyelitis 23 months after flame injury, which covered 50% of the total body surface area. Management included the resection of two ribs and coverage with an omental flap, overlaid by a split-thickness skin graft during the same surgical procedure. Declaration of interest: The authors have no conflict of interest to declare.

[A tamponade complicating an acute eosinophilic pericarditis due to a myeloproliferative/myelodysplastic syndrome]. / Une tamponnade compliquant une péricardite à éosinophiles au cours d'un syndrome myéloprolifératif/myélodysplasique.

Cardiac involvement in eosinophilia is potentially fatal and requires early diagnosis and prompt treatment. We report here the case of a 71-year-old female patient with eosinophilia>10,000/mm(3) for 2 months due to a myeloproliferative/myelodysplastic syndrome, with a rapidly progressive exertional dyspnea explained by an important circumferential eosinophilic pericarditis. Due to a rapid evolution to a tamponade, an emergent surgical drainage was performed. Subsequent medical treatment combined high-dose corticosteroids (1mg/kg/day) with hydroxyurea and imatinib. The outcome was favourable with regression of the effusion, of the volume overload symptoms and decrease in eosinophilia.

[Congenital malformations of the lung, the radiologist's point of view]. / Malformations pulmonaires congénitales, le point de vue du radiologue.

Congenital lung malformations include a complex range of developmental abnormalities. Currently, most are diagnosed prenatally or during early childhood. They may, however, be discovered later, incidentally or in connection with non-specific symptoms, sometimes severe. Knowledge of their radiological appearances is necessary for their detection. Proper technique and analysis of cross-sectional imaging, computed tomography and magnetic resonance imaging, allow a definitive diagnosis in most patients and pre-treatment evaluation of surgical cases. This review will describe the radiological aspects of congenital pulmonary malformations, especially those which may occur in late childhood or adult life. When present, alternative diagnoses will be discussed. A distinction will be made between anomalies originating from bronchopulmonary structures, such as bronchial atresia, bronchogenic cyst, congenital lobar overinflation, cystic adenomatoid malformation, and forms related to vascular anomalies (vascular rings, anomalous left pulmonary artery, pulmonary underdevelopment, proximal interruption of the pulmonary artery, pulmonary sequestration, scimitar syndrome).

Resection of giant typical carcinoid tumor with cardiopulmonary bypass support.

Carcinoids, defined as well-differentiated neuroendocrine tumors, are classified as typical or atypical based on their microscopic pathological features. Typical carcinoids have a favorable prognosis after complete resection, with 10-year survival rates of up to 90%. We present the surgical strategy used to achieve a left pneumonectomy and the indications for cardiopulmonary bypass (CPB) support in a patient with a huge typical carcinoid tumor.

Impairment of cardiovascular autonomic pattern in obese adolescents with Type 2 diabetes mellitus.

UNLABELLED: The aim of this study was to assess the behaviour of insulin sensitivity and insulin resistance (IR) indexes in a group of obese adolescents with Type 2 diabetes mellitus (T2DM) in comparison to obese adolescents without diabetes and normal controls, moreover to compare these parameters with the cardiac autonomic pattern. Seven T2DM obese (12.7 ± 0.5 yr), 18 obese without T2DM, and 10 nonobese control adolescents age matched were studied. In all subjects we performed oral glucose tolerance test (OGTT) with insulin and glucose determination, 24-h electrocardiogram Holter, blood pressure monitoring, ecohocardiogram. RESULTS: serum lipids were significantly higher in obese and T2DM. Insulin sensitivity was significantly reduced in T2DM and obese vs controls; T2DM showed a more pronounced oral glucose insulin sensitivity (OGIS) reduction vs obese. Both obese and T2DM presented an higher IR. T2DM showed an impaired ß-cell function, with insulin areas under the curve and disposition index significantly reduced in comparison to controls and obese who showed similar values. A progressive reduction of vagal indexes and an increase of sympathetic indexes were found in obese adolescents and were more pronounced in T2DM. These parameters were correlated with OGIS and ß-cell function parameters in both obese and T2DM adolescents. T2DM showed a significant relative wall thickness increase suggesting a trend toward concentric remodeling. In conclusion, T2DM adolescents are characterized by a more marked IR reduced ß-cell function in comparison to non-diabetic obese. These modifications may lead to an early impairment of the autonomic pattern.

Intensive insulin therapy in preschool-aged diabetic children: from multiple daily injections to continuous subcutaneous insulin infusion through indwelling catheters.

In this study, glycemic control, diabetes care indices and quality of life (QoL) were assessed in 2 groups of newly diagnosed Type 1 diabetic subjects <6 yr old who were randomized to multiple daily injections with (Group A) or without (Group B) an indwelling catheter. Group A [12 males (M)/8 females (F), mean age 3.2+/-1.4 yr] and Group B (9M/11F, mean age 3.9+/-1.8 yr) were evaluated at baseline and after 6 and 12 months of treatment. No significant difference was observed in metabolic control (glycosylated hemoglobin) or in the number of hypoglycemic events between the groups. Patients in Group A had a greater number of daily insulin injections, monitored blood glucose more frequently and had a lower total daily insulin dose per kg (p<0.05). QoL was better in group A. At the end of the study 30% of group A patients progressed to continuous sc insulin infusion (CSII), while no child in Group B switched to a different insulin regimen. Based on these findings, indwelling catheter therapy may be helpful for selected CSII candidates.

Age-related differences in metabolic response to continuous subcutaneous insulin infusion in pre-pubertal and pubertal children with Type 1 diabetes mellitus.

The aim of this study was to evaluate clinical and metabolic data in a cohort of Type 1 diabetes (T1DM) children before and after 2 yr of continuous s.c. insulin infusion (CSII). Forty seven T1DM patients were subdivided into two groups: Group A (20 pre-pubertal children, mean age 7.43+/-3.19 yr); Group B (27 pubertal adolescents, mean age 14.47+/-1.91 yr). No statistically significant differences in body mass index (BMI) occurred in either groups after starting CSII or during follow-up. The frequency of mild-hypoglycemias significantly declined during pump therapy only in Group A (p<0.05). Both pre-pubertal and pubertal patients required a significant reduction in their total insulin requirement after 12 and 24 months of CSII. The total percentage of daily insulin doses delivered as basal rates was similar in both groups and was negatively associated (beta=-2.956, p=0.05) with glycosylated hemoglobin (HbA1c) values. No significant correlation was found between the percentage of the basal insulin rate and the number of daily boluses. Differences in timing of the highest insulin requirement were observed between the two groups. Group A had a higher insulin basal rate late in the evening (20:00-24:00 h), while Group B had a higher insulin requirement early in the morning (03:00-07:00 h). The HbA1c levels significantly improved in Group A after 6-12 and 24 months of CSII. In Group B a reduction of HbA1c values was observed only after 6 months of pump therapy (p=0.05). CSII is an effective therapy for all ages but different metabolic requirements should also be taken into account.

[Empowering leadership style among health care workers. A study on the nurse manager]. / Empowering leadership style in ambito sanitario. Uno studio sul coordinatore infermieristico.

The aim of the study is to supply a contribution to the validity analysis of the Empowering Leadership Questionnaire (ELQ) in the Italian context. The ELQ has been developed in order to measure empowering leadership style in organizational contexts and, in the present work, has been administered to a group of health care workers in order to evaluate the Nurse Manager's leadership style. Three hundred and eleven individuals from an important Local Health Unit of the Veneto Region participated in the study, filling out a self-administered structured questionnaires. Correlations between ELQ, task-oriented, relationship-oriented and transformational leadership stile are addressed. Moreover, the relationships between ELQ, organizational commitment, job burnout, turnover intentions and job satisfaction are analyzed. Exploratory, confirmatory, reliability analyses and path analyses techniques are applied. Results support the main results obtained by the authors of the scale. In addition, with regards to ELQ predictive validity, the selected dependent variables (turnover intentions and job satisfaction) are significantly influenced by some of the ELQ dimensions, via the mediation of affective commitment and job burnout, supporting the value of the ELQ measures in the healthcare context.

Ipsilateral shoulder pain after thoracotomy surgery: a prospective, randomized, double-blind, placebo-controlled evaluation of the efficacy of infiltrating the phrenic nerve with 0.2%wt/vol ropivacaine.

BACKGROUND: The aim of this prospective, randomized, double-blind, placebo-controlled study was to evaluate the efficacy of phrenic nerve infiltration with ropivacaine 0.2% on the incidence and severity of ipsilateral shoulder pain after thoracotomy in patients receiving continuous thoracic epidural analgesia. METHODS: Fifty ASA physical status II-III patients, receiving thoracic epidural analgesia for post-thoracotomy pain, were randomly allocated to receive infiltration of the ipsilateral phrenic nerve with either ropivacaine 0.2% 10 mL (ropivacaine, n = 25), or saline 0.9% (control, n = 25) just before lung expansion and chest closure. A blinded observer recorded the incidence and severity of ipsilateral shoulder pain 6, 12, 24, 36 and 48 h after surgery. Postoperative respiratory function was also evaluated with blood gas analyses. RESULTS: The cumulative incidences of ipsilateral shoulder pain during the first 24 h after surgery were 8/25 in the ropivacaine and 16/25 in the control groups (P = 0.047), with median (range) onset times for shoulder pain of 2 (2-24) h with ropivacaine and 0.5 (0.5-24) h in controls (P = 0.005). No differences were reported on the second postoperative day. The areas under the curves of the amount of pain over time were 0 (0-2760) mm h for the ropivacaine and 350 (0-1900) mm h for the control groups (P = 0.06). Postoperatively, similar reductions in indices of oxygenation were observed in both groups. CONCLUSIONS: Phrenic nerve infiltration with ropivacaine 0.2% 10 mL reduced the incidence and delayed the onset of ipsilateral shoulder pain during the first 24 h after open lung resection, with no clinically relevant effects on respiratory function.

A prospective, randomized, blinded comparison between continuous thoracic paravertebral and epidural infusion of 0.2% ropivacaine after lung resection surgery.

BACKGROUND: The aim of this prospective, randomized, blinded study was to compare analgesic efficacy of continuous paravertebral and epidural analgesia for post-thoracotomy pain. METHODS: Forty-two ASA physical status II-III patients undergoing lung resection surgery were randomly allocated to receive post-thoracotomy analgesia with either a thoracic epidural (group EPI, n = 21) or paravertebral (group PVB, n = 21) infusion of 0.2% ropivacaine (infusion rate: 5-10 mL h-1). The degree of pain at rest and during coughing, haemodynamic variables and blood gas analysis were recorded every 12 h for the first 48 h. RESULTS: The area under the curve of the visual analogue pain score during coughing over time was 192 (60-444) cm h-1 in group EPI and 228 (72-456) cm h-1 in group PVB (P = 0.29). Rescue morphine analgesia was required in four patients of group EPI (19%) and five patients of group PVB (23%) (P = 0.99). The PaO2/FiO2 ratio reduced significantly from baseline values in both groups without between-group differences. The median (range) percentage reduction of systolic arterial pressure from baseline was -9 (0 to -9)% in group PVB and -17 (0 to -38)% in group EPI (P = 0.02); while clinically relevant hypotension (systolic arterial pressure decrease >30% of baseline) was observed in four patients of group EPI only (19%) (P = 0.04). Patient satisfaction with the analgesia technique was 8.5 (8-9.8) cm in group EPI and 9 (7.5-10) cm in group PVB (P = 0.65). CONCLUSIONS: Continuous thoracic paravertebral analgesia is as effective as epidural blockade in controlling post-thoracotomy pain, but is associated with less haemodynamic effects.

Endotracheal migration of a central venous catheter.

Subcutaneous infusion ports for prolonged central venous access are commonly used for drug administration and parenteral nutrition in a wide range of chronic diseases. The extensive use of these devices has to be balanced against its complications, some of which potentially life-threatening. We describe the case of a patient admitted to our unit with haemoptysis and cough. At bronchoscopy the tip of the central venous catheter was discovered protruding into the tracheal lumen. The catheter was pulled out from the subcutaneous pouch under simultaneous surgical control of the tracheal fistula orifice.

Surgical outcome of combined pulmonary and atrial resection for lung cancer.

OBJECTIVES: The study was carried out to assess the short and long-term outcome of patients with non-small cell lung cancer infiltrating the left atrium treated by surgery. METHODS: We retrospectively collected the hospital files of twenty-three consecutive patients operated on between 1982 and 2001 in two units of Thoracic Surgery. Four patients received an induction regimen. Fourteen right pneumonectomies, 8 left pneumonectomies and 1 right inferior lobectomy were performed. No cardiopulmonary bypass was employed. RESULTS: In all patients the diagnosis of T4 atrial invasion was confirmed by pathological examination. A complete resection was achieved in nineteen patients (83%). With respect to nodal staging, there were 13 N0, 5 N1 and 4 N2 cases, respectively. Two deaths occurred during the one month postoperative period (9%). Three patients had postoperative atrial fibrillation. Two other patients had postpneumonectomy empyema without bronchopleural fistula and recovered, one after thoracoscopic debridement and the second after open window thoracostomy. Follow-up was completed on September 2002; only one patient was lost to follow-up. Median survival, excluding the perioperative mortality, was 20 months (range 4 - 62 months). The survival rate, calculated with the Kaplan-Meier method, was estimated as 63% at 1 year, 2 % at 3 years and 10% at 5 years. Using a Cox model analysis, lymph node stage and completeness of resection were not independent prognostic factors. CONCLUSIONS: In cases of NSCLC with left atrial invasion complete resection is technically feasible in most instances without cardiopulmonary bypass. The acceptable operative risk and the encouraging long-term survival observed in this series suggest that NSCLC invading the left atrium should not be systematically considered as a definitive contraindication to surgery.

Histological and immunohistochemical study of the bronchial stump with flap coverage in an animal model.

OBJECTIVE: The purpose of our study was to evaluate the healing process of the bronchial stump after pneumonectomy reinforced with different pedicled flaps in an animal model. The specimens were analyzed by means of histology and immunohistochemistry. MATERIALS AND METHODS: We have considered 45 New Zealand White male rabbits that underwent a left pneumonectomy under general anesthesia. Nine animals had no bronchial coverage and represented the controls. The other 36 rabbits were divided into three groups of 12 and had bronchial coverage with either diaphragmatic, intercostal or pericardial flaps. The histological examinations were performed on the animals sacrificed 7, 14 and 30 days after surgery. Immunohistochemical analyses were done on the specimens on postoperative day 7 and 14. On postoperative day 7, the specimens were examined for expression of proliferating cell nuclear antibody (PCNA) expression. On postoperative day 14, neoangiogenesis was measured by CD31 expression. The measurements of antibody expression were done with a computer-assisted morphometric count and analyzed with the t test. RESULTS: On postoperative day 14, standard histology showed more evident neoangiogenesis in the bronchial stump specimens covered with intercostal and diaphragmatic flaps compared to pericardial flaps and controls. The immunohistochemical evaluation of PCNA by morphometric computer-assisted analysis did not show any statistically significant differences among the groups. The CD31 morphometric count revealed a higher and statistically significant antibody expression in muscular flaps compared to pericardial flaps and controls. CONCLUSIONS: Our study showed that bronchial coverage with a pedicled muscular flaps promotes the production of new vessels and gives the possibilities to optimize the healing process of a bronchial stump after pneumonectomy.

Pulse rate in childhood: reference limits.

BACKGROUND AND AIM: Systematic quantitative resting pulse rate measurements may represent an additional parameter for the study of cardiovascular risk factors in youth as well as in adulthood. The aim of this study was to evaluate resting pulse rate and its distribution curve in order to define reference limits in a sample of adolescents from Turin, Italy. METHODS AND RESULTS: The study population consisted of 2230 children aged 12-18 years, who were randomly enrolled from Turin Junior High Schools. All of the participants underwent pulse rate, blood pressure and height measurements. The 5th and 95th percentiles of the pulse rate in boys and girls are reported by age and height. The pulse rate was higher in the girls, but progressively decreased with age and somatic growth in both genders. CONCLUSIONS: The present study provides reference blood pressure values by age, gender and height in a sample of male and female adolescents.

Biological markers in non-small cell lung cancer. Retrospective study of 10 year follow-up after surgery.

BACKGROUND: The biological markers in non-small cell lung cancer (NSCLC) have been widely studied and encouraging results have shown that products of some oncogenes and other molecular markers can predict the aggressiveness of the disease and the outcome of the patients. METHODS: To verify the reliability of these prognostic markers we have studied retrospectively the expression of c-erbB-2 and 67Ki (growth regulation), p53 (cell cycle regulation and apoptosis), bcl-2 (apoptosis) and CD31 and CD34 (angiogenesis) in 78 patients operated on for NSCLC with curative intent between January 1987 and December 1988 and followed up for 10 years. For the determination of the biological markers we have used the ABC (Avidin-Biotin-Peroxidase complex) immunohistochemical method. The Cox regression model was used for the univariate and multivariate analysis. RESULTS: Nineteen patients (24%) were alive after 10 years and 59 (76%) died. The univariate analysis of the relationship between the 10-year survival and the expression of the markers was significant only for p53 (p=0.0097). Stratifying the patients according to the 3 histological subtypes (squamous cell carcinoma, adenocarcinoma and large cell undifferentiated carcinoma) the correlation between markers and survival pointed out that the only significant one was p53 (p=0.0459) in adenocarcinoma. In the same way considering the stages p53 was significant in stage IIIa (p=0.0357). The multivariate analysis emphasized that p53 was the only significant marker with respect to the 10-year survival (p=0.0091). Examining the histological groups significant was only p53 in adenocarcinoma (p=0.0192) and in large cell undifferentiated carcinomas (p=0.0290). This marker is also significant in pathological stage II (p=0.0271) and IIIa (p=0.0402). Apart from histology and staging the 10-year survival was 33% for p53 negative versus 10% for p53 positive. In patients with adenocarcinoma the 10-year survival was 40% for p53 negative and 6% for p53 positive. CONCLUSIONS: In conclusion our results emphasize the importance of p53 as a prognostic factor in 10-year survival in patients with adenocarcinoma and in stage II and IIIa.

Azygos vein aneurysm as a diagnostic pitfall. The role of thoracoscopy.

We report the case of an azygos vein aneurysm that was found intraoperatively in a 66-year-old woman followed for esophageal carcinoma. She underwent video-assisted thoracoscopy surgery (VATS) for biopsy of a mediastinal mass. This mass was diagnosed in the 2nd year of postoperative follow-up for a T2N0M0 esophageal carcinoma by computed tomography, which revealed a heterogeneous mass of ~2 cm in diameter in a retrotracheal location. Preoperative echoendoscopy demonstrated an extraesophageal lesion. A diagnostic thoracoscopy was done in order to exclude a metastatic lymph node disease.

Mediastinoscopy and permanent venous access device positioning through the same incision.

We report herein our technique for positioning of permanent venous access device in patients undergoing mediastinoscopy for diagnosis and/or staging of thoracic malignancies. Through the same 3-cm skin incision employed for mediastinoscopy, access to right internal jugular vein is obtained and the prepectoral pocket for chamber positioning is prepared. The technique is simple, safe and provides increased patient acceptability.

Surgical treatment of primary and metastatic sternal tumours.

BACKGROUND: Primary and metastatic malignancies of the sternum are uncommon. Surgery that is the best treatment for the majority of primary sternal tumors, and arguably for metastatic lesions, has improved permitting us to perform wide resection and simultaneous reconstruction safely. METHODS: From January 1988 to December 1998 we treated 13 patients, 4 with primary chondrosarcoma and 9 with sternal metastasis, 5 breast cancer, 3 kidney cancer and 1 thyroid cancer. In 3 patients total sternectomy was performed and in 10 a partial sternectomy associated with resection of the anterior segment of the ribs in 7 cases and resection of the clavicle in 5 patients. Bone reconstruction was done in the majority of cases (5) with Marlex mesh with methylmethacrylate and in 3 cases rib grafts were used to strengthen a Vicryl mesh. The major pectoralis muscle was the most frequently used soft tissue, 9 of 12. RESULTS: Our postoperative mortality was 15%, 2 cases. The median overall survival was 48 months. All the primary tumours were alive after a mean follow-up of 34 months (range 4-84 months). While survival of the sternal metastasis was 24 months. CONCLUSIONS: Surgical resection and reconstruction of sternal lesions represent a basic step in the treatment of the primary tumors with encouraging survival results while in the metastatic lesions surgery can be a part of a multimodality approach with unsatisfactory results.

The bilobectomies for lung cancer.

BACKGROUND: The purpose of our retrospective study is to confirm that bilobectomy is a feasible operation with an oncological value. METHODS: From 1981 to 1998, 46 patients underwent bilobectomy for lung cancer. Eight upper and middle lobectomies (UML) and 38 middle and lower lobectomies (MLL) were performed. Intraoperative pneumoperitoneum was done in 11 MLL. We have considered operative mortality, postoperative complications, the persistence of drainage tubes and the length of hospital stay and the data were statistically compared with those relative to right lobectomies. Survival was estimated with the Kaplan-Meier method and the curves were compared with those of the right lobectomies and right pneumonectomies using the log-rank test. RESULTS: Overall morbidity was 43.4%. Mortality was 6.5%. Mean chest tube persistence was 7.8 days and mean hospital stay was 14 days. No statistical significance was found about these data comparing the UML and MLL separately and the bilobectomies with the right lobectomies. The pneumoperitoneum done in the MLL enabled a shorter hospital stay, statistically significant, in comparison with MLL without pneumoperitoneum. The overall 5-year survival rate was 38%. Considering the I and the II stages no statistical differences in survival were found considering the right lobectomies and right pneumonectomies. CONCLUSIONS: The bilobectomies can have a role in treatment of lung cancer that is equal to the other standard major resections.