Non-invasive ventilation after surgery.

After surgery, hypoxemia and/or acute respiratory failure (ARF) mainly develop following abdominal and/or thoracic surgery. Anesthesia, postoperative pain and surgery will induce respiratory modifications: hypoxemia, pulmonary volumes decrease and atelectasis associated to a restrictif syndrome and a diaphragm dysfunction. Maintenance of adequate oxygenation in the postoperative period is of major importance, especially when pulmonary complications such as ARF occur. Although invasive endotracheal mechanical ventilation has remained the cornerstone of ventilatory strategy for many years for severe acute respiratory failure, several studies have shown that mortality associated with pulmonary disease is largely related to complications of postoperative reintubation and mechanical ventilation. Therefore, major objectives for anesthesiologists and surgeons are first to prevent the occurrence of postoperative complications and second if ARF occurs is to ensure oxygen administration and carbon dioxide CO2 removal while avoiding intubation. Non-invasive ventilation (NIV) does not require endotracheal tube or tracheotomy and its use is well established to prevent ARF occurrence (prophylactic treatment) or to treat ARF to avoid reintubation (curative treatment). Studies shows that patient-related risk factors, such as chronic obstructive pulmonary disease (COPD), age older than 60 years, American Society of Anesthesiologists ASA class of II or higher, obesity, functional dependence, and congestive heart failure, increase the risk for postoperative pulmonary complications. Rationale for postoperative NIV use is the same as the post-extubation NIV use plus the specificities due to the respiratory modifications induced by the surgery and anesthesia. Postoperative NIV improves gas exchange, decreases work of breathing and reduces atelectasis. The aims of this article are (1) to review the main respiratory modifications induced by surgery and anesthesia which justify postoperative NIV use (2) to offer some recommendations to apply safely postoperative NIV and (3) to present the main results obtained with preventive and curative NIV in a surgical context.

How to choose an anesthesia ventilator?

During the past few years, many manufacturers have developed a new generation anesthesia ventilators or anesthesia workstations with innovative technology and introduced so-called new ventilatory modes in the operating room. The aim of this article is to briefly explain how an anesthesia ventilator works, to describe the main differences between the technologies used, to describe the main criteria for evaluating technical and pneumatic performances and to list key elements not to be forgotten during the process of acquiring an anesthesia ventilator.

Improvement in clinical evaluation of PET/CT images with high resolution algorithms.

AIM: Positron emission tomography/computed tomography (PET/CT) diagnosis relies on quality of the reconstructed images which strongly depends on the algorithms used. The aim of this work was to assess if the introduction of high resolution algorithms allows a better identification of reduced diameter lesions, leading to improved diagnosis in clinical setting. METHODS: The performances of a Siemens Biograph6 True Point PET/CT used for this work were checked for both standard and high resolution algorithms. Clinical studies of thirteen patients referred for PET/CT were selected and grouped according to the metabolic tumor volume and their position in the FOV and then reconstructed with both algorithms; clinical studies were estimated in terms of geometric characteristics and uptake values (SUVmax, SUVmean) of the lesions. RESULTS: FWHM, spatial resolution, contrast ratio and image quality of the PET/CT scanner used for this work are in agreement with the performances declared by the manufacturers. For the clinical studies, the results obtained using TrueX algorithm showed an increase in SUVmax and SUVmean of 20% and 10% respectively for lesions with volume higher than 2 cm3 and of about 26% and 15% for smaller lesions. The enhancement of SUVmean was around 10% for in axis lesions and of about 12% for off axis lesions. For SUVmax the increase was 23% for both the positions. For small lesions TrueX algorithm led to a metabolic volume higher than with the iterative one while no significant differences were found for big lesions. CONCLUSION: The advances in 3D PET reconstruction algorithms lead to images with improved quantitative accuracy and image quality performance.

[A single effective way to reduce post-thyroidectomy discomfort: a clinical trial]. / Un metodo semplice ed efficace per ridure il discomfort dopo tiroidectomia: un trial clinico.

AIM: Nausea, with or without vomiting (postoperative nausea and vomiting, PONV), occurs up to 60-76% after thyroidectomy and other head and neck surgeries. Due to the fact that patients typically have only mild-to-moderate pain after thyroid or parathyroid surgery, PONV might be the main source of discomfort, and it may be perceived as the most unpleasant aspect of postoperative recovery. This study aims to assess the effects of a preoperative single dose of 8 mg dexamethasone on the nausea, vomiting, pain, and subjective vocal function after thyroidectomy in patients undergoing surgery for benign disease. METHODS: Seventy patients operated on for thyroidectomy were randomized in two groups: Group A, 8 mg/2 mL of dexamethasone administered in 100 mL of physiologic saline given intravenously (i.v.) 20 minutes before the induction of anesthesia; group B, 2 mL NaCl 0.9% in 100 mL of physiologic saline. Postoperative therapy has been standardized. PONV have been evaluated with a scale of 4, degrees (0-3), pain by a Visual Analog Scale (0-100) and subjective vocal function by a Visual Analog Scale (0-100) at 8, 24, 32 and 48 hours after surgery. RESULTS: The severity of nausea was less in patients of group A (P=0.0001); Dexamethasone patients reported significantly less pain (P=0.008); no differences were noted about the subjective voice analysis (P=0.693). No steroid-related complications occurred. CONCLUSION: Dexamethasone 8 mg i.v. is a safe and effective method to reduce PONV and pain after thyroid resection and we advise its routine use.

Use of coagulant spray glue (Glubran 2) for aerostatic purposes in pulmonary parenchyma resections in pigs: a preliminary study.

BACKGROUND: The aim of our study was to test the aerostatic validity of a cyan-acrylic glue (Glubran 2), applied by means of a spray catheter, on an experimental pig model. MATERIALS AND METHODS: 15 young pigs were divided into three study groups of 5 based on surgical techniques: (1) atypical pulmonary resection with mechanical suturing and reinforcement with continuous suturing; (2) resection of the pulmonary parenchyma with a cold scalpel, followed by local application of Glubran 2; (3) atypical pulmonary resection with mechanical suturing followed by application of Glubran 2. RESULTS: The mean aerostasis time was calculated at 3.5 +/- 1.26 s. The histopathological analysis did not show any particular differences when comparing the effects of the treatments carried out with Glubran 2 spray glue and the standard treatments. No statistically significant differences were recorded in the short- and medium-term survival of pigs treated with Glubran 2 compared with the respective control groups. CONCLUSIONS: The application of Glubran 2 spray on wounds caused by pulmonary resections in pigs proved to have a rapid and effective influence for the purposes of aerostasis without significant differences in air losses and survivals.

Advanced thyroid carcinoma: an experience of 385 cases.

AIMS: To report clinical outcomes of a large series of cases with advanced thyroid cancer. STUDY DESIGN: Three hundred and eighty-five patients at the UICC stages III and IV were selected for the study with thyroid cancer. RESULTS: Papillary carcinoma and sclerosing carcinoma have better survival than the Hürthle cell and insular types. Lymphatic metastasis does not appear to worsen the prognosis. All the tumour forms offer the chance of long survival. CONCLUSIONS: Surgical treatment is the primary treatment of thyroid carcinoma. The combined treatments of surgery, metabolic beam therapy, suppressive hormone therapy, radiotherapy and chemotherapy cure a high percentage of patients with the tumour at an advanced stage.

Specific features of differentiated thyroid carcinoma in patients over 70 years of age.

BACKGROUND AND OBJECTIVES: Among the geriatric population, there is a lower incidence of thyroid carcinoma (TC), but it accounts for 30% of all thyroid disorders compared to 6-8% in younger subjects. Prognosis, moreover, is worse in the elderly, as demonstrated by the fact that 81% of deaths related to these tumors occur in patients over 55. The aim of this retrospective study was to identify the characteristics of differentiated thyroid carcinoma (DTC) peculiar to the elderly. METHODS: Of 638 patients who underwent surgery for DTC over a period of 30 years, 46 were more than 70 years old. All the elderly patients had undergone radioioidine and TSH-suppression therapy following surgical resection. RESULTS AND CONCLUSIONS: Despite these measures, the rate of recurrence was 26.5% at 5 years and 63.6% at 10 years. The 5- and 10-year disease-specific survival rates were 87.8% and 63.6%, respectively. On an average, survival was 55.1 months when death was disease-related, and with regard to histological type, it was longer in papillary carcinoma than in the follicular variant, and longest of all in occult sclerosing carcinoma. Survival was greatest in patients with tumors less than 2 cm in diameter, characterized by the absence of extraglandular spread and by lymph node metastasis.

[Ergonomic improvements obtained by the realization of an automatic methane cylinder-storage system in a control station]. / Miglioramenti ergonomici ottenuti con la realizzazione di un impianto automatico per l'accatastamento delle bombole di metano per autotrazione in una stazione di collaudo.

In a control station where liquid-methane cylinder for vehicle transport are inspected, the realization of an automatic cylinder-storage system not only managed to reduce space shortage inside the plant so avoiding possible accidents due to collisions between fork lift trucks and gathered cylinders or lorries, but also noticeably improved environment by reducing noise, total dust concentration and whole body vibration transmitted through the seats to lift truck operators.

[Assessment of microclimate at a natural gas compression plant]. / Valutazione del microclima nel capannone dei turbocompressori in una centrale di compressione del gas.

The Authors evaluate microclimatic conditions in a natural gas compression plant, inside the turboblower station, and find that technical maintenance operators may be subject to heat stress hazard during summer months.

[Risk of electromagnetic fields in control board and switchboard rooms at petrochemical plants]. / Rischio da campi elettromagnetici nelle sale quadro e cabine di smistamento e controllo degli impianti petrolchimici.

Authors evaluate electromagnetic field exposure (in the range (5-30,000 Hz) in control board and switchboard rooms of petrochemical plants. According to measured values and international guidelines, they conclude that operators should be exposed without adverse effects.

[Risk of electromagnetic fields in electric power stations and substations of a petrochemical plant]. / Rischio da campi elettromagnetici nelle cabine elettriche e sottostazioni di uno stabilimento petrolchimico.

Authors evaluate electromagnetic field exposure in the low-frequency range (5-30,000 Hz) in electric power stations and substations of petroleum processing plant. According to the measured values and the reference exposure limits considered, they conclude that operators should be exposed without adverse effects.

Predicting prostate biopsy outcome by findings at digital rectal examination, transrectal ultrasonography, PSA, PSA density and free-to-total PSA ratio in a population-based screening setting.

The study offers a retrospective analysis of the positive predictive value (PPV) of several variables, i.e. digital rectal examination (DRE), transrectal ultrasonography (TRUS), PSA value, PSA density (PSAD), and free/total PSA ratio (F/T), for the histologic outcome of 179 prostate biopsies performed within a population-based screening trial. The ratio of spared benign biopsies to missed cancers (SBB/MC) if biopsy results had been decided on the basis of single variables was also evaluated. PPV was 82.9% for DRE, 56.3% for TRUS, 26.6% for PSA (cutoff > or =4 ng/mL), 47.4% for PSA (cutoff > or =10 ng/mL), 42.0% for PSAD (cutoff 0.15), 59.2% for PSAD (cutoff 0.20), 34.9% for F/T (cutoff 0.20) and 40.0% for F/T (cutoff 0.15). SBB/MC was 121/23 for DRE, 96/12 for TRUS, 11/10 for PSA (cutoff > or =4 ng/mL), 107/34 for PSA (cutoff > or =10 ng/mL), 87/23 for PSAD (cutoff 0.15), 109/26 for PSAD (cutoff 0.20), 45/8 for F/T (cutoff 0.20) and 70/14 for F/T (cutoff 0.15). Multivariate analysis of the association with biopsy outcome showed the highest odds ratio for TRUS (13.24, 95% CI=4.4-30.7), and considerably lower values for DRE (4.17, 95% CI=2.0-8-9), PSAD (cutoff 0.20: 3.24, 95% CI=-1.8-5.7) and F/T (cutoff <0.15: 3.16, 95% CI=1.7-1.8). None of the possible variable combinations was clinically useful: the highest PPV (83.3%) was obtained with a combination of suspicious DRE/TRUS, PSAD >0.20 and F/T <0.15, which nevertheless missed 20 of 52 cancers.

Octreoscan SPET evaluation in the diagnosis of pancreas neuroendocrine tumors.

The study describes the results of Octreoscan SPET (OCTSPET) qualitative and semi-quantitative evaluation in 38 patients with suspected pancreatic neuroendocrine tumors. SPET studies were acquired at 4 and 24 hours after the injection of 111-220 MBq of 111-In-pentetreotide (Octreoscan). Qualitative and semi-quantitative evaluations were performed. The semi-quantitative approach was based on the time course of Tumor/Non Tumor ratios (TNTinc) from 4 and 24 hours. The OCTSPET results were true positive in 18 of 19 patients (10 gastrinoma, 5 insulinoma, 1 neuroendocrine tumor, 1 glucagonoma and 1 carcinoid) and false negative in one insulinoma. Besides, 20 of 38 patients (52%) had clinical plans modified after OCTSPET; OCTSPET was the only positive diagnostic test in 14 of 19 patients (73%) and guided the surgery decision in 14 of 25 patients (56%). In conclusion, these data indicate that Octreoscan represents an excellent tool for the diagnosis of pancreatic neuroendocrine tumors.

Lymphoscintigraphy and gamma probe tracing in detecting breast cancer lymph node involvement: can they replace axillary lymph node dissection?

BACKGROUND: Axillary lymph node status is the most important pathological determinant of prognosis in early breast cancer. However, axillary lymph node dissection (ALND) performed for pathological assessment is not without costs and morbidity. Recently, radioisotope-guided sentinel node biopsy (SNB) has been proposed as a promising technique for staging breast cancer patients. AIM OF THE STUDY: In this study we report our experience (76 patients) in radioguided sentinel node (SN) biopsy in breast cancer. The study was divided into two phases: the first represents our learning curve, necessary to establish our guidelines for its use in clinical practice, while the second phase was aimed at assessing the feasibility of SN localization using preoperative lymphoscintigraphy and intraoperative gamma probe (GP) detection. METHODS: All patients underwent lymphoscintigraphy (LS) up to two hours after tracer delivery (99mTc-micro-nanocolloid, four i.d. injections of 200 microCi/200 miccroL around the primary lesion) 24 hours before surgery and GP tracing during surgery. Subsequently ALND was performed for pathological assessment. RESULTS: SNs were identified in 73/76 patients using LS and in 72/76 using GP. In one case the SN was detected by GP alone while in two cases GP was not able to locate the SN although it had been identified by means of LS. Thirty-three of these 73 patients had axillary node involvement. In 31/33 cases the SN was the only positive node. No positive nodes were found in the remaining 40 ALNDs where SNs were identified. Thus, according to our experience 40/73 ALNDs could have been avoided. SNB seems to be a very interesting technique but further experience in lymph node radioisotope tracing is needed.

Radioisotopic lymphatic mapping of the sentinel node in melanoma: importance of immunohistochemistry.

BACKGROUND: Elective lymph node dissection (ELND) for patients with malignant melanoma is still controversial. A possible alternative could be biopsy of the first tumor draining lymph node, the sentinel node (SN), which can be identified by means of radionuclide techniques. AIM: Our study was undertaken to assess the accuracy of lymph node biopsy and to stress the importance of immunohistochemistry (IHC) in the pathological assessment of the SN for improved staging of the primary tumor. METHODS: We performed lymphoscintigraphy (LS) in 183 melanoma patients (89 with melanoma of the legs, 11 of the arms and 83 of the trunk). Our protocol consisted of preoperative peritumoral i.d. injection of 99mTc-labeled microcolloid to define the regional lymphatic basin and identify the sentinel node by means of planar scintigraphy. In 147 of the 183 cases a gamma probe (GP) was used during surgery to trace the SN. Vital blue dye was used during surgery in all cases. The SNs were excised for pathological examination. The pathological status of the SN was defined by means of examination of frozen sections, hematoxylin-eosin staining and immunohistochemistry for S-100 and HMB-45 MAb. RESULTS: At least one separate focus of activity was identified by LS in 182 out of 183 patients; in all 147 cases where a GP was used, it was successful in tracing the SN. LS with cutaneous mapping of the SN successfully guided the surgical excision in 177 of the 183 cases; in the 7 remaining cases, i.e. 7 out of 83 cases with SNs in the axillary basin, GP was not used and no elective node dissection was performed. Metastases were found in 39 of these 177 cases. In all 39 cases the SNs were the only positive nodes in the basin. Of the 39 metastases 18 were identified by means of frozen section, 12 by means of hematoxylin-eosin, and 9 by means of immunohistochemistry. We therefore emphasize the importance of immunohistochemistry in the pathology of LS for improved staging of the primary tumor.

Evaluation with breast scintigraphy of breast lesions of indeterminate significance after conventional triple diagnostic approach.

The role of breast scintigraphy in the evaluation of 30 women with an uncertain diagnosis following triple assessment was investigated. Scintigraphy was positive in 7 of 13 cancers and 3 of 17 benign lesions and dubious in 1 of 13 cancers and 2 of 17 benign lesions. Sensitivity ranged from 61.5% to 53.8% depending whether dubious lesions were designated as positive or negative. This study shows that breast scintigraphy is not sufficiently sensitive or specific to use in the evaluation of lesions of uncertain diagnosis following triple assessment.

Cytogenetic, molecular and phenotypic characterization of the newly established renal carcinoma cell line KJ29. Evidence of translocations for chromosomes 1 and 3.

The established non papillary human renal carcinoma cell line (RCC) KJ29 was submitted to a multiparametric characterization to evaluate its potential use for in vitro and in vivo studies. The cell line grows in vitro as monolayer as well as cell suspension. Cytogenetic analysis has shown a modal chromosome number of 50 with some marker chromosomes, including rearrangements of chromosomes 1 and 3. The antigenic phenotype is characterized by co-expression of cytokeratin and vimentin, as well as expression of urothelium differentiation antigens, low levels of class II MHC antigens and no class I antigens. A differential expression of the VLA-3 integrin heterodimer has been detected between the adherent and non adherent cell population. The cell line which is highly tumorigenic in athymic mice displays expression of erb B-2 and c-met oncogenes and high expression of cell-cycle related and Ha-ras 1 genes.

Serum amylase and tissue polypeptide antigen as biochemical indicators of salivary gland injury during iodine-131 therapy.

The study evaluated the possibility of using serum alpha-amylase and tissue polypeptide antigen (TPA) as biochemical markers of radiation injury in the salivary gland of patients with thyroid carcinoma treated with iodine-131. The results demonstrated that the two molecules increased 1 day after 131I administration and returned to near control values on the 3rd day. The increase was greater and longer lasting in those patients treated with the higher 131I administered activity. However, when the patients were divided into groups based on recovery time, which determined patients with different radionuclide elimination rates, the increase in the two molecules was greater and more lasting in those subjects with a longer period of hospitalization. A comparison with the values obtained from patients with tumours of the head and neck treated with external radiotherapy demonstrated that after the 1st day of treatment the salivary gland received an absorbed dose which, based on alpha-amylase levels, ranged between 0.24 and 1.89 Gy and, based on TPA levels, between 0.28 and 2.29 Gy.