Predictive and prognostic value of preoperative symptoms in the surgical treatment of pulmonary aspergilloma.

BACKGROUND: Surgical resection is widely accepted as the treatment of choice for pulmonary aspergilloma (PA). However, the technique involved ranks among the most challenging in thoracic surgery and remains associated with considerable morbidity and mortality. To improve the outcomes, it is essential to establish clear recommendations for optimal timing of surgery and selection of patients. To facilitate this, we analyzed the impact of preoperative clinical factors on the results of treatment. METHODS: Medical records of patients treated surgically for PA between 1979 and 2007 were retrospectively reviewed for clinical variables of potential impact on the surgical outcome with emphasis on preoperative symptoms. RESULTS: Sixty-four patients, including 22 cases of simple aspergilloma and 42 cases of complex aspergilloma were enrolled in the study. Univariable analysis followed by multivariable logistic regression identified weight loss and massive hemoptysis as risk factors for postoperative morbidity [odds ratio (OR) = 8.856, P = 0.006 and OR = 6.9, P = 0.021, respectively]. Ten-year cumulative survival in simple aspergilloma and complex aspergilloma was 88.3% and 70.6%, respectively (P = 0.042). Multivariable analysis by Cox proportional hazard model showed that younger age and lack of massive hemoptysis were independent favorable prognostic factors [hazard ratio (HR) = 1.13, P = 0.0004 and HR = 4.71, P = 0.0319, respectively). CONCLUSION: Massive hemoptysis is an independent unfavorable predictive and prognostic factor in the surgical treatment of PA. We believe that in operable cases, early surgical resection may be recommended even in asymptomatic patients. This strategy may prevent development of life-threatening symptoms and offers a realistic chance of permanent cure with acceptable mortality and morbidity.

Surgical treatment of mediastinal parathyroid adenoma: rationale for intraoperative parathyroid hormone monitoring.

BACKGROUND: Recent publications have recommended parathyroidectomy guided solely by preoperative imaging. However, when the parathyroid adenoma is located deep in the mediastinum, the surgeon often encounters difficulties to localize and completely remove all hyperfunctioning parathyroid tissues. Thus, we hypothesized that patients with mediastinal adenoma differ substantially from cervical cases and require a specific strategy. The aim of this study was to evaluate the efficacy of intraoperative serum parathyroid hormone monitoring (ioPTH) used to guide completeness of targeted mediastinal parathyroidectomy. METHODS: In a 10-year period, 33 patients underwent targeted mediastinal parathyroidectomy with ioPTH for primary sporadic hyperparathyroidism. A greater than 50% drop in ioPTH was considered confirming successful resection. If ioPTH failed to decline adequately, the operation was extended to complete cervical exploration. We analyzed the impact of ioPTH on the final surgical outcome. RESULTS: In 26 patients the adenoma was correctly identified and removed at targeted mediastinal parathyroidectomy. In 7 patients lack of adequate ioPTH drop after targeted mediastinal parathyroidectomy triggered continued exploration, providing success at complete cervical exploration in 6 patients. In 1 patient this strategy failed owing to an undiagnosed lesion in the posterior mediastinum. Use of ioPTH decreased the failure rate from a potential 21.2% without ioPTH to 3% in the actual series. CONCLUSIONS: Mediastinal parathyroid adenoma represents a distinct subset of primary hyperparathyroidism and requires a specific diagnostic and therapeutic approach. In these cases ioPTH monitoring is a reliable and effective method to confirm curative resection. It is an important adjunct predictor of postoperative successful outcome, which allows a low failure rate and avoids unnecessary reoperations.

Surgery for pulmonary aspergilloma in immunocompetent patients: no benefit from adjuvant antifungal pharmacotherapy.

BACKGROUND: The optimal treatment strategy for pulmonary aspergilloma (PA) remains controversial. Among a variety of options, surgical removal of the mycetoma is considered the most effective. However, it ranks among the most challenging procedures and is associated with considerable mortality and morbidity. Previous studies showed that the use of antifungal agents improved outcomes in high-risk surgical patients with mycotic infections. We hypothesized whether combining antifungal pharmacotherapy with surgical resection in patients with PA could yield a strategy more beneficial than surgery alone. METHODS: Medical records of 72 patients with PA treated surgically at our department between January 1984 and December 2007, were retrospectively reviewed for clinical variables including adjuvant antifungal pharmacotherapy and the outcomes of treatment. RESULTS: Ten-year cumulative survival was 74.8% in patients with adjuvant antifungals and 78.9% after surgery alone (p = 0.11). Multivariable analysis by logistic regression model (chi(2) = 11.41; degrees of freedom = 5; p = 0.043) identified pneumonectomy as a significant risk factor for postoperative morbidity (odds ratio = 6.499; 95% confidence interval 1.388 to 30.423; p = 0.018). Multivariable analysis using the Cox proportional hazard model (chi(2) = 26.3; degrees of freedom = 7; p = 0.00045) revealed that female gender, forced expiratory volume in 1 second greater than 75%, and simple aspergilloma were independent favorable prognostic factors (hazard ratio = 10.86, p = 0.013; hazard ratio = 13.45, p = 0.004; and hazard ratio = 11.97, p = 0.028, respectively). Neither univariable nor multivariable analysis indicated that antifungals significantly affected morbidity or survival. CONCLUSIONS: Adjuvant antifungal pharmacotherapy appears not to improve the results of surgical treatment for PA, and may cause severe adverse effects. We believe that whenever definitive surgical removal of the mycetoma is feasible, antifungals may not be beneficial.

A rare case of solitary plasmacytoma mimicking a primary lung tumor.

Extramedullary plasmacytomas, especially located in the thorax, are very rare. We present a 31-year-old patient who was diagnosed with a solitary plasmacytoma located in the lung mimicking a primary lung tumor. After several weeks, this developed into multiple myeloma.

Dynamics of nasopharyngeal colonization by gram-negative rods in patients with resectable lung cancer during short-term hospitalization.

We determined the frequency of colonization of nasopharynx by Gram-negative rods in 63 patients with lung cancer undergoing thoracic surgery who routinely receive antimicrobial prophylaxis. Throat and nasal specimens were taken from each patient twice: on the day of hospital admission (examination I) followed by thoracic surgery and on the fourth day after thoracic surgery (examination II). The isolated strains were identified using API 20E or API 20NE microtests. Susceptibility to selected antimicrobial agents was detected by the disc diffusion method according to Clinical Laboratory Standards Institute recommendations. A total of 27 strains of Gram-negative rods were cultured from 21 patients. During short-term hospitalization, in patients with lung cancer undergoing thoracic surgery and preoperative prophylaxis, qualitative and quantitative changes in Gram-negative rods colonizing the nasopharynx were observed. A statistically significant increase in the frequency of these bacteria on mucous membranes of nasopharynx in examination II was found (Chi-squared test, p<0.00001). The strains of Enterobacteriaceae were highly susceptible to antimicrobial agents, whereas most of the non-fermenting rods were classified as multi-drug resistant organisms.

EDTA as a potential agent preventing formation of Staphylococcus epidermidis biofilm on polichloride vinyl biomaterials.

Polichloride vinyl (PCV) is a widely used thermoplastic polymer, also in the production of medical devices. In the present study we assess the influence of EDTA in vitro on the biofilm structure formed by Staphylococcus epidermidis isolates on PCV biomaterials (Nelaton and Thorax catheters). The 6 strains of S. epidermidis were isolated from nasopharynx of hospitalised patients. It was found that all isolates were able to form the biofilm on both PCV biomaterials, irrespective of adhesion properties (cell surface properties, ability to slime production, minimal time needed for adhesion). The EDTA showed bacteriostatic effect against planktonic cells of the isolates (MIC = 0.25-0.5 mmol/l; MBC = 10.0- >25.0 mmol/l; MBC/MIC = 20, 30, 40, >50). The adhesion process and also formation of the biofilm was inhibited by EDTA at concentrations 1.0-2.0 mmol/l (2-8 x MIC). The eradication of the mature biofilm was achieved at 2.0-4.0 mmol/l EDTA (4-8 x MIC ) for two strains, while for the other four isolates, concentration of EDTA needed for eradication effect was >32 mmol/l (> 128 x MIC ). Data obtained in this paper suggest that EDTA may be regarded as a useful agent preventing formation of the S. epidermidis biofilm on PCV biomaterials.

Saccular aneurysm of the superior vena cava detected by computed tomography and successfully treated with surgery.

Vascular lesions must be considered in the differential diagnosis of mediastinal masses. Systemic venous aneurysms are an extremely rare cause of dilatation of the mediastinal shadow on plain chest roentgenograms. We describe what we believe to be the 10th case in the literature of a saccular aneurysm of the superior vena cava, which was detected by computed tomography in a 59-year-old woman and was successfully treated with surgery.

[Active and passive smoking among students of Polish high schools]. / Aktywne i bierne palenie wsród uczniów polskich szkól srednich.

The survey was conducted among 29540 students in different secondary schools. All interviewers were 17.42 +/- 1.14 years old. The aim od this work was to define the relation between smoking adolescent and their health. The group of smokers consisted of 5112 (60.26%) men and 3370 (33.70%) women. The main causes of initiating smoking reported by respondents included curiosity--(47.91%) followed by stress (39.82%) and alcohol (6.77%). Smoking tobacco by parents at home results in inspiring by their children the unwholesome ingredients of tobacco smoke. Frequent staying among tobacco smokers significantly influences decision of starting or giving up smoking tobacco (59.24%). The obtain results may be helpful in preparing effective educational and preventive project among students, which can eliminate or lower the influence of factors predisposing to start and continue smoking tobacco. Special programs should be worked out for children showing early health consequences of smoking cigarettes. Giving up smoking is possible for "young" smokers, if they have not developed the symptoms of addiction.

[Smoking among secondary school students in Stalowa Wola]. / Rozpowszechnienie palenia tytoniu wsróds stalowowolskich gimnazjalistów.

Smoking is recognized as major, the most prevalent, and at the same time the only removable factor of many diseases. The major causes of starting smoking are: stress, curiosity and staying among people who smoke tobacco. The research was conducted among students of secondary school in Stalowa Wola in the form of an anonymous poll. The sample group included 2763 people. The group of smokers included 334 people (12.09%). Results of the research were subjected to a precise statistical analysis. The fact that 24.55% young age smokers smoke more than 20 cigarettes a day is worth stressing. In spite of short time of tobacco smoking, the investigated group has reported some negative health ailments. An attempt was made to identify the combination of features affecting smoking, including sex, origin, company of smokers, economic conditions (p < 0.05). The statistical analysis revealed a significant correlation between the number of cigarette smoked, economic conditions and the intention to stop smoking (p < 0.05). The obtained results may be helpful in preparing effective educational and preventive project among students, which can eliminate or lower the influence of factors predisposing to start and continue smoking tobacco.

[A rare case of gaseous gangrenous mediastinitis]. / Rzadki przypadek zgorzeli gazowej sródpiersia.

We report a case of a cervical phlegmone and mediastinitis descending from peridental abscess in 32-year old student. Emergency left thoracotomy was performed after CT evaluation in which multiple fluid levels and gas spaces were found. After 72 hours bacterial strains showed Clostridium perfringens in fluid taken from left pleural cavity and patient was sent to Hiberbaric Center in Gdynia, where he underwent hyperbaric oxygen therapy. After 10 days the patient was brought back in good condition to our Department. After 3 days he died because of sudden massive bleeding caused by necrosis of aorta wall.

Indices of immune activation after bronchial carcinoma surgery.

The aim of the study was to examine the levels of IL-2 and soluble receptor sIL-2R involved in the activation of TH1 lymphocytes, C-reactive protein (CRP) and serum amyloid A (SAA), whose synthesis is induced by IL-6 and IL-1, in the patients with bronchial carcinoma subjected to surgical procedures. The studies involved 35 patients operated on for bronchial carcinoma and 17 patients requiring thoracic surgery due to other reasons. The immune parameters were determined preoperatively and three, seven, 10 days after the operation. The control group consisted of 22 healthy individuals whose parameters were determined only once. The analysis revealed that the serum IL-2 level found in the patients was three times higher than that in controls. Moreover, the average sIL-2 level was also statistically higher in the group of patients. The results obtained three days after the procedure showed decreased IL-2 levels in both groups subjected to surgery (due to bronchial carcinoma or other reasons). The findings of subsequent determinations performed seven and 10 days after the operation showed that the values observed 10 days after surgery were higher than the preoperative ones. The sIL-2 levels three days after the operation significantly increased in both groups of patients, however, on next examinations they started to vary; the slL-2R decreased in the bronchial carcinoma patients and increased in the other group. The results of CRP and SAA examinations revealed higher values in the bronchial carcinoma patients compared to controls. The SAA levels were extremely high (82.54 in patients and 3.17microg/ml in controls). The postoperative levels of this protein showed a similar tendency--a rapid postoperative increase and gradual normalization in subsequent examinations. However, in both cases the values observed 10 days after the operation were higher than those in the control group. An extremely high increase in SAA levels after surgery (82.54-preoperatively versus 961.6 microg/ml-postoperatively) is noteworthy. Our preliminary results on the immune indices after bronchial carcinoma surgery are consistent with those observed after the operations for other neoplastic tumours; decreased levels of serum IL-2 in the postoperative period need further studies concerning the postoperative administration of exogenous IL-2.