Percutaneous radiofrequency ablation of spinal osteoid osteoma under CT guidance.

OBJECTIVE: Osteoid osteoma (OO) accounts for approximately 10-12% of all benign bone tumours and 3% of all bone tumours. Spinal involvement appears in 10-25% of all cases. The purpose of this study was to evaluate the safety and efficacy of CT-guided radiofrequency (RF) ablation in the treatment of spinal OOs and report our experience. METHODS: 13 patients suffering from spinal OO and treated at the authors' institution using CT-guided RF ablation were retrospectively evaluated. The RF probe was introduced through a 11-G Jamshidi(®) needle, and the lesion was heated at 90°C for 6 min. RESULTS: All procedures were considered technically successful as the correct positioning of the probe was proven by CT. 11 of the 13 patients reported pain relief after RF ablation. In two cases, RF ablation was repeated 1 month after the first procedure. Pain relief was achieved in both cases after the second procedure. No recurrence was reported throughout the follow-up. No complications like skin burn, soft-tissue haematoma, infection, vessel damage or neurological deficit were reported. CONCLUSION: This study demonstrates that CT-guided percutaneous RF ablation is a safe and effective method for the treatment of spinal OOs. ADVANCES IN KNOWLEDGE: The data of this study support the efficacy and safety of the recently applied CT-guided percutaneous RF ablation technique for the treatment of spinal OOs.

Donor lung pretreatment with surfactant in experimental transplantation preserves graft hemodynamics and alveolar morphology.

In experimental lung transplantation, the reduction of endogenous surfactant properties occurs after graft preservation and transplant reperfusion. The aim of this study was to evaluate the efficacy of donor lung pretreatment with exogenous surfactant on graft damage after ischemia and reperfusion. Fourteen (control group A, n = 8; study group B, n= 6) young female white pigs (mean weight 27 +/- 3.5 kg) were used in a newly developed autotransplantation model within situcold ischemia. In study group B, before thoracotomy, 1.5 ml/kg surfactant apoprotein-A-free surfactant was administrated into the left main bronchus via flexible bronchoscopy. Belzer UW solution was used for lung preservation. Cold ischemia was achieved for 3 hr with interlobar lung parenchyma temperature at 8 +/- 1.3 degrees C, and central temperature maintained at 37.20 +/- 0.5 degrees C. Animals were sacrificed after 3 hr of graft reperfusion. At the end of reperfusion, pulmonary vascular resistance index (was 447.80 dyn/sec.cm(5).m(2)(+/-66.8) in group A vs 249.51 in group B (P< 0.001) and serum nitric oxide was adequately preserved. The mean alveolar surface area estimated by computerized morphometry was 5280.84 (4991.1) microm(2)(group A) vs 3997.89 (3284.70) microm(2)(group B;P< 0.005). Histology revealed milder macrophage and lymphocyte infiltration in group B at the end of reperfusion. Pretreatment of donor lung with an surfactant apoprotein-A -free surfactant agent appears to be beneficial in terms of maintaining serum NO and reducing hemodynamic disturbances. Furthermore, alveolar histology and stereomorphology are better preserved.

Neutrophil deformability in patients with sepsis, septic shock, and adult respiratory distress syndrome.

OBJECTIVE: To investigate the deformability of morphologically active and passive neutrophils in patients with sepsis (SP), septic shock (SS), and adult respiratory distress syndrome (ARDS). DESIGN: Prospective, observational study. SETTING: A university hospital intensive care unit and research laboratory. PATIENTS: Six patients with sepsis, six patients with septic shock, and six patients with ARDS. Eight healthy volunteers and eight ventilated but noninfected patients served as controls. INTERVENTIONS: None. MEASUREMENTS AND MAIN RESULTS: Morphologically passive and active neutrophil deformability as defined by the micropipette method was significantly decreased in patients with SP, SS, and ARDS associated with sepsis as compared with both control groups. Neutrophils from SS and ARDS patients were significantly more rigid as compared with neutrophils from SP patients but they did not differ from each other. The percentage of activated neutrophils was significantly higher in SP, SS, and ARDS patients. Increased passive neutrophil rigidity was significantly attenuated after coincubation with cytochalasin D. Tumor necrosis factor-alpha and interleukin-1beta serum levels were significantly higher in SP, SS, and ARDS patients. CONCLUSIONS: The entire neutrophil population is less deformable in SP, SS, and ARDS patients. The decreased deformability of passive neutrophils suggests that a direct mechanism involving actin polymerization, distinct from cell activation, is involved. These observations may be important in the mechanism of impaired vascular flow in patients with sepsis.

Treatment of patients with severe acute necrotizing pancreatitis based on prospective evaluation.

BACKGROUND/AIMS: To examine the impact of a prospectively applied diagnostic and treatment protocol in patients with severe acute necrotizing pancreatitis. METHODOLOGY: During a 4-year period (1993-1996), 26 patients were treated for necrotizing pancreatitis, as documented by contrast-enhanced computed tomography (CE-CT). All patients were prospectively treated by medical means. Patients with persistent systemic inflammatory response syndrome underwent fine-needle aspiration for bacterial cultures. In case of positive results operative intervention was followed, while in negative results the conservative management was continued. Fine-needle aspiration was repeated every 5-7 days if systemic inflammatory response syndrome persisted or worsened. Sixty-five patients hospitalized during the preceding 11 years (1982-1992), when such a treatment was not constantly applied, served as controls. RESULTS: Infected pancreatic necrosis was demonstrated in 7 of the 26 patients (27%) and was treated by open drainage and/or post-operative lavage with a mortality rate of 14.2%. Thirteen patients in whom fine-needle aspiration was not necessary and 6 with negative cultures after fine-needle aspiration (73%) followed conservative treatment and the mortality rate was 5.2%. The total mortality rate of 7.7% was significantly lower than the mortality rate of 26.2% observed in the control group (p = 0.05). CONCLUSIONS: Recent evolution made in the management of severe necrotizing acute pancreatitis can lead to better results in the context of a strictly applied treatment protocol. Such protocols may improve mortality and serve as controls in future study.

Comparison between two fat emulsions: Intralipid 30 cent vs intralipid 10 cent in critically ill patients.

Fat emulsions, Intralipid 30% and Intralipid 10% were compared in terms of the resulting plasma levels of different lipid components and clinical tolerance in critically-ill patients with multi-injuries. Sixteen critically-ill patients with severe systemic inflammatory response were randomly assigned to two groups, each one comprised of eight patients. Each group was administered the same quantity of fat/Kg/day either Intralipid 30% or Intralipid 10%. The infusion lasted 12|h daily for 6 days. During the infusion of the fat emulsion, a lower median plasma concentration of triglycerides, phospolipids and free cholesterol was observed in patients who received Intralipid 30% compared with those who received Intralipid 10%. The above observations were sustained 4 h after the termination of the infusion. Free fatty acids had a higher mean plasma concentration in the group of patients who received Intralipid 30%. There were no differences between the two groups as far as the median plasma concentration of cholesterol and lipoproteins (LDL, HDL, VLDL) are concerned. On the contrary, there was an increase in LpX in the Intralipid 10% group. From the above findings, we draw the conclusion that Intralipid 30% revealed better profiles of different lipid components than Intralipid 10% in critically-ill patients. The new emulsion of higher concentration in triglyceride was proved clinically safe and its use is suggested for critically-ill patients who require total parenteral nutrition.

Cricothyroidotomy and the anatomy of the cricothyroid space. An autopsy study.

Airway management is one of the main dictums in anaesthesia, emergency medicine and critical care. Endotracheal intubation, tracheostomy and cricothyroidotomy are all approved methods to secure a patient's airway. Cricothyroidotomy is performed in the space between the anterior inferior border of the thyroid cartilage and the anterior superior border of the cricoid cartilage. We studied 107 autopsies with special interest in the anatomy of the cricothyroid space.

Objective evaluation of the difficulty of endotracheal intubation. A comparative study of two different laryngoscope blades.

A method for objective evaluation of the difficulty of endotracheal intubation is described. Our data indicate that the angle formed by the light-beam axis of the laryngoscope blade and the laryngotracheal axis, which we call "angle phi", is analogous to the degree of difficulty of endotracheal intubation. Using this method, we compared the effectiveness of a standard Macintosh and a modified bevelled Macintosh blade in 27 tracheostomized Intensive Care Unit patients under general anaesthesia. Statistical analysis of our results indicate that the bevelled blade significantly facilitates endotracheal intubation.

Enteral nutrition is superior to parenteral nutrition in severe acute pancreatitis: results of a randomized prospective trial.

BACKGROUND: Parenteral nutrition is well established for providing nutritional support in acute pancreatitis while avoiding pancreatic stimulation. However, it is associated with complications and high cost. Benefits of enteral feeding in other disease states prompted a comparison of early enteral feeding with total parenteral nutrition in this clinical setting. METHODS: Thirty-eight patients with acute severe pancreatitis were randomized into two groups. The first (n = 18) received enteral nutrition through a nasoenteric tube with a semi-elemental diet, while the second group (n = 20) received parenteral nutrition through a central venous catheter. Safety was assessed by clinical course of disease, laboratory findings and incidence of complications. Efficacy was determined by nitrogen balance. The cost of nutritional support was calculated. RESULTS: Enteral feeding was well tolerated without adverse effects on the course of the disease. Patients who received enteral feeding experienced fewer total complications (P < 0.05) and were at lower risk of developing septic complications (P < 0.01) than those receiving parenteral nutrition. The cost of nutritional support was three times higher in patients who received parenteral nutrition. CONCLUSION: This study suggests that early enteral nutrition should be used preferentially in patients with severe acute pancreatitis.

Comparative study of magnetic resonance angiography, digital subtraction angiography, duplex ultrasound examination with surgical and histological findings of atherosclerotic carotid bifurcation disease.

This study was designed in order to determine the diagnostic accuracy in imaging of the extracranial arteries by using magnetic resonance angiography (MRA), digital subtraction angiography (DSA), B-mode duplex ultrasonic examination (DUE) in comparison with the surgical and histological findings of the specimen removed after endarterectomy. The degree of stenosis of the arterial lumen of the surgical specimen was compared with the imaging findings of MRA, DSA and DUE: a) the degree of agreement of stenosis with histologic findings was found in 89% of cases for MRA, in 93% for DSA and 88% for DUE; b) the correlation of morphology of the plaque showed agreement in 91% of the cases with MRA, in 94% with DSA and 87% with DUE; c) the constitution of the plaque was in agreement with DUE findings in 96% of cases. There is no significant difference between the three methods, as far as the estimation of degree of carotid stenosis and morphology of the atheromatous plaque in the carotid arteries. MRA findings are similar with those of DSA and DUE with a high sensitivity and specificity concerning the constitution of the plaque. The combination of MRA and DUE provides all the necessary information concerning the extracranial segments of the cerebral arteries for the preoperative evaluation of patients with carotid disease.

Three-dimensional time-of-flight MR angiography and MR imaging versus conventional angiography in carotid artery dissections.

A retrospective analysis comparing the three-dimensional time-of-flight MR angiography, MR imaging and transfemoral digital substraction angiography (DSA) in cases of carotid artery dissection was made. During a 2-year period, 12 cases (11 males and 1 female), aged between 16 and 60 years, were submitted to our Hospital with the symptoms of TIA, stroke or cranial nerve palsies and the suspicion of carotid dissection. Transfemoral angiograms were done in other Institutions, while the MRI and MRA were performed in our diagnostic center. Blind interpretation of MR and angiography images was made by two independent radiologists. MR angiography in combination with MR imaging was more accurate than conventional angiography in the diagnosis of carotid artery dissection. Respective sensitivity and specificity were 100% and 100% for MRI with MRA and 91.6% and 100% for conventional angiography. From the analysis of this small series, we can conclude that MR angiography in combination with MR imaging is a reliable noninvasive method for use in diagnosis of extracranial internal carotid artery dissection.

Failure of the laryngeal mask airway (LMA) to ventilate patients with severe tracheal stenosis.

The Laryngeal Mask Airway (LMA) was used during the resuscitation process in two patients with severe tracheal stenosis. In both cases the LMA failed to restore ventilation and both succumbed as a result of hypoxemic cardiac arrest.

Effects of propofol and thiopentone on polymorphonuclear leukocyte functions in vitro.

Anesthetic agents may impair host defense mechanisms including polymorphonuclear leukocyte (PMNL) function. We have studied the effects of thiopentone and propofol in low (thiopentone 10 mg/L, propofol 2 mg/l) and high (thiopentone 40 mg/L, propofol 6 mg/L) clinically relevant concentrations on PMNL adherence, chemotaxis, phagocytosis and killing in vitro. The results demonstrated that thiopentone in both concentrations significantly decreases all PMNL functions tested and had a direct influence on the PMNLs in terms of their chemotactic response. In contrast, propofol decreases significantly only PMNL chemotaxis but not adherence, phagocytosis and killing. The effect of propofol was not attributable to the lipid carrier vehicle, as Intralipid with same formulation had no effect on PMNL function. We conclude that propofol is a relatively safe agent from the viewpoint of PMNL function in vitro, which may be of potential clinical benefit.

The use of the laryngeal mask airway in CPR.

The laryngeal mask airway (LMA) was used within the hospital in 50 cardiac arrest cases during cardio-pulmonary resuscitation (CPR). The LMA was inserted mainly by junior anaesthesia staff members with no previous experience with its use. The LMA was easily inserted providing a clear and unobstructed airway in 98% of the patients with clinically satisfactory ventilation and very good blood gas values. No signs of regurgitation or aspiration were detected.

Liver lesion on computed tomography and ultrasonography in adult Niemann Pick disease related to sea blue histiocyte syndrome--a case report.

The case of a 42-year-old man with Niemann Pick disease and a liver lesion is presented. The lesion was hypodense on CT and had mixed echogenicity on US. Hepatosplenomegaly, interstitial infiltration of the lungs, an absence of neurological signs, family history, laboratory data, sea blue histiocytes in the bone marrow and Niemann Pick's cells in the liver suggested a subtype of Niemann Pick disease (Type B), with a focal lesion in the liver due to thus condition. We believe that this is the first case in the literature. Niemann Pick disease and its subtypes, as also the sea blue histiocyte syndrome are briefly discussed.