Complications after ultrasonic lung parenchyma biopsy: a strong note for caution.

BACKGROUND: This study aimed to determine the possible cause for an unacceptable frequency of postresectional pneumothorax in cases of ultrasonic scalpel use without a further reinforcing maneuver in lung biopsy during video-assisted thoracic surgery (VATS). METHODS: Data for a series of 16 consecutive VATS lung biopsy patients (group A) in which a disturbingly high number of minor and medium complications occurred were compared with data for a group of 20 patients previously subject to the same ultrasonic lung biopsy method (group B) without complication. RESULTS: The two groups were identical in terms of all significant factors considered in relation to ultrasonic scalpel biopsy. Six notable air leakage complications occurred among the 16 patients of group A. One patient needed redrainage while still in the hospital. Two other patients required readmission and redrainage. In 4 of the 16 cases, late pneumothorax was detected after a "silent" 48-h postoperative period prolonging their hospital stay. Altogether, three medium complications occurred in group A, as compared with none in group B. The drainage duration in group B was not significantly shorter than in group A . Multivariate analysis showed a significant difference in complications favoring group B (odds ratio, 1.88). CONCLUSIONS: A high postoperative air leakage rate was observed in a simple case series using an unsecured harmonic scalpel after a randomized trial of the same method in the same institute with a diametrically opposite outcome. The medium complication rate of 3 in 16 cases is unacceptable for a minor procedure such as lung biopsy. The two groups differed only in their thromboembolic prophylaxis protocol. Therefore, it is hypothesized that the recent introduction of low-molecular-weight heparin from day 1 may influence the complication rate. The authors' observation calls for caution in use of the harmonic scalpel on lung tissue without reinforcing maneuvers (i.e., stitches or clips). To avoid unnecessary complications, operative technique adjustment is recommended.

Effect of myelopoietic and pleiotropic cytokines on colony formation by blast cells of children with acute lymphoblastic leukemia.

The aim of this study was to see whether pleiotropic or myeloid hematopoietic growth factors, which do not stimulate normal lymphoid cells, can induce proliferation of blast cells of the acute lymphoid leukemia (ALL) of childhood. Bone marrow cells of 13 children with untreated ALL (nine common ALL, two myeloid antigen positive ALL and two early T-cell ALL) formed colonies of leukemic blast cells in primary methylcellulose cultures. Spontaneous growth was observed in three of 13 cases, whereas phytohemagglutinin-stimulated leukocyte conditioned medium (PHA-LCM), a conventional source of various natural human cytokines, induced colony formation in ten of 13 cases. A similar rate of responsiveness was seen with recombinant human granulocyte colony-stimulating factor (G-CSF), granulocyte-macrophage colony-stimulating factor (GM-CSF) and stem cell factor (SCF); a combination of these three cytokines induced colony formation in all cases studied. The effect of these growth factors on colony formation seemed to be dose-dependent in some cases. Of the stimuli studied, GM-CSF induced the smallest number of colonies, whereas the effects of G-CSF, SCF and PHA-LCM were similar in this respect. Combination of cytokines proved to be even more efficient in inducing clonal proliferation of leukemic lymphoblasts. In double combinations, G-CSF and GM-CSF as well as G-CSF and SCF were able to potentiate each other's effects. Triple combination of these cytokines mediated the most potent growth stimulus. Our results demonstrate that myeloid and pleiotropic cytokines are able to stimulate clonal proliferation of pediatric leukemic lymphoblasts. This may present a potential hazard to children with ALL while on adjuvant therapy with hematopoietic growth factors. In vitro colony assays performed prior to or in parallel with the administration of hematopoietic growth factors to ALL patients may help to forecast their possible effects on leukemic cells in vivo.

A synthetic gamma-lactone group with beta-lactamase inhibitory and sporulation initiation effects.

Previous studies showed that some lactones have beta-lactamase inhibitory or antibacterial effects, others--like A-factor (a gamma-butyrolactone) and its derivatives--stimulate sporulation in Streptomyces griseus strains. Our experiments were aimed at exploring whether synthetic gamma-lactones had such effects. None of the seven gamma-lactones studied showed antibacterial activity, but two of them inhibited beta-lactamases isolated from various bacteria. These two gamma-lactones did not reduce colony formation of murine bone marrow cells in vitro, indicating that they were not toxic to proliferating mammalian cells. Four gamma-lactones, including the two inhibiting beta-lactamase, stimulated sporulation in the non-sporulating S. griseus bald 7 mutant. Further studies of gamma-lactones as potential inhibitors of beta-lactamase seem to be warranted.

Palliative treatment of malignant pleural effusions by video-assisted thoracoscopic surgery.

Malignant pleural effusion (MPE) are associated with significant morbidity. Prompt clinical evaluation followed by aggressive treatment often results in successful palliation. Video-assisted Thoracic Surgery (VATS) today can be employed in the diagnosis and treatment of idiopatic and known MPE. Between January 1994 and December 1998 233 MPE patients were treated with pleurodesis. 206 of them underwent tube thoracostomy and drainage alone followed by chemical pleurodesis. In 27 out of the 233 cases VATS management was applied. These patients had undiagnosed pleural effusions or recurrent MPE following failed previous drainage and pleurodesis. The cause of the effusion was breast cancer in 11 patients, lung cancer in 9, urogenital cancer in 3, mesothelioma in 2 and other in 2. VATS intervention was thoracoscopic exploration with biopsy and directed chemical sclerosis in undiagnosed MPE (19/27) and lysis of pleural adhesions with partial decortication and pleurodesis in recurrent effusions (8/27). VATS managements were successful 26/27 after mean follow up of 6 months. Had not mortality postoperatively and severe morbidity. Chest tubes were removed 1.5 +/- 0.5 days postoperatively and hospital stay were averaged 4 +/- 1 days. We concluded that VATS is a safety and effective way of managing selected patients with pleural effusions.

Predictive value of MRI in lung cancer.

Pathologic results of 543 lymph nodes removed during 164 radical surgery for lung cancer is compared with the expected findings based on preoperative MRI imaging. Specificity of T2 weighted MRI images were 95.5% for individual lymph nodes and 88.1% for TNM staging, respectively. Sensitivity was found to be 89.4% for lymph nodes and 94.6% for TNM staging of the patient. The accuracy of the MRI imaging was 84.7%. Properly chose MRI imaging and interpretation sounds to be no inferior to more invasive methods as collar mediastinoscopy, Chamberlain procedure or VATS exploration.

Comparison of the toxicity of fluconazole and other azole antifungal drugs to murine and human granulocyte-macrophage progenitor cells in vitro.

We studied the inhibitory effects on colony formation by granulocyte-macrophage colony forming units (cfu-gm) of eight azole antifungal agents in vitro. All agents, except fluconazole, inhibited colony formation dose-dependently with 50% inhibitory concentrations (IC50) in the range of 0.78-49 micromol/L in cultures of murine and human bone marrow. For human cells, the IC50 values were 0.553 mg/L for itraconazole, 1.24 mg/L for saperconazole, 2.58 mg/L for clotrimazole, 5.33 mg/L for miconazole, 6.17 mg/L for econazole, 6.27 mg/L for ketoconazole and 8.38 mg/L for oxiconazole. The IC50 of itraconazole for human cfu-gm in vitro was similar to the plasma level of this drug recommended for systemic antifungal therapy (>0.5 mg/L) thus indicating the potential clinical relevance of our data. The IC50 of ketoconazole for human cfu-gm in vitro may be exceeded by plasma levels produced in vivo by high (> or =400 mg) doses, whereas fluconazole failed to reduce colony formation by 50% even at 100 mg/L, a concentration not reached in vivo even after extremely high doses (2000 mg/day). To most of the drugs studied, murine progenitor cells seemed to be less sensitive than the human ones. There was, however, a close correlation between the murine and human log IC50 values of the drugs (r2 = 0.964, P< 0.001), suggesting that cultures of murine bone marrow may be suitable to predict the in-vitro toxicity of azole antifungals to human cfu-gm.

A case of fibrin sealant application for closing benign trachea-esophageal fistula (TEF).

Surgical treatment of upper airway-esophageal communications are frequently lead to failure. Having previous experience of thoracic administration of Tissucol fibrin glue authors attempted the local application in a case of TEF. A young lady suffering from myasthenia gravis required longstanding artificial ventilation. Not surprisingly a TEP developed in the area of the tracheostomy. There was no room for surgical repair of the TEF. Two administrations of rapid acting form of Tissucol was needed following local astringent therapy and enzymatic debridement to achieve a complete and permanent closure of a tracheobronchial sinus in a diameter of 5 mm. In addition of meticulous technique and of general supporting therapy special attention was paid to the followings: 1/healthy wound edges 2/ local infection control 3/dry environment 4/patient building up strategy.

[Effect of imidazole antifungal agents on colony formation by murine bone marrow CFUc (colony forming units in culture]. / Antifungális hatású imidazol-származékok hatása egér csontvelósejtek in vitro kolóniaképzésére.

In spite of modern antifungal therapy, the prognosis of systemic mycoses in neutropenic patients is usually poor without recovery of neutrophil counts. So, even a minor myelotoxicity might be a significant disadvantage of any drug used for the treatment of neutropenic patients with fungal infections. Since "Colony Forming Units in culture" (CFUc), the common progenitors of granulocytes and macrophages, are supposed to be a major target of agents damaging bone marrow, we studied the inhibitory effect of four imidazole antifungal drugs to colony formation by murine CFUc in vitro. Clotrimazole, econazole, miconazole or ketoconazole were added to soft agar bone marrow cell cultures at final concentrations of 1 to 30 mg/l at the beginning of the 7 day culture period. A dose-dependent inhibitory effect on colony formation by CFUc was observed with all imidazole drugs studied. The 50 percent inhibitory concentrations (IC50s) were 3.54 mg/l for clotrimazole, 8.07 mg/l for econazole, 14.04 mg/l for miconazole, and 16.11 mg/l for ketoconazole. Human pharmacokinetic data available in the literature on these drugs may help to assess the potential in vivo relevance of our results. The serum levels of clotrimazole and econazole, even after oral administration, remain lower than those found to inhibit colony formation by murine bone marrow in our experiments. Taking into consideration that clotrimazole and econazole are used only topically in the clinical practice, our data do not suggest any clinically significant suppression of bone marrow by these two drugs. Intravenous administration of high doses of miconazole, however, may result in serum concentrations approaching the IC50 for colony formation by murine bone marrow cells in vitro. As for ketoconazole, it may suppress the proliferation of murine bone marrow progenitor cells in vitro at concentrations produced in vivo by high doses (12.5-18 and 30-50 mg/l after 400 or 600 mg, respectively). The serum levels produced by a daily dose of 200 mg ketoconazole (about 4 mg/l), however, did not reduce significantly the number of colonies in murine bone marrow cultures. Our present results warrant further studies of the myelotoxicity of miconazole and ketoconazole in vivo in mice with neutropenia induced by cytostatic agents.

Effect of granulocyte colony-stimulating factor on granulopoiesis of congenital neutropenic children.

We report on two patients with congenital neutropenia, who were treated with filgrastim (recombinant human granulocyte-colony stimulating factor, G-CSF). A poor growth of bone marrow colonies and low sensitivity of colony forming units to colony stimulating factor in vitro before treatment seemed to be associated with a requirement for higher doses of G-CSF to achieve good clinical response in vivo.

Effect of ethyldeoxyuridine on 5-fluorouracil-induced neutropenia.

It is supposed that the toxic effect of 5-fluorouracil (5FU) on tumour cells may be increased by pretreatment with ethyldeoxyuridine (EDU). We studied the effect of this combination on neutrophil count in mice. Our present studies demonstrated that the neutropenia induced by 5 x 20 mg/kg 5FU became more severe when each dose of 5FU was preceded by 200 mg/kg EDU.

[Management of secondary pneumothorax]. / A másodlagos légmell kezeléséröl.

Results on treatment of 445 episodes of 420 patients suffering from spontaneous pneumothorax (sptx) are reported. The overall mortality was 1.4%. No death was encountered during the treatment of 246 primary sptx patients. Mortality of secondary ptx was 3.4%. Detailed data of the recent 92 patients are analysed. Recurrence rate of drainage (ICC) therapy of primary sptx was 8/33. Five out of eight patients were operated on. 16 thoracotomies were performed altogether in this group of patients. 3/18 patients were lost in the ICC treatment only subgroup of secondary sptx panel. 1/25 patient died in the ICC+pleurodesis subgroup of secondary sptx patients. Drainage and subsequent thoracotomy in case of failure of ICC treatment or of numerous recurrences is the choice to follow in primary sptx cases. Apart from exceptions there is no room for chemical pleurodesis in this form of ptx. On the other hand the ICC drainage with pleurodesis offers the best chances in the treatment of secondary sptx. Tetracycline and Vibramycin were proven as the best pleurodesis materials in first instances. Tissucol is recommended to use in case of failure of previous pleurodesis attempts.

Focal nodular hyperplasia of the liver after clomiphene treatment in a young boy.

The case of a 3.5-year-old boy treated unsuccessfully with clomiphene for cryptorchidism is reported. Nine months later focal nodular liver hyperplasia developed. Clomiphene promotes testicular descent by stimulating endogenous production of gonadotropins and their releasing factors. A causal relationship between the hepatic lesion and clomiphene treatment has been supposed. In our case subsequent fertility can only be expected from orchidopexy performed as soon as possible. Hepatic function must be checked during and after clomiphene treatment also in children.

Monitoring of Clomid-hMG-hCG controlled ovulation by ultrasound and a rapid (15 minutes) total urinary estrogen assay.

A simple and rapid assay for estimation of total urinary estrogens is presented. The test is based on a commercial latex agglutination inhibition assay designed for urinary estrogens in pregnancy. To obtain the appropriate sensitivity range for the application of the test it was necessary to concentrate the urine using self contained C 18 mini cartridges. A fairly good correlation was found between the obtained values from the urine and estradiol-17 beta estimated by radio-immunoassay in serum (correlation coefficient r = 0,77). Comparing those results and regarding the number of follicles present at ultrasonic examination, and/or laparoscopy a value of 23,79-31,29 mg/l TE in urine/follicle was calculated according to 300-400 pg/ml serum/follicle, at which ovulation should be induced. Even withstanding the inherent limitations of this semiquantitative test and some loss of precision in terms of absolute values, when combined with ultrasound, excellent guidelines were established by this rapid and simple test to determine ovulation induction by hCG.