Post-thoracotomy intercostal artery pseudoaneurysm manifesting as a chest wall metastasis.

Intercostal artery pseudoaneurysm (IAP) represents an extremely rare vascular abnormality developing after an insult to the vascular wall with blood collection within the vascular wall layers and subsequent dilatation. Treatment options, apart from observation, include embolization, endovascular stenting, and surgical correction. We describe the case of a 73-year-old male patient with colonic adenocarcinoma pulmonary metastasis. Repetitive wedge resections and a right lower lobectomy were performed to remove multiple metastatic lesions. At follow-up assessment, the patient reported localized thoracotomy site pain progressing with time and unresponsive to oral analgesics. Chest computed tomography (CT) revealed a pseudoaneurysm of 4-cm diameter of the right 5th intercostal artery. The patient underwent embolization of the lumen and was discharged from the hospital after 24 h. Successive CT re-assessment checks were unremarkable.

The Antimicrobial Properties of Modified Pharmaceutical Bentonite with Zinc and Copper.

Pharmaceutical grade bentonite, containing a high amount of montmorillonite, enriched with zinc (Zn) or copper (Cu) (ZnBent and CuBent, respectively) was used as the main component for the creation of formulations for cutaneous use and tested for their antimicrobial capacity. Bentonite (Bent) with added phenoxyethanol (PH) as a preservative and unmodified bentonite were used as control groups. The mineralogical composition, structural state, and physical or chemical properties, before and after the modification of the samples, were characterized utilizing X-ray Diffraction Analysis (XRD), Fourier-Transform Infrared Spectroscopy (FTIR) and X-ray Fluorescence (XRF) techniques, and Scanning Electron Microscope-Energy Dispersive Spectroscopy (SEM, SEM-EDS) analyses. In addition, the profile of zinc and copper concentration from two types of surfaces ZnBent and CuBent, and into Phosphate-Buffered Saline (PBS) are discussed. Finally, the formulations in the form of basic pastes were challenged against bacteria, molds, and yeasts, and their performance was evaluated based on the European Pharmacopeia criteria. The Cu-modified bentonite performed excellently against bacteria and yeasts, while the Zn-modified bentonite only showed great results against yeasts. Therefore, Cu-modified bentonite formulations could offer antimicrobial protection without the use of preservatives.

Evaluation of the Antimicrobial Protection of Pharmaceutical Kaolin and Talc Modified with Copper and Zinc.

Six pharmaceutical pastes were prepared using chemically modified kaolin and talc powders. Tests were conducted to determine their structural and chemical characteristics as well as their antimicrobial protection, thus rendering them suitable for cosmetic and pharmaceutical uses. Kaolin and talc were treated chemically via the cation exchange method to load the clay particles with copper and zinc ions, two cations well known for their antimicrobial properties. Mineralogical analyses were conducted by using X-ray diffraction (XRD) before and after the modification, confirming the mineralogical purity of the samples. Scanning electron microscopy was also used in conjunction with energy dispersed spectroscopy (SEM-EDS) to obtain chemical mapping images, revealing the dispersion of the added metals upon the clay minerals surfaces. Moreover, chemical analysis has been performed (XRF) to validate the enrichment of the clays with each metal utilizing the cation exchange capacity. All modified samples showed the expected elevated concentration in copper or zinc in comparison to their unmodified versions. From the X-ray photoelectron spectroscopy (XPS), the chemical state of the samples' surfaces was investigated, revealing the presence of salt compounds and indicating the oxidation state of adsorbed metals. Finally, the resistance of pastes in microbial growth when challenged with bacteria, molds, and yeasts was assessed. The evaluation is based on the European Pharmacopeia (EP) criteria.

Raw and modified palygorskite in water treatment applications for low-concentration ammonium removal.

Raw palygorskite (Pal) samples went under acid (H-Pal), NaCl (Na-Pal), and CaCl2 treatment (Ca-Pal) in order to be examined as ammonium (NH4 + ) sorbents from aqueous solutions. The samples were characterized by XRD and FT-IR techniques to examine potential structural differences after modifications, and batch kinetic experiment series were applied to determine the optimal conditions for NH4 + removal. According to thermodynamic analysis, the removal reaction for sodium- and calcium-treated samples was endothermic (ΔΗ0  > 0, 1.65 kJ/mol and 24.66 kJ/mol, respectively), in contrast with the exothermic reactions of raw and acidic-treated palygorskite samples (ΔΗ0  < 0, -37.18 kJ/mol and -27.56 kJ/mol respectively). Moreover, each sample presented a different order of sorbed ions preference, whereas the strong affinity for Ca2+ sorption was common in all cases since the NH4 + removal inhibited. Nevertheless, a similar pattern was followed for raw and modified samples at isotherm study, rendering the linear form of Freundlich isotherm to express better the NH4 + sorption on palygorskite sample, indicating that it is a heterogeneous procedure. In all cases, the NH4 + maximum uptake was within 15 min using 8 g/L of each sorbent, especially for the Na-Pal sample, which could reach almost 100% removal of low concentration NH4 + . PRACTITIONER POINTS: Modified palygorskite samples were tested for NH4 + removal from aqueous solutions. NaCl-treated palygorskite had the higher removal efficiency, which could reach almost 100% removal of low concentration NH4 + . NH4 + maximum uptake was within 15 minutes using 8 g/L of each sorbent. NH4 + adsorption was an endothermic reaction for NaCl- and CaCl2 -treated palygorskite sorbents. NH4 + adsorption was an exothermic reaction for raw and acid-treated palygorskite sorbents.

The ideal and impartial medical expert: tips and tricks for a safe medicolegal practice.

There is no doubt that in recent years our profession has witnessed a steady increase in the number of complaints it receives regarding patient treatment. Patients and families raise such complaints having considered that the treatment offered by clinicians was substandard. Although many of these are resolved with direct correspondence from the hospital and meetings, several others lead to legal proceedings. Legal teams and judges, when cases reach court, rely heavily on medical experts. The wise men, who can offer an advice on the specific case and assist Justice. It is then obvious that the role of clinicians as medical expects becomes vital. In fact, their true role is of paramount importance not so much for the successful outcome of a case but mainly for the provision of justice for both claimants and defendants. The article will try and identify the challenges that medical experts face in the current litigation climate and with the opinion of a thoracic surgery expert, will tease out important elements which are necessary to drive a modern and safe clinical and medico legal practice.

Ninety-day hospital costs for anatomic lung resections†.

OBJECTIVES: The study aimed to assess the total cost (TC) and relative cost (RC) of 90-day postoperative care at the hospital after anatomic lung resection. METHODS: Six hundred and forty lung resections (April 2014-September 2016) were performed at a single centre (547 lobectomies, 55 pneumonectomies and 38 segmentectomies). TC was calculated up to 90 days from the date of surgery and included the postoperative cost of the index hospitalization and the costs of hospital or emergency department readmissions, clinic appointments, medications and radiology post-discharge up to 90 days from the operation. RC was calculated as the difference between the TC and the postoperative cost of the index hospitalization. Bivariate comparisons were performed by using the Mann-Whitney test. Multivariable regression analysis was used to identify the factors associated with TC. RESULTS: Median TC was €12 389.5 [interquartile range (IQR) 8455-23 043] for pneumonectomy, €9192.1 (IQR 6897-17 274) for open lobectomy, €7932.5 (IQR 5806-12 697) for video-assisted thoracoscopic surgery (VATS) lobectomy and €6609.9 (IQR 5215-13 907) for VATS segmentectomy. Median RCs were €4461.4 (IQR 1240-11 828) for pneumonectomy, €3326.8 (IQR 1626-8271) for open lobectomy, €2729.3 (IQR 1348-6312) for VATS lobectomy and €2771.5 (IQR 1229-9705) for segmentectomy. RC accounted for 36% of the TC for pneumonectomy, 36% for open lobectomy, 34% for VATS lobectomy and 42% for segmentectomy. Generalized linear models showed that age (P = 0.024), carbon monoxide lung diffusion capacity (P = 0.030) and body mass index (P = 0.015) were inversely associated with TC, whereas male gender (P = 0.054) was associated with increased cost. CONCLUSIONS: Cost-saving measures should be implemented to target not just the in-hospital but also the post-discharge period, particularly in patients with risk factors associated with increased cost.

Performance of wider parenchymal lung resection than preoperatively planned in patients with low preoperative lung function performance undergoing video-assisted thoracic surgery major lung resection.

OBJECTIVES: Pulmonary assessment before major lung resections is used to determine patient's operability. In marginal cases, extensive pulmonary assessment is additionally important under the fear of a more radical parenchymal removal. This study investigates the outcome of wider lung parenchymal resections in patients with low lung functional status undergoing video-assisted thoracic surgery (VATS) major lung resection. METHODS: The medical records of patients who underwent VATS major lung resection for cancer, over a period of 5 years (August 2009-August 2014), were retrospectively reviewed. Patients with postoperative forced expiratory volume in first second (ppoFEV1) or postoperative diffusional capacity for carbon monoxide (ppoDLCO) <40% who underwent wider lung resection than preoperatively planned (Group A) were compared with patients with ppoFEV1 or ppoDLCO <40% who underwent the planned operation (Group B) and patients with ppoFEV1 and ppoDLCO >40% who underwent wider resection than preoperatively planned (Group C). Data analysed included demographics, past medical history, the surgery planned and performed, the reason for higher parenchymal resection, the clinical and pathological stage, the length of stay (LOS), the morbidity, the 30-day mortality and the survival. RESULTS: Overall, 73 patients were analysed (15 patients in Group A, 50 patients in Group B and 8 patients in Group C). The mean age was 68.5 years and 31.5% were males. The wider lung resection regarded 7 patients who underwent bilobectomy instead of lobectomy and 16 patients who underwent pneumonectomy instead of lobectomy. The main reason for higher resection was the wider invasion of the mass (21 patients). The age, gender and body mass index between three groups were similar, whereas ppoFEV1 and ppoDLCO were different (P < 0.001 and P < 0.001 respectively). Conversions, pulmonary morbidity and the 30-day mortality between groups were similar (P = 0.67, P = 0.88 and P = 0.33, respectively). LOS between groups was not different (P = 0.46). Survival rate between groups was also similar (log-rank, P = 0.79). CONCLUSIONS: Wider lung parenchymal resection than preoperatively anticipated may be performed, even in patients with low lung functional status, without increased adverse outcome when compared with patients with good lung function. This finding indicates that the preoperative risk stratification based on lung function tests is questionable.

Management of bronchial carcinoids: international practice survey among the European Society of Thoracic Surgeons.

OBJECTIVE: This study aims to assess the international practice of management of bronchial carcinoids. MATERIALS & METHODS: A survey designed by the Neuroendocrine Tumors of the Lung Working Group, was conducted among the members of the European Society of Thoracic Surgeons. RESULTS: A total of 172 centers worldwide replied to the questionnaire. General agreement was observed concerning the use of anatomic resections and parenchyma-sparing surgery, the importance of lymphadenectomy, the adjuvant regimens in N(+) atypical carcinoids and the role of surgery for local recurrences. Controversies emerged in the use of nuclear medicine imaging and measurement of serum markers and on the timing of follow-up. CONCLUSION: This survey provides the largest international overview of the current practice in the management of bronchial carcinoids and identifies discrepancies that could be the focus of future investigations.

Pneumomediastinum.

Pneumomediastinum is a condition in which air is present in the mediastinum. This condition can result from physical trauma or other situations that lead to air escaping from the lungs, airways or bowel into the chest cavity. Pneumomediastinum is a rare situation and occurs when air leaks into the mediastinum. The diagnosis can be confirmed via chest X-ray or CT scanning of the thorax. The main symptom is usually severe central chest pain. Other symptoms include laboured breathing, voice distortion (as with helium) and subcutaneous emphysema, specifically affecting the face, neck, and chest. Pneumomediastinum can also be characterized by the shortness of breath that is typical of a respiratory system problem. It is often recognized on auscultation by a "crunching" sound timed with the cardiac cycle (Hamman's crunch). Pnemomediastinum may also present with symptoms mimicking cardiac tamponade as a result of the increased intrapulmonary pressure on venous flow to the heart. The tissues in the mediastinum will slowly resorb the air in the cavity so most pneumomediastinums are treated conservatively.

Cystic lung lesions in the pediatric and adult population: surgical experience at the Brompton Hospital.

BACKGROUND: Cystic lung lesions are found in the adult and pediatric populations. We present our 19-year experience with such lesions from a single institution. METHODS: We retrospectively reviewed our experience with such lung pathology, comparing the pediatric and adult populations with regard to their spectrum of pathology, presentation, surgical procedures, and postoperative morbidity and mortality. RESULTS: Forty-six operations were performed on 44 patients (24 children and 20 adults). Cystic adenomatoid malformation was the most common pathology in the pediatric group (53.9%), followed equally by simple cysts and sequestrations (15.4%). In three of the pediatric patients malignant features were identified after resection; bronchoalveolar carcinoma in 2 patients with cystic adenomatoid malformation and pleuropulmonary blastoma in 1 patient with bilateral cystic disease. In the adult population the most common pathology was simple cysts in 8 (40%), followed by cystic adenomatoid malformation in 5 (25%) and sequestrations in 2 patients (10%). The majority of the children, 16 (61.5%), required operation because of expanding or infected cysts, recurrent cysts, or chest infections; 4 were operated on as an urgent basis. In contrast, the majority of adults 11 (55%) were asymptomatic or had no specific symptoms, and all operations were elective. A larger number of major resections (65.4% versus 55%) were necessary in the pediatric group, possibly due to differences in the pathology. However, morbidity was comparable in the two groups with no mortality. CONCLUSIONS: Operation for cystic lung disease is safe. Asymptomatic cysts in children should be resected to avoid later complications of the cysts, which could make operation more difficult. Patients should be evaluated for associated congenital anomalies. Conservative anatomic resections should be attempted to salvage functional lung tissue. Careful histologic examination of the resection specimen is mandatory to identify occult malignancy.