Impact of multiple lymphatic basin drainage in truncal melanoma patients.

INTRODUCTION: In many patients with cutaneous melanoma that affects the trunk area, there is lymphatic drainage to multiple basins (MLBD). This study aimed to examine whether MLBD is associated with disease outcomes. METHODS: Lymphatic mapping and sentinel lymph node (SLN) biopsy were performed in 161 patients with truncal melanoma. The number and location of draining nodal basins were established during the preoperative lymphoscintigraphy using technetium-99 m rhenium sulphide nanocolloid. RESULTS: MLBD was present in 59 (37%) patients, and single lymphatic basin drainage (SLBD) in 102 (63%) patients. Patients with MLBD showed no increased risk for SLN metastasis compared to patients with SLBD (27% versus 29%, respectively). There was no significant difference in disease-free survival (DFS) between patients with MLBD and those with SLBD. Five-year DFS was 64% for patients with MLBD and SLBD. Multivariate analysis showed that the presence of ulceration (p = 0.01) was an independent predictor of SLN metastasis, while melanoma thickness (p = 0.01) and SLN metastasis (p = 0.01) were independent predictors of DFS. In patients with a negative SLN, five-year DFS was 74% for patients with MLBD and 73% for those with SLBD. Multivariate analysis showed that melanoma thickness (p = 0.00) was an independent predictor of DFS. CONCLUSION: MLBD does not negatively impact the disease outcome in patients with truncal melanoma.

Real-time chest-wall-motion tracking by a single optical fibre grating: a prospective method for ventilator triggering.

OBJECTIVE: The ventilators involved in non-invasive mechanical ventilation commonly provide ventilator support via a facemask. The interface of the mask with a patient promotes air leaks that cause errors in the feedback information provided by a pneumatic sensor and hence patient-ventilator asynchrony with multiple negative consequences. Our objective is to test the possibility of using chest-wall motion measured by an optical fibre-grating sensor as a more accurate non-invasive ventilator triggering mechanism. APPROACH: The basic premise of our approach is that the measurement accuracy can be improved by using a triggering signal that precedes pneumatic triggering in the neuro-ventilatory coupling sequence. We propose a technique that uses the measurement of chest-wall curvature by a long-period fibre-grating sensor. The sensor was applied externally to the rib-cage and interrogated in the lateral (edge) filtering scheme. The study was performed on 34 healthy volunteers. Statistical data analysis of the time lag between the fibre-grating sensor and the reference pneumotachograph was preceded by the removal of the unwanted heartbeat signal by wavelet transform processing. MAIN RESULTS: The results show a consistent fibre-grating signal advance with respect to the standard pneumatic signal by (230 ± 100) ms in both the inspiratory and expiratory phases. We further show that heart activity removal yields a tremendous improvement in sensor accuracy by reducing it from 60 ml to 0.3 ml. SIGNIFICANCE: The results indicate that the proposed measurement technique may lead to a more reliable triggering decision. Its imperviousness to air leaks, non-invasiveness, low-cost and ease of implementation offer good prospects for applications in both clinical and homecare ventilation.

Rib-cage-movement measurements as a potential new trigger signal in non-invasive mechanical ventilation.

Non-invasive ventilation performed through an oronasal mask is a standard in clinical and homecare mechanical ventilation. Besides all its advantages, inevitable leaks through the mask cause errors in the feedback information provided by the airflow sensor and, hence, patient-ventilator asynchrony with multiple negative consequences. Here we investigate a new way to provide a trigger to the ventilator. The method is based on the measurement of rib cage movement at the onset of inspiration and during breathing by fibre-optic sensors. In a series of simultaneous measurements by a long-period fibre grating sensor and pneumotachograph we provide the statistical evidence of the 200 ms lag of the pneumo with respect the fibre-optic signal. The lag is registered consistently across three independent delay metrics. Further, we discuss exceptions from this trend and identify the needed improvements to the proposed fibre-sensing scheme.

Non-invasive respiratory monitoring using long-period fiber grating sensors.

In non-invasive ventilation, continuous monitoring of respiratory volumes is essential. Here, we present a method for the measurement of respiratory volumes by a single fiber-grating sensor of bending and provide the proof-of-principle by applying a calibration-test measurement procedure on a set of 18 healthy volunteers. Results establish a linear correlation between a change in lung volume and the corresponding change in a local thorax curvature. They also show good sensor accuracy in measurements of tidal and minute respiratory volumes for different types of breathing. The proposed technique does not rely on the air flow through an oronasal mask or the observation of chest movement by a clinician, which distinguishes it from the current clinical practice.

Effects of alternate fasting or very low calorie diet and low calorie diet on metabolic syndrome in severely obese patients.

BACKGROUND AND AIM: Weight loss improves the metabolic syndrome (MetS) features and related clinical abnormalities in obese subjects. The aim of this study was to assess the effects of a non-surgical therapeutic program on the MetS in severely obese patients. PATIENTS AND METHODS: Sixty-four extremely obese patients were involved in the therapeutic program, which consisted of two alternating phases: the three-week therapeutic fasting or semi-fasting in hospital conditions and the low calorie diet with dosed physical activity in outpatient conditions. At the baseline we measured: anthropometric parameters, blood pressure and lipid profile. Subjects underwent an oral glucose tolerance test and insulin resistance/sensitivity was evaluated by the homeostasis model assessment and the oral glucose insulin sensitivity. After weight reduction by at least 10%, all mentioned assessments were repeated. RESULTS: None of the patients had significant adverse effects. Forty-one patients aged 43.0±11.5 years completed the study. The mean weight loss was 27 kg or 18% of the initial weight (p<0.01), which was followed by a significant decrease of the insulin resistance, the overall prevalence of MetS (32%) and all MetS parameters, without the significant change in high-density lipoprotein. This weight loss pogram substantially improves the MetS in extremely obese patients. CONCLUSION: The tailored alternating either fasting or semi- fasting should be considered as an optional approach to manage extreme obesity and related metabolic abnormality.

Uncertainties in the current understanding of gas exchange in spontaneous pneumothorax: effective lung ventilation may persist in a smaller-sized pneumothorax.

Clinical aspects of spontaneous pneumothorax (SP) are far more clear than some patophysiological issues. The exact mechanism that maintains adequate oxygenation in spontaneous pneumothorax of lesser size is still unclear. Experimental and rare studies in humans could not explicitely confirm whether it is hyperventilation of the nonaffected lung, still effective gas exchange within the affected lung, or hypoxic vasoconstriction. Similarly, it is unclear why the severity of dyspnoea sometimes differs between patients with the same size of SP. The idea that a certain degree of effective lung ventilation might exist in SP of lesser size was based on clinical observation of these patients on admission, on our measurements of pleural pressures and oxygenation in a group of patients with SP of different size and on rare experimental studies. Clinical observation that oxygenation was not significantly impaired in patients with SP of lesser size, without documented hyperventilation, served as a base for critical analysis of possible factors influencing oxygenation in SP of lesser size. Our hypothesis that pleural pressure swings in a partially collapsed lung, but still slightly expanding in inspiration, enable a certain degree of gas exchange, was confirmed both by several experimental studies and by our measurements. On the other hand, our clinical observation that patients with SP of greater size frequently differ in the severity of dyspnoea suggested the need of a more detailed analysis of the causes of hypoxaemia in these patients. The fact that hypoxaemia in these patients usually cannot be abolished by the existing hyperventilation, means that in SP of greater size, despite minimal lung volume, circulation in the pulmonary artery system still exists, causing right to left blood shunting. The fact that the severity of dyspnoea is not equal in all patients with complete SP means that hypoxic vasoconstriction exists only in some of them, following a still unknown pattern. Literature data and our measurements suggest that without further studies of hypoxic vasoconstriction in the acute phase of SP, the exact answer is not possible.

[Massive pneumonia with severe acute respiratory insufficiency after chicken pox in a female patient]. / Masivna pneumonija s teskom akutnom respiracionom insuficijencijom kod bolesnice posle prelezane varicele.

A female patient who developed massive bilateral pneumonia with severe respiratory insufficiency during recovery from varicella, is presented. Blood serologic analyses detected the cause of infection--Mycoplasma pneumoniae, while Streptococcus pneumoniae was isolated by bacteriological examination of the sputum. M. pneumoniae is a causative agent of acute upper and lower respiratory airway infections with a frequently mild clinical picture. This agent rarely provokes massive pneumonia with severe clinical appearance as described in the patient, who had immunodeficiency due to previous infection with Varicella zoster virus.

[Massive hemoptysis as a rare complication in a patient with cystic fibrosis]. / Masivne hemoptizije kao retka komplicacija kod bolesnika s sicticnom fibrozom.

A female patient, 28 years old, with massive haemoptysis as a complication of cystic fibrosis, is described. Cystic fibrosis is a systemic disease with common pulmonary manifestations. Chronic inflammatory process causes the proliferation of bronchial arteries, and their erosion is followed by bleeding. Transitory haemoptysis is common in patients with cystic fibrosis, but massive haemoptysis is a rare complication of this disease.

Correlation analysis of alveolar macrophage cytochemical parameters in smoking and pulmonary oncology.

Cytochemical examination of alveolar macrophages (AM) obtained by bronchoalveolar lavage (BAL) was performed in healthy volunteers (11 non-smokers and 11 smokers) and in 9 patients with squamous lung carcinoma (all of them smokers or ex-smokers) in order to analyze its peculiarities related to the smoking habit and to lung malignancy. Assessment of non-specific esterases: alpha-naphthyl acetate esterase (ANAE) and butyrate esterase (BUT), chloroacetate esterase (CHL), acid phosphatase (AcP), intracellular glycogen (PAS reaction), lipids (Sudan black B reaction-SBB) and iron (Perl's reaction) was performed by a semiquantitative cytochemical method (1). A significant correlation was obtained between BUT and stage of squamous lung carcinoma (varying between I and IV) (r = 0.52, p < 0.05). There was a correlation between BUT and Perl's in healthy controls (r = 0.76, p < 0.05). The same type of correlation was observed in control smokers (r = 0.64, p < 0.05), in addition to a correlation between CHL and AcP (r = 0.69, p < 0.05). There was no significant BUT/Perl's correlation in patients with squamous cell lung carcinoma (r = 0.23, p > 0.05), but significant AcP/CHL correlation as was observed in control smokers (r = 0.73, p < 0.05), and a "new" type of correlation was shown to exist between ANAE and SBB (r = 0.77, p < 0.05). In spite of the unresolved nature of lung cancer, correlation analysis of cytochemical parameters in AM might have an important part in the analysis of their relative contribution to the development of smoking-related disorders and lung malignancies.

[Pulmonary function in persons with kyphoscoliosis]. / Plucna funkcija kod osoba sa kifoskoliozom.

Pulmonary function in 25 patients with a severe degree of kyphoscoliosis was studied. Severe restrictive ventilatory insufficiency and hypoxaemic-hypercapnic respiratory failure were discovered. Isolated deformities of the vertebral column were diagnosed in 15 patients while ten patients, apart from diagnosed kyphoscoliosis, had associated chronic obstructive pulmonary diseases. Significant differences in pulmonary function impairment between these two groups, i.e. patients with associated chronic obstructive pulmonary disease, were observed. This indicates that associated pulmonary disease accelerates the development and course of respiratory failure. Respiratory blood gas analysis in 11 patients over the course of two years showed significant worsening of hypoxaemia and hypercapnia, which implies that in patients with kyphoscoliosis the disease has a rapid progression once the respiratory failure develops.

[Smoking and doctors]. / Pusenje duvana i lekari.

The smoking control greatly depends on the general public opinion against smoking. It depends on many factors including the important role of health workers, especially of physicians. The authors interviewed 229 doctors working in the Belgrade University Clinical Centre. They had to answer a WHO questionnaire. The results were as follows: 34% of smokers, 18% of ex-smokers (no significant difference between sexes), and 48% of non-smokers. In the group of smokers 46% tried to strop smoking, but unsuccessfully. In a 5-year period 9% will continue to smoke; 24% will stop smoking, and 66% intend to stop smoking. The reason for those who will stop smoking are their children to whom they wish to give a good example (77%). In the group of non-smokers the reason was their own health. However, the experience of physicians is a good example for their patients (79% of non-smokers and 59% of smokers). For prohibition of tobacco advertising are 78% of non-smokers and 64% of smokers. About 40% of smokers and 25% of non-smokers plead for the permanent raising of tobacco price as a decreasing factor in tobacco consumption. However, all agree with the need of placing a ban on tobacco sales to children. In conclusion, doctors should be at the head of the smoking control and fight against smoking.