Bone marrow embolism: should it result from traumatic bone lesions? A histopathological human autopsy study

Bone marrow embolism (BME) is likely a consequence of fractures in which pulmonary vessels are the most affected. However, some cases of BME were reported in the absence of trauma. Thus, a traumatic injury might not be necessary for developing BME. This study discusses BME cases in patients without signs of fractures or blunt trauma. The discussion addresses various possible mechanisms for the appearance of BME. Options include cancer in which bone marrow metastasis is a suggestive cause. Another proposal is the chemical theory where bone marrow fats are released via lipoprotein lipase in a pro-inflammatory state, resulting in vascular/pulmonary obstruction. Other cases discussed in this study are hypovolemic shock and drug-abuse related BME. All autopsy cases with BME were included regardless of the cause of death for a period of 2 years. Autopsies involved complete dissection with the macroscopic evaluation of the affected organs, including the heart, lungs, and brain. Tissues were also prepared for microscopic examination. Of the 11 cases, eight showed non-traumatic BME (72%). These findings conflict with theories in the literature that BME most commonly occurs after fractures or trauma. One of the eight cases exhibited mucinous carcinoma; one is presented with hepatocellular carcinoma; and two cases showed severe congestion. Lastly, one case was found to be associated with each of the following conditions: liposuction, drug abuse, pulmonary hypertension, and heart failure. Each case suggests a different pathophysiology for developing BME, yet the exact mechanisms are not fully understood. Further study of non-traumatic associated BME is recommended.

The prevalence of nodal upstaging during robotic lung resection in early stage non-small cell lung cancer

BACKGROUND

Pathologic nodal upstaging can be considered a surrogate for completeness of nodal evaluation and quality of surgery. We sought to determine the rate of nodal upstaging and disease-free and overall survival with a robotic approach in clinical stage I NSCLC.

METHODS

We retrospectively reviewed patients with clinical stage I NSCLC after robotic lobectomy or segmentectomy at three centers from 2009 to 2012. Data were collected primarily based on Society of Thoracic Surgeons database elements.

RESULTS

Robotic anatomic lung resection was performed in 302 patients. The majority were right sided (192; 63.6%) and of the upper lobe (192; 63.6%). Most were clinical stage IA (237; 78.5%). Pathologic nodal upstaging occurred in 33 patients (10.9% [pN1 20, 6.6%; pN2 13, 4.3%]). Hilar (pN1) upstaging occurred in 3.5%, 8.6%, and 10.8%, respectively, for cT1a, cT1b, and cT2a tumors. Comparatively, historic hilar upstage rates of video-assisted thoracoscopic surgery (VATS) versus thoracotomy for cT1a, cT1b, and cT2a were 5.2%, 7.1%, and 5.7%, versus 7.4%, 8.8%, and 11.5%, respectively. Median follow-up was 12.3 months (range, 0 to 49). Forty patients (13.2%) had disease recurrence (local 11, 3.6%; regional 7, 2.3%; distant 22, 7.3%). The 2-year overall survival was 87.6%, and the disease-free survival was 70.2%.

CONCLUSIONS

The rate of nodal upstaging for robotic resection appears to be superior to VATS and similar to thoracotomy data when analyzed by clinical T stage. Both disease-free and overall survival were comparable to recent VATS and thoracotomy data. A larger series of matched open, VATS and robotic approaches is necessary.

Potential biomarkers for predicting outcomes in CABG cardiothoracic surgeries

The variations in recovery time, complications, and survival among cardiac patients who have undergone coronary artery bypass graft (CABG) procedures are vast. Many formulas and theories are used to predict clinical outcome and recovery time, and current prognostic predictions are based on medical and family history, lifestyle, co-morbidities, and performance status. The identification of biomarkers that provide concrete evidence supporting clinical outcome has greatly affected the field of medicine, helping clinicians in many medicine sub-specialties to forecast clinical course. Recent studies have discovered biomarkers that may be used as predictors of cardiac patients' status post-cardiothoracic surgery, and the applications are numerous. In this review, we assess currently available cardiac biomarkers as predictors of clinical outcome for post-operative CABG patients. Data were collected from various studies in which cardiac biomarkers were measured in pre-operative and post-operative CABG patients.

Comparison of contrast enhanced magnetic resonance angiography with invasive cardiac catheterization for evaluation of children with pulmonary atresia

Complete assessment of the source of pulmonary blood supply and delineation of the anatomy of pulmonary arteries are essential for the management and prognostic evaluation of pulmonary atresia (PA) patients. Invasive cardiac catheterization is considered the gold standard imaging modality to achieve this. We investigated the role of contrast enhanced magnetic resonance angiography (MRA) to evaluate the pulmonary blood supply and the anatomy of the pulmonary arteries and compared this with cardiac catheterization in children with PA. We studied 20 children with PA. Median age was 2.5 years (range 6 months–13 years). All patients were examined with cardiac catheterization and contrast enhanced MRA, and the results of both modalities were compared. There was a complete agreement between both modalities in the detection of the main pulmonary artery morphology and determination of the confluence state of the central pulmonary arteries. There was an 88% agreement for patency of the ductus arteriosus and 66% for patency of the surgically placed shunt. There was a complete agreement between both techniques on determining the presence of collaterals more than 2.5 mm. Twenty-eight collaterals of less than 2.5 mm were detected only by contrast enhanced MRA. There was a strong correlation between both modalities in measuring the pulmonary arteries and collaterals diameter (P<0.001). Contrast enhanced MRA is a safe and accurate non-invasive technique to evaluate the pulmonary artery morphology and the sources of pulmonary blood supply in children with PA.

Developmental Changes of Bull (Bos taurus) Genitalia as Evaluated by Caliper and Ultrasonography

The objective of the present study is to follow the growth of the testes and the pelvic genitalia in cattle bulls, using ultrasonographic examination and measurements of external genitalia by caliper. Six Friesian bulls were examined periodically from 3 to 24 months of age with 3-month interval. Scrotum circumference (SC) and length were measured by tape. Testicular length, width and depth were measured by caliper. Scrotal contents including testes and epididymis, and the pelvic genitalia including bulbourethral gland (BUG), prostate and seminal glands (SG) were examined using transrectal ultrasonography. Scrotal circumference, length and the three dimensions of the testes showed significant increase with the advancement of age. Significant correlation was present between SC and testes breadth. At the same time, testis breadth as estimated by sonar showed positive correlation with that estimated by caliper. A positive correlation was also found between testicular breadth with each of the BUG and SG. Finally, it was concluded that ultrasonography gave appreciable benefits in studying the developmental changes of the testes and accessory glands of growing bulls. The obtained data could provide a useful tool for predicting bull puberty and fertility.

Nifedipine versus fentanyl to prevent the pressor response to tracheal intubation

Thirty six patients ASA 1 or 2, undergoing surgery that required tracheal intubation, were allocated randomly into three groups of twelve each. Before induction of anesthesia, they received either saline, 10 mg, nifedipine sublingual, or fentanyl 1.5 micrograms.kg-1 IV. Heart rate (HR), systolic blood pressure (SAP), diastolic blood pressure (DBP), and mean blood pressure (MAP), were recorded automatically every minute for 5 minutes before induction of anesthesia, and for 5 minutes after intubation. Nifedipine was better than fentanyl in blocking the pressor response. The fentanyl dose was too small to abolish this response completely. The increase in HR and blood pressure were most evident in the control group, followed by fentanyl, and the least increase was seen with nifedipine.

Nifedipine versus fentanyl to prevent the pressor response to tracheal intubation

Thirty six patients, ASA I or II, undergoing surgery that required tracheal intubation, were allocated randomly into three groups of twelve. Before induction of anesthesia, they received either saline, nifedipine sublingual 10 mg or fentanyl 1.5 micrograms.kg-1 i.v. Heart rate, systolic blood pressure, diastolic blood pressure and mean blood pressure (MAP) were recorded automatically every minute for 5 minutes before induction of anesthesia, and for 5 minutes after intubation. Nifedipine was better than fentanyl in blocking the pressor response to intubation. The fentanyl dose was too small to abolish this response completely. The increase in HR and blood pressure were most evident in the control group, followed by fentanyl, and the least increase was seen with nifedipine.