Use of High Dose Corticosteroids Reversed COVID-19 Associated ARDS in a Patient Listed for Lung Transplantation

Introduction

In acute respiratory distress syndrome (ARDS) patients with irreversible lung damage, lung transplantation from a ventilator and/or extracorporeal membrane oxygenation support (ECMO) is feasible. Recently, selection criteria for lung transplant candidates with a COVID-19 associated ARDS have been published. Here, we report the efficacy of high dose corticosteroids as ultimate salvage therapy, despite Meduri scheme attempts, in a patient listed for transplantation.

Case Report

A 50-year-old female with a medical history of Multiple Sclerosis (relapsing-remitting type under treatment with anti-alpha4 -integrin therapy), was tested positive for COVID-19. She deteriorated and was admitted to the hospital. High flow oxygen and dexamethasone (six milligram daily), were started but unfortunately, she developed a severe ARDS with need for mechanical ventilation and ECMO support. Corticosteroids according to the Meduri scheme and ciprofloxacin were started. Weaning trials were initiated but failed and CT-thorax showed consolidation and presumed fibrosis. After 37 days on ECMO, she was evaluated and listed for bilateral lung transplantation. A corticosteroid pulse therapy of 1000 mg of methylprednisolone IV for three days during antibiotic coverage with piperacillin/tazobactam was started and within three days the clinical condition of the patient improved and she could be weaned from ECMO (51 days of ECMO) and delisted from the lung transplantation waiting list. Nowadays, patient does not require oxygen, is at home and revalidating.

Summary

Here, we report the efficacy of a regimen with high dose corticosteroids as ultimate salvage therapy, despite Meduri scheme attempts, in a patient listed for transplantation. Corticosteroids are beneficial for immunomodulation and may reduce hyperinflammation. Our trial with administration of high dose corticosteroids pulse therapy in COVID-19 ARDS patients refractory to corticosteroids according to “classical schemes” has been successful and is informative. Further studies, will hopefully further elucidate responders and non-responders to high dose corticosteroid pulse therapy and preferably answer the question if prophylactic use of antibiotics and antifungals (in view of possible complications such as pulmonary aspergillosis and mucormycosis) is prudent in this vulnerable group.

Aortic Dissection Limited to Abdominal Aorta: an Underrecognized Entity?

BACKGROUND

Aortic dissection limited to the abdominal aorta is a rare clinical entity with non-specific clinical features. Optimal treatment, as well as natural history and progression of the disease, remain unclear. In 1992 we -reported 5 cases of isolated abdominal aortic dissection (IAAD) and in the present paper we update our series with 5 additional patients. A concise literature review is also provided.

METHODS

Between 1992 and 2014, we diagnosed 5 patients with IAAD (4 men, mean age 60.6 years, range 45-77). No patient presented with acute onset of symptoms. One patient was diagnosed with a periumbilical bruit, and diagnosis was made with magnetic resonance (MR)-angiography. Other diagnoses were incidental findings on computed tomographic (CT) scanning. Dissection was located infrarenally in four cases and at the celiac trunk in one case.

RESULTS

All cases were treated conservatively with hypertension control and close follow-up. Follow-up period ranged from 10 months to 20 years and was performed yearly by CT- or MR-angiography and blood pressure monitoring. All patients remained symptom-free, all dissection lengths remained stable. Slowly increasing post-dissection aneurysmal dilatation was encountered in two patients. We combined results of these five new patients with five previously diagnosed and reported patients at our center. Treatment was surgical in only one out of 10 patients. There was no disease-related mortality during follow-up.

CONCLUSIONS

Based on our case series, IAAD remains a rare clinical condition with relative benign clinical course. Treatment was almost exclusively conservative. Recent publications state IAAD might be underrecognized and under-diagnosed compared to thoracic aortic dissections.

Preclose Percutaneous Endurant™ Endografting with the Proglide™ Device: a Safe and Feasible Combination

BACKGROUND

Endovascular repair of abdominal aortic aneurysms has been revolutionized over the last two decades. Opening the doors for a percutaneous approach by avoiding surgical exposure of the vascular access site. The goal of this report is to analyze the feasibility and efficacy of using Perclose Proglide™ through a preclose technique in a percutaneous approach to Endurant™ endografting for Asymptomatisch infrarenal aortic aneurysms in an elective setting.

METHODS

Between April 2011 and April 2014, 45 consecutive patients underwent percutaneous endovascular aortic aneurysm repair (PEVAR) for an asymptomatic infrarenal aortic aneurysm. Closure of percutaneous access sites was ensured with Perclose Proglide in a "preclose" technique. Data were collected in a prospective maintained database with a follow-up period of one month. Patient demographics, aneurysmal characteristics, procedural details and complications were recorded.

RESULTS

A total of 170 Proglide devices were used to close 85 access sites. Adequate hemostasis was obtained in 96.5 percent (82 of 85 access sites). Conversion to a femoral cutdown was necessary in 2.4% (2 of 85 access sites). The mean hospitalization was 2.6 days and 86.7 percent of patients were discharged within 2 days. The incidence of post-procedural access-related complications was 2.2%.

CONCLUSIONS

PEVAR using the Perclose Proglide in preclosing 14Fr to 20Fr access sites for Endurant endografting in the treatment of asymptomatic infrarenal aortic aneurysms is feasible and effective. Moreover, the percutaneous approach allows for procedures to be performed under local anesthesia, while providing a low risk for access-related complications and a relatively short hospitalization.

Malignant Pleural Mesothelioma : Rationale for a New TNM Classification

BACKGROUND

Malignant pleural mesothelioma (MPM) is a rare but aggressive thoracic malignancy with a poor prognosis. In this regard, a well-defined staging system is of utmost importance in order to correctly diagnose and assign an appropriate treatment to the patient.

METHODS

The current TNM-staging system (7th edition) enables to either clinically or pathologically stage the severity of the disease according to extension of the tumor (T), number of nodes (N) and presence of metastases (M). Patients with stage I-III are considered for surgery, while palliative treatment is indicated for stage IV patients according to the current classification.

RESULTS

Despite its widespread use, the validity of this staging system is questioned due to the low prevalence, histological variety and retrospective nature of the previous study design. In addition, the role of specific treatment modalities including surgery, has yet to be determined, especially for treatment of early-stage disease. In this regard, the International Association for the Study of Lung Cancer (IASLC) initiated the multi-centre, prospective "Mesothelioma Staging Project" in order to address limitations of the 7th edition and to optimize the staging system in accordance to current needs.

CONCLUSIONS

An improved staging system will contribute to the design of prospective multi-institutional clinical trials investigating novel treatment strategies for mesothelioma. In this way comparison of outcome between different medical centres also becomes feasible.

BRAVISSIMO: 12-month results from a large scale prospective trial

The BRAVISSIMO study is a prospective, non-randomized, multi-center, multi-national, monitored trial, conducted at 12 hospitals in Belgium and 11 hospitals in Italy. This manuscript reports the findings up to the 12-month follow-up time point for both the TASC A&B cohort and the TASC C&D cohort. The primary endpoint of the study is primary patency at 12 months, defined as a target lesion without a hemodynamically significant stenosis on Duplex ultrasound (>50%, systolic velocity ratio no greater than 2.0) and without target lesion revascularization (TLR) within 12 months. Between July 2009 and September 2010, 190 patients with TASC A or TASC B aortoiliac lesions and 135 patients with TASC C or TASC D aortoiliac lesions were included. The demographic data were comparable for the TASC A/B cohort and the TASC C/D cohort. The number of claudicants was significantly higher in the TASC A/B cohort, The TASC C/D cohort contains more CLI patients. The primary patency rate for the total patient population was 93.1%. The primary patency rates at 12 months for the TASC A, B, C and D lesions were 94.0%, 96.5%, 91.3% and 90.2% respectively. No statistical significant difference was shown when comparing these groups. Our findings confirm that endovascular therapy, and more specifically primary stenting, is the preferred treatment for patients with TASC A, B, C and D aortoiliac lesions. We notice similar endovascular results compared to surgery, however without the invasive character of surgery.

TNM-classification for lung cancer: from the 7th to the 8th edition

Most tumors are staged according to the Tumor-Node-Metastasis (TNM) classification. For lung cancer a new edition was introduced in 2009 and generally applied since 2010. This 7th TNM-classification is based on a large, international retrospective database. Important changes were made regarding the T, N, M factors and specific subcategories were added. However, this 7th edition is still purely based on anatomical information. Other prognosticators such as laboratory results, histology, tumor markers and molecular genetic factors are not yet considered. To prepare the 8th TNM classification a prospective database developed by the International Association for the Study of Lung Cancer (IASLC), is currently enrolling patients from all continents. In this way, more precise and reliable data will become available on specific subdivisions of the T, N and M factors. If proven to be prognostically valid, other parameters will be included as histology, demographic data and specific biochemical and molecular predictive and prognostic factors. All centers with a large experience in thoracic oncology are encouraged to participate in this prospective database.

Endarterectomy combined with retrograde stenting for tandem lesions of the carotid artery

OBJECTIVES

Due to its location in the chest wall, surgical treatment of lesions at the origin of the brachiocephalic trunk or common carotid artery (CCA) is unattractive. Complete endovascular treatment of lesions at the origin of the common carotid artery or brachiochephalic trunk combined with high-grade lesions at the carotid bifurcation carries a high risk for distal emboli before cerebral protection is installed. Therefore, the combination of open carotid endarterectomy with retrograde stenting of the proximal lesion through one stage is most attractive.

METHODS

Eleven patients were treated with a combined procedure for tandem lesions at the origin of the brachiocephalic trunk or common carotid artery (CCA) and the carotid bifurcation. Endpoint of this evaluation was the 30-day MACE (Major Adverse Cardiovascular Events).

RESULTS

All procedures were finished as planned and no conversion was necessary. Thirty-day mortality was 0%. One patient developed a restenosis after only 4 days for which he underwent a re-PTA procedure. The 30-day MACE was 0%. None of the patients needed additional treatment during follow-up (mean follow-up 33 months; range: 11 to 60) although one patient developed a non-significant stenosis during follow-up.

CONCLUSIONS

Combined treatment of tandem lesions of the carotid artery is safe and effective in the long-term.

Restaging the mediastinum in non-small cell lung cancer after induction therapy: non-invasive versus invasive procedures

OBJECTIVE

Nodal status after induction therapy in patients with stage III non-small cell lung cancer (NSCLC) is an independent prognostic factor for survival. Prognosis is poor in patients with persisting mediastinal lymph node involvement.

METHODS

From February 2000 to September 2007, restaging for NSCLC was performed in 25 patients (23 men, 2 women) by computed tomography (CT), positron emission tomography (PET) as well as repeat mediastinoscopy. Initial proof of N2 or N3 disease was obtained by mediastinoscopy.

RESULTS

The non-invasive restaging modalities CT and PET had a rather low accuracy of 64% and 72%, respectively. Repeat mediastinoscopy performed better with an accuracy of 84%.

CONCLUSION

Histological proof of mediastinal involvement after induction therapy in NSCLC is necessary to select those patients who will benefit from surgical resection. When a first mediastinoscopy has been performed to obtain pathological proof of N2 or N3 disease, repeat mediastinoscopy proves to be more accurate than CT or PET scanning for mediastinal restaging.

TNM-Classification for Lung Cancer: From the 7(th) to the 8(th) Edition

Most tumors are staged according to the Tumor-Node-Metastasis (TNM) classification. For lung cancer a new edition was introduced in 2009 and generally applied since 2010. This 7(th) TNM-classification is based on a large, international retrospective database. Important changes were made regarding the T, N, M factors and specific subcategories were added. However, this 7(th) edition is still purely based on anatomical information. Other prognosticators such as laboratory results, histology, tumor markers and molecular genetic factors are not yet considered. To prepare the 8(th) TNM classification a prospective database developed by the International Association for the Study of Lung Cancer (IASLC), is currently enrolling patients from all continents. In this way, more precise and reliable data will become available on specific subdivisions of the T, N and M factors. If proven to be prognostically valid, other parameters will be included as histology, demographic data and specific biochemical and molecular predictive and prognostic factors. All centers with a large experience in thoracic oncology are encouraged to participate in this prospective database.

Emergency endovascular aneurysm repair for ruptured abdominal aortic aneurysms: an institutional experience

OBJECTIVES

Emergency endovascular aneurysm repair (eEVAR) for ruptured abdominal aortic aneurysms (rAAA) is still under investigation. Since installation of an urgent eEVAR kit in our hospital, all patients with a rAAA or urgent thoracic aortic aneurysm are candidates for eEVAR or eTEVAR (emergency thoracic EVAR), respectively. For this study, we analyzed all rAAA patients treated with eEVAR.

METHODS

Data were recorded prospectively. Criteria for an eEVAR were an infrarenal neck > or = 15 mm, acceptable landing zone, angles below 70 degrees and a good femoral approach. We prefer preoperative angio CT-scan but in case of instability, an intra-aortic balloon can stabilize the patient during angiography (in the OR) to decide between open or eEVAR repair. Follow-up was performed on regular intervals by duplex or CT-scan. Thirty-day mortality and overall survival were calculated.

RESULTS

Since 2006, nine male rAAA patients with a mean age of 73 years (range : 62-82) had eEVAR repair. Aneurysm diameter was 8 cm (range : 5.8-11). The Hardman index was 1.5 (range : 0-3). In eight patients an aorto-uni-iliac device was placed succesfully followed by a femorofemoral crossover bypass. The 30-day operative mortality was 12.5% (one patient with septic shock). Three patients showed a type 2 endoleak with stable diameter during follow-up but one patient showed expansion 4 years after treatment.

CONCLUSIONS

Treating rAAA with eEVAR in selected patients with acceptable anatomy and a kit permanently available in the operating room yielded good results by a surgical team trained for both open and eEVAR repair. The conversion rate was low (11%) and the survival (immediate and 30-days) was excellent (87.5%).

Quality of life after lung cancer surgery: a review

The long-term goals of lung cancer surgery include cancer control, survival and quality of life (QoL). In a patient population with a high mortality rate, evaluation and preservation of QoL after treatment is imperative. Lung cancer patients already have a significant lower QoL compared to an age-matched healthy population with significant impairment in physical and emotional functioning. Lung cancer surgery causes further deterioration of QoL, especially in the first 3 to 6 months after surgery. While some studies suggest that QOL returns to baseline levels at 6 to 9 months postoperatively, others report that QOL is still significantly impaired at 6 and 12 months after surgery. Age, extent of surgery, preoperative lung function, access technique, and adjuvant treatment may all influence postoperative QoL. This review presents the basic concepts of QoL research, several commonly used QoL measurement instruments, and a summary of the available data on post-lung cancer surgery QoL.

Different indications for repeat mediastinoscopy: single institution experience of 79 cases

AIM

Different indications exist for repeat mediastinoscopy or remediastinoscopy (reMS). Presently, it is a valuable restaging tool in non-small cell lung cancer (NSCLC). Not only does it provide pathological evidence of mediastinal downstaging, it also selects those patients who will benefit from a subsequent surgical resection and determines prognosis. However, other indications for reMS exist. The authors reviewed their overall experience with reMS.

METHODS

From June 1994 until September 2007, 79 reMS were performed in 75 patients (65 men and 10 women). Mean age was 67.4 years (range 35 to 85 years).

RESULTS

ReMS was performed after induction therapy in 54 cases (68.4%), for recurrent lung cancer in 7 cases (8.9%), metachronous second primary lung cancer in 2 cases (2.5%), for lung cancer occurring after an unrelated disease such as sarcoidosis in 1 case (1.2%), for an inadequate first procedure in 8 cases (10.1%) and for a non-malignant disease such as sarcoidosis or lymphoma in 7 cases (8.9%). ReMS was technically feasible in all patients. There was no mortality. One hemorrhage was encountered from a bronchial artery during reMS which was controlled by packing and one tear in the bronchial wall which was treated conservatively. In patients with lung cancer (71 patients), reMS was positive in 29 cases (40.8%). ReMS provided a definitive diagnosis in 3 patients with sarcoidosis and in one patient with lymphoma .

CONCLUSIONS

Although mostly performed as a restaging procedure after induction therapy in non-small cell lung cancer, reMS can also safely be performed for other indications providing pathological evidence of mediastinal involvement.

Early endothelial dysfunction in young type 1 diabetics

OBJECTIVES

Endothelial dysfunction is a known precursor of atherosclerosis and can be assessed by measuring the brachial artery flow-mediated dilatation (FMD) via ultrasonography. This study investigated endothelial function in young type 1 diabetics without cardiovascular morbidity or diabetes-related pathology.

METHODS

Young diabetics and healthy controls were recruited, both meeting strict inclusion and exclusion criteria. To prove absence of subclinical atherosclerosis, intima-media thickness (IMT) measurements at the carotid bifurcation were done in all of them. FMD was measured at the brachial artery. The results were compared using the t-test and the influences of different variables on FMD were assessed using multiple linear regression.

RESULTS

Twenty-six diabetics (23.4+/-5.8 years) and 36 healthy volunteers (23.1+/-2.8 years) were recruited. The duration of diabetes was 9.2+/-5.3 years; metabolic control was moderate (HbA1c 7.6+/-1.0%) and IMT was normal in both groups. FMD was significantly impaired in type 1 diabetics (7.13+/-0.43 vs. 8.77+/-0.43%; p=0.002). The FMD grade was associated with diabetes and age. Patients with a good metabolic control (HbA1c</=7.0%) had a better FMD.

CONCLUSIONS

In type 1 diabetics, even without preclinical or clinical atherosclerosis, endothelial function is already disturbed and can be detected using ultrasonography.

[Stage III NSCLC. The surgeon's role in exploration and treatment]

The role of surgery in stage IIIA non-small cell lung cancer (NSCLC) remains controversial. Different restaging techniques exist to evaluate response after induction therapy and these are subdivided into non-invasive, invasive and alternative or minimally invasive techniques. Remediastinoscopy provides pathological evidence of response after induction therapy. Stage IIIA-N2 NSCLC represents a heterogeneous spectrum of locally advanced disease and different subsets exist. When N2 disease is discovered during thoracotomy a resection should be performed if this can be complete. Most patients with pathologically proven N2 disease detected during preoperative work-up will be treated by induction therapy followed by surgery or radiotherapy. In two large, recently completed, phase III trials there was no difference in overall survival between the surgical and radiotherapy arm. Surgical resection may be recommended in those patients with proven mediastinal downstaging after induction therapy who can preferentially be treated by lobectomy. Patients with bulky N2 disease are mostly treated with combined chemoradiotherapy although the precise treatment scheme has not been determined yet. Also, stage IIIB is mostly treated by concurrent or sequential chemoradiotherapy. Surgery is rarely indicated in T4N0-1 disease unless a complete resection can be obtained, in some selected cases after induction therapy.

Mycotic aneurysm of the descending thoracic aorta. Review and case report

A 74-year-old male presented with bilateral invalidating claudication. A bilateral percutaneous transluminal angioplasty (PTA) with stenting of both superficial femoral arteries was performed but complicated by an urosepsis with Escherichia coli and a septic phlebitis at the site of an intravenous line. The phlebitis was complicated by a local abcedation for which incision and drainage were performed. One month after discharge he was readmitted at our hospital with septic fever and positive hemocultures for Escherichia coli. Positron emission tomography-computed tomographic scan (PET/CT-scan) showed a mycotic aneurysm of the thoracic aorta. Because no cryopreserved donor aorta was available and the aneurysm size rapidly increased, an open in situ repair was performed with a Dacron silver prosthesis soaked in rifampicin. His recovery was further complicated by a perforated toxic megacolon for which a subtotal colectomy was performed. Further recovery was uncomplicated and 10 months after the aortic repair patient is still free from infection.

Decision making about operability in non-small cell lung cancer

With the introduction of combined modality therapy and better staging techniques, the role of surgical resection for non-small cell lung cancer is continuously redefined. The final aim of surgical treatment for lung cancer is complete resection, also after neoadjuvant or induction therapy. Precise criteria for complete resection have recently been defined. Definite indications for surgery include clinical stages I, II and resectable IIIA. The precise role for surgical resection in stage IIIA-N2 lung cancer remains controversial but only downstaged patients should be considered. Stage IIIB is mostly treated by chemoradiotherapy. Accurate peroperative or surgical staging is necessary, as well regarding the tumour as nodal factor, to determine the extent of resection. A systematic nodal dissection should be performed including at least three hilar and three mediastinal lymph node stations. Post-induction surgical therapy often represents a greater technical challenge due to a pronounced hilar and mediastinal fibrosis. Downstaging is an important prognostic factor and persisting mediastinal lymph node involvement carries a poor prognosis. The optimal restaging method has not been established yet, but a pathological proof should be obtained. Remediastinoscopy is feasible with an acceptable accuracy but less invasive techniques are currently evaluated.

Spontaneous pseudo-aneurysm of the deep femoral artery treated by a covered stent

PURPOSE

To present the management of a spontaneous pseudo-aneurysm of the deep femoral artery by an endovascular technique.

CASE REPORT

An 82-year-old man presented with a painless pulsating mass at the level of the upper right thigh without any previous history of trauma, surgery or puncture of the femoral artery. The mass proved to be a pseudo-aneurysm of the deep femoral artery. Thrombin injection with simultaneous balloon inflation at the neck of the aneurysm did not result in a long-lasting thrombosis. Since both general and epidural anaesthesia were absolutely contra-indicated, and because of severe stenotic lesions of the femoro-popliteal axis, we chose to exclude this aneurysm under local anaesthesia with a balloon-expandable covered Jo-stent in order to maintain patency of the deep femoral artery. Twenty months postoperatively, the aneurysm is still thrombosed while the patency of both the superficial and deep femoral artery is preserved.

CONCLUSIONS

This case demonstrates that an endovascular approach can be an excellent treatment for aneurysms of the deep femoral artery, thereby avoiding an open surgical procedure while preserving the patency of the deep femoral artery.

Quality of life evolution after lung cancer surgery: A prospective study in 100 patients

OBJECTIVE

To evaluate quality of life (QoL) evolution after thoracic surgery for lung cancer with the European Organisation for Research and Treatment of Cancer (EORTC) QoL Questionnaire-C30 and the lung cancer specific module LC13.

METHODS

A prospective QoL registration started in 2002 for all patients undergoing major pulmonary surgery for malignant disease. Between January 2002 and November 2004, 100 patients were included. Questionnaires were administered pre-operatively and 1, 3, 6 and 12 months post-operatively (MPO) with response rates of 100%, 71%, 77%, 83% and 76%, respectively.

PROCEDURES

lobectomy 61%, pneumonectomy 17%, and wedge resection 22%. Approaches: anterolateral thoracotomy 79%, posterolateral thoracotomy 13% and video-assisted thoracic surgery (VATS) 8%.

RESULTS

Lobectomy and wedge resection are comparable in QoL evolution. Both resections are characterized by a 1 month temporary decrease in QoL functioning scores and an increase in pain symptoms. Lobectomy patients report an increase in dyspnea in the first month post-operatively, not seen after wedge resection. With exception of thoracic pain after lobectomy, QoL scores approximated baseline values 3MPO indicating good recovery. After pneumonectomy, there is no return to baseline in physical functioning, role functioning, pain, shoulder function and dyspnea in a 12 months follow-up period. Other QoL scores were comparable with baseline values. Pneumonectomy was significantly associated with a less favorable QoL score evolution when compared with lobectomy. Comparing antero- and posterolateral thoracotomy, significant differences in pain and dyspnea were seen in favor of the anterolateral technique. Comparing thoracotomy to VATS, significant differences were seen in physical functioning, QoL and thoracic pain in favor of VATS.

CONCLUSIONS

The present study documented QoL evolution profiles comparing pre-operative status with deficits and changes at 1, 3, 6 and 12 months after pulmonary surgery. Lung cancer surgery is well tolerated by the majority of patients. Lobectomy patients have a more favorable physical functioning and less thoracic pain, compared to pneumonectomy. Antero- and posterolateral thoracotomy are comparable for QoL evolution. After posterolateral thoracotomy more post-operative pain and dyspnea was seen. Post-operative physical functioning, pain and QoL are in favor of VATS.

Superior sulcus tumor arising in an azygos lobe

A non-small cell lung cancer presenting as a superior sulcus tumor in an azygos lobe has not yet been reported. We present such a case in a 69-year-old man undergoing complete resection after induction chemoradiotherapy and discuss the specific location of a superior sulcus tumor and the aberrant anatomy of an azygos lobe.

Association of colonic atresia and Hirschsprung's disease in the newborn: report of a new case and review of the literature

Colonic atresia (CA) is an infrequent cause of lower gastrointestinal obstruction in the neonate. Coexistence with aganglionosis of the colon (Hirschsprung's disease) has been reported but is generally not recognized in the neonatal period. We report another case and present a review of the literature. A boy with a lower gastrointestinal obstruction, caused by a CA type III, had creation of a proximal colostomy and a distal mucous fistula on the 1st day of life. In the preoperative work-up before restoring the continuity, rectal suction biopsies revealed the presence of Hirschsprung's disease. When the boy was 6 months old, a distal colectomy and reanastomosis were done. Creation of a colostomy and reanastomosis in a second procedure is recommended for treating a type III CA unless distal aganglionosis has been ruled out.

Long-term results of primary stenting for long and complex iliac artery occlusions

OBJECTIVES

To evaluate the long-term results of recanalization with primary stenting for long and complex iliac artery occlusions.

DESIGN

Retrospective non-randomized study.

METHODS

Between 1996 and 2004, 38 patients underwent recanalization of an occluded iliac artery with subsequent stenting for TASC B lesions in 12 patients, TASC C in 10 and TASC D in 16. Thirty-one patients had Fontaine stage 2 B, four patients had stage 3 and one patient had stage 4. Two patients (5.4%) presented with acute ischemia and received trombolysis before recanalization. Patency results were calculated using Kaplan and Meier analysis. The mean follow-up was 26 months.

RESULTS

Technical success was 97.4%. Thirty-day mortality was 2.7%. The primary patency rate was 94%, 89% and 77% at 1, 3 and 5 years respectively. Three re-occlusions (8.1%) and one restenosis (2.7%) were observed during follow-up. The secondary patency (SP) rate was 100%, 94% and 94% after 1, 2 and 3 years. Fifteen patients underwent an associated procedure. A kissing stent procedure in three patients, a contralateral PTA of an iliac stenosis in 8, a femoro-femoral bypass in 2, a femoropopliteal bypass in 1 and an femoral endarterectomy in 2. The procedure related complication rate was 5.4%.

CONCLUSION

Long-term results of iliac recanalization are excellent without major complications if the procedure is technically successful. The endovascular procedure can be an alternative to an iliofemoral or aortobifemoral bypass in a high risk population.

Paravertebral schwannoma with high uptake of fluorodeoxyglucose on positron emission tomography

A paravertebral mass was discovered in a 27-year-old woman, while investigating a painful shoulder and arm. CT, MRI and fine needle aspiration cytology (FNAC) pointed in the direction of a benign mass, but positron emission tomography (PET) showed a high uptake of [(18)F]fluorodeoxyglucose (FDG), which was indicative of a malignant lesion. Pathological analysis of the thoracoscopically resected tumour gave us the final diagnosis of a benign schwannoma. This report demonstrates that a high uptake of FDG in a non-malignant mediastinal tumour is possible.

Video-assisted thoracic surgery (VATS) for primary spontaneous pneumothorax: how I do it ?

The precise management of primary spontaneous pneumothorax remains controversial due to the lack of large prospective randomized trials. This not only regards the indications for conservative or invasive treatment but also the precise technique for air evacuation and recurrence prevention. The technique of video-assisted thoracic surgery is described as it is performed in our centre for the treatment of primary spontaneous pneumothorax.

Aortic graft infection from appendicitis. A case report

Fifteen years after aortobifemoral bypass and five years after left femoropopliteal bypass, a 73-year old man presented with a vague abdominal pain syndrome. After an extensive work-up, aortobifemoral graft infection was suspected; an appendiceal abscess infiltrating the prosthesis was discovered during exploratory laparotomy. Appendectomy was performed followed by removal of the vascular graft, the latter being replaced by a bilateral axillofemoral prosthesis. Aortic graft infection from appendicitis is an extremely rare condition; a review of similar cases is presented.

Unusual complications of preperitoneal mesh implantation in the treatment of inguinal hernia

More and more prosthetic materials are being used in the treatment of inguinal hernia. This report deals with some unusual but devastating complications, occurring after preperitoneal mesh implantation. A 56-year old male patient underwent a Stoppa-repair for a bilateral inguinal hernia. Two years postoperatively, a localized abdominal wall abscess was treated with antibiotics and drainage. A barium enema and a CT-scan of the abdomen were performed to rule out an enteric fistula; the CT-scan unexpectedly revealed a tumoral mass involving the sigmoid colon, and an explorative laparotomy was done. Peroperatively, part of the mesh was found to penetrate the bowel wall and a sigmoidectomy with removal of the mesh was performed. Two years later, ingrowth of the urinary bladder by the remains of the mesh was the unfortunate peroperative finding when the patient was operated on for an inflammatory mass, involving the bladder wall. The patient needed two more interventions for persisting wound fistulas. All the remains of the mesh have been removed and all fistulas have been widely excised. Nowadays, the patient is recovering well with complete healing of all wounds. Although infection of prostheses used in the treatment of hernias has been described, late and serious complications related to mesh implantation, such as perforation of the colon and the bladder, have seldom been reported.

Intensive insulin therapy in critically ill patients

BACKGROUND

Hyperglycemia and insulin resistance are common in critically ill patients, even if they have not previously had diabetes. Whether the normalization of blood glucose levels with insulin therapy improves the prognosis for such patients is not known.

METHODS

We performed a prospective, randomized, controlled study involving adults admitted to our surgical intensive care unit who were receiving mechanical ventilation. On admission, patients were randomly assigned to receive intensive insulin therapy (maintenance of blood glucose at a level between 80 and 110 mg per deciliter [4.4 and 6.1 mmol per liter]) or conventional treatment (infusion of insulin only if the blood glucose level exceeded 215 mg per deciliter [11.9 mmol per liter] and maintenance of glucose at a level between 180 and 200 mg per deciliter [10.0 and 11.1 mmol per liter]).

RESULTS

At 12 months, with a total of 1548 patients enrolled, intensive insulin therapy reduced mortality during intensive care from 8.0 percent with conventional treatment to 4.6 percent (P<0.04, with adjustment for sequential analyses). The benefit of intensive insulin therapy was attributable to its effect on mortality among patients who remained in the intensive care unit for more than five days (20.2 percent with conventional treatment, as compared with 10.6 percent with intensive insulin therapy, P=0.005). The greatest reduction in mortality involved deaths due to multiple-organ failure with a proven septic focus. Intensive insulin therapy also reduced overall in-hospital mortality by 34 percent, bloodstream infections by 46 percent, acute renal failure requiring dialysis or hemofiltration by 41 percent, the median number of red-cell transfusions by 50 percent, and critical-illness polyneuropathy by 44 percent, and patients receiving intensive therapy were less likely to require prolonged mechanical ventilation and intensive care.

CONCLUSIONS

Intensive insulin therapy to maintain blood glucose at or below 110 mg per deciliter reduces morbidity and mortality among critically ill patients in the surgical intensive care unit.

Femoral venoarterial extracorporeal membrane oxygenation for severe reimplantation response after lung transplantation

Severe pulmonary reimplantation response after lung transplantation is not very common, although the mortality can be high. We present a patient who developed an extremely severe reperfusion injury after bilateral lung transplantation. Because of severe hypoxia and hemodynamic instability, despite aggressive ventilator settings, venoarterial extracorporeal membrane oxygenation (ECMO) was instituted using the femoral approach at the bedside. During ECMO, the patient developed a thoracic wall hematoma that was treated with transfusion alone. After 50 h of ECMO, his chest radiograph had dramatically improved, his oxygen need had been reduced to 50%, and he was successfully weaned from ECMO. Two years later, he is doing extremely well. Therefore, institution of ECMO using the femoral approach can be performed safely at the bedside in the ICU, and can be lifesaving in the context of a very severe reimplantation response after lung transplantation.

Reliability and validity of the Critical Care Family Needs Inventory in a Dutch-speaking Belgian sample

OBJECTIVE

The purpose of the study was to provide psychometric evaluation of the Dutch version of the Critical Care Family Needs Inventory.

SETTING

The study took place in an intensive care unit of a university hospital.

PARTICIPANTS

The participant group included 200 adult family members visiting a patient within the 72-hour interval after admission to the intensive care unit.

RESULTS

Principal factor analysis with varimax rotation resulted in a 5-factor solution distinguishing 5 need types: need for information, need for comfort, need for support, need for assurance and anxiety reduction, and need for proximity and accessibility. The internal consistency of the resulting subscales ranged from 0.80 to 0.62, and all factors were significantly related to each other. The Critical Care Family Needs Inventory subscales were found to be clearly related to the demographic variables age, sex, and education level.

CONCLUSION

The reliability and validity of the Dutch-language Critical Care Family Needs Inventory as a diagnostic tool in family needs assessment are supported.

Stapled versus hand-sewn vascular anastomoses. An experimental study in the rabbit

OBJECTIVE

Narrowing of vascular anastomoses is a frequently encountered surgical problem, with intimal hyperplasia being one of its most important causes. The aim of the present study was to compare in a rabbit model 'manual' (hand-sewn) with 'stapled' anastomoses (using a staple device) with respect to occurrence and severity of intimal hyperplasia.

MATERIALS AND METHODS

Twenty-four male rabbits (mean weight 2,849 g) were randomly allocated to one of two groups (n = 12). An end-to-end anastomosis of the left femoral artery was performed in all animals under general anesthesia. The anastomosis was hand sewn in group 1, while a vascular closure stapler (VCS) was used in group 2. Both anastomotic time and total operation time were recorded. After 28 days, the rabbits were sacrificed. The femoral artery of operated and nonoperated sides were removed and prepared for anatomopathological examination. The I/M ratio (= difference between tunica intima and tunica media) was determined on hematoxylin-eosin stained slides. All results were analyzed using Student's t test.

RESULTS

Mean anastomotic times were 25 +/- 7 min for the 'manual' group and 17 +/- 9 min for the 'stapled' group (p = 0.02). There was no significant difference in the total operation time (55 +/- 15 vs. 41 +/- 18 min, p = 0.057). All animals survived the anastomosis procedure. In the group of 'manual' anastomosis, morbidity was significantly higher. At the moment of sacrifice, all anastomoses were patent. There was no difference in the I/M ratio between the groups.

CONCLUSIONS

The use of VCS is a promising alternative to hand-sewn anastomoses. It takes less time to perform a stapled anastomosis, the technique has a shorter learning period and morbidity seems to be lower when vascular anastomoses are applied with the VCS in this rabbit model.

Lamellar bone formation in an atherosclerotic plaque of the carotid artery, with a review of histogenesis--a case report

Longer existing atherosclerotic lesions may contain calcifications; lamellar bone rarely develops within them. A 59-year-old man was referred with a progressive stroke. A high-grade stenosis of the left common carotid artery, formed by an ulcerating atherosclerotic plaque with a free-floating thrombus, was detected on angiography. An urgent endarterectomy was performed. Surprisingly this plaque contained pieces of lamellar bone, proved by histologic examination.

The effect of CO2 pneumoperitoneum on the growth of a solid colon carcinoma in rats

BACKGROUND

In order to investigate the effect of carbon dioxide (CO(2)) pneumoperitoneum on solid colon carcinomas, we used a colon anastomosis tumor model in 30 male syngeneic WAG rats, which were divided, at random into three groups.

METHODS

In all rats, 10(6) CC531 S colon carcinoma cells were injected as an enema into the colon. Subsequently, a transection and a reanastomosis of the colon descendens was performed via laparotomy. After 2 weeks, group 1 (n = 10) was anesthetized as an anesthesia control group. Group 2 (n = 10) had a laparotomy that was closed after 20 min. In group 3 (n = 10), a CO(2) pneumoperitoneum of </=6 mmHg was created and maintained during 20 min. After 2 weeks, all rats were killed, and total tumor weight and volume was measured.

RESULTS

At necroscopy tumor growth was found in 16 rats (group 1: six; group 2: five; group 3: five). No difference in tumor growth (weight or volume) was found between the three groups.

CONCLUSION

In our solid colon carcinoma model, CO(2) pneumoperitoneum did not enhance tumor growth.

Effects of suramin on anastomotic colon tumors in a rat model

BACKGROUND

The development of antiangiogenic drugs offers new promise in the treatment of malignancy. Suramin has been reported to inhibit tumor growth by blocking angiogenesis and has been used in clinical trials. The aim of the present study was to examine the effects of suramin on colonic anastomotic tumors in the rat.

METHODS

(a) Colonic anastomotic tumor was induced in 120 WAG/RIJ rats. Half of the animals were given 100 mg/kg of suramin intraperitoneally at the time of tumor induction. Rats were sacrificed after 2, 4 and 8 weeks; tumor take and tumor weight were evaluated. (b) The number of red blood cell clusters per x 400 field was counted in each tumor. (c) A lymphocyte transformation test was performed in four groups of animals, 2 weeks before and 2 weeks after tumor implantation and/or suramin administration.

RESULTS

(a) A significant enhancement of tumor growth was observed in the suramin-treated animals. (b) This was accompanied by a significant increase in functional blood vessels. (c) Suramin-treated rats had markedly decreased lymphocyte stimulation, pointing to a possible immunosuppressive effect.

CONCLUSIONS

The growth of an anastomotic colon tumor is rather enhanced by a single intraperitoneal administration of 100 mg/kg suramin in the rat, possibly by an unexpected immunosuppressive effect.

Comparison between plain and gentamicin containing collagen sponges in infected peritoneal cavity in rats

OBJECTIVE

To study the usefulness of gentamicin-containing sponges in the infected peritoneal cavity in rats.

DESIGN

Controlled study.

MATERIAL

83 Male Wistar rats, 36 of which were treated by plain sponge, 36 by gentamicin-impregnated sponge, and 11 acted as controls.

INTERVENTIONS

A standard model of intraperitoneal infection was developed by making a 1 cm long incision in the caecum.

MAIN OUTCOME MEASURES

Postoperative mortality, macroscopic and microscopic features of infection, and bacterial concentrations in the abdomen on days 3, 6, and 9.

RESULTS

In the respective groups 2, 3 and 2 animals died during operation and 4/34 (11%), 3/33 (9%); and 0/9 died before day 3. There were appreciable reductions in the number of animals with features of infection after 3 days but these were not significant at 6 or 9 days.

CONCLUSION

Gentamicin-containing collagen sponges placed on a septic focus in the abdomen reduce local infection for at least 3 days.

Neuroendocrinology of prolonged critical illness: effects of exogenous thyrotropin-releasing hormone and its combination with growth hormone secretagogues

The catabolic state of prolonged critical illness is associated with a low activity of the thyrotropic and the somatotropic axes. The neuroendocrine component in the pathogenesis of these low activity states was assessed by investigating the effects of continuous intravenous infusions of TRH, GH-releasing peptide-2 (GHRP-2), and GHRH. Twenty adult patients, critically ill for several weeks, were studied during two consecutive nights. They had been randomly allocated to one of three combinations of peptide infusions, each administered in random order: TRH (one night) and placebo (other night), TRH + GHRP-2 (one night) and GHRP-2 (other night), or TRH + GHRH + GHRP-2 (one night) and GHRH + GHRP-2 (other night). The peptide infusions were started after a 1-microgram/kg bolus and infused (1 microgram/kg per h) until 0600 h. Blood sampling was performed every 20 min, and pituitary hormone secretion was quantified by deconvolution analysis. Reduced pulsatile fraction of TSH, GH, and PRL secretion and low serum concentrations of T4, T3, insulin growth factor-I (IGF-I), IGF-binding protein-3 (IGFBP-3), and the acid-labile subunit (ALS) were documented in the untreated state. Infusion of TRH alone or in combination with GH secretagogues augmented nonpulsatile TSH release 2- to 5-fold; only TRH + GHRP-2 increased pulsatile TSH secretion (4-fold). Average rises in T4 (40-54%) and in T3 (52-116%) were obtained with all three combinations, whereas reverse T3 levels did not increase, except when TRH was infused alone. Pulsatile GH secretion was amplified > 6- and > 10-fold, respectively, by GHRP-2 and GHRH + GHRP-2 infusions, generating mean increases of serum IGF-I (66% and 106%), IGFBP-3 (50% and 56%), and ALS (65% and 97%) within 45 h. The addition of TRH did not alter the GH secretory patterns. TRH infusion increased PRL release only when combined with GH secretagogues. No effects on serum cortisol were detected. In conclusion, the pathogenesis of the low activity state of the thyrotropic and somatotropic axes in prolonged critical illness appears to have a neuroendocrine component, because these axes are both readily activated by coinfusion of TRH and GH secretagogues.

Thyrotrophin and prolactin release in prolonged critical illness: dynamics of spontaneous secretion and effects of growth hormone-secretagogues

OBJECTIVE

Infusion of GH secretagogues appears to be a novel endocrine approach to reverse the catabolic state of critical illness, through amplification of the endogenously blunted GH secretion associated with a substantial IGF-I rise. Here we report the dynamic characteristics of spontaneous nightly TSH and PRL secretion during prolonged critical illness, together with the concomitant effects exerted by the administration of GH-secretagogues, GH-releasing hormone (GHRH) and GH-releasing peptide-2 (GHRP-2) in particular, on night-time TSH and PRL secretion.

PATIENTS AND DESIGN

Twenty-six critically ill adults (mean +/- SEM age: 63 +/- 2 years) were studied during two consecutive nights (2100-0600 h). According to a weighed randomization, they received 1 of 4 combinations of infusions, within a randomized, cross-over design for each combination: placebo (one night) and GHRH (the next night) (n = 4); placebo and GHRP-2 (n = 10); GHRH and GHRP-2 (n = 6); GHRP-2 and GHRH + GHRP-2 (n = 6). Peptide infusions (duration 21 hours) were started after a bolus of 1 microgram/kg at 0900 h and infused (1 microgram/kg/h) until 0600 h.

MEASUREMENTS

Serum concentrations of TSH and PRL were determined by IRMA every 20 minutes and T4, T3 and rT3 by RIA at 2100 h and 0600 h in each study night. Hormone secretion was quantified using deconvolution analysis.

RESULTS

During prolonged critical illness, mean night-time serum concentrations of TSH (1.25 +/- 0.42 mlU/l) and PRL (9.4 +/- 0.9 micrograms/l) were low-normal. However, the proportion of TSH and PRL that was released in a pulsatile fashion was low (32 +/- 6% and 16 +/- 2.6%) and no nocturnal TSH or PRL surges were observed. The serum levels of T3 (0.64 +/- 0.06 nmol/l) were low and were positively related to the number of TSH bursts (R2 = 0.32; P = 0.03) and to the log of pulsatile TSH production (R2 = 0.34; P = 0.03). GHRP-2 infusion further reduced the proportion of TSH released in a pulsatile fashion to half that during placebo infusion (P = 0.02), without altering mean TSH levels. GHRH infusion increased mean TSH levels and pulsatile TSH production, 2-fold compared to placebo (P = 0.03) and 3-fold compared to GHRP-2 (P = 0.008). The addition of GHRP-2 to GHRH infusion abolished the stimulatory effect of GHRH on pulsatile TSH secretion. GHRP-2 infusion induced a small increase in mean PRL levels (21%; P = 0.02) and basal PRL secretion rate (49%; P = 0.02) compared to placebo, as did GHRH and GHRH + GHRP-2.

CONCLUSIONS

The characterization of the specific pattern of anterior pituitary function during prolonged critical illness is herewith extended to the dynamics of TSH and PRL secretion: mean serum levels are low-normal, no noctumal surge is observed and the pulsatile fractions of TSH and PRL release are reduced, as was shown previously for GH. Low circulating thyroid hormone levels appear positively correlated with the reduced pulsatile TSH secretion, suggesting that they have, at least in part, a neuroendocrine origin. Finally, the opposite effects of different GH-secretagogues on TSH secretion further delineate particular linkages between the somatotrophic and thyrotrophic axes during critical illness.

The somatotropic axis in critical illness: effect of continuous growth hormone (GH)-releasing hormone and GH-releasing peptide-2 infusion

Prolonged critical illness is characterized by protein hypercatabolism and preservation of fat depots, associated with blunted GH secretion, elevated serum cortisol levels, and low insulin-like growth factor I (IGF-I) concentrations. In this condition, GH is readily released in response to a bolus of GHRH and GH-releasing peptide-2 (GHRP-2) and, paradoxically, to TRH. We further explored the altered somatotropic axis and cortisol secretion in critical illness by examining the effects of continuous GHRH and/or GHRP-2 infusion. Twenty-six critically ill adults (mean age +/- SEM, 63 +/- 2 yr) were studied during 2 consecutive nights (2100-0600 h). According to a weighed randomization, they received one of four combinations of infusions within a randomized cross-over design for each combination: placebo (one night) and GHRP-2 (the other night; n = 10), placebo and GHRH (n = 4), GHRH and GHRP-2 (n = 6), and GHRP-2 and GHRH plus GHRP-2 (n = 6). The peptide infusions (duration, 21 h) were started after a bolus of 1 microgram/kg at 0900 h and infused (1 microgram/kg/h) until 0600 h. Serum concentrations of GH were determined every 20 min, cortisol every hour, and IGF-I at 2100 and 0600 h on each study night. The placebo profiles showed pulsatile GH secretion with low secretory burst amplitude [0.062 +/- 0.008 microgram/L distribution volume (Lv)/min], high burst frequency (6.6 +/- 0.4 events/9 h), and detectable basal secretion (0.041 +/- 0.009 microgram/L/min) in the face of low serum IGF-I (106 +/- 11 micrograms/L). IGF-I correlated positively and significantly with the basal component, the pulsatile component, and the total amount of nightly GH secretion. GHRH elicited a 2- to 3-fold increase in the mean GH concentration (P = 0.006), the GH secretory burst amplitude (P = 0.007), and basal GH secretion (P = 0.03). GHRP-2 provoked a 4- to 6-fold increase in the mean GH concentration (P < 0.0001), the GH secretory burst amplitude (P = 0.002), and basal GH secretion (P = 0.0007), which were associated with a 61 +/- 13% increase in serum IGF-I within 24 h (P = 0.02). Compared to GHRP-2 alone, GHRH plus GHRP-2 elicited a further 2-fold increase in the mean GH concentration (P = 0.04) and GH basal secretion (P = 0.02), and an additional 40 +/- 6% rise in serum IGF-I (P = 0.04). GHRH and GHRP-2 infusion did not alter elevated cortisol levels. In critically ill adults, low serum IGF-I levels were positively correlated with diminished pulsatile and increased basal GH secretion. Both basal and pulsatile GH secretion were moderately increased by continuous infusion of GHRH, substantially increased by GHRP-2, and strikingly increased by GHRH plus GHRP-2. GHRP-2 alone or combined with GHRH elicited a robust rise in circulating IGF-I levels within 24 h without altering serum cortisol levels. These findings open perspectives for GH secretagogues as potential antagonists of the catabolic state in critical care medicine.

Randomized, controlled trial of selective digestive decontamination in 600 mechanically ventilated patients in a multidisciplinary intensive care unit

OBJECTIVE

To evaluate the efficacy of two regimens of selective decontamination of the digestive tract in mechanically ventilated patients.

DESIGN

Prospective, randomized, concurrent trial.

SETTING

Multidisciplinary intensive care unit (ICU) in a 1,800-bed university hospital.

PATIENTS

Consecutive patients (n = 660) who were likely to require mechanical ventilation for at least 48 hrs were randomized to one of three groups: conventional antibiotic regimen (control group A); oral and enteral ofloxacin-amphotericin B (group B); and oral and enteral polymyxin E-tobramycin-amphotericin B (group C). Both treatment groups received systemic antibiotics for 4 days (ofloxacin in group B and cefotaxime in group C).

INTERVENTIONS

Patients were randomized to receive standard treatment (control group A, n = 220), selective decontamination regimen B (group B, n = 220), and selective decontamination regimen C (group C, n = 220). After early deaths and exclusions from the study, 185 controls (group A) and 193 (group B)/200 (group C) selective decontamination regimen patients were available for analysis.

MEASUREMENTS AND MAIN RESULTS

Measurements included colonization and primary/secondary infection rate, ICU mortality rate, emergence of antibiotic resistance, length of ICU stay, and antimicrobial agent costs. The study duration was 19 months. The patient groups were fully comparable for age, diagnostic category, and severity of illness. One third of patients in each group suffered a nosocomial infection at the time of admission. There was a significant difference between treatment group B and control group A in the number of infected patients (odds ratio of 0.42, 95% confidence interval of 0.27 to 0.64), secondary lower respiratory tract infection (odds ratio of 0.47, 95% confidence interval of 0.26 to 0.82), and urinary tract infection (odds ratio of 0.47, 95% confidence interval of 0.27 to 0.81). Significantly more Gram-positive bacteremias occurred in treatment group C vs. group A (odds ratio of 1.22, 95% confidence interval 0.72 to 2.08). Infection at the time of admission proved to be the most significant risk factor for subsequent infection in control and both treatment groups. ICU mortality rate was almost identical (group A 16.8%, group B 17.6%, and group C 15.5%) and was not significantly related to primary or secondary infection. Increased antimicrobial resistance was recorded in both treatment groups: tobramycin-resistant enterobacteriaceae (group C 48% vs. group A 14%, p < .01), ofloxacin-resistant enterobacteriaceae (group B 50% vs. group A 11%, p < .02), ofloxacin-resistant nonfermenters (group B 81% vs. group A 52%, p < .02), and methicillin-resistant Staphylococcus aureus (group C 83% vs. group A 55%, p < .05). Antimicrobial agent costs were comparable in control and group C patients; one third less was spent for group B patients.

CONCLUSIONS

In cases of high colonization and infection rates at the time of ICU admission, the preventive benefit of selective decontamination is highly debatable. Emergence of multiple antibiotic-resistant microorganisms creates a clinical problem and a definite change in the ecology of environmental, colonizing, and infecting bacteria. The selection of multiple antibiotic-resistant Gram-positive cocci is particularly hazardous. No beneficial effect on survival is observed. Moreover, selective decontamination adds substantially to the cost of ICU care.

Oesophagopleural fistula--a rare sequel of pneumonectomy

Postpneumonectomy oesophagopleural fistula (OPF) is a devastating situation occurring in 0.2-1.0% of the patients undergoing pneumonectomy. Distinction is made between OPF appearing after pneumonectomy for chronic inflammation and suppuration, and OPF after pneumonectomy for lung cancer. Early and late fistulas (the former appearing within three months of the operation) are found in both groups. We report a case of OPF occurring almost five years after pneumonectomy for malignant lymphoma of the lung. Common signs of OPF are postpneumonectomy empyema and presence of previously ingested food particles in the empyema cavity. Treatment is extremely difficult and prolonged, and often not successful. Amelioration of the nutritional status, drainage of the postpneumonectomy space and closure of the fistula by injecting a sclerosing substance should be attempted. If this fails, the fistula should be closed by direct suture reinforced by a muscular or omental flap.

Pituitary responsiveness to GH-releasing hormone, GH-releasing peptide-2 and thyrotrophin-releasing hormone in critical illness

OBJECTIVE

Protein hypercatabolism and preservation of fat depots are hallmarks of critical illness, which is associated with blunted pulsatile GH secretion and low circulating IGF-I, TSH, T4 and T3. Repetitive TRH administration is known to reactivate the pituitary-thyroid axis and to evoke paradoxical GH release in critical illness. We further explored the hypothalamic-pituitary function in critical illness by examining the effects of GH-releasing hormone (GHRH) and/or GH-releasing peptide-2 (GHRP-2) and TRH administration.

PATIENTS AND DESIGN

Critically ill adults (n = 40; mean age 55 years) received two i.v. boluses with a 6-hour interval (0900 and 1500 h) within a cross-over design. Patients were randomized to receive consecutively placebo and GHRP-2 (n = 10), GHRH and GHRP-2 (n = 10), GHRP-2 and GHRH+GHRP-2 (n = 10), GHRH+GHRP-2 and GHRH+GHRP-2 + TRH (n = 10). The GHRH and GHRP-2 doses were 1 microgram/kg and the TRH dose was 200 micrograms. Blood samples were obtained before and 20, 40, 60 and 120 minutes after each injection.

MEASUREMENTS

Serum concentrations of GH, T4, T3, rT3, thyroid hormone binding globulin (TBG), IGF-I, insulin and cortisol were measured by RIA; PRL and TSH concentrations were determined by IRMA.

RESULTS

Critically ill patients presented a striking GH response to GHRP-2 (mean +/- SEM peak GH 51 +/- 9 micrograms/l in older patients and 102 +/- 26 micrograms/l in younger patients; P = 0.005 vs placebo). The mean GH response to GHRP-2 was more than fourfold higher than to GHRH (P = 0.007). In turn, the mean GH response to GHRH+GHRP-2 was 2.5-fold higher than to GHRP-2 alone (P = 0.01), indicating synergism. Adding TRH to the GHRH+GHRP-2 combination slightly blunted this mean response by 18% (P = 0.01). GHRP-2 had no effect on serum TSH concentrations whereas both GHRH and GHRH+GHRP-2 evoked an increase in peak TSH levels of 53 and 32% respectively. The addition of TRH further increased this TSH response > ninefold (P = 0.005), elicited a 60% rise in serum T3 (P = 0.01) and an 18% increase in T4 (P = 0.005) levels, without altering rT3 or TBG levels. GHRH and/or GHRP-2 induced a small increase in serum PRL levels. The addition of TRH magnified the PRL response 2.4-fold (P = 0.007). GHRP-2 increased basal serum cortisol levels (531 +/- 29 nmol/l) by 35% (P = 0.02); GHRH provoked no additional response, but adding TRH further increased the cortisol response by 20% (P = 0.05).

CONCLUSIONS

The specific character of hypothalamic-pituitary function in critical illness is herewith extended to the responsiveness to GHRH and/or GHRP-2 and TRH. The observation of striking bursts of GH secretion elicited by GHRP-2 and particularly by GHRH+GHRP-2 in patients with low spontaneous GH peaks opens the possibility of therapeutic perspectives for GH secretagogues in critical care medicine.