Evaluation of Monaldi's approach with regard to needle decompression of the tension pneumothorax-A cadaver study

BACKGROUND

Although needle decompression of tension pneumothorax through the second intercostal space in the midclavicular line (Monaldi's approach) is a life-saving procedure, severe complications have been reported after its implementation. We evaluated the procedure by comparing how it was performed on cadavers by study participants with different training levels.

METHODS

Six participants including one thoracic surgeon performed bilateral thoracic drainage after Monaldi on 82 torsos. After the thoraces were opened, the distances from the internal thoracic artery (A), the site of the puncture (B) and the midclavicular line (C) were measured bilaterally with reference to the median of the sternum. Further, it was determined whether the participants had correctly identified the second intercostal space. The differences between B-A and C-B were analysed.

RESULTS

The needle was placed in the second intercostal space in 136 hemithoraces (83%). The thoracic surgeon showed a hit rate of 0% laceration of adjacent vessels. All the other participants had hit rates between 10% and 15%. The interval B-A ranged from 2.88 to 5.06cm in right and from 3.00 to 5.00cm in left hemithoraces. The distance C-B lay between 1.03cm and 1.87cm (right side), and 0.84cm and 2.02cm (left side).

CONCLUSION

In our collective, the main problem was failure to assess correctly the lateral extension of the clavicle. If this fact is emphasized during training, Monaldi's approach is a safe method for needle decompression of pneumothorax.

Sensory nerve supply of the distal radio-ulnar joint with regard to wrist denervation

The objective of this study was to determine the precise departure points of the articular branches innervating the distal radio-ulnar joint from the anterior and posterior interosseous nerves. The study sample consisted of 116 upper limbs from adult human cadavers. The articular branches were prepared under the dissection microscope to take measurements using the radial styloid process as point of reference. The articular branch departed from the anterior interosseous nerve at a mean distance of 2.9 cm proximal to the styloid for a radius length of 20.5 cm, and 3.7 cm for a radius length of 26.5 cm, respectively. For the posterior interosseous nerve, the departure point was at a mean distance of 3.1 cm (radius length of 20.5 cm) and at 4.0 cm (radius length of 26.5 cm). Apart from a single branch from the posterior interosseous nerve, all articular branches were located distal to the proximal border of the pronator quadratus. Results indicate that wrist denervation from the volar approach, if performed at the proximal border of the pronator quadratus, or from the dorsal approach at a distance of 4.8 cm (for a radius length of 20.5 cm) or 6.2 cm (for a radius length of 26.5 cm) proximal to the radial styloid process, will eliminate the nerve supply to the distal radio-ulnar joint in the majority of cases.

Minimally invasive approach to the radial nerve--A new technique

PURPOSE

To describe a minimally invasive approach to find the radial nerve (RN) simply and safely by tracing the posterior antebrachial cutaneous nerve (PACN) without damaging muscles, using only the surgeon's hand to define a window for the skin incision.

BACKGROUND

Although it is absolutely necessary to locate the radial nerve during osteosynthesis of the humerus, the literature lacks guidelines on how to do so.

METHODS

We have dissected the upper extremities of 54 adult human cadavers, embalmed using Thiel's method. After the PACN was identified in a defined space, its course was traced proximally by incising the lateral intermuscular septum (LIS) of the upper arm and thereby reaching the radial nerve (RN). Subsequently, using the lateral epicondyle (LE) of the humerus as a reference point, the distances to the points where the PACN perforated the LIS, and where the RN was identified, were measured. These individual data were related to the total length of the humerus.

RESULTS

The results indicate that with this approach and without harming musculature, the RN can be reached by tracing the PACN at a height of 11.1-13.0 cm (females) and 11.9-14.0 cm (males) starting from the LE.

CONCLUSION

Our examination shows the PACN to be a convenient guide to the RN.

Preoxygenation of different preservation solutions for porcine pancreas preservation

INTRODUCTION

Organ preservation quality impacts porcine islet cell isolation and transplantation success. Among several preservation methods, the two-layer method is promising, but technically demanding and fails to deliver sufficient oxygen. The use of hyperbaric oxygenation may be an easier, more effective method to supply high partial pressure of oxygen (pO(2)) for organ storage. Therefore, the aim of this study was to test the capability of preoxygenation of various preservation solutions with HBO to maintain high pO(2) levels.

METHODS

University of Wisconsin (UW), Custodiol, Perfadex, or Celsior solutions were preoxygenated in a pressure chamber. NaCl served as the control. pO(2) levels were measured at defined times. The oxygen storage capability was evaluated by leaving the storage bottles open for 2 minutes.

RESULTS

It was feasible to preoxygenate preservation solutions. The best solution to maintain high pO(2) tensions was Perfadex, followed by Celsior, and UW.

DISCUSSION

The greater the amount of oxygen in the preservation solution, the more oxygen can be delivered to the preserved pancreas. Further studies on the influence of preoxygenated preservation solutions on the porcine pancreas are warranted to improve organ quality, porcine islet cell isolation, and transplantation success.

Hyperbaric Oxygenation in the Treatment of Life-Threatening Isobutyl Nitrite-Induced Methemoglobinemia—A Case Report

Methemoglobinemia usually results from exposure to oxidizing substances such as nitrates or nitrites. Iron within hemoglobin is oxidized from the ferrous (Fe2+) state to the ferric (Fe3+) state, resulting in the inability to transport oxygen and carbon dioxide. Clinically, this condition causes functional cyanosis. As methemoglobin levels increase, patients show evidence of cellular hypoxia in all tissues. Death usually occurs when methemoglobin fractions approach 70% of total hemoglobin. We describe the case of a 35-year-old female patient with severe life-threatening isobutyl nitrite-induced methemoglobinemia of 75% of total hemoglobin. Toluidine-blue was administered as first-line antidotal therapy immediately, followed by hyperbaric oxygenation. The patient recovered uneventfully and could be discharged 3 days later.

Early enteral feeding compared with parenteral nutrition after oesophageal or oesophagogastric resection and reconstruction

After resective and reconstructive surgery in the gastrointestinal tract, oral feeding is traditionally avoided in order to minimize strain to the anastomoses and to reduce the inherent risks of the postoperatively impaired gastrointestinal motility. However, studies have given evidence that the small bowel recovers its ability to absorb nutrients almost immediately following surgery, even in the absence of peristalsis, and that early enteral feeding would preserve both the integrity of gut mucosa and its immunological function. The aim of this study was to investigate the impact of early enteral feeding on the postoperative course following oesophagectomy or oesophagogastrectomy, and reconstruction. Between May 1999 and November 2002, forty-four consecutive patients (thirty-eight males and six females; mean age 62, range 30–82) with oesophageal carcinoma (stages I–III), who had undergone radical resection and reconstruction, entered this study (early enteral feeding group; EEF). A historical group of forty-four patients (thirty-seven males and seven females; mean age 64, range 41–79; stages I–III) resected between January 1997 and March 1999 served as control (parenteral feeding group; PF). The duration of both postoperative stay in the Intensive Care Unit (ICU) and the total hospital stay, perioperative complications and the overall mortality were compared. Early enteral feeding was administered over the jejunal line of a Dobhoff tube. It started 6 h postoperatively at a rate of 10 ml/h for 6 h with stepwise increase until total enteral nutrition was achieved on day 6. In the controls oral enteral feeding was begun on day 7. If compared to the PF group, EEF patients recovered faster considering the duration of both stay in the ICU and in the hospital. There was a significant difference in the interval until the first bowel movements. No difference in overall 30 d mortality was identified. A poor nutritional status was a significant prognostic factor for an increased mortality. Early enteral feeding significantly reduces the duration of ICU treatment and total hospital stay in patients who undergo oesophagectomy or oesophagogastrectomy for oesophageal carcinoma. The mortality rate is not affected.

Hydroxymethylfurfural: an enemy or a friendly xenobiotic? A bioanalytical approach

Hydroxymethylfurfural (HMF), a well-known heterocyclic Maillard reaction product, has often been studied for its potential toxic, mutagenic, and carcinogenic effects. Recent clinical studies, however, have strongly suggested that HMF might have exciting antitumor potential. We report on the development and validation of a bioanalytical assay for HMF that could be suitable as a basis for pharmacokinetic models in cancer patients. Two strategies were tested, i.e., direct and indirect methodologies. A direct isocratic LC determination at 283 nm was designed. Two indirect attempts involved derivatization coupled to HPLC-UV. It was possible to resolve the stereoisomers of the HMF derivative, and factors influencing their equilibrium ratio are discussed. HMF was extracted from the biomatrix by solid-phase extraction using different cartridges. A comparative study was made of the implemented methods as well as the extraction protocols. Both indirect assays proved to be more sensitive and were used to assess HMF quantitatively in human plasma. However, the newly introduced derivatization conditions led to the highest sensitivity with a LOD (S/N ratio = 3) of at least 2 pmol analyte on column. The assay selectivity was satisfactory in pre- and post-dose real samples. The mean recoveries of the assays were 79% and 89%, with acceptable accuracies and reproducibilities. Figure Schematic representation of hydroxymethylfurfural (HMF) in human plasma.

Development and validation of a liquid chromatographic method for the determination of hydroxymethylfurfural and alpha-ketoglutaric acid in human plasma

Hydroxymethylfurfural (HMF) and alpha-ketoglutaric acid (KG) have been recently investigated as potential cancer cell damaging agents. We herein report for the first time a validated quantitative assay for their simultaneous determination in human plasma which is amenable to be applied in the future screening of the target compounds in human probands in order to properly design a targeted chemotherapeutic regimen for certain types of malignant tumors. A simple liquid chromatographic method in conjunction to derivatization after a two-step optimized solid phase clean-up procedure is described. The method is based on the reaction of HMF and KG with 2-nitrophenylhydrazine or 2,4-dinitrophenylhydrazine in an aqueous environment. Reaction conditions were studied with respect to pH, reagent volume, reaction temperature and time. Exact testing of such parameters beside careful selection of the mobile phase composition rendered feasible the quantification of the chemically significantly differing analytes along a single chromatographic run. The formed derivatives could be separated isocratically by reversed-phase LC on a C(8)-column. Detection in the UV and in the visible range is possible. Results showed good recovery and reproducibility with detection limits (S/N=3) down to 2 picomoles analyte on column. Resolution of the syn and anti geometric isomers of the HMF and KG derivatives is possible. The isomeric ratio in relation to the reaction pH is discussed.

Hyperbaric Oxygen in Tinnitus: Influence of Psychological Factors on Treatment Results?

INTRODUCTION

The standard treatment of subjective tinnitus hardly reaches the level of placebo controls. Though the effectiveness of hyperbaric oxygenation (HBO) for subjective tinnitus has never been objectified, it is still advocated by some institutions. We analyzed the effectiveness of hyperbaric oxygen treatment in the context of accompanying factors.

PATIENTS AND METHODS

We randomized 360 patients suffering from tinnitus into 2 HBO treatment protocols (group A: 2.2 bar for 60 min bottom time and group B: 2.5 bar for 60 min bottom time once a day for 15 days). All patients were asked to fill in a questionnaire (social and medical history, tinnitus characteristics, pre-HBO duration of tinnitus, prior therapy, pretreatment expectation, accompanying symptoms). A subjective assessment of the therapeutic effect was obtained.

RESULTS

Twelve patients (3.3%) experienced complete remission of tinnitus, in 122 (33.9) the intensity lessened, and 44 (12.2%) had a subjectively agreeable change of noise characteristics. No change was found in 157 cases (43.6%) and 25 (6.9%) experienced deterioration. There was no statistically significant difference between groups A and B (p > 0.05). Out of 68 patients with a positive expectation of HBO effects, 60.3% stated that the tinnitus had improved whereas only 47.2 and 19%, respectively, out of patients who underwent therapy with an indifferent (n = 271) or negative expectation (n = 21) reported an improvement. The influence of subjective expectation on the outcome was statistically significant (p < 0.05).

CONCLUSION

The therapeutic effects of HBO on subjective tinnitus may be substantially influenced by psychological mechanisms.

Hyperbaric oxygen (HBO2) in tinnitus: influence of psychological factors on treatment results?

HBO2 for subjective tinnitus has never been objectified, yet it is still advocated by many institutions. We analyzed the therapeutic effect of HBO2 treatment in the context of accompanying factors, especially focusing on the patients' attitude towards HBO2 prior to therapy.

METHODS

360 patients suffering from tinnitus were investigated in this study. They were randomized into 2 hyperbaric treatment protocols, one at 2.2, the other at 2.5 bar, 60 min bottom time each. All patients were asked to fill in a questionnaire (social and medical history, tinnitus characteristics, pre-HBO2 duration oftinnitus, prior therapy, pre-treatment expectation, accompanying symptoms) immediately before and one month after HBO2 treatment. The subjective impact of tinnitus on daily life was assessed using a score from 1 to 10 prior to HBO2 and one month after the treatment.

RESULTS

12 patients (3.3%) experienced complete remission of tinnitus, in 122 (33.9%) the intensity lessened, and 44 (12.2%) had a subjectively agreeable change of noise characteristics. 157 (43.6%) stated no change and 25 (6.9%) experienced deterioration. There was no statistically significant difference between the two hyperbaric protocols (p > 0.05). Out of 68 patients with positive expectation towards HBO2 therapy 60.3% stated that the tinnitus had improved whereas out of the patients who underwent therapy with indifferent (N = 271) or negative expectations (N = 21) only 47.2% and 19%, respectively, reported an improvement. The influence of both positive and negative anticipation on the outcome was statistically significant (p < 0.05).

CONCLUSION

The therapeutic effects of HBO2 on subjective tinnitus might be greatly due to psychological mechanisms triggered by the attitude of the patient towards HBO2 therapy prior to the treatment.

Invasion of blood vessels as significant prognostic factor in radically resected T1-3N0M0 non-small-cell lung cancer

OBJECTIVES

Radical resection is the therapy of choice in non-small-cell lung cancer (NSCLC). However, even in early stages (T1N0, T2N0) up to 35% of patients will experience recurrence. The aim of this retrospective study was to evaluate the prognostic influence of lymph vessel or blood vessel invasion in N0 patients.

METHODS

A total of 72 patients (male, 49; female, 23; median age 59; range 40-72) with NSCLC entered the study. The stages were T1-3N0 (T1, 25; T2, 41; T3, 6). Thirteen pneumonectomies and 59 lobectomies or bilobectomies with systematic lymphadenectomy and R0 resection were performed. Histologically, 24 adenocarcinomas, 31 squamous cell carcinomas and 14 subtypes of large cell carcinoma were found. In 22 cases microscopic invasion of the lymphatic vessels and in 11 invasions of blood vessels were found. Six patients showed invasion of either structure.

RESULTS

The patients were followed up for at least 5 years or until death. During the follow-up period 27 patients died (21 because of recurrence and 6 because of diagnosis not related to NSCLC). The 5 years overall survival amounted to 62.5%. In cases with invasion of the blood vessels the survival rate was 23.5%, in cases without invasion 74.5% (P< or = 0.01), whereas lymph vessel invasion had no significant impact on survival. Multivariate analysis covering T stages, histological subtypes, location of the tumor, grading, age, sex, and invasion of the lymphatic or the blood vessels showed invasion of the blood vessels as the only factor with significant prognostic impact in the study population.

CONCLUSIONS

In resectable N0 patients with NSCLC the microscopic invasion of blood vessels should be considered as an additional prognostic parameter.

Vacuum assisted closure system in the management of cervical anastomotic leakage after gastric pull-up

We propose the use of the vacuum assisted closure (VAC) system for the management of cervical anastomotic leakage after esophagectomy and reconstruction by gastric pull-up. The VAC system converts the open cervical wound into a controlled closed wound with major advantages: No need of a nasogastric tube for decompression, no need of a nasoenteric tube for feeding because of the possibility to maintain a semisolid oral diet and no need of frequent daily changes of dressings.

Comparison of 5-aminolaevulinic acid and porphyrin photosensitization for photodynamic therapy of malignant bronchial stenosis: a clinical pilot study

BACKGROUND AND OBJECTIVES

Photosan, a mixture of porphyrin oligomers as sensitizer for photodynamic therapy (PDT), carry the risk of prolonged photosensitivity of the skin. New sensitizer such as 5-aminolaevulinic acid (ALA) with low rates of skin phototoxicity appear to be promising alternatives. The aim of this study was to evaluate the efficacy of ALA compared to Photosan for PDT in malignant tracheo-bronchial stenosis. Reduction of tumor stenosis, increase in quality of life, and phototoxicity were considered as primary objectives. Improvement in clinical symptoms due to reduction of tumor stenosis, for example hemotysis, dyspnea, and poststenotic pneumonia were considered as secondary objectives.

PATIENTS AND METHODS

After diagnostic work-up, photosensitization was done in 16 patients with ALA (60 mg/kg BW, oral, 6-8 hours prior to PDT) and in 24 patients with Photosan (2 mg/kg BW, i.v., 48 hours before PDT). The light dose was calculated as 100 J/cm(2) tumor length. Light at 630 nm was applied using a pumped dye laser. In both groups, additional hyperbaric oxygenation was applied at a level of 2 absolute atmospheric pressure.

RESULTS

Stenosis diameter and Karnofsky performance status showed a significant improvement in favor of the Photosan-group, P = 0.00073 and 0.00015, respectively. In both groups no sunburn occurred due to phototoxicity of the sensitizer.

CONCLUSION

Despite the limitations of a non-randomized study, photosensitization with Photosan seems to be more effective in PDT of malignant tracheo-bronchial stenosis compared to ALA.

Does new photosensitizer improve photodynamic therapy in advanced esophageal carcinoma?

BACKGROUND AND OBJECTIVE

Polyhematoporphyrin (Photosan) as sensitizers for photodynamic therapy (PDT) in advanced esophageal cancer carry the risk of prolonged photosensitivity of the skin. New sensitizers such as 5-aminolaevulinic acid (ALA) with low rates of skin phototoxicity appear to be promising alternatives. The aim of this study was to evaluate the efficacy of ALA compared to Photosan for PDT in advanced esophageal carcinoma regarding phototoxicity of the skin, reduction of dysphagia, tumor stenosis, and tumor length and Karnovsky performance status.

STUDY DESIGN/MATERIALS AND METHODS

After diagnostic work-up, photosensitization was done in 22 patients with ALA (60 mg/kg body weight, oral, 6-8 hours prior to PDT) and in 27 patients with Photosan (2 mg/kg body weight, i.v., 48 hours before PDT). The light dose was calculated as 300 J/cm fibre tip. Light at 630 nm was applied using a pumped dye laser. In both groups, additional hyperbaric oxygenation was applied at a level of 2 absolute atmospheric pressure.

RESULTS

Improvement regarding dysphagia, stenosis diameter, and tumor length could be obtained in both treatment arms with a significant difference in favour of the Photosan-group, P = 0.02; P = 0.0000; and P = 0.000014, respectively. The Karnovsky performance status also improved in both groups and showed no significant difference (P = 0.12). The median survival time for the ALA-group was 8.0 months, compared with 9.0 months for the Photosan group. No sunburn or other major treatment related complication occurred in both treatment arms. Thirty-day mortality was 0%.

CONCLUSION

Despite the limitations of a non-randomized study, photosensitzation with Photosan seems to be more effective in PDT of advanced esophageal carcinoma compared to ALA.

Photosensitization with hematoporphyrin derivative compared to 5-aminolaevulinic acid for photodynamic therapy of esophageal carcinoma

BACKGROUND

Hematoporphyrin derivatives (HpD) as sensitizers for photodynamic therapy (PDT) in advanced esophageal cancer carry the risk of prolonged photosensitivity of the skin. New sensitizers such as 5-aminolaevulinic acid (ALA) with low rates of skin phototoxicity appear to be promising alternatives. The aim of this study was to evaluate the efficacy of ALA compared with HpD for PDT in advanced esophageal carcinoma regarding phototoxicity of the skin, reduction of dysphagia, tumor stenosis and length, and Karnovsky performance status.

METHODS

After diagnostic workup, photosensitization was done in 22 patients with ALA (60 mg/kg body weight, oral, 6 to 8 hours before PDT) and in 27 patients with a hematoporphyrin derivative (2 mg/kg body weight, intravenously, 48 hours before PDT). The light dose was calculated as 300 J/cm fiber tip. Light at 630 nm was applied using a pumped dye laser. In both groups, additional hyperbaric oxygenation was applied at a level of 2 absolute atmospheric pressure.

RESULTS

Improvement regarding dysphagia, stenosis diameter, and tumor length could be obtained in both treatment arms with a significant difference in favor of the HpD group (p = 0.02; p = 0.0000; and p = 0.000014, respectively). A questionnaire of patients in the HpD group confirmed that the ability of swallowing a meal was superior compared with the discomfort from limitation to sun exposure. No sunburn or other major treatment-related complication occurred in both treatment arms.

CONCLUSIONS

Despite the limitations of a nonrandomized study, photosensitzation with HpD seems to be more effective in PDT of advanced esophageal carcinoma compared with ALA.