Mediastinitis continues to be an important and life-threatening complication after median sternotomy despite advances in prevention and treatment strategies, with an incidence of 0.25-5%. It can also ...occur as extension of infection from adjacent structures such as the oesophagus, airways and lungs, or as descending necrotizing infection from the head and neck. In addition, there is a chronic form of 'chronic fibrosing mediastinitis' usually caused by granulomatous infections. In this expert consensus, the evidence for strategies for treatment and prevention of mediatinitis is reviewed in detail aiming at reducing the incidence and optimizing the management of this serious condition.
Thoracic trauma is the third most common cause of death after abdominal injury and head trauma in polytrauma patients. The purpose of this study was to investigate epidemiological data, treatment and ...outcome of polytrauma patients with blunt chest trauma in order to help improve management, prevent complications and decrease polytrauma patients' mortality.
In this retrospective study we included all polytrauma patients with blunt chest trauma admitted to our tertiary care center emergency department for a 2-year period, from June 2012 until May 2014. Data collection included details of treatment and outcome. Patients with chest trauma and Injury Severity Score (ISS) ≥18 and Abbreviated Injury Scale (AIS) >2 in more than one body region were included.
A total of 110 polytrauma patients with blunt chest injury were evaluated. 82 of them were males and median age was 48.5 years. Car accidents, falls from a height and motorbike accidents were the most common causes (>75%) for blunt chest trauma. Rib fractures, pneumothorax and pulmonary contusion were the most common chest injuries. Most patients (64.5%) sustained a serious chest injury (AIS
3), 19.1% a severe chest injury (AIS
4) and 15.5% a moderate chest injury (AIS
2). 90% of patients with blunt chest trauma were treated conservatively. Chest tube insertion was indicated in 54.5% of patients. The need for chest tube was significantly higher among the AIS
4 group in comparison to the AIS groups 3 and 2 (p < 0.001). Also, admission to the ICU was directly related to the severity of the AIS
(p < 0.001). The severity of chest trauma did not correlate with ICU length of stay, intubation days, complications or mortality.
Although 84.5% of patients suffered from serious or even severe chest injury, neither in the conservative nor in the surgically treated group a significant impact of injury severity on ICU stay, intubation days, complications or mortality was observed. AIS
was only related to the rate of chest tube insertions and ICU admission. Management with early chest tube insertion when necessary, pain control and chest physiotherapy resulted in good outcome in the majority of patients.
Cloud microphysics is one of the major sources of uncertainty in numerical weather prediction models. In this work, the ability of a numerical weather prediction model to correctly predict ...high-impact weather events,
i.e., hail and heavy rain, using different cloud microphysics schemes is evaluated statistically. Polarimetric C-band radar observations over 30 convection days are used as the observation dataset. Simulations are made using the regional-scale Weather Research and Forecasting (WRF) model with five microphysics schemes of varying complexity (double moment, spectral bin (SBM), and Predicted Particle Properties (P3)). Statistical characteristics of heavy-rain and hail events of varying intensities are compared between simulations and observations. All simulations, regardless of the microphysics scheme, predict heavy-rain events (15, 25, and 40 mm h−1) that cover larger average areas than those observed by radar. The frequency of these heavy-rain events is similar to radar-measured heavy-rain events but still scatters by a factor of 2 around the observations, depending on the microphysics scheme.
The model is generally unable to simulate extreme hail events with reflectivity thresholds of 55 dBZ and higher, although they have been observed by radar during the evaluation period. For slightly weaker hail/graupel events, only the P3 scheme is able to reproduce the observed statistics. Analysis of the raindrop size distribution in combination with the model mixing ratio shows that the P3, Thompson two-moment (2-mom), and Thompson aerosol-aware schemes produce large raindrops too frequently, and the SBM scheme misses large rain and graupel particles. More complex schemes do not necessarily lead to better results in the prediction of heavy precipitation.
The thymus plays a crucial role in the development of immune system, regulating the maturation, selection and migration of T lymphocytes. Alterations in lymphatic content and structure of the thymus ...are observed in many autoimmune diseases. Moreover, changes of the epithelial component may cause the development of thymic tumours. Thymoma is a rare epithelial tumor of the anterior mediastinal compartment with a wide spectrum of clinical presentations. The causes of thymoma are still unknown and several hypotheses have been formulated. Thymomas show a variable course causing, frequently, a prolonged clinical history. The presence of metastasis at the time of diagnosis is very uncommon. Even if about 30% of the patients with thymoma are asymptomatic, they may have local symptoms (such as cough, pain, hoarseness, and dyspnea) or paraneoplastic disorders. The role of immune system in the pathogenesis of these tumors and related paraneoplastic syndromes is not completely clear. A clinical diagnosis, especially if the first manifestation is a thymoma-associated paraneoplastic disease, is not always easy and should be supported by an appropriate imaging in order to guide the proper management for each patient. In this article, we would like to give an overview of the local and systemic clinical manifestations, which can be found in patients affected by thymoma.
Abstract
OBJECTIVES
Smoke generated from electrocautery dissection contains irritating and/or carcinogenic components. The aim of this study was to investigate the effectiveness of a mobile smoke ...evacuation system (SES) in protecting surgical personnel from these hazardous fumes.
METHODS
Standardized cuts with an electrocautery device were performed on fresh porcine tissue, and the generated surgical fume was analysed with and without the additional use of a mobile SES using a real-time proton-transfer-reaction time-of-flight mass spectrometer. Furthermore, 2 different surgical masks were tested to investigate their filter capacity.
RESULTS
Several toxic and/or carcinogenic volatile organic compounds including 1,3-butadiene, benzene and furfural were found in concentrations clearly above the limits that were set by the National Institute of Occupational Safety and Health: 1,3-butadiene at 19.06 ± 1.54 ppm (limit: 5 ppm), benzene at 6.21 ± 1.33 ppm (limit: 0.5 ppm) and furfural at 14.34 ± 2.97 ppm (limit: 2 ppm). Although the mobile SES was able to reduce these substances to a certain degree, butadiene and benzene still remained above the permissible exposure limits with concentrations of 14.21 ± 0.07 and 1.16 ± 0.05, respectively. Both surgical masks were unable to reduce the ‘inhaled’ concentrations of volatile organic compounds.
CONCLUSIONS
Although the SES reduced the concentrations of most of the detected volatile organic compounds to a certain amount, especially the carcinogenic substances, butadiene and benzene remained high above exposure limits. According to the abovementioned significant data, further investigation on this topic is imperative, especially when considering that surgical masks were absolutely ineffective in protecting individuals from the toxic smoke and that the cautery was only used for 10 s in this experiment.
Malignant pleural mesothelioma (MPM) is an aggressive cancer with dismal prognosis, largely due to poor response rates to and rapid relapse after first-line pemetrexed (MTA)/cisplatin chemotherapy. A ...better understanding of the molecular mechanisms underlying chemotherapy sensitivity and duration represents a significant but still unmet clinical need. In this study, we reported on a kinome CRISPR/Cas9 knockout screen that identified several G
-M checkpoint kinases, including WEE1, whose loss of function sensitizes MPM cells to standard chemotherapy. We further showed that deregulation of the G
-M checkpoint contributes to chemotherapy resistance, and that WEE1 inhibition synergizes with cisplatin/MTA, leading to enhanced MPM cell death
and potent antitumor effects
Mechanistically, WEE1 blockage overrides chemotherapy-induced G
-M cell-cycle arrest and promotes premature mitotic entry, which causes DNA damage accumulation and ultimately apoptosis. Our results suggest a new therapeutic combination for MPM, and support the application of CRISPR/Cas9-based functional genomics in identifying novel therapeutic targets to potentiate existing cancer therapies.
Abstract
OBJECTIVES
Blunt chest trauma after mechanical resuscitation manoeuvres appears to have a significant impact on the often complicated course. Due to a lack of data in the literature, the ...purpose of this study was to investigate the feasibility and immediate outcome of chest wall stabilization for flail chest in this vulnerable patient population.
METHODS
We retrospectively reviewed the medical records of patients after cardiopulmonary resuscitation between January 2014 and December 2018 who were diagnosed with flail chest. We attempted to compare patients after surgery with those after conservative treatment.
RESULTS
Of a total of 56 patients with blunt chest trauma after mechanical resuscitation and after coronary angiography, 25 were diagnosed with flail chest. After the exclusion of 2 patients because of an initial decision to palliate, 13 patients after surgical stabilization could be compared with 10 patients after conservative therapy. Although there was no significant difference in the total duration of ventilatory support, there was a significant advantage when the time after stabilization to extubation was compared with the duration of ventilation in the conservative group. The presence of pulmonary contusion, poor Glasgow Coma Scale score or the development of pneumonia negatively affected the outcome, but additional sternal fracture did not.
CONCLUSIONS
Surgical stabilization for chest wall instability is well tolerated even by this vulnerable patient population. Our results should be used for further randomized controlled approaches. It is necessary to evaluate the situation with all parameters in an interdisciplinary manner and to decide on a possible surgical therapy at an early stage if possible.
Rib fractures are common and are diagnosed in up to 39% of patients with blunt chest trauma 1, 2.
Abstract
OBJECTIVES: Traumatic flail chest is a potentially life threatening injury, often associated with prolonged invasive mechanical ventilation and intensive care unit stay. This study evaluates ...the usefulness and cost-effectiveness of surgical rib stabilization in patients with flail chest resulting in ventilator dependent respiratory insufficiency.
METHODS: A retrospective study on a consecutive series of patients with flail chest with the need for mechanical ventilation was performed. Effectiveness of rib fixation was evaluated in terms of predictors for prolonged ventilation, cost-effectiveness and outcome.
RESULTS: A total of 61 patients underwent flail chest stabilization using a locked titanium plate fixation system between July 2010 and December 2015 at our institution. 62% (n = 38) of patients could be weaned from the ventilator within the first 72 h after surgery. Multiple linear regression analysis revealed that closed head injury, bilateral flail chest, number of stabilized ribs and severity of lung contusion were the main independent predictors for prolonged mechanical ventilation (Odds ratio (OR) 6.88; 3.25; 1.52 and 1.42) and tracheostomy (OR 9.17; 2.2; 1.76 and 0.84), respectively. Furthermore cost analysis showed that already a two day reduction in ICU stay could outweigh the cost of surgical rib fixation.
CONCLUSIONS: Operative rib fixation has the potential to reduce ventilator days and ICU stay and subsequently hospital costs in selected patients with severe traumatic flail chest requiring mechanical ventilation. Especially associated closed head injury can adversely affect mechanical ventilation time. Furthermore the subgroups of patients sustaining a fall from a height and those with flail chest after cardiopulmonary re-animation seem to profit only marginally from surgical rib fixation.
Objective
First rib resection is a well-recognized treatment option for thoracic outlet syndrome (TOS). In case of a vascular insufficiency that can be provoked and/or progressive neurologic symptoms ...without response to conservative treatment, surgical decompression of the space between the clavicle and the first rib is indicated. The aim of this paper is to present our experience with a new minimally invasive robotic approach using the da Vinci Surgical System®.
Methods
Between January 2015 and October 2017, eight consecutive first rib resections in seven patients were performed at our institution. Four patients presented with neurologic (one bilateral), and three patients with vascular (venous) impairment. In all cases, a transthoracic robotic-assisted approach was used. The first rib was removed using a 3-port robotic approach with an additional 2-cm axillary incision in the first six patients. The latest resection was performed through only three thoracic ports.
Results
Median operative time was 108 min, and the median hospital stay was 2 days. Postoperative courses were uneventful in all patients. Clinical follow-up examinations showed relief of symptoms in all nonspecific TOS patients, and duplex ultrasonography confirmed complete vein patency in the remaining patients 3 months after surgery.
Conclusions
While there are limitations in conventional transaxillary, subclavicular and supraclavicular approaches in the first rib resection, the robotic method is not only less invasive but also allows better exposure and visualization of the first rib. Furthermore, the technique takes advantage of the benefits of the da Vinci Surgical System® in terms of 3D visualization and improved instrument maneuverability. Our early experience clearly demonstrates these advantages, which are also supported by the very good outcomes.
PDF
