Lael Anson Best

Enhanced Presurgical Pain Temporal Summation Response Predicts Post-Thoracotomy Pain Intensity During the Acute Postoperative Phase

UNLABELLED Recent evidence points to an association between experimental pain measures obtained preoperatively and acute postoperative pain (POP). We hypothesized that pain temporal summation (TS) might be an additional predictor for POP insofar as it represents the neuroplastic changes that occur in the central nervous system following surgery. Therefore, a wide range of psychophysical tests (TS to heat and mechanical repetitive stimuli, pain threshold, and suprathreshold pain estimation) and personality tests (pain catastrophizing and anxiety levels) were administered prior to thoracotomy in 84 patients. POP ratings were evaluated on the 2nd and 5th days after surgery at rest (spontaneous pain) and in response to activity (provoked pain). Linear regression models revealed that among all assessed variables, enhanced TS and higher pain scores for mechanical stimulation were significantly associated with greater provoked POP intensity (overall r2 = 0.225, P = .008). Patients who did not demonstrate TS to both modalities reported lower scores of provoked POP as compared with patients who demonstrated TS in response to at least 1 modality (F = 4.59 P = .013). Despite the moderate association between pain catastrophizing and rest POP, none of the variables predicted the spontaneous POP intensity. These findings suggest that individual susceptibility toward a greater summation response may characterize patients who are potentially vulnerable to augmented POP. PERSPECTIVE This study proposed the role of pain temporal summation assessed preoperatively as a significant psychophysical predictor for acute postoperative pain intensity. The individual profile of enhanced pain summation is associated with the greater likelihood of higher postoperative pain scores.

A nanomaterial-based breath test for short-term follow-up after lung tumor resection

UNLABELLED In this case study, we demonstrate the feasibility of nanomaterial-based sensors for identifying the breath-print of early-stage lung cancer (LC) and for short-term follow-up after LC-resection. Breath samples were collected from a small patient cohort prior to and after lung resection. Gas-chromatography/mass-spectrometry showed that five volatile organic compounds were significantly reduced after LC surgery. A nanomaterial-based sensor-array distinguished between pre-surgery and post-surgery LC states, as well as between pre-surgery LC and benign states. In contrast, the same sensor-array could neither distinguish between pre-surgery and post-surgery benign states, nor between LC and benign states after surgery. This indicates that the observed pattern is associated with the presence of malignant lung tumors. The proof-of-concept presented here has initiated a large-scale clinical study for post-surgery follow-up of LC patients. FROM THE CLINICAL EDITOR Monitoring for tumor recurrence remains very challenging due to post-surgical and radiation therapy induced changes in target organs, which often renders standard radiological identification of recurrent malignancies inaccurate. In this paper a novel nanotechnology-based sensor array is used for identification of volatile organic compounds in exhaled air that enable identification of benign vs. malignant states.

Heparanase is overexpressed in lung cancer and correlates inversely with patient survival.

Heparanase is an endo‐β‐D‐glucuronidase that is capable of cleaving heparan sulfate (HS) side chains at a limited number of sites, yielding HS fragments of still appreciable size (approximately 5‐7 kDa). Heparanase activity has been detected frequently in several cell types and tissues. Heparanase activity correlates with the metastatic potential of tumor‐derived cells, a correlation that has been attributed to enhanced cell dissemination as a consequence of HS cleavage and remodeling of the extracellular matrix barrier.

Contralateral Internal Mammary Silicone Lymphadenopathy Imitates Breast Cancer Metastasis

This case report presents a unique, late complication of breast reconstruction surgery. A woman, who underwent left mastectomy and several reconstruction procedures with silicone implants presented with symptomatic enlarged internal mammary lymph nodes on her contralateral side. The nodes, which were suspicious for breast cancer metastasis on positron-emission tomographic computed tomography, were removed by thoracoscopy. The histopathologic result revealed silicone adenopathy. This report is particularly interesting because it presents a rare case in which silicone has migrated to the contralateral internal mammary nodes. This complication was not previously documented in the medical literature and serves as a possible differential diagnosis to metastatic breast cancer.

Comparison of VivaSight double-lumen tube with a conventional double-lumen tube in adult patients undergoing video-assisted thoracoscopic surgery

The efficiency of a double‐lumen tube depends on its position in the airways, which can be verified by fibreoptic bronchoscopy. The VivaSight DL is a single‐use double‐lumen tube with a camera embedded in the tubes right side. The view from the camera appears continuously on a monitor. In this prospective study of 71 adult patients, we compared intubation times using either the VivaSight DL or a conventional double‐lumen tube. Median (IQR [range]) duration of intubation with visual confirmation of tube position was significantly reduced using the VivaSight DL compared with the conventional double‐lumen tube (51 (42–60 [35–118]) s vs 264 (233–325 [160–490]) s, respectively, p < 0.0001). None of the patients allocated to the VivaSight DL required fibreoptic bronchoscopy during intubation or surgery. The VivaSight DL enables significantly more rapid intubation compared with the conventional double‐lumen tube.

Aberrant right subclavian artery- suggested mechanism for esophageal foreign body impaction: Case report

Aberrant right subclavian artery (ARSA) is asymptomatic in most cases. This variant anatomy can cause dysphagia in elderly patients. Impaction of foreign body in the esophagus is rarely the presenting symptom of ARSA. We present an eighty four years old patient who first presented with esophageal foreign body impaction and was diagnosed with an aberrant right subclavian artery compressing the esophagus just below the site of impaction.We assume that the exact place of impaction was not incidental and that a relative narrowing of the esophagus caused by the vascular anomaly is responsible for this specific presentation.

Never say no to a damaged muscle: the applications of previously damaged pectoralis major and latissimus dorsi muscles for chest wall reconstruction.

The nondamaged latissimus dorsi and pectoralis major muscles are widely reported in the literature as being the most frequently used for chest wall reconstruction. In this study, we report a series of 9 patients with full-thickness chest wall defects who underwent reconstruction with previously damaged latissimus dorsi or pectoralis major muscles. Nine patients underwent chest wall reconstruction over a period of 3 years using previously damaged latissimus dorsi or pectoralis major muscles. The thoracic defect was posttraumatic in 3 patients and post-tumor resection in 6 patients. Three patients had previous radiation therapy. In 8 cases, the full-thickness chest wall defects were completely closed. The only failure encountered was in one patient who had a long lasting fistula. The proximal based island flap that was inserted into the tract showed good vascular supply and viability; however, it did not solve the clinical problem. Keeping in mind the basic rule of medicine (“Primum Non Nocere”) and a thorough knowledge of the surgical anatomy of these muscles are essential for the successful application of these previously damaged muscles for chest wall reconstruction.

Involvement of Heparanase in Empyema: Implication for Novel Therapeutic Approaches.

Pleural empyema is an inflammatory condition that progresses from acute to chronic, life-threatening, phase. The incidence of empyema has been increasing both in children and adults worldwide in the past decades, mainly in healthy young adults and in older patients. Despite continued advances in the management of this condition, morbidity and mortality have essentially remained static over the past decade. Better understanding of the disease and the development of new therapeutic approaches are thus critically needed. Heparanase is an endoglucuronidase that cleaves heparan sulfate chains of proteoglycans. These macromolecules are most abounded in the sub-endothelial and sub-epithelial basement membranes and their cleavage by heparanase leads to disassembly of the extracellular matrix that becomes more susceptible to extravasation and dissemination of metastatic and immune cells. Here, we provide evidence that heparanase expression and activity are markedly increased in empyema and pleural fluids, associating with disease progression. Similarly, heparanase expression is increased in a mouse model of empyema initiated by intranasal inoculation of S. pneumonia. Applying this model we show that transgenic mice over expressing heparanase are more resistant to the infection and survive longer.

The Role of Pain Catastrophizing in the Prediction of Acute and Chronic Postoperative Pain

Background and Objectives: Despite the established association between greater pain catastrophizing and enhanced postoperative pain, it is still unclear: (i) what is the relative contribution of each of the pain catastrophizing scale (PCS) dimensions in the prediction of acute and chronic postoperative pain; and (ii) whether PCS scores mediate the association between acute and chronic postoperative pain intensity. Methods: The current prospective, observational study was conducted at Rambam Health Care Campus, Haifa, Israel. PCS was obtained in 48 pain-free patients a day before an elective thoracotomy in response to tonic heat pain. Acute postthoracotomy pain (APTP) was assessed during rest, including general pain (Rest general ), and incision-related pain (Rest incision ), and in response to provoked physical activity, including hand elevation (Provoked hand ) and cough (Provoked- cough ). Chronic postthoracotomy pain (CPTP) was assessed after 4.5±2.3 months. Results: Of the PCS subscales, only rumination: (i) was correlated with Rest general scores (r=0.337, P=0.027); and (ii) predicted chronic postthoracotomy pain in a regression analysis (P=0.001). General PCS and its subscales mediated the correlation between Rest general and chronic postthoracotomy pain intensity (Ps<0.006). Conclusions: Findings may elucidate the unique role of the rumination subscale in reflecting an individuals postoperative acute and chronic pain responsiveness. The transition from acute to chronic postoperative pain seems to be facilitated by enhanced pain catastrophizing.

C-Reactive Protein Predicts Pleurodesis Success in Malignant Pleural Effusion Patients

Dear Editor: Malignant pleural effusions (MPEs) often cause debilitating symptoms that result in impaired quality of life. The limited clinical success of pleurodesis necessitates MPE management advancement. The clinical predictive value of objective markers, such as pH and adenosine deaminase, is still debated. The goal of the current study was to explore an objective indicator attesting to whether or not an MPE patient would benefit from talc pleurodesis. We hypothesized that C-reactive protein (CRP) levels in the intrapleural fluid would predict the clinical improvement in the patient’s condition after talc installation objectively, as reflected by chest x-ray (CXR), and subjectively, via reports of respiratory symptoms, both evaluated one month posttreatment. The underlying rationale was that CRP levels represent an existing inflammation, and therefore the attempt to further induce a local inflammatory reaction via the installation of a chemical agent in the pleural space would be clinically constructive. The current prospective study included 63 consecutive patients with symptomatic MPE, 35 of whom were included in the final analyses. Four grams of talc mixed in 150 ml of saline were administered after complete drainage of the pleural effusion. Based on posttreatment CXR evaluations, pleurodesis was successful in 19 patients (54.29%). Based on subjective reports, pleurodesis was successful in 17 patients (48.58%). The subjective success criterion was in excellent agreement with the objective success criterion (j = 0.942). Of age, gender, CRP, pH, total protein, and lactate dehydrogenase, logistic regression analyses indicated that CRP was the sole predictor for the success of the pleurodesis procedure assessed objectively by CXR (P = 0.018), while CRP and age were the sole predictors for pleurodesis success assessed subjectively (P = 0.042). CRP levels in the patients who underwent a successful pleurodesis versus unsuccessful pleurodesis were different, based on posttreatment evaluations, both objective (CXR; P = 0.021) and subjective (individual reports; P = 0.039). MPE patients with CRP levels ‡ 30 mg/L will most probably undergo a successful pleurodesis procedure, as assessed both objectively by CXR and subjectively by individual reports (P < 0.0001). Due to the pleurodesis failure and high complication rates, it is reasonable to determine the patients in whom the pleurodesis procedure will succeed. Pleurodesis success rates among malignant pleural effusion patients may be as low as 47%. However, of the 10 malignant pleural effusion patients of the current study, who demonstrated CRP levels greater than the critical threshold of 30 mg/L, 9 patients (90%) were successfully treated by pleurodesis. Bielsa and colleagues reported that malignant effusions specifically due to lung cancer are particularly prone to a failed procedure. In the current study group, of the six lung cancer patients, five (83.3%) demonstrated a successful pleurodesis using the aforementioned CRP threshold value. In conclusion, pleural effusion CRP levels may reliably predict pleurodesis success and symptomatic failure among MPE patients. Therefore, it may be advantageous when selecting patients for pleurodesis to incorporate in the clinic routine tests of pleural fluid CRP levels.