Riad Naim Younes

When to remove a chest tube? ☆: A randomized study with subsequent prospective consecutive validation

BACKGROUND Operative procedures on the pleural space are usually managed by chest tube drainage. Timing for removing the tube is empirically established, with wide variation among surgeons. Our objective was to evaluate the effectiveness and safety of establishing a volume of 200 mL/d of uninfected drainage as a threshold for removal of chest tube, as compared with more frequently used volumes of 100 and 150 mL/d. STUDY DESIGN A prospective randomized study was performed in a single institution. Patients (n = 139) submitting to pleural drainage after surgical procedures were randomized to one of three groups, defined by the planned timing of chest tube removal (depending on the threshold volume per day of pleural fluid drained): G-100 (< or = 100 mL/d, n = 44); G-150 (< or =150 mL/d, n = 58); and G-200 (< or = 200 mL/d, n = 37). Subsequently, another 91 consecutive patients had chest tubes removed when drainage was less than 200 mL/d (G-val, prospective validation group). All patients had similar discharge and 60-day followup. Drainage time, hospital stay, and reaccumulation rate were registered. RESULTS Drainage time (median days: 3.5 for G-100, 3 for G-150, 3 for G-200, 3 for G-val) and hospital stay (median days: 4 for G-100, 3 for G-150, 3 for G-200, 3 for G-val) were not statistically different among groups. Radiologic reaccumulation rates were 9.1% for G-100, 13.1% for G-150, 5.4% for G-200, and 10.9% for G-val, and the thoracenteses rates were 2.3%, 0.8%, 2.7%, and 3.3%, respectively, with no major differences among groups (G-100 versus G-150 versus G-200; G-200 versus G-val). CONCLUSIONS Increasing the threshold of daily drainage to 200 mL before removing the chest tube did not markedly affect drainage, hospitalization time, or overall costs, nor did it increase the likelihood of major pleural fluid reaccumulation. This volume (200 mL/d) could be recommended for chest tube withdrawal decision for uninfected pleural fluid with no evidence of air leaks.

Evaluation of Gastric Greater Curvature Invagination for Weight Loss in Rats

Background: Many bariatric endocopic or surgical procedures performed today reduce gastric capacity and/or induce an early sensation of satiety, alone or in combination with a distal enteric intervention. A form of prosthetic gastric wrap was used in the past for treating obesity with a high rate of reintervention. Nissen gastric fundoplication used in the treatment of gastroesophageal reflux disease induces a small but significant weight loss. We report the effect of gastric greater curvature invagination on weight in rats. Methods: 30 rats were randomly divided into 3 groups. 10 rats in the first group (sham) were anesthesized and weighed. The rats from the second group (lap) were in addition submitted to a laparotomy plus visceral manipulation. In the third group (inv), invagination of the greater curvature of the stomach was added. All animals were weighed on the 7th and 21st days. They were then autopsied on the 21st day. Results: The mean body weight of the invagination group became statistically less than the laparotomy and sham groups at 7 and 21 days. The mean weight of the peritesticular fat pad from the inv group was also significantly less than from the sham group but not different from the lap group. Conclusion: Gastric greater curvature invagination significantly decreases weight in rats.

Pleurodesis in Patients with Malignant Pleural Effusions: Talc Slurry or Bleomycin? Results of a Prospective Randomized Trial

The purpose of this study was to evaluate the efficacy, safety, and cost of bedside pleurodesis for malignant pleural effusions using talc slurry (TS) or bleomycin (BL) in a prospective randomized trial, and to determine prognosticators for procedure failure. From June 1997 to June 1999 a series of 71 patients entered this trial. They underwent 37 procedures with TS (4 g) and 34 with BL (60 units) via tube thoracostomy. Success was defined as no recurrence of pleural effusion or asymptomatic recurrence of a small amount of effusion. Pleural effusion-free survival curves were used to analyze the success rates and the prognosticators of failure. Follow-up ranged from 3 days to 26 months (median 2.5 months). No difference in success rates was detected between TS or BL (log-rank test: p = 0.724). There were no major complications related to the procedure. The independent prognosticators of failed pleurodesis were the use of steroids (p = 0.004) and the volume of pleural fluid drained during the first thoracentesis when it was more than 900 ml (p = 0.029). The average cost of intervention per patient was significantly lower for TS (p < 0.001). There was no significant difference between the success rates for TS and BL as agents of bedside pleurodesis for malignant pleural effusions. Because of its significantly lower cost, TS should be considered the agent of choice. The use of steroids and the volume drained during the first thoracentesis (if more than 900 ml) were independent prognosticators of pleurodesis failure. The role of this latter finding as a marker of pleurodesis failure awaits more data.

High frequency of immature dendritic cells and altered in situ production of interleukin-4 and tumor necrosis factor-α in lung cancer

IntroductionAntigen-presenting cells, like dendritic cells (DCs) and macrophages, play a significant role in the induction of an immune response and an imbalance in the proportion of macrophages, immature and mature DCs within the tumor could affect significantly the immune response to cancer. DCs and macrophages can differentiate from monocytes, depending on the milieu, where cytokines, like interleukin (IL)-4 and granulocyte-macrophage colony-stimulating factor (GM-CSF) induce DC differentiation and tumor necrosis factor (TNF)-α induce DC maturation. Thus, the aim of this work was to analyze by immunohistochemistry the presence of DCs (S100+ or CD1a+), macrophages (CD68+), IL-4 and TNF-α within the microenvironment of primary lung carcinomas.ResultsHigher frequencies of both immature DCs and macrophages were detected in the tumor-affected lung, when compared to the non-affected lung. Also, TNF-α-positive cells were more frequent, while IL-4-positive cells were less frequent in neoplastic tissues. This decreased frequency of mature DCs within the tumor was further confirmed by the lower frequency of CD14-CD80+ cells in cell suspensions obtained from the same lung tissues analyzed by flow cytometry.ConclusionThese data are discussed and interpreted as the result of an environment that does not oppose monocyte differentiation into DCs, but that could impair DC maturation, thus affecting the induction of effective immune responses against the tumor.

Use of Pentastarch Solution in the Treatment of Patients with Hemorrhagic Hypovolemia: Randomized Phase II Study in the Emergency Room

Abstract. This study evaluates the hemodynamic effects of the administration of 10% pentastarch solution (PS) during the initial treatment of hypovolemia in trauma patients. This prospective randomized phase II study included trauma patients admitted to the emergency room with hemorrhagic hypovolemia: systolic blood pressure (SBP) < 90 mmHg. Upon admission, the patients were randomized to receive 10% PS (n= 12) or isotonic 0.9% NaCl solution (IS) (n= 11), infused intravenously in 250-ml boluses, repeated until SBP > 100 mmHg. Blood pressure, infused volumes necessary to maintain SBP, and overall survival rates were determined and compared between groups. SBP increased significantly following either IS (from 64.4 ± 9.2 mmHg to 111.1 ± 6.3 mmHg), or PS (from 63.7 ± 10.6 mmHg to 108.1 ± 9.8 mmHg) when compared to admission values (p < 0.05). Endovenous volumes infused were greater (p= 0.001) in IS patients (1420 ± 298 ml) than in PS patients (356 ± 64 ml). No blood was transfused into PS patients, compared to 370 ± 140 ml of red blood cells transfused into IS patients (p= 0.015). Mortality rates were similar in the two groups (p= 0.725). We concluded that PS is a safe, efficient method for inducing hemodynamic recovery of hypovolemic trauma patients, with a clear reduction in the intravenous volumes required for acute resuscitation.

Nuclear/cytoplasmic ratio correlates strongly with survival in non-disseminated neuroendocrine carcinoma of the lung

In order to verify whether quantitative morphological indices of neuroendocrine carcinoma of the lung may help to predict survival, 47 biopsies (from 37 males and 10 females; 16–82 years of age) were studied by light microscopy. Areal fractions of nuclei, cytoplasm, stroma, and blood vessels were determined using a standard point counting method. The counts were made in six non‐coincident microscopic fields in each case, and the areal fractions of nuclei, of the entire tumour cell, stroma, blood vessels and the nuclear/cytoplasmic ratio were computed. In a multivariate linear regression analysis, survival in months after biopsy was considered the dependent variable of age and of all morphometric parameters listed above. The significance level was set at 5%. For all patients (disregarding staging) survival was negatively correlated (P< 0.001, multiple r=0.5435) with age and nuclear/cytoplasmic ratio. When only patients with disease confined to the thorax (stages I. II and III) were taken into account, the accuracy of the Function predicting survival increased considerably (P=0.004, multiple r=0.7957). The use of simple stereological methods therefore, proved to be of value in predicting survival in patients with neuroendocrine carcinomas of the lung.

Evaluation of the effects of ozone therapy in the treatment of intra-abdominal infection in rats

INTRODUCTION The antibacterial effect of ozone (O3) has been described in the extant literature, but the role of O3 therapy in the treatment of certain types of infection remains controversial. OBJECTIVES To evaluate the effect of intraperitoneal (i.p.) O3 application in a cecal ligation/puncture rat model on interleukins (IL-6, IL-10) and cytokine-induced neutrophil chemoattractant (CINC)-1 serum levels, acute lung injury and survival rates. METHODS Four animal groups were used for the study: a) the SHAM group underwent laparotomy; b) the cecal ligation/puncture group underwent cecal ligation/puncture procedures; and c) the CLP+O2 and CLP+O3 groups underwent CLP+ corresponding gas mixture infusions (i.p.) throughout the observation period. IL-6, CINC-1 and IL-10 concentrations were determined by enzyme-linked immunosorbent assay (ELISA). Acute lung injury was evaluated with the Evans blue dye lung leakage method and by lung histology. P<0.05 was considered significant. RESULTS CINC-1 was at the lowest level in the SHAM group and was lower for the CLP+O3 group vs. the CLP+O2 group and the cecal ligation/puncture group. IL-10 was lower for the SHAM group vs. the other three groups, which were similar compared to each other. IL-6 was lower for the SHAM group vs. all other groups, was lower for the CLP+O3 or CLP+O2 group vs. the cecal ligation/puncture group, and was similar for the CLP+O3 group vs. the CLP+O2 group. The lung histology score was lower for the SHAM group vs. the other groups. The Evans blue dye result was lower for the CLP+O3 group vs. the CLP+O2 group and the cecal ligation/puncture group but similar to that of the SHAM group. The survival rate for the CLP+O3 group was lower than for the SHAM group and similar to that for the other 2 groups (CLP and CLP+O2). CONCLUSION Ozone therapy modulated the inflammatory response and acute lung injury in the cecal ligation/puncture infection model in rats, although there was no improvement on survival rates.

Surgical treatment of lung metastases of head and neck tumors

BACKGROUND Head and neck tumors often spread to the lungs, with a variety of presentations. The ideal treatment for those patients is still controversial. Resection of lung metastases was shown to significantly influence overall survival of patients. OBJECTIVE To evaluate results of surgical resection of lung nodules in patients with head and neck primary tumors. METHODS A retrospective analysis was made of 53 patients with head and neck tumors and lung nodules (no other metastases detected in other organs) admitted to our department. They were separated into two groups: OPER (thoracotomy, n = 26), and NOTOPER (no thoracotomies, n = 27). Overall survival was compared (Kaplan-Meier, log-rank) between groups. RESULTS Overall median survival of all patients was 10 months, of OPER 20 months, and of NOTOPER 6 months (P <0.0001). Complete resection (n = 19) of lung metastases was associated with the greatest survival rate (median 23 months). Patients submitted to incomplete resection (n = 7) had a median survival of 16 months, compared with 7 months for patients who received only chemotherapy (n = 7) and 4 months for patients (n = 20) with no treatment (P <0.0001). CONCLUSION Resection of lung metastases offers a significant survival benefit for patients with head and neck primary tumors, when compared with the current chemotherapeutic regimens. It should be considered for all patients clinically fit and who present with no extrapulmonary disease.

THE LEVEL OF NICOTINE DEPENDENCE IS AN INDEPENDENT RISK FACTOR FOR CANCER. A CASE CONTROL STUDY

BACKGROUND Less than 20% of lifetime smokers will ever develop cancer. Smoking habits characteristics, particularly the level of nicotine dependence level, were not fully evaluated as a marker of risk. METHODS Case-control study of voluntary patients prospectively enrolled in a smoking cessation program in a cancer hospital. For each cancer case, patients of the same age and sex were selected. The Beck Depression Inventory, an instrument for the diagnosis of depressive mood and clinical depression, and the Fagerström Test Questionnaire, a questionnaire that has a good correlation with nicotine levels, used to determine the degree of dependence on nicotine, were applied. Age on admission to the study, sex, and number of pack-years were also evaluated. RESULTS From May 1999 to May 2002, 56 cancer patients (case) and 85 matching controls (control) were identified in the population studied. There was no difference regarding pack-years. Fagerström Test Questionnaire was significantly higher in patients with cancer (7.5+/-1.9) compared to controls (6.3+/-2.0). We found a Fagerström Test Questionnaire>7 in 73.2% of the cancer cases versus 43.5% of the controls (p=0.001). The proportion of depressed patients was higher in the cancer group (37.5% x 17.6%). Logistic regression adjusted for age and tobacco consumption disclosed that Fagerström Test Questionnaire score>7 has an odds ratio for cancer of 3.45 (95% CI 1.52-7.83, p=0.003). CONCLUSION Fagerström Test Questionnaire higher than 7 was identified as a risk factor for cancer in smokers with similar tobacco consumption.

Pulmonary metastasectomy for malignant melanoma: Prognostic factors for long-term survival

More than 80% of patients with metastatic melanoma initially show only one distant organ site involvement, most commonly the lungs. Several studies on patients with pulmonary metastatic diseases have determined prognostic factors for survival; however, these studies included patients with a variety of primary tumor types and failed to discriminate melanoma-specific prognostic factors. Surgical therapy has been shown in several studies to be associated with a 5-year survival rate as high as 39%. We retrospectively analyzed 48 patients with previously treated melanoma who developed pulmonary metastases and were admitted between 1990 and 2006. The overall survival was estimated using Kaplan–Meier analysis. Log-rank and Breslow’s tests were used to compare survival differences for each variable. Multivariate analyses to determine the independent prognostic factors for overall survival were performed using the Cox proportional hazard model, as identified by the univariate analyses. The median overall survival for all patients was 32 months, with an estimated 5-year survival rate of 36%. Multivariate analyses identified the type of resection and the number of malignant nodules resected as independent prognostic factors for overall survival. We observed a significant survival benefit from pulmonary metastasectomy for a subset of patients with metastatic pulmonary melanoma.