Internal Mammary Artery Compression After Pectus Excavatum Repair Does Not Increase Risk of Hemorrhagic Complications in Pediatric Patients

Objectives: Minimal invasive repair of pectus excavatum (MIRPE) described by Nuss is the most popular correction nowadays of this deformity. During the introduction of the bars, they can hurt or compress the internal mammary arteries (IMA). The aim of this study was to observe the prevalence of IMA compression in children after MIRPE. Also, we examined if IMA obstruction increases the risk of complications at bar removal, and if these vascular changes are reversible. Materials and Methods: All patients operated on pectus excavatum in our tertiary pediatric surgical center between 2013 and 2019 were involved in the study. Data of age, sex, number of bars and characteristics of the deformity were examined. IMA flow was checked by Doppler ultrasound (DUS) after MIRPE and after bar removal, too. Results: Among 41 patients with mean age of 15.2 years there were 18 asymmetrical deformities, 23 sternal rotations. Mean pectus index was 4.01. After the Nuss procedure 7(9%) stenoses and 10(12%) occlusions of IMA were found on DUS. After bar removal 3 of 4 stenoses have resolved, but all examined occlusions (3/3) persisted. There were no complications during bar removals. Conclusion: IMA compression after MIRPE in children is uncommon, and is not influenced by severity of deformity. Obstruction of these vessels does not increase the risk of hemorrhagic complications at bar removal. Data of larger cohort are needed to determine reversibility of these changes. © Copyright © 2021 Kovács, Pásztor and Rieth

A túlfújt endotrachealis mandzsetta szerepe a légcsősérülések diagnosztikájában [The role of an overinflated endotracheal tube in the diagnosis of tracheal injuries]

Tracheobronchial injury is an uncommon, but often life-threatening condition. It is mostly caused by blunt thoracic or neck trauma, difficult or prolonged intubation associated with nasogastric tube insertion. An early diagnosis and treatment can be lifesaver. The diagnosis is often late because of atypical symptoms and unspecific radiological signs, and due to the presence of severe coexistent injuries. Generally, the classic hallmark during physical examination is a progressive, extensive surgical emphysema. Radiological signs are often atypical, which makes the diagnosis more difficult. The most frequent signs found on computed tomography are also unspecific, mostly surgical emphysema, pneumomediastinum or pneumothorax may be noted. We present three patients suffering from airway laceration caused by car accident, difficult intubation, and prolonged utilization of nasogastric and endotracheal tube. All the patients had an overdistended endotracheal balloon herniated outside the extratracheal space along the rupture of the tracheal wall. These external balloons were all detected on radiography. This is a direct and pathognomic sign of airway injury, suggesting complete rupture in the tracheal wall. In our report, we would like to highlight the diagnostic role of an overinflated cuff. Orv Hetil. 2020; 161(25): 1063-1068

Quantitative estimation of nerve fiber engagement by vagus nerve stimulation using physiological markers

Background Cervical vagus nerve stimulation (VNS) is a rapidly emerging bioelectronic treatment for brain, metabolic, cardiovascular and immune disorders. Its desired and off-target effects are mediated by different nerve fiber populations and knowledge of their engagement could guide calibration and monitoring of VNS therapies. Objective /Hypothesis: Stimulus-evoked compound action potentials (eCAPs) directly provide fiber engagement information but are currently not feasible in humans. A method to estimate fiber engagement through common, noninvasive physiological readouts could be used instead of eCAP measurements. Methods In anesthetized rats, we recorded eCAPs while registering acute physiological response markers to VNS: cervical electromyography (EMG), changes in heart rate (ΔHR) and breathing interval (ΔBI). Quantitative models were established to capture the relationship between A-, B- and C-fiber type activation and those markers, and to quantitatively estimate fiber activation from physiological markers and stimulation parameters. Results In bivariate analyses, we found that EMG correlates with A-fiber, ΔHR with B-fiber and ΔBI with C-fiber activation, in agreement with known physiological functions of the vagus. We compiled multivariate models for quantitative estimation of fiber engagement from these markers and stimulation parameters. Finally, we compiled frequency gain models that allow estimation of fiber engagement at a wide range of VNS frequencies. Our models, after calibration in humans, could provide noninvasive estimation of fiber engagement in current and future therapeutic applications of VNS

Tetraplegia sikeres multidiszciplináris kezelése mellkassebészeti műtéttel. Unicentrikus mediastinalis Castleman-betegség esete = Successful multidisciplinary management of tetraplegia with a thoracic operation Unicentric, mediastinal Castleman disease

Absztrakt: A Castleman-betegség egy ritka, lymphoproliferativ betegség, melynek pontos oka ismeretlen. Diagnosztikájának alapja az adekvát szövettani vizsgálat. Míg az unilocularis formánál a betegség a leggyakrabban a mellkast érinti, és az épben történő sebészi eltávolítás a tünetek megszűnését eredményezheti, addig a multilocularis formánál egyéb kezelési formák egészíthetik ki vagy válthatják fel a műtéti eltávolítást. Munkánkban egy Castleman-betegség miatt multidiszciplináris kezelésen átesett beteg esetét mutatjuk be. Az 56 éves férfi betegnél kivizsgálása előtt 18 héttel, egy felső légúti infekciót követően beszédnehezítettség, nyelészavar, felső és alsó végtagi progresszív paresis jelentkezett. Plazmaferézisre a beteg panaszai átmenetileg megszűntek ugyan, de a sebészi mintavételek a mellkas-CT-n látott mediastinalis lymphadenomegalia eredetét nem tudták igazolni. Így az 5 cm-es subcarinalis nyirokcsomó eltávolítása vagy mintavételezése miatt került a beteg osztályunkra. Átvételkor mind a négy végtagon jelentős atrófia, hipotónia, tetraplegia volt látható, és testszerte areflexia igazolódott. Osztályunkon posterolateralis thoracotomiából eltávolítottuk az 5,5 × 3,5 cm-es subcarinalis nyirokcsomó-konglomerátumot. A szövettani vizsgálat Castleman-betegséget jelzett. 3 nappal a műtét után a végtagok mozgása megindult, a 9. napon már járókerettel járóképessé vált, ezt követően neurológiai rehabilitációs osztályra került. Ekkor a felső végtagokban közel megtartott, míg az alsó végtagokban 4/5-ös izomerőt észleltek. Ezt követően a beteg metilprednizolon-, B1-vitamin-, kalcium-citrát- és famotidinkezelésben részesült; 2 héttel átvétele után otthonába bocsátották, ekkor már járókeret nélkül biztonságosan közlekedett. Tünetei 3 hónappal a műtét után csaknem teljes mértékben megszűntek. A Castleman-betegség diagnosztikája és kezelése multidiszciplináris feladat. Ha a páciens műtéti teherbíró képessége engedi, akkor az unilocularis Castleman-betegség terápiás eszköztárában a sebészeti eltávolításnak kiemelt szerepe kell, hogy legyen. OrvHetil. 2020; 161(1): 33–38. | Abstract: Castleman disease is a rare lymphoproliferative disease the exact cause of which is not known. The diagnosis is based on the adequate histological examination. While in the unifocal form, the disease most commonly affects the chest, and symptoms may resolve as a result of intact excision of the tumour; other treatment methods may be performed in addition to or instead of surgical incision in the case of the multifocal form. We present the case of a patient with Castleman disease who received multidisciplinary treatment. Speech difficulty, dysphagia, and progressive paresis occurred in the upper and lower extremities of the 56-year-old male patient 18 weeks before his check-up examinations. Although the complaints temporarily resolved with plasmapheresis, surgical sampling could not confirm the origin of the mediastinal lymphadenomegaly detected with thoracic CT. The patient was admitted to our department to remove the 5 cm large subcarinal lymph node or to gain a tissue sample from it. On admission, significant atrophy, hypotonia and tetraplegia were seen in the four extremities, and areflexia was detected all over the body. The 5.5 × 3.5 cm large subcarinal lymph node conglomerate was removed from posterolateral thoracotomy. Histology was performed, Castleman disease was confirmed. 3 days after the surgery, the patient was able to move the extremities, and then on the 9th postoperative day, the patient could walk using a walking frame, and he was transferred back to the Department of Neurorehabilitation. At transfer, the muscle strength of the upper extremities was almost intact, and 4/5 muscle strength was detected in the lower extremities. After this, methylprednisolone, vitamin B1, calcium citrate, famotidine therapy was administered, and 2 weeks after his transfer, he was discharged home; at that time, the patient was able to walk safely without a walking frame. The symptoms resolved almost completely 3 months after the surgery. Diagnosis and treatment of Castleman disease are multidisciplinary tasks. If the patient is suitable for surgery, surgical removal has to play a key role in the treatment of unifocal Castleman disease. Orv Hetil. 2020; 161(1): 33–38

Effectiveness and safety of opicapone in Parkinson’s disease patients with motor fluctuations: the OPTIPARK open-label study

Background The efficacy and safety of opicapone, a once-daily catechol-O-methyltransferase inhibitor, have been established in two large randomized, placebo-controlled, multinational pivotal trials. Still, clinical evidence from routine practice is needed to complement the data from the pivotal trials. Methods OPTIPARK (NCT02847442) was a prospective, open-label, single-arm trial conducted in Germany and the UK under clinical practice conditions. Patients with Parkinson’s disease and motor fluctuations were treated with opicapone 50 mg for 3 (Germany) or 6 (UK) months in addition to their current levodopa and other antiparkinsonian treatments. The primary endpoint was the Clinician’s Global Impression of Change (CGI-C) after 3 months. Secondary assessments included Patient Global Impressions of Change (PGI-C), the Unified Parkinson’s Disease Rating Scale (UPDRS), Parkinson’s Disease Questionnaire (PDQ-8), and the Non-Motor Symptoms Scale (NMSS). Safety assessments included evaluation of treatment-emergent adverse events (TEAEs) and serious adverse events (SAEs). Results Of the 506 patients enrolled, 495 (97.8%) took at least one dose of opicapone. Of these, 393 (79.4%) patients completed 3 months of treatment. Overall, 71.3 and 76.9% of patients experienced any improvement on CGI-C and PGI-C after 3 months, respectively (full analysis set). At 6 months, for UK subgroup only (n = 95), 85.3% of patients were judged by investigators as improved since commencing treatment. UPDRS scores at 3 months showed statistically significant improvements in activities of daily living during OFF (mean ± SD change from baseline: − 3.0 ± 4.6, p < 0.0001) and motor scores during ON (− 4.6 ± 8.1, p < 0.0001). The mean ± SD improvements of − 3.4 ± 12.8 points for PDQ-8 and -6.8 ± 19.7 points for NMSS were statistically significant versus baseline (both p < 0.0001). Most of TEAEs (94.8% of events) were of mild or moderate intensity. TEAEs considered to be at least possibly related to opicapone were reported for 45.1% of patients, with dyskinesia (11.5%) and dry mouth (6.5%) being the most frequently reported. Serious TEAEs considered at least possibly related to opicapone were reported for 1.4% of patients. Conclusions Opicapone 50 mg was effective and generally well-tolerated in PD patients with motor fluctuations treated in clinical practice. Trial registration Registered in July 2016 at clinicaltrials.gov (NCT02847442)