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Latest Research on Pleurisy
     
Curr Treat Options Cardiovasc Med. 2008 Apr;10(2):101-11.
Update on vena cava filters.
Carman TL, Alahmad A.
Teresa L. Carman, MD Section of Vascular Medicine, Department of Cardiovascular Medicine, Cleveland Clinic, 9500 Euclid Avenue, Desk S-60, Cleveland, OH 44145, USA. tcarmanmd@aol.com.

Inferior vena cava (IVC) filter placement has increased dramatically over the past two decades. Filters are indicated to prevent pulmonary embolism in patients with venous thromboembolism (VTE) and a contraindication to anticoagulation or a complication of anticoagulation. Some of this increased use is the result of expanding relative indications for filter placement, including placement for primary prophylaxis. The US Food and Drug Administration has approved 11 filters for permanent deployment, two of which--the Günther-Tulip (Cook Medical, Bloomington, IN) and the OptEase (Cordis Endovascular, Miami Lakes, FL)--are optionally retrievable. Once anticoagulation is deemed safe, all patients should be fully anticoagulated to prevent propagation and recurrent thromboembolism. Complications related to IVC filters include procedure-related issues, device complications, and secondary VTE. Therefore, the decision regarding filter placement and/or retrieval must be individualized.

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Ann Thorac Surg. 2008 Mar;85(3):1039-43.
Decortication after lung transplantation.
Boffa DJ, Mason DP, Su JW, Murthy SC, Feng J, McNeill AM, Budev MM, Mehta AC, Pettersson GB.
Department of Thoracic and Cardiovascular Surgery, Cleveland Clinic, Cleveland, Ohio 44195, USA.

BACKGROUND: Compromise of a pulmonary allograft by restrictive or infectious pleural-space pathology may be amenable to surgical intervention; however, the role of decortication in this patient population has not yet been substantiated. To address this issue, indications and outcomes of decortication after lung transplantation were examined at our institution. METHODS: From February 1990 to December 2006, 553 patients underwent lung transplantation; postoperative decortications were performed 27 times in 24 patients (4.3%). RESULTS: Indications for decortication included presumed empyema (15), loculated effusion (7), hemothorax (3), and fibrothorax (2). Decortication was performed at a median of 81 days after transplantation (range, 12 days to 7.8 years). Complete lung reexpansion was achieved after 19 of 27 decortications (70%). Infection was cleared from the pleural space in 9 of 15 empyema patients (64%). Survivals at 1, 3, 6, and 12 months after decortication were 85%, 73%, 65%, and 60%, respectively. Operative mortality (30-day or in-hospital) was 23%, and median length of stay was 19 days. CONCLUSIONS: Decortication may alleviate the compromise of a transplanted lung by restrictive or infectious pleural-space disease, but operative risk is substantial.

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Intern Emerg Med. 2008 Mar 21 [Epub ahead of print]
Deep venous thrombosis of the neck and pulmonary embolism in patients with a central venous catheter admitted to cardiac rehabilitation after cardiac surgery: a prospective study of 815 patients.
Frizzelli R, Tortelli O, Di Comite V, Ghirardi R, Pinzi C, Scarduelli C.
Multifunctional Rehabilitation, Bozzolo Hospital, Viale 25 Aprile n. 71, 46012, Bozzolo (MN), Italy, rino.frizzelli@ospedalimantova.it.

Central venous catheters (CVCs) are widely used for therapeutic purposes and to measure hemodynamic variables that cannot be recorded from a peripheral vein. However, the method can involve complications. In cardiac surgery, CVCs are electively placed in the right internal jugular vein but there is little information on deep venous thrombosis (DVT) in catheterized veins (CVC-related DVT) or on secondary pulmonary embolism (PE). The impact of CVC-related DVT and PE in cardiac surgery and measures to prevent PE were assessed. We used ultrasonography (US) to check the point of insertion of CVC in 815 patients in the intensive cardiac rehabilitation unit after heart surgery. In this series, 386 patients (48%) had CVC-related DVT; those already receiving anticoagulant, and considered at low risk, continued that therapy, while those taking an antiplatelet agent (aspirin 100 mg daily) but deemed at high risk of PE from the US findings were given an anticoagulant instead. Only patients with CVC-related DVT at low risk of PE continued taking aspirin. At 3 months, there were no cases of PE among patients receiving an anticoagulant, but six on antiplatelet had non-fatal PE. The prevalence of PE in the whole series of 815 patients was 0.7%. CVC-related DVT is a frequent complication of heart surgery. Anticoagulant therapy started early does not prevent thrombus formation but probably prevents PE, whereas antiplatelet gives no such protection. Sonographic screening of the CVC removal in intensive care unit may be useful for avoiding PE after CVC-related DVT.

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Expert Rev Med Devices. 2008 Mar;5(2):153-166.
Advances in endovascular interventions for deep vein thrombosis.
Lin PH, Barshes NR, Annambhotla S, Kougias P, Huynh TT.
Division of Vascular Surgery & Endovascular Therapy, Michael E DeBakey Department of Surgery, Baylor College of Medicine, Houston VAMC (112), 2002 Holcomb Blvd, Houston, TX 77030, USA. plin@bcm.edu , Division of Vascular Surgery & Endovascular Therapy, Michael E DeBakey Department of Surgery, Baylor College of Medicine, and the Michael E DeBakey VA Medical Center, Houston, TX, USA. nbarshes@bcm.edu , Division of Vascular Surgery & Endovascular Therapy, Michael E DeBakey Department of Surgery, Baylor College of Medicine, and the Michael E DeBakey VA Medical Center, Houston, TX, USA. annambho@bcm.edu , Division of Vascular Surgery & Endovascular Therapy, Michael E DeBakey Department of Surgery, Baylor College of Medicine, and the Michael E DeBakey VA Medical Center, Houston, TX, USA. kougias@bcm.edu , Division of Vascular Surgery & Endovascular Therapy, Michael E DeBakey Department of Surgery, Baylor College of Medicine, and the Michael E DeBakey VA Medical Center, Houston, TX,
USA. thuynh@bcm.edu.

Deep vein thrombosis (DVT) can lead to significant clinical sequelae resulting in negative impact on patients' lifestyle. Clinical consequences of DVT may include acute symptoms, such as limb swelling and pain or chronic symptoms, such as venous ulceration, due to post-thrombotic syndrome. An overwhelming DVT may lead to sudden death due to pulmonary embolism. Conventional treatment of DVT includes initial systemic anticoagulation with possible thrombus removal in symptomatic patients who fail medical therapy. Recent advances in endovascular technologies have led to the development of a variety of minimally invasive, catheter-based strategies to remove venous thrombus. These technologies utilize various mechanical principles, including catheter-directed thrombolytic infusion, rheolytic thrombectomy, mechanical fragmentation or ultrasound energy to remove intraluminal thrombus. The adjunctive role of thrombolytic agents in these mechanical thrombectomy devices has resulted in
an augmented treatment modality in interventional management of iliofemoral DVT. This article reviews the current advances in this technology and discusses the techniques of percutaneous treatment strategies of venous thrombotic conditions.

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Thromb Haemost. 2008 Mar;99(3):502-10.
Treatment of pulmonary embolism: The use of low-molecular-weight heparin in the inpatient and outpatient settings.
Hull RD.
Thrombosis Research Unit, 601 South Tower Foothills Hospital, 1403-29 Street NW, Calgary, Alberta, Canada T2N 2T9. E-mail: rdhull@ucalgary.ca.

Pulmonary embolism (PE) remains a major clinical problem associated with considerable mortality and morbidity. In patients with PE, appropriate anticoagulant therapy has been shown to significantly reduce both recurrence and mortality. Low-molecular-weight heparin (LMWH) is at least as effective as unfractionated heparin (UFH) in the treatment of PE, with a similar risk of bleeding. Furthermore, LMWH offers more predictable pharmacokinetics and anticoagulant effects. As a result, current guidelines from both the American College of Chest Physicians and the joint American College of Physicians/American Academy of Family Physicians recommend the use of LMWH over UFH (in patients with submassive PE). Outpatient treatment with LMWH has been shown to be feasible in many patients, and offers the potential for cost-savings and improvements in health-related quality of life. Further data are needed to support an evidence-based recommendation for the use of LMWH in the outpatient treatment of PE.

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An Pediatr (Barc). 2008 Feb;68(2):92-98.
Is the incidence of parapneumonic pleural effusion increasing?
[Article in Spanish]
Bueno Campaña M, Agúndez Reigosa B, Jimeno Ruiz S, Echávarri Olavarría F, Martínez Granero MA.
Área de Pediatría y Neonatología. Fundación Hospital Alcorcón. Madrid. España. mbueno@fhalcorcon.es.

INTRODUCTION: Streptococcus pneumoniae is the microorganism most frequently associated with complicated pleural effusion. After the introduction of the heptavalent pneumococcal vaccine, there was a decline in the incidence of invasive pneumococcal disease and, to a lesser extent, in that of pneumonia. However, the incidence of empyema apparently increased. The antipneumococcal heptavalent vaccine was introduced in Spain in 2001. OBJECTIVES: To determine whether the incidence of pleural effusion secondary to pneumonia has increased in hospitalized patients and to examine the possible influence of the antipneumococcal heptavalent vaccine on the incidence rate of parapneumonic effusions. PATIENTS AND METHODS: Patients aged less than 16 years old admitted to our hospital with a diagnosis of pneumonia between 1999 and 2005 were retrospectively reviewed. We calculated the annual incidence rate of pleural effusion with respect to the total number of patients admitted with pneumonia and with respect to patients considered to have probable bacterial pneumonia, based on previously established criteria. RESULTS: A total of 337 patients were analyzed, of which 213 (63.2 %) met the criteria for a diagnosis of probable bacterial pneumonia. Pleural effusion was found in 34 patients (15.9 %), and 13 of these effusions (38 %) were complicated. No clear trend was detected in the annual incidence of probable bacterial pneumonia per 100 admitted patients, although the highest numbers were detected in the last two years of the study period. The percentage of complications (effusions) remained constant (mean: 16.28 %). No differences were found in the effusion rate between vaccinated and unvaccinated patients (12.5 % vs 18.6 %). CONCLUSIONS: The trend in the incidence of parapneumonic pleural effusions was parallel and proportional to that of probable bacterial pneumonia.

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J Laparoendosc Adv Surg Tech A. 2008 Feb;18(1):131-5.
Current application of thoracoscopy in children.
Tsao K, St Peter SD, Sharp SW, Nair A, Andrews WS, Sharp RJ, Snyder CL, Ostlie DJ, Holcomb GW.
Department of Surgery, Children's Mercy Hospital, Kansas City, Missouri, USA.

BACKGROUND: The safety and efficacy of thoracoscopy for thoracic lesions and conditions in children is evolving. Our experience with thoracoscopy has expanded in recent years. Therefore, we reviewed our most recent 7-year experience to examine the current applications for thoracoscopy in children. METHODS: A retrospective review of all patients undergoing a thoracoscopic operation at Children's Mercy Hospital (Kansas City, MO) between January 1, 2000, and June 18, 2007, was performed. Data points reviewed included patient demographics, type of operation, final diagnosis, complications, and recovery. RESULTS: During the study period, 230 children underwent 231 thoracoscopic procedures. The mean age was 9.6 +/- 6.1 years with a mean weight of 36.6 +/- 24.1 kg. Fifty percent of the patients were male. The thoracoscopic approach was used for decortication and debridement for empyema in 79 patients, wedge resection for lung lesions in 37, exposure for correction of scoliosis in 26, excision or biopsy of an extrapulmonary mass in 26, operation for spontaneous pneumothorax in 25, lung biopsy for a diffuse parenchymal process in 15, lobectomy in 9, repair of esophageal atresia with a tracheoesophageal fistula (EA-TEF) in 8, clearance of the pleural space for hemothorax or effusion in 3, diagnosis for trauma in 1, and repair of bronchopleural fistula in 1. Conversion was required in 3 patients, all of whom were undergoing a lobectomy. Two of these were right upper lobectomies and the other was a left lower lobectomy with severe infection and inflammation. The mean time of chest tube drainage (excluding scoliosis and EA-TEF patients) was 2.9 +/- 2.0 days. There were no major intraoperative thoracoscopic complications. A correct diagnosis was rendered in all patients undergoing a biopsy. One patient required a second thoracoscopic biopsy to better define a mediastinal mass. Two patients developed postoperative atelectasis after scoliosis procedures. One pa
tient had a small persistent pneumothorax after a bleb resection for a spontaneous pneumothorax. This subsequently resolved. CONCLUSIONS: In pediatric patients with thoracic pathology, thoracoscopy is highly effective for attaining the goal of the operation, with a low rate of conversion and complications.

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Chirurg. 2008 Jan;79(1):83-96.
[Treatment of pleural empyema.]
[Article in German]
Klopp M, Pfannschmidt J, Dienemann H.
Chirurgische Abteilung, Thoraxklinik am Universitätsklinikum, Amalienstraße 5, 69126, Heidelberg, Deutschland, Michael.Klopp@urz.uni-heidelberg.de.

Pleural empyema remains a frequently encountered clinical problem and is responsible for significant morbidity and mortality worldwide. Its diagnosis may be difficult; delays in diagnosis and treatment may contribute to morbidity, complications, and mortality. The management of parapneumonic effusion and empyema depends on timely, stage-dependent therapy and the underlying etiology. Thoracentesis and antibiotics remain the cornerstones of treatment in stage I disease. In the early fibrinopurulent phase (stage II) thoracoscopic methods should be considered. As treatment strategy for this stage, fibrinopurulent pleural empyema entails thorough debridement of multiloculated collections from the pleural cavity by video-assisted thoracic surgery. After evacuation of multilocular effusions and the removal of fibrin deposits with drainage by two intercostal chest tubes, irrigation treatment helps to achieve clarity of the pleural discharge. Open thoracotomy and decortication are reserved for organized, multiloculated empyema with lung entrapment (stage III disease). Early drain removal may lead to rapid symptomatic recovery and complete resolution.

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Am J Med Sci. 2008 Jan;335(1):21-5.
Clinical implications of unexpandable lung due to pleural disease.
Doelken P.
Division of Pulmonary, Critical Care, Allergy, and Sleep Medicine, Medical University of South Carolina, Charleston, South Carolina 29425, USA. doelkenp@musc.edu

Unexpandable lung due to pleural disease may manifest itself as a hydropneumothorax after pleural drainage procedure or as an inability to completely drain a pleural effusion due to chest pain. The condition is a mechanical complication of a variety of pleural disorders. Of these, malignant lung entrapment and inflammatory lung entrapment are considered complications of active pleural disease, and management is primarily dependent on the nature of the active process. Trapped lung is a sequela of remote inflammation of the pleural space. Trapped lung is usually asymptomatic but may be the cause of dyspnea in some patients. The only available treatment of symptomatic trapped lung is surgical decortication. Surgical decortication should only be considered after other causes of dyspnea have been excluded.

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Surg Obes Relat Dis. 2007 Dec 5 [Epub ahead of print]
Safety and efficacy of intravascular ultrasound-guided inferior vena cava filter in super obese bariatric patients.
Kardys CM, Stoner MC, Manwaring ML, Barker M, Macdonald KG, Pender JR, Chapman WH 3rd.
Department of Surgery, Section of Bariatric and Minimally Invasive Surgery and Section of Vascular Surgery, East Carolina University Brody School of Medicine, Greenville, North Carolina.

BACKGROUND: The morbidly obese (body mass index >40 kg/m(2)) are at significant risk of postoperative venous thromboembolism (VTE). Pulmonary embolism is the leading cause of death after Roux-en-Y gastric bypass, approximating .5%. Because of the technical limitations with fluoroscopy and table weight limits, it has been our practice at our university-based bariatric center to offer intravascular ultrasound (IVUS)-guided inferior vena cava filter (IVCF) placement at Roux-en-Y gastric bypass to patients with a history of VTE, hypercoagulable state, or profound immobility. METHODS: The hospital and outpatient records of all 594 patients who underwent Roux-en-Y gastric bypass from January 1, 2004 to October 31, 2006 were reviewed. The patients who had undergone concurrent IVUS-guided IVCF placement were selected. The co-morbidities, outcomes, and complications were recorded. RESULTS: Of the 594 patients, 31 (mean body mass index 71.2 +/- 2.96 kg/m(2)) had undergone concurrent IVUS-guided IVCF placement. The indications included a history of VTE (n = 5), a known hypercoagulable state (n = 2), and profound immobility (n = 25). The technical success rate was 96.8%. One filter was malpositioned in the iliac vein. No catheter site complications occurred. A ventilation/perfusion scan and computed tomography scan each detected pulmonary embolism in 2 surviving patients within 2 months postoperatively. Two patients died, 1 on postoperative day 8 and 1 on postoperative day 15 (6.4%). The mean follow-up time was 262.8 +/- 37.3 days. Autopsy excluded VTE or IVCF-related issues as the cause of death in both patients. CONCLUSION: These results suggest the efficacy of IVUS-guided IVCF placement in preventing mortality from pulmonary embolism in high-risk bariatric patients. IVUS-guided IVCF placement can be safely performed with an excellent success rate in high-risk patients who would not otherwise be candidates for intervention because of the technical limitations of fluoroscopy.

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Compr Ther. 2007 Winter;33(4):184-91.
Pulmonary embolism—a state of the clot review.
Dimarsico L, Cymet T.
Department of Medicine, Sinai Hospital of Baltimore, Baltimore, MD, USA; Johns Hopkins School of Medicine, Baltimore, MD, USA.

The assessment for pulmonary emboli is still Stone Age. History and physical findings are not sensitive or specific making it difficult to establish the diagnosis. PE is still potentially fatal. Death most often results from the severity of the clot, although delay in treatment may play a role. Clots, including deep venous thrombosis and pulmonary emboli, are the first disease that falls clearly under the Hospitalist specialty. An argument over what imaging is ideal continues to rage on, without any clear leader at this point. The CT scan and Ventilation/Perfusion scan are the two modalities being used most often. However without the use of a pretest probability the sensitivity and specificity can go down to less than 80%. The many new anticoagulants and oral therapies have widened the armamentarium, without increasing the success of therapy.

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Am J Surg. 2007 Dec;194(6):814-8; discussion 818-9.
Postoperative pulmonary embolism: timing, diagnosis, treatment, and outcomes.
Hope WW, Demeter BL, Newcomb WL, Schmelzer TM, Schiffern LM, Heniford BT, Sing RF.
Department of Surgery, Carolinas Medical Center, 1000 Blythe Blvd, MEB #601, Charlotte, NC 28203, USA.

BACKGROUND: Postoperative pulmonary embolism (PE) remains a major health concern. The purpose of our study was to evaluate our experience with postoperative PE. METHODS: We retrospectively reviewed the medical records of patients who had a postoperative PE at our institution. RESULTS: Our study included 115 patients. Prophylaxis was administered preoperatively in 31% of patients and postoperatively in 56% of patients. The diagnosis was obtained by computed tomography scan in 74 patients (64%), ventilation-perfusion scan in 24 patients (21%), angiogram in 8 patients (7%), and other modalities in 9 patients (8%). The time elapsed between surgery and the diagnosis of PE varied significantly by patient age (<40 y: 3 d, compared with 40-60 y: 11 d; P = .02). The majority of patients with PE were treated with anticoagulation (83%). Morbidity and mortality rates both were 9%. CONCLUSIONS: Age has a significant impact on the timing of postoperative PE, with the majority of cases being diagnosed with a computed tomography scan, and treated with anticoagulation.

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Compr Ther. 2007 Winter;33(4):237-46.
Diagnosis and management of pleural effusions: a practical approach.
Diaz-Guzman E, Dweik RA.
Department of Pulmonary, Allergy and Critical Care Medicine, Cleveland Clinic, Cleveland, OH, USA.

Pleural effusion is defined as an abnormal amount of pleural fluid accumulation in the pleural space and is the result of an imbalance between excessive pleural fluid formation and pleural fluid absorption. Although the list of causes of pleural effusions is extensive, the great majority of the cases are caused by pneumonia, congestive heart failure, and malignancy. In this article, we provide an overview of the most common causes of pleural effusions likely to be encountered by the general practitioner, and a practical approach to the diagnosis and management of this common condition.

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Cochrane Database Syst Rev. 2007 Oct 17;(4):CD001876.
Corticosteroids for tuberculous pleurisy.
Engel ME, Matchaba PT, Volmink J.
Faculty of Health Sciences, University of Cape Town, Department of Medicine, J47 Old Main Building, Groote Schuur Hospital, Observatory, South Africa, 7925. mark.engel@mrc.ac.za

BACKGROUND: Corticosteroids used in addition to antituberculous therapy have been reported to benefit people with tuberculous pleurisy. However, research findings are inconsistent, raising doubt as to whether such treatment is worthwhile. Concern also exists regarding the potential adverse effects of corticosteroids, especially in HIV-positive people. OBJECTIVES: To evaluate the effects of adding corticosteroids to drug regimens for tuberculous pleural effusion. SEARCH STRATEGY: In May 2007, we searched the Cochrane Infectious Diseases Group Specialized Register, CENTRAL (The Cochrane Library 2007, Issue 2), MEDLINE, EMBASE, LILACS, Current Controlled Trials, and reference lists of articles. SELECTION CRITERIA: Randomized and quasi-randomized controlled trials comparing any corticosteroid with no treatment, placebo, or other active treatment (both groups should receive the same antituberculous drug regimen) in people diagnosed with tuberculous pleurisy. DATA COLLECTION AND ANALYSIS: Two authors independently assessed trial methodological quality and extracted data. Data were analysed using relative risks (RR) and weighted mean difference (WMD) with 95% confidence intervals (CI). The fixed-effect model was applied in the absence of statistically significant heterogeneity. MAIN RESULTS: Six trials with 633 participants met the inclusion criteria; one trial included only HIV-positive people. Compared to control, corticosteroid use was associated with less residual pleural fluid at four weeks (RR 0.76, 95% CI 0.62 to 0.94; 394 participants, 3 trials) and reduced pleural thickening (RR 0.69, 95% CI 0.51 to 0.94; 309 participants, 4 trials). We found no evidence of an effect of corticosteroids on death from any cause (194 participants, 1 trial), respiratory function (191 participants, 2 trials), residual pleural fluid at eight weeks (399 participants, 4 trials), or pleural adhesions (123 participants, 2 trials). Although discontinuation of treatment due to adverse events was more frequent in participants receiving corticosteroids than placebo (RR 2.80, 95% CI 1.12 to 6.98; 586 participants, 6 trials), the effects were generally mild. The risk of Kaposi sarcoma may be increased in HIV-positive people receiving corticosteroids (RR 13.00, 95% CI 0.74 to 227.63; 194 participants, 1 trial). AUTHORS' CONCLUSIONS: There are insufficient data to support evidence-based recommendations regarding the use of adjunctive corticosteroids in people with tuberculous pleurisy. Randomized controlled trials that are sufficiently powered to evaluate the effects of corticosteroids on both morbidity and mortality are needed. The effects of corticosteroids on HIV-related complications, such as Kaposi sarcoma, should be assessed in people co-infected with HIV.

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Pharmacotherapy. 2007 Jul;27(7):995-1000.
Dosage and effectiveness of intrapleural doxycycline for pediatric postcardiotomy pleural effusions.
Hoff DS, Gremmels DB, Hall KM, Overman DM, Moga FX.
Department of Pharmacy, Children's Heart Clinic at Children's Hospitals and Clinics of Minnesota, Minneapolis, Minnesota 55404, USA. david.hoff@childrensmn.org

STUDY OBJECTIVE: To determine the effectiveness of intrapleural doxycycline for the treatment of postcardiotomy pleural effusions in pediatric patients. DESIGN: Retrospective case series. SETTING: Intensive care unit in a pediatric tertiary care center. PATIENTS: Sequential sample of 12 pediatric patients who underwent cardiotomy for congenital heart disease and received doxycycline pleurodesis for persistent pleural effusion that lasted more than 7 days between December 21, 2001, and May 23, 2005. MEASUREMENTS AND MAIN RESULTS: Mean age of the patients was 1 year (range 2 wks-2.5 yrs). Eighteen courses of doxycycline were administered among the 12 patients. An average dose of 19.1 mg/kg/dose of parenteral doxycycline was diluted in normal saline to a final syringe concentration of 2-8 mg/ml and injected through a chest tube. The patient was rotated according to a protocol. The doxycycline dose remained in the pleural space for approximately 6 hours before being drained under suction. Treatment success was defined as achievement of 0-ml/hour chest tube output after a doxycycline dose. The overall treatment success rate was 94% (17 of 18 courses). The mean times from dosing to treatment success and chest tube removal were 76 hours (range < 1 to 140 hrs) and 130 hours (range 8-453 hrs), respectively. Seventy-two percent of the courses (13 of 18) achieved treatment success within 96 hours and chest tube removal within 168 hours after dosing. Doxycycline concentration did not appear to be related to treatment success. Chest pain was the most common adverse effect. CONCLUSION: Intrapleural doxycycline infusion is effective for postcardiotomy pleural effusion in pediatric patients with persistent chest tube drainage lasting more than 7 days.

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AORN J. 2007 Jun;85(6):1199-1208; quiz 1209-12.
The wider scope of video-assisted thoracoscopic surgery.
Khraim FM.
University of New York at Buffalo, School of Nursing, USA.

In the past, rudimentary devices were used to look closely into the chest; currently, advanced video technology, computers, and high-tech electronics are being used to perform many surgical procedures that formerly required a large, open incision. The goal of video-assisted thoracoscopic surgery (VATS) is the same as for comparable open procedures, but it is accomplished with less pain, less patient morbidity, and a shorter hospital stay. In addition to evaluating and treating thoracic injuries, VATS has demonstrated effectiveness in detecting and managing many other conditions, such as pleural disease, interstitial lung disease, and thoracic malignancies.

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Curr Opin Pediatr. 2007 Jun;19(3):328-32.
Thoracic empyema, application of video-assisted thoracic surgery and its current management.
Fuller MK, Helmrath MA.
Michael E. DeBakey Department of Surgery, Baylor College of Medicine, Houston, TX 77030, USA.

PURPOSE OF REVIEW: Pneumonia in children is frequently complicated by pleural effusions, which rarely progress to empyema. Appropriate clinical management depends on correctly diagnosing the stage of the disease process. Recently, increasing use of video-assisted thoracic debridement has altered the traditional management of pleural effusions and empyema in children, resulting in decreasing reliance on thoracentesis and earlier surgical intervention. RECENT FINDINGS: We review the current literature supporting the clinical indications for video-assisted thoracic debridement compared with traditional management, including the use of thoracentesis, chest tube placement, fibrinolytic therapy and open thoracotomy in children with empyema. Recent studies support the early application of video-assisted thoracic debridement in children with empyema compared with traditional therapy, as it decreases the number of procedures and studies performed and the duration of chest tube drainage and is associated with less pain and shorter recovery period than open thoracotomy. SUMMARY: We propose a clinical algorithm supporting the early use of video-assisted thoracic debridement in the management of empyema in children.

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Am Fam Physician. 2007 May 1;75(9):1357-64.
Pleurisy.
Kass SM, Williams PM, Reamy BV.
Department of Family Medicine, Uniformed Services University of the Health Sciences, Bethesda, Maryland 20814, USA. smkass@us.med.navy.mil

Pleuritic chest pain is a common presenting symptom and has many causes, which range from life-threatening to benign, self-limited conditions. Pulmonary embolism is the most common potentially life-threatening cause, found in 5 to 20 percent of patients who present to the emergency department with pleuritic pain. Other clinically significant conditions that may cause pleuritic pain include pericarditis, pneumonia, myocardial infarction, and pneumothorax. Patients should be evaluated appropriately for these conditions before an alternative diagnosis is made. History, physical examination, and chest radiography are recommended for all patients with pleuritic chest pain. Electrocardiography is helpful, especially if there is clinical suspicion of myocardial infarction, pulmonary embolism, or pericarditis. When these other significant causes of pleuritic pain have been excluded, the diagnosis of pleurisy can be made. There are numerous causes of pleurisy, with viral pleurisy among the most common. Other etiologies may be evaluated through additional diagnostic testing in selected patients. Treatment of pleurisy typically consists of pain management with nonsteroidal anti-inflammatory drugs, as well as specific treatments targeted at the underlying cause.

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Clin Oncol (R Coll Radiol). 2007 Apr;19(3):182-7. Epub 2007 Jan 29.
The role of radiotherapy in the treatment of malignant pleural mesothelioma.
Waite K, Gilligan D.
Oncology Centre, Addenbrooke's Hospital, Hills Road, Cambridge CB2 2QQ, UK. kathryn.waite@addenbrookes.nhs.uk

Radiation therapy for the treatment of malignant pleural mesothelioma has historically been limited by its efficacy. However, the increasing incidence of this tumour and the emergence of new technologies present a number of opportunities and challenges for this treatment modality. Radiotherapy is used to palliate mesothelioma patients with chest wall pain. Responses of over 60% have been seen, although the duration of response is often disappointing. The optimum dose has not been shown and many of the previous studies were small retrospective studies. An improved response has been seen in several studies where hyperthermia was added to radiotherapy. However, further investigation of this technique, which is not widely available, is required. There has not been any comparison of radiotherapy with chemotherapy in the palliation of patients with malignant pleural mesothelioma. Prophylactic chest wall radiotherapy to intervention sites successfully reduces the incidence of malignant seeding along the intervention tracts. However, the optimum dose and timing of treatment are not clear. There is no role for radical radiotherapy alone, but the role of radiotherapy as part of multimodality therapy is discussed. There have been studies of intensity-modulated radiotherapy as part of multimodality therapy and this technique needs to be evaluated further.

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J Thorac Cardiovasc Surg. 2007 Mar;133(3):786-90.
The role of awake video-assisted thoracoscopic surgery in spontaneous pneumothorax.
Pompeo E, Tacconi F, Mineo D, Mineo TC.
Thoracic Surgery Division, Tor Vergata University School of Medicine, Rome, Italy. pompeo@med.uniroma2.it

OBJECTIVE: We assessed in a randomized study the feasibility and efficacy of awake video-assisted thoracoscopic bullectomy with pleural abrasion to treat spontaneous pneumothorax. METHODS: Between January 2001 and June 2005, a total of 43 patients with primary spontaneous pneumothorax were randomly assigned by computer to undergo video-assisted thoracoscopic bullectomy and pleural abrasion under sole thoracic epidural anesthesia or general anesthesia with single-lung ventilation (control group). Primary outcome measures included technical feasibility and patient satisfaction with anesthesia as scored into 4 grades (from 1, unsatisfactory, to 4, excellent). Secondary outcome measures included global operating room time, assessment of thoracic pain by visual analog pain scale, number of nursing care calls, hospital stay, and recurrences within 12 months. RESULTS: In the awake group, technical feasibility was scored as excellent, good, and satisfactory in 8, 7, and 6 patients, respectively. Intergroup comparisons (awake versus control) showed that global operating room time (78.0 +/- 20.0 vs 105.0 +/- 15.0 minutes, P < .0001), perioperative visual analog pain scale score (2.0 +/- 3.0 vs 3.5 +/- 2.0, P = .005), nursing care calls (2.0 +/- 1 vs 3.0 +/- 3.0, P = .017), hospital stay (2.0 +/- 1.0 days vs 3.0 +/- 1.0 days, P < .0001), and overall costs (2540 euros +/- 352 euros vs 3550 euros +/- 435 euros, P < .0001) were significantly better in the awake group. In the awake group, 5 patients (23.8%) could be discharged within the first 24 postoperative hours. One patient in the awake group and 2 patients in the control group had recurrences within 12 months (difference not significant). CONCLUSION: In our study, awake video-assisted thoracoscopic bullectomy with pleural abrasion proved easily feasible and resulted in shorter hospital stays and reduced procedure-related costs while providing equivalent outcome to procedures performed under general anesthesia.

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Semin Pediatr Surg. 2007 Feb;16(1):14-26.
Minimal access thoracic surgery in the pediatric population.
Engum SA.
Indiana University School of Medicine, James Whitcomb Riley Hospital for Children, Indianapolis, Indiana 46202, USA. sengum@iupui.edu

Thoracoscopy was initially described for use in children to obtain pulmonary biopsy samples in the immunocompromised patient. With refinements in technique, development of better instrumentation, and advances in pediatric anesthesia, there are now many diagnostic and therapeutic indications for the use of thoracoscopy in children. One of the most common indications includes pleural debridement for empyema. Many centers consider this the optimal approach for biopsy of mediastinal lesions and excision of bronchogenic or duplication cysts. The technique is useful for pleural disorders, such as spontaneous pneumothorax and chylothorax. Thoracoscopy has been used to achieve exposure for spinal diskectomy in children with thoracic scoliosis, and newer techniques are being developed in performing anatomic lobectomies, repair of esophageal atesias, and closure of diaphragmatic hernias. The role of the robot in pediatric thoracoscopy is still in the early stages of definition.

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Surg Endosc. 2007 Feb;21(2):280-4. Epub 2006 Nov 21.
Video-assisted thoracic surgery in the treatment of pleural empyema.
Solaini L, Prusciano F, Bagioni P.
Thoracic Surgery Unit, Department of Surgery, S. Maria delle Croci Hospital, V.le Randi, 5, 48100, Ravenna, Italy. lsolaini@libero.it

BACKGROUND: The use of video-assisted thoracic surgery (VATS) in the treatment of pleural empyema has been proposed since the early 1990s, but among surgeons, its use varies considerably, and the results are discordant. This report aims to provide a retrospective assessment of the authors' experience and the literature on VATS in an effort to ascertain rational criteria for the use of this technique. METHODS: Over a period of 12 years, a total of 120 cases of pleural empyema were recorded. The patients were assessed with chest x-ray, computed tomography, ultrasound, and thoracentesis. On the basis of clearly defined clinical and radiographic parameters, 38 patients underwent VATS immediately, whereas the remaining 82 were treated initially by means of tube thoracostomy. The latter was found to be sufficient for only 10 patients. Consequently, for the remaining 72 patients, it was decided to proceed also with VATS. RESULTS: The procedure was performed completely by VATS in 101 patients (91.8%), whereas in 9 patients (8.2%) it was necessary to convert to thoracotomy. The postoperative course was uneventful for 98 of the 110 patients (89%), whereas the remaining 12 patients experienced complications, including one case of persistent empyema (0.9%) treated by thoracotomy. The mean chest tube duration was 6 days (range, 3-25 days). The mean postoperative hospital stay was 7.1 days (range, 5-17 days). Of the 80 patients completing a 6-month follow-up evaluation, the results were considered good for 72, moderately good for 8, and less than satisfactory for 2 patients. CONCLUSIONS: In conclusion, the authors consider VATS to be the technique of first choice for the treatment of pleural empyema when the disease is advanced or tube thoracostomy fails. It provides excellent results with a low level of invasiveness and considerably reduces the need for thoracotomy. These results can be achieved with good videothoracoscopic experience and the use of a very precise technique.

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Rev Port Pneumol. 2007 Jan-Feb;13(1):53-70.
[Complicated pleural effusion in children - Therapeutical approach.]
[Article in Portuguese]
Martins S, Valente S, Nunes David T, Pereira L, Barreto C, Bandeira T.
Interna de Internato Complementar de Pediatria / Resident of Paediatrics.

Pediatric management of complicated pleural effu- sion (CPE) remains controversial. Different approa- ches include antibiotics and chest tube drainage alone or the use of fibrinolitics, videothorascoscopy (VTC) and surgical decortication through thora- cotomy. The aim of the present study was to review, eva- luate and update technical approach to CPE. We retrospectively reviewed the clinical files of children admitted to the Pediatric Respiratory Ward between 1992 and 2003 with the diagnosis of CPE. Twenty- -five patients were included [15 male (60%)]. Mean (+/-SD) age was 37,4 (+/-37,0) months. Bacteria were identified in 17/25 (68%) [S. aureus in 6/17 (35%), St. pneumoniae in 5/17 (29%)], 16/17 (94%)in the pleu- ral fluid. Twenty-five children were treated with an- tibiotics and thoracocentesis (100%). Chest tube drainage was required in 22/25 (88%) with mean (+/-DP) duration of 14,2 (+/-7,8) days. Fibrinolitics were employed in 1 only case and surgical decortication in 11/25 (44%). One patient (4%) was submitted to primary VTC. Median length of stay was 30,4 (+/-15,1) days and no deaths were recorded. Center skills in CPE management are critical on the choice of the technique and the timing of approach. This seems to influence immediate prognosis. Rev Port Pneumol 2007; XIII (1): 53-70 Key-words: Pleural effusion, pleural empyema, child.

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Best Pract Res Clin Gastroenterol. 2007;21(1):55-75.
Management of ascites and hepatic hydrothorax.
Cardenas A, Arroyo V.
Institut de Malalties Digestives i Metaboliques, University of Barcelona, Hospital Clinic, Villaroel 170, Barcelona 08036, Spain. acardena@cliic.ub.es

The natural course of patients with cirrhosis is frequently complicated by the accumulation of fluid in the peritoneal or pleural cavities and interstitial tissue. Functional renal abnormalities that occur as a consequence of decreased effective arterial blood volume are responsible for fluid accumulation in the form of ascites and hepatic hydrothorax. Ascites is the most common complication of cirrhosis and poses an increased risk for infections, renal failure and mortality. Patients have a poor prognosis and it is estimated that nearly half will die in approximately 2 years without liver transplantation. Hepatic hydrothorax is defined as a pleural effusion greater than 500 mL (mostly right-sided) in patients with cirrhosis without cardiopulmonary disease; the estimated prevalence is approximately 5-10%. Liver transplantation is the most definitive cure for both conditions in those patients that are suitable candidates. However, the mainstay of therapy for minimizing fluid accumulation in both conditions includes sodium restriction and administration of diuretics. This article reviews the most current concepts of pathogenesis, clinical findings, diagnosis, and treatment of these complications of cirrhosis.

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Arch Bronconeumol. 2006 Dec;42(12):660-2.
[Outpatient management of malignant pleural effusion using a tunneled pleural catheter: Preliminary experience]
[Article in Spanish]
Seijo L, Campo A, Alcaide AB, Lacunza MM, Armendariz AC, Zulueta JJ.
Departamento de Neumologia, Clinica Universitaria, Universidad de Navarra, Pamplona, Navarra, Espana. lmseijo@unav.es

Inpatient management of malignant pleural effusion includes the placement of a conventional thoracostomy tube for drainage and talc slurry pleurodesis and/or a surgical approach consisting of video-assisted thoracoscopic talc insufflation. Both techniques require prolonged hospital stays of up to 1 week. Unfortunately, life expectancy in patients with this disease does not usually exceed 6 months, and so the primary aim of any palliative intervention intended to improve quality of life should be to avoid hospital admissions and to relieve pain as far as possible. Of the few outpatient alternatives to hospital management the most frequently used is repeated thoracentesis. We describe the outpatient management of malignant pleural effusion by placement of a tunneled pleural catheter in a patient with stage IIIB lung adenocarcinoma. In our opinion, the use of this catheter offers a viable alternative to conventional therapy and is better tolerated.

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Chest. 2006 Dec;130(6):1857-63.
Efficacy and complications of small-bore, wire-guided chest drains.
Horsley A, Jones L, White J, Henry M.
Molecular Medicine Centre, Western General Hospital, Crewe Road South, Edinburgh EH4 2XU, UK. alex.horsley@ed.ac.uk

BACKGROUND: Small-bore Seldinger-type chest drains have become increasingly popular in recent years, but there are few data on their effectiveness. METHODS: Data were collected prospectively at the time of drain insertion and continued until drain removal. Patients completed a visual analog score (VAS) of pain on drain insertion. RESULTS: Fifty-two drains were inserted in 44 patients over 10 months. Drain sizes ranged from 12 to 20F. The mean (+/- SEM) patient age was 64 +/- 2 years, and mean duration of drainage was 4.5 +/- 0.5 days. Fourteen drains (27%) were inserted for pneumothoraces, 19 drains (37%) for malignant effusions, 10 drains (19%) for empyema, 5 drains (10%) for parapneumonic effusions, and 4 drains (8%) for other effusions. Pain VAS ranged from 3 to 66 mm (maximum, 100 mm; average [+/- SD], 23 +/- 16 mm). Although the overall drain failure rate was 37%, there was only one serious complication (empyema), and this compares well with historical control subjects. Success rate was highest when used to treat malignant effusions (83%) and pneumothoraces (64%); drains inserted for empyema were more likely to block (overall success rate, 20%). There was no correlation between the type of fluid or size of drain and likelihood of blockage. CONCLUSIONS: Seldinger-type drains are a well-tolerated and effective method of draining pneumothoraces and uncomplicated effusions. They are more likely to block when draining empyemas but have a comparable failure rate in pneumothorax to large-bore drains.

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Cir Cir. 2006 Nov-Dec;74(6):409-14.
[Surgical procedures in 156 cases of pleural effusion: immediate results.]
[Article in Spanish]
Cicero-Sabido R, Paramo-Arroyo RF, Navarro-Reynoso FP, Pimentel-Ugarte L.
Servicio de Neumologia y Cirugia de Torax "Alejandro Celis," Hospital General de Mexico, Facultad de Medicina, Universidad Nacional Autonoma de Mexico, Apartado postal 7-933, 06702 Mexico, D.F., Mexico.

Background. Pleural effusion is a common clinical entity. Proper diagnosis and management are important for successful treatment. We undertook this study to evaluate immediate results of the procedures used in a group of cases with pleural effusion. Methods. Of 2589 patients at first consultation, 787 were hospitalized and 156 had pleural effusion. Diagnostic and therapeutic procedures used were evaluated. Results. With thoracentesis and evacuation of liquid, 23 nonneoplastic cases had resolution. Chest tube drainage with water seal was performed in 133 patients. This procedure suppressed the effusion in 109 patients, but in 24 patients another approach was necessary. In this group there were 35 neoplastic and 96 nonmalignant cases, the latter 36 were provoked by iatrogenic management. Twenty two cases of pneumothorax considered as gaseous effusion and 10 cases of chronic empyema sequelae of pleural effusions were also studied. Proportion comparison demonstrated significant differences between neoplastic and nonneoplastic effusions (p =0.001) and in cases managed with minimally invasive procedures and chest tube drainage (p =0.001). The performance of pleurodesis and thoracoscopy is discussed. In chronic cases, indications of open window thoracostomy and myoplasty are elucidated. Conclusions. In pleural effusion, opportune diagnosis and proper management are essential. A drainage tube can solve the majority of cases. Pneumothorax must be treated in the same way. In chronic empyema, open window thoracostomy and myoplasty are indicated. Careless patient management and poor treatment lead to iatrogenic complications.
 

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