Making the transition from video-assisted thoracoscopic surgery to chest tube with fibrinolytics for empyema in children: Any change in outcomes?

BACKGROUND: There is ongoing variation in the use of video-assisted thoracoscopic surgery (VATS) and chest tube with fibrinolytics (CTWF) for empyema in children. Our objective was to report outcomes from a centre that recently made the transition from VATS to CTWF as the primary treatment modality. METHODS: We conducted a historical cohort study of children with empyema treated with either primary VATS (between 2005 and 2009) or CTWF (between 2009 and 2013). RESULTS: Sixty-seven children underwent pleural drainage for empyema during the study period: 28 (42%) were treated with primary VATS, and 39 (58%) underwent CTWF. There were no significant differences between the VATS and CTWF groups for length of stay (8 v. 9 d, p = 0.61) or need for additional procedures (4% v. 13%, p = 0.19). Length of stay varied widely for both VATS (4-53 d) and CTWF (5-46 d). Primary VATS failed in 1 (4%) patient, who required an additional chest tube, and CTWF failed in 5 (13%) patients. Additional procedures included 3 rescue VATS, 2 additional chest tubes and 1 thoracotomy. All patients recovered and were discharged home. CONCLUSION: Primary VATS and CTWF were associated with similar outcomes in children with empyema. There appears to be a subset of children at risk for treatment failure with CTWF. Further research is needed to determine if these patients would benefit from primary VATS.

CONTEXTE: Il existe une certaine variation dans le choix de l'intervention chirurgicale thoracoscopique assistée par vidéo (CTAV) ou de l'installation d'un drain thoracique accompagné de fibrinolytiques (DTIF) pour traiter la pleurésie purulente chez les enfants. L'objectif de cette étude était de décrire les résultats observés dans un centre ayant récemment remplacé la CTAV par le DTIF comme traitement de première intention. MÉTHODES: Nous avons mené une étude de cohorte rétrospective auprès d'enfants atteints de pleurésie purulente, qui ont été traités soit par CTAV (entre 2005 et 2009), soit par l'installation d'un DTIF (entre 2009 et 2013). RÉSULTATS: Pendant la période à l'étude, 67 enfants ont subi un drainage pleural. De ce nombre, 28 (42 %) ont été traités par CTAV, et 39 (58 %) par DTIF. Aucune différence significative n'a été observée entre ces 2 groupes sur le plan de la durée du séjour (8 j. [CTAV] contre 9 j. [DTIF], p = 0,61) et du recours à des interventions supplémentaires (4 % [CTAV] contre 13 % [DTIF], p = 0,19). La durée du séjour était toutefois très variable dans les 2 cas : entre 4 et 53 jours dans le groupe de la CTAV, et entre 5 et 46 jours dans celui du DTIF. La CTAV a échoué dans un cas (4 %), et un drain thoracique supplémentaire a dû être installé. La pose d'un DTIF s'est soldée par un échec dans 5 cas (13 %), qui ont nécessité 3 CTAV d'urgence, l'installation de 2 drains thoraciques additionnels et une thoracotomie. Tous les patients se sont rétablis et ont obtenu leur congé. CONCLUSION: La CTAV et le DTIF employés comme traitements de première intention sont associés à des résultats semblables chez les enfants atteints de pleurésie purulente, mais l'installation d'un DTIF semble être plus susceptible d'échouer chez un sous-ensemble d'enfants. D'autres recherches seront nécessaires pour déterminer s'il serait préférable d'avoir recours à la CTAV comme traitement de première intention.

A case of new onset keratosis pilaris after discontinuation of erlotinib.

IMPORTANCE: Keratosis pilaris and keratosis pilaris-like eruptions have been reported in association with RAF inhibitors sorafenib and vemurafenib. We describe herein what is to our knowledge the first reported case of new onset keratosis pilaris after discontinuation of EGFR inhibitor erlotinib. OBSERVATIONS: A 60 year-old female with stage IV lung cancer was treated with erlotinib (100 mg/d). The patient elected to discontinue erlotinib after four years secondary to adverse systemic reactions. However, five months later small, monomorphic, rough, folliculocentric papules with surrounding mild erythema characteristic of keratosis pilaris were noted on upper back and arms. CONCLUSIONS AND RELEVANCE: This serves as the first documented case of new onset keratosis pilaris in a patient after discontinuation of erlotinib. We report the present case to show the possible association of keratosis pilaris with not only RAF inhibitors, but also the EGFR inhibitor erlotinib. Further investigation will determine whether this is a class effect with other systemic EGFR inhibitors.

Bracing in pediatric patients with pectus carinatum is effective and improves quality of life.

PURPOSE: The purpose of this study was to examine the effectiveness and patient satisfaction with bracing for pectus carinatum (PC). MATERIALS AND METHODS: Twenty-five PC patients were treated between August 2007 and October 2011. Most patients were male (21/25,84%) with a mean age of 14.4 ± 2.0 yrs. A lightweight, patient controlled, external brace (Braceworks, Calgary, AB) was used. Monthly follow-up with anterior-posterior (AP) width measurements occurred until bracing was completed. Three quality of life (QOL) questionnaires were used: SF-36, SSQ, and PEEQ. RESULTS: Group 1 involved twenty patients who successfully completed bracing (12/25,56%) or who are still bracing (8/25,32%). Group 2 comprised five patients who failed bracing (2/25,8%) or who were noncompliant (3/25,12%). One patient who failed bracing underwent successful Ravitch repair. AP width decreased more in those with successful bracing (2.31 vs 0.64 cm, p=0.05). Questionnaires were completed by 19/25 (76%) patients. Pre-bracing, the SF-36, and PEEQ revealed that few patients were symptomatic, although most still avoided activities which showed their chest. The SSQ revealed that the majority of patients were very satisfied with their post-bracing appearance, experienced minimal discomfort while bracing, and would use the brace again. Self-esteem increased significantly after bracing (7.5 vs 8.7, p=0.01). CONCLUSIONS: Bracing in PC patients is very effective in a compliant patient with close follow-up. Surgical repair remains feasible if bracing fails.