RESUMO
Context: Tuberculous pleurisy (TP) is the most common manifestation of extrapulmonary tuberculosis and the most frequent cause of pleural effusion (PE). Clinicians make a definitive diagnosis of TP based on the isolation of the mycobacterium tuberculosis (MTB) from PE or a pleural biopsy. Since the currently available tests for TP all have limitations in making a definitive diagnosis, clinicians urgently need new diagnostic tests. Objective: The study intended to compare the value in clinically diagnosing TP of the paraffin-embedded sample test (PEST), using pleural-effusion samples; an adenosine deaminase assay (ADA) using pleural fluid; and the T cell enzyme-linked immunospot test (T-SPOT), using peripheral-blood. Design: The research team performed a retrospective observational study. Setting: The study took place at the Sir Run Run Hospital, Nanjing Medical University in Nanjing, Jiangsu, China. Participants: Participants were 37 patients with suspected TP who had been admitted to the hospital between September 2018 and December 2022. Outcome Measures: The research team assessed the diagnostic performance of PEST, ADA, and T-SPOT in the TP group, calculating the positive rate, sensitivity, specificity, negative predictive value (NPV), and positive predictive value (PPV) of the tests. Results: Among the 37 participants, the testing confirmed that 24 had TP (64.86%), with 13 not having TP (35.14%). The PEST test produced a sensitivity of 83.3% for TP, with 20 out of 24 participants in the TP group testing positive (95% CI: 61.8 to 94.5), which was superior to the ADA, with only 9 out of the 24 participants (37.5%) in the TP group testing positive (95% CI: 19.6 to 59.2), with P < .001. Conclusions: The PEST test possesses a high diagnostic value, and clinicians can use it as a time-saving, noninvasive, and highly sensitive method for TP diagnosis. It can be adjunct method to the currently used tests for diagnosing TP. A combination of several detection methods could promote effective treatment.
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Derrame Pleural , Tuberculose Extrapulmonar , Tuberculose Pleural , Humanos , Tuberculose Pleural/diagnóstico , Tuberculose Pleural/patologia , Inclusão em Parafina , Sensibilidade e Especificidade , Derrame Pleural/diagnóstico , Derrame Pleural/microbiologiaRESUMO
OBJECTIVE: There have been case reports of adverse events of hypoglossal nerve stimulator (HNS) implantation not seen in previous clinical trials, including pneumothorax and pleural effusion. The purpose of this study was to determine the rates of these complications and potential risk factors. STUDY DESIGN: Retrospective case-control study during 2014 to 2021. SETTING: Twenty-five health care organizations across the United States. METHODS: The TriNetX Research Network was queried by using disease codes to retrospectively identify patients with obstructive sleep apnea who underwent HNS implantation. Rates of pneumothorax, pleural effusion, other complications, and need for revision/replacement or explant were determined. RESULTS: We identified 1813 patients from 25 health care organizations who underwent HNS implantation. The average age was 60 years, and there were 68% males and 32% females. Of the cohort, 2.4% (n = 44 from 7 implant centers) experienced a pneumothorax, and 0.6% (n = 11) were diagnosed with a pleural effusion on the day of surgery. Patients who experienced pneumothorax were more likely to have a history of chronic lower respiratory diseases when compared with those who did not (odds ratio, 2.2; 95% CI, 1.1-4.1; P = .02). CONCLUSION: The incidence of intraoperative pneumothorax and pleural effusion during HNS implantation may be greater than initially thought. Patients with chronic lower respiratory diseases may be at increased risk. This should be communicated with patients during the informed consent process.
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Terapia por Estimulação Elétrica , Derrame Pleural , Pneumotórax , Masculino , Feminino , Humanos , Pessoa de Meia-Idade , Pneumotórax/etiologia , Pneumotórax/complicações , Estudos Retrospectivos , Estudos de Casos e Controles , Nervo Hipoglosso , Derrame Pleural/diagnóstico , Derrame Pleural/epidemiologia , Derrame Pleural/etiologia , Doença Iatrogênica/epidemiologia , Terapia por Estimulação Elétrica/efeitos adversosRESUMO
The consensus published in this issue was developed over a period of 1.5 years, and it was discussed and revised by the expertpanel from pleural and mediastinal diseases working group (preparatory) of Chinese Thoracic Society and external experts in several meetings. This article introduced the purpose, process and thinking in the writing of the consensus, hoping to provide a reference for readers to understand the content of this consensus and to make reasonable application in clinical practice.
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Medicina Tradicional Chinesa , Derrame Pleural , Humanos , Consenso , Derrame Pleural/diagnóstico , Pleura , ChinaRESUMO
OBJECTIVE: Thoracoscopic debridement under local anesthesia is a useful approach for complicated parapneumonic effusion or empyema (CPE) and is a less invasive procedure than video-assisted thoracoscopic surgery under general anesthesia. There are various methods of thoracoscopic debridement under local anesthesia, although the optimal timing of treatment is unknown. The objective of this study was to verify the efficacy and safety of our video-assisted flexible thoracoscopic debridement (VAFTS-D) procedure under local anesthesia, and to investigate the clinical features associated with the success of VAFTS-D. METHODS: The study included 71 consecutive patients with CPE who underwent VAFTS-D. The primary outcome was success of VAFTS-D. We retrospectively analyzed the efficacy and safety of VAFTS-D from the clinical data obtained from hospital medical records, and used univariate logistic analyses to identify potential predictors of the outcome. RESULTS: VAFTS-D was considered successful in 62 of 71 patients (87.3%). Two of the remaining nine patients died and the other seven patients required subsequent operation under general anesthesia. Complications due to VAFTS-D occurred in six patients (8.5%). Duration of empyema < 10 days (P = 0.024) and negative bacterial culture in pleural effusion (P = 0.029) were independently associated with the success of VAFTS-D by univariate logistic regression analysis. CONCLUSION: VAFTS-D might be an acceptable first-line procedure in patients with suspected CPE. VAFTS-D should be performed as early as possible for a successful outcome, and to obtain useful information on the pleural cavity.
Assuntos
Empiema Pleural , Derrame Pleural , Anestesia Local , Desbridamento/métodos , Empiema Pleural/complicações , Empiema Pleural/cirurgia , Humanos , Derrame Pleural/etiologia , Derrame Pleural/cirurgia , Estudos Retrospectivos , Instrumentos Cirúrgicos , Cirurgia Torácica Vídeoassistida/efeitos adversos , Cirurgia Torácica Vídeoassistida/métodos , Toracoscopia/métodos , Resultado do TratamentoAssuntos
Tubos Torácicos , Estado Terminal , Corpos Estranhos/cirurgia , Cavidade Pleural/cirurgia , Derrame Pleural/terapia , Cirurgia Assistida por Computador/métodos , Idoso de 80 Anos ou mais , Anestesia Local/métodos , Corpos Estranhos/complicações , Insuficiência Cardíaca/complicações , Hematoma/complicações , Hematoma/terapia , Humanos , Doenças Renais Císticas/complicações , Masculino , Derrame Pleural/complicações , Doença Pulmonar Obstrutiva Crônica/complicações , Insuficiência Respiratória/complicações , Insuficiência Respiratória/terapia , Ruptura , Choque Séptico/complicações , Choque Séptico/terapia , Toracentese , Tomografia Computadorizada por Raios X , UltrassonografiaRESUMO
The main clinical manifestations of pleural effusion are exertional dyspnea, predominantly dry cough, and pleuritic chest pain. To treat pleural effusion appropriately, it is important to determine its etiology; which however, remains unclear in nearly 20% of cases.A 73-year-old man with a history of invasive pulmonary tuberculosis (TB), had been experiencing chest congestion and dyspnea with undiagnosed pleural effusion for six years. After a series of clinical examination and laboratory tests, there was still no clear diagnosis. Despite administering diuretics and intermittent draining, the patient's condition aggravated progressively. He sought further treatment at Dongzhimen Hospital Respiratory Outpatient Clinic. The patient was treated with Zanthoxylum and Trichosanthes Decoction (Jiao Mu Gua Lou Tang). After one and a half years, his symptoms greatly improved and ultrasound revealed that the pleural effusion had apparently absorbed.It is suggested that TCM herbal formulas can play a critical role in preventing the progression of complicated, undiagnosed pleural effusion, especially in cases of poor response to conventional therapy and thoracentesis. Additional studies on the functions and mechanisms of the medicinals are warranted.
Assuntos
Medicina Tradicional Chinesa , Derrame Pleural , Idoso , Dispneia/tratamento farmacológico , Dispneia/etiologia , Humanos , Masculino , Medicina Tradicional Chinesa/efeitos adversos , Derrame Pleural/diagnóstico por imagem , Derrame Pleural/tratamento farmacológico , Derrame Pleural/etiologiaRESUMO
BACKGROUND: To investigate outcomes and morbidity of patients undergoing secondary cytoreductive surgery (CRS) and hyperthermic intraperitoneal chemotherapy (HIPEC) in recurrent ovarian cancer. MATERIALS AND METHODS: Between April 2014 and January 2019, a total of 51 recurrent ovarian cancer patients receiving secondary CRS and HIPEC were retrospectively reviewed. RESULTS: Among the 51 patients, median peritoneal cancer index score was 13 (range 3-34), and completeness of cytoreduction (CC) score of 0/1 was achieved in 41 patients (78.8%). Regimen of HIPEC included cisplatin and paclitaxel in 39 (75%) cases. The median follow-up duration of survivors was 20.2 months. Sixteen (30.8%) patients remained free of recurrence after HIPEC. The median progression-free survival (PFS) and overall survival (OS) were 11.8 months and 34.5 months respectively. Multivariate analysis showed previous chemotherapy <2 lines (HR 0.24, 0.11-0.52; p = 0.001), chemotherapy-free interval ≥6 months (HR 0.19, 0.09-0.37; p < 0.001) and CA125 < 35 U/mL before HIPEC (HR 0.133, 0.021-0.0832; p = 0.031) were good prognostic factors for PFS. CC0/1 was not significant in multivariate analysis. The most common grade 3/4 toxicity was anemia (17.3%), pleural effusion (11.5%) and renal insufficiency (5.7%). Patients with age ≥50, peritoneal carcinomatosis index (PCI) ≥ 11, operation time ≥10 h and diaphragm surgery had significantly higher incidence of pleural effusion. CONCLUSIONS: The current study showed adding HIPEC to secondary CRS might prolong PFS especially in patients with previous chemotherapy <2 lines, chemotherapy-free interval ≥6 months and CA125 < 35 U/mL before HIPEC.
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Hipertermia Induzida , Neoplasias Ovarianas , Neoplasias Peritoneais , Derrame Pleural , Humanos , Feminino , Carcinoma Epitelial do Ovário/tratamento farmacológico , Carcinoma Epitelial do Ovário/cirurgia , Quimioterapia Intraperitoneal Hipertérmica , Neoplasias Peritoneais/tratamento farmacológico , Neoplasias Peritoneais/etiologia , Hipertermia Induzida/efeitos adversos , Estudos Retrospectivos , Protocolos de Quimioterapia Combinada Antineoplásica/uso terapêutico , Terapia Combinada , Recidiva Local de Neoplasia , Taxa de Sobrevida , Neoplasias Ovarianas/tratamento farmacológico , Neoplasias Ovarianas/etiologia , Derrame Pleural/etiologiaRESUMO
Introdução: O derrame pleural modifica as capacidades pulmonares, provocando distúrbio ventilatório restritivo. As terapias respiratórias evitam a progressão e tratam a restrição de volumes pulmonares. Objetivo: Comparar o efeito agudo de três recursos fisioterapêuticos em pacientes com derrame pleural após procedimento de drenagem torácica. Métodos: Estudo experimental, randomizado e prospectivo, realizado com 60 pacientes com derrame pleural, todos hospitalizados. A amostra foi dividida em 3 grupos com 20 pacientes, cada grupo recebeu uma terapia respiratória: exercícios respiratórios, Threshold PEP™ ou Powerbreathe®. Para avaliar a função pulmonar foram utilizados, a espirometria, a manovacuometria e o peak flow. Os atendimentos foram diários, seguiu-se o protocolo de 4 séries de 15 repetições. Análise estatística: aplicou-se os testes qui-quadrado de Pearson, Shapiro-Wilk, Friedman, Wilcoxon e correlação de Spearman. Para todos os testes considerou-se o nível de significância de 5%. Resultados: Os exercícios respiratórios resultaram em diferenças significativas na capacidade vital forçada (CVF), antes 1,66±0,60 e depois 1,84±0,50 (p=0,01), no volume expiratório forçado no primeiro segundo (VEF1), antes 1,25±0,46 e depois 1,57±0,52 (p=0,01), enquanto o grupo tratado com Threshold PEP™ a diferença significativa foi apenas na CVF, antes 1,49±0,78 e depois 1,78±0,85 (p=0,04). Em relação à força muscular respiratória, nenhuma das terapias resultou em diferença significativa na PImax e PEmax. Conclusão: O protocolo com exercícios respiratórios demonstrou superioridade na função pulmonar quando comparado com o Threshold PEP™ e Powerbreath®, tornando-se mais indicado no manejo de pacientes com derrame pleural após drenagem torácica.
Assuntos
Humanos , Derrame Pleural , Exercícios Respiratórios , Modalidades de Fisioterapia , PneumopatiasRESUMO
BACKGROUND Post-cardiac injury syndrome, including pleural effusion as a delayed complication of permanent pacemaker implantation, has rarely been reported. To resolve pleural effusion, prolonged chest tube placement is often required. Anti-inflammatory agents combined with diuretics are also often prescribed. Saireito, a Japanese herbal medication, which is a combination of Goreisan and Shousaikoto, has both anti-inflammatory and water-modulation properties and has been used for edema (lymph edema, cerebral edema) and inflammation (chronic nephritis). CASE REPORT We describe a 71-year-old woman with a history of syncope and bradycardia who underwent dual permanent pacemaker implantation (placed in the right chest because of a persistent left superior vena cava) without complications. Two months later, she came to the hospital as an outpatient with a dry cough, and was diagnosed with right-sided pleural effusion. A pleural fluid analysis revealed exudative effusion, according to Light's criteria. The fluid was negative for infectious etiology. Chest X-ray, computed tomography, and echocardiography revealed no signs of pericardial effusion or perforation of the pacemaker lead to outside the heart. The pleural effusion persisted despite use of anti-inflammatory medication for several weeks and diuretics for a short period. Saireito was administered with good response; the pleural effusion resolved completely and there was no deterioration of renal function. CONCLUSIONS The present case highlights the clinical significance of Saireito as an effective therapeutic agent for late-onset pacemaker-related pleural effusion, without adverse effects such as renal dysfunction.
Assuntos
Marca-Passo Artificial , Derrame Pleural , Idoso , Medicamentos de Ervas Chinesas , Feminino , Humanos , Japão , Medicina Kampo , Derrame Pleural/etiologia , Derrame Pleural/terapia , Veia Cava SuperiorRESUMO
Chylothorax is a rare clinical sign in patients with diffuse large B-cell lymphoma (DLBCL), which is often challenging to manage and has a poor prognosis. We report the case of a 59-year-old woman who presented with right pleural effusion at the time of DLBCL diagnosis. Lymphadenopathy rapidly improved in response to chemotherapy. However, the pleural effusion progressed and was identified as chylothorax by thoracentesis. Because attempts to manage the condition with fasting and central venous nutrition were unsuccessful, we performed ultrasound-guided intranodal lipiodol lymphangiography from the inguinal lymph node. Although leak sites were not detected, the pleural effusion markedly improved on the day after the examination and resolved after 2 months. Lymphangiography is a minimally invasive examination with few complications. It contributes not only to the identification of leak sites but also to the improvement and resolution of chylothorax. Therefore, lymphangiography should be considered for refractory chylothorax that is unresponsive to chemotherapy or nutritional management.
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Quilotórax , Linfoma Difuso de Grandes Células B , Derrame Pleural , Óleo Etiodado , Feminino , Humanos , Linfografia , Pessoa de Meia-IdadeRESUMO
A male patient in his sixties with a long-term history of schizophrenia had been received glycerin enema once or twice a week in a mental hospital. He was emergently transferred to our hospital due to fever, vomiting, hematuria, and dyspnea. Laboratory findings on admission showed an elevation of white blood cells indicating inflammation, hemolysis, and renal dysfunction. Plain CT showed pleural effusion and ascites, elevated levels of perirectal fat, in addition to extraintestinal gas. Based on these findings, he was diagnosed with rectal damage caused by the glycerin enema and associated hemolysis with acute renal failure. He was kept under conditions of nil by mouth and received intravenous antibiotics, diuretic drug, and haptoglobin. Eventually, his condition improved with these conservative therapies. In this case, it is assumed that the hemolysis was caused by the influx of glycerin in the cytoplasm and an increase of osmotic pressure. Care should be taken during glycerin enema, which is widely used in daily practice as well as in home care settings.
Assuntos
Injúria Renal Aguda , Derrame Pleural , Injúria Renal Aguda/induzido quimicamente , Enema/efeitos adversos , Glicerol , Hemólise , Humanos , MasculinoRESUMO
BACKGROUND: The aim of this study is to compare the diagnostic efficacy and safety of video-assisted thoracoscopic surgery (VATS) with awake VATS (AVATS) pleural biopsy in undiagnosed exudative pleural effusions. METHODS: The diagnostic efficacy of pleural biopsy by uniportal VATS under general anesthesia or AVATS under local anesthesia and sedation performed by the same surgeon in patients with undiagnosed exudative pleural effusion between 2007 and 2020 were retrospectively evaluated. Test sensitivity, specificity, positive predictive value and negative predictive value were compared as well as age, gender, comorbidities, procedure safety, additional pleural-based interventions, duration time of operation and length of hospital stay. RESULTS: Of 154 patients with undiagnosed exudative pleural effusion, 113 (73.37%) underwent pleural biopsy and drainage with VATS, while 41 (26.62%) underwent AVATS pleural biopsy. Sensitivity, specificity, positive predictive value and negative predictive value were 92, 100, 100, and 85.71% for VATS, and 83.3, 100, 100, and 78.9% for AVATS, respectively. There was no significant difference in diagnostic test performance between the groups, (p = 0.219). There was no difference in the rate of complications [15 VATS (13.3) versus 4 AVATS (9.8%), p = 0.557]. Considering additional pleural-based interventions, while pleural decortication was performed in 13 (11.5%) cases in the VATS group, no pleural decortication was performed in AVATS group, (p = 0.021). AVATS group was associated with shorter duration time of operation than VATS (22.17 + 6.57 min. Versus 51.93 + 8.85 min., p < 0.001). Length of hospital stay was relatively shorter in AVATS but this was not statistically significant different (p = 0.063). CONCLUSIONS: Our study revealed that uniportal AVATS pleural biopsy has a similar diagnostic efficacy and safety profile with VATS in the diagnosis and treatment of patients with undiagnosed pleural effusion who have a high risk of general anesthesia due to advanced age and comorbidities. Accordingly, uniportal AVATS pleural biopsy may be considered in the diagnosis and treatment of all exudative undiagnosed pleural effusions.
Assuntos
Anestesia Geral , Anestesia Local , Sedação Consciente , Pleura/patologia , Derrame Pleural/etiologia , Derrame Pleural/patologia , Cirurgia Torácica Vídeoassistida/métodos , Adulto , Idoso , Idoso de 80 Anos ou mais , Biópsia , Feminino , Seguimentos , Humanos , Tempo de Internação , Masculino , Pessoa de Meia-Idade , Duração da Cirurgia , Avaliação de Resultados em Cuidados de Saúde , Pleura/cirurgia , Valor Preditivo dos Testes , Estudos Retrospectivos , Sensibilidade e Especificidade , VigíliaRESUMO
BACKGROUND: Pleural effusion (PE) is one of the most common complications of advanced recurrent ovarian cancer. However, no studies have revealed the risk factors for PE after surgery. The purpose of this study is to observe the incidence and risk factors of PE after cytoreductive surgery (CRS) and hyperthermic intraperitoneal chemotherapy (HIPEC) in patients with late-stage and recurrent ovarian cancer. METHODS: A retrospective analysis of 77 patients with late-stage and recurrent ovarian cancer after CRS + HIPEC was conducted. According to the presence of PE within 7 days after operation, two groups were formed. The basic information, surgical process, and laboratory examinations of the two groups were analyzed and compared to conduct a regression analysis. RESULTS: The incidence of postoperative PE was 57.1% (44/77 patients). Among these patients, the prevalence of grade I-II and grade III-IV PE was 42.8% (33/77 patients) and 14.3% (11/77 patients), respectively. There were statistically significant differences between the two groups in terms of preoperative PE, the duration of surgery, intraoperative blood loss, postoperative level of albumin, intestinal involvement, and diaphragmatic involvement. Among these, preoperative PE and diaphragmatic involvement were identified as independent risk factors of postoperative PE. CONCLUSIONS: Patients with late-stage and recurrent ovarian cancer invariably develop postoperative PE after CRS + HIPEC. Preoperative PE and diaphragmatic involvement are independent risk factors of postoperative PE. It is estimated that the incidence of postoperative PE among patients with these two independent risk factors is approximately 100%. Hence, we should promote the prevention and treatment of PE to improve its prognosis.
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Hipertermia Induzida , Neoplasias Ovarianas , Neoplasias Peritoneais , Derrame Pleural , Terapia Combinada , Procedimentos Cirúrgicos de Citorredução/efeitos adversos , Feminino , Humanos , Hipertermia Induzida/efeitos adversos , Quimioterapia Intraperitoneal Hipertérmica , Neoplasias Ovarianas/tratamento farmacológico , Neoplasias Peritoneais/tratamento farmacológico , Derrame Pleural/etiologia , Estudos Retrospectivos , Fatores de RiscoRESUMO
INTRODUCTION: Diagnosing tuberculous pleurisy is important in Japan because it currently has a moderate tuberculosis prevalence. However, physicians often have difficulty making a diagnosis. It was reported that thoracoscopy under local anesthesia is useful for the diagnosis of tuberculous pleurisy, but there are no reports focusing on elderly patients. METHODS: In this study, the usefulness of thoracoscopy under local anesthesia was evaluated in elderly patients. Among 170 patients who underwent thoracoscopy under local anesthesia at our hospital during 11 years from January 2008 to December 2018, those aged 75 years or older (n = 75) were investigated retrospectively. RESULTS: A total of 55 patients underwent thoracoscopy under local anesthesia for detailed examination of pleural effusion of unknown cause. Of these, 18 were diagnosed as tuberculous pleurisy. The median age was 82 years (range: 75-92 years). The diagnosis of tuberculous pleurisy was made in 11 patients in whom Mycobacterium tuberculosis was detected and in four patients whose pathological findings indicated epithelioid granuloma accompanied by caseous necrosis. Clinical diagnosis was made in the remaining three patients based on thoracoscopic findings of the pleural cavity and a high level of adenosine deaminase in pleural fluid. No serious complications attributable to the examination were observed in any patient. CONCLUSIONS: Thoracoscopy under local anesthesia was useful for the diagnosis of tuberculous pleurisy in elderly patients, with useful information being also obtained for the treatment of tuberculosis.
Assuntos
Derrame Pleural , Tuberculose Pleural , Idoso , Idoso de 80 Anos ou mais , Anestesia Local , Humanos , Japão , Pleura , Estudos Retrospectivos , Toracoscopia , Tuberculose Pleural/diagnósticoRESUMO
BACKGROUND: Medical thoracoscopy is the gold standard for the diagnosis of pleural diseases. To date, no consensus exists regarding the choice of sedative and analgesic agents in patients undergoing local anesthetic thoracoscopy (LAT), and questions are raised as to whether sedatives may add to respiratory side effects. OBJECTIVE: The aim of the study was to test the hypothesis that administration of midazolam associated with lidocaine versus lidocaine alone in patients with LAT adds to respiratory side effects. METHODS: We randomly assigned 80 patients to a 1:1 study to 2 groups: local anesthesia by lidocaine (n = 40) versus lidocaine and midazolam (n = 40), with the primary end point being the mean lowest oxygen saturation. The secondary end points were cardiovascular parameters, complications, days of drainage, hospital stay, and patients' quality of life (QoL) as assessed by a visual analog scale (VAS). RESULTS: The mean age of all patients was 66.6 ± 13.1 years. The study comprised 50 males (62.5%). No difference was observed in the demographics between the 2 groups. No significant difference was observed between the 2 groups in oxygen saturation (primary end point). A significant difference was observed in favor of the midazolam group regarding the QoL assessed by VAS. CONCLUSION: Midazolam does not add to respiratory side effects when it is used with lidocaine for LAT, while patients' QoL is actually improved in this group. Therefore, in our department, we changed our startegy in favor of the association of lidocaine and midazolam.
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Adjuvantes Anestésicos/administração & dosagem , Anestesia Local , Anestésicos Locais/administração & dosagem , Lidocaína/administração & dosagem , Pneumopatias/diagnóstico , Midazolam/administração & dosagem , Qualidade de Vida , Toracoscopia/métodos , Adjuvantes Anestésicos/efeitos adversos , Idoso , Anestésicos Locais/efeitos adversos , Feminino , Humanos , Lidocaína/efeitos adversos , Masculino , Midazolam/efeitos adversos , Pessoa de Meia-Idade , Manejo da Dor/métodos , Derrame Pleural/diagnósticoRESUMO
BACKGROUND: Preeclampsia (PE) refers to the development of hypertension and new-onset proteinuria or progressive organ damage (especially kidney) in a previously normotensive pregnant women after 20 weeks of gestation. Thus, new-onset nephrotic syndrome due to PE before 20 weeks of gestation seems to be rare, making its diagnosis difficult in this time period. CASE PRESENTATION: A 28-year-old woman presented with a new-onset nephrotic syndrome at 16 weeks of gestation. A high dose of oral glucocorticoids (prednisolone, 40 mg) was initiated for presumed glomerulonephritis since she presented with severe nephrotic syndrome before 20 weeks of gestation, however, the treatment was not effective. At 21 weeks of gestation, we confirmed that the soluble fms-like tyrosine kinase-1 (sFlt-1)/placental growth factor (PlGF) ratio was very high (sFlt-1, 13,400 pg/mL; PlGF, 21.9 pg/mL; serum sFlt-1/PlGF ratio 611.9). Therefore, we diagnosed nephrotic syndrome due to PE, and oral glucocorticoids were discontinued. After she underwent a cesarean section at 24 weeks & 3 days, we performed a kidney biopsy. Focal segmental sclerotic lesions with epithelial cell hyperplasia and foam cells in the tubular poles were seen on light microscopy. On immunofluorescence tests, C4d staining showed linear peripheral patterns in the glomeruli. Electron microscopy revealed diffuse subendothelial edema with focal foot process effacement. The histological diagnosis was severe glomerular endotheliosis with focal segmental glomerulosclerosis. Furthermore, the histology of placenta was consistent with PE. Eight months after delivery, her proteinuria disappeared completely. CONCLUSIONS: We not only confirmed an abnormal serum sFlt-1/PlGF ratio but also presented the histology compatible with pure PE in the kidney and placenta in a case of nephrotic syndrome before 20 weeks of gestation. The serum sFlt-1/PlGF ratio may be useful in determining the treatment strategy for atypical cases of pregnant women with nephrotic syndrome, particularly before 20 weeks of gestation.
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Glomerulosclerose Segmentar e Focal/patologia , Síndrome Nefrótica/diagnóstico , Pré-Eclâmpsia/diagnóstico , Adulto , Anti-Hipertensivos/uso terapêutico , Cesárea , Edema/fisiopatologia , Feminino , Furosemida/uso terapêutico , Glomerulosclerose Segmentar e Focal/fisiopatologia , Glucocorticoides/uso terapêutico , Humanos , Síndrome Nefrótica/patologia , Síndrome Nefrótica/fisiopatologia , Síndrome Nefrótica/terapia , Fator de Crescimento Placentário/sangue , Derrame Pleural/fisiopatologia , Pré-Eclâmpsia/sangue , Pré-Eclâmpsia/fisiopatologia , Pré-Eclâmpsia/terapia , Prednisolona/uso terapêutico , Gravidez , Segundo Trimestre da Gravidez , Recuperação de Função Fisiológica , Albumina Sérica Humana/uso terapêutico , Inibidores de Simportadores de Cloreto de Sódio e Potássio/uso terapêutico , Receptor 1 de Fatores de Crescimento do Endotélio Vascular/sangueRESUMO
INTRODUCTION: The evolution of the microbial epidemiology of pleuropulmonary infections complicating community-acquired pneumonia has resulted in a change in empirical or targeted antibiotic therapy in children in the post Prevenar 13 era. The three main pathogens involved in pleural empyema in children are Streptococcus pneumoniae, Staphylococcus aureus and group A Streptococcus. METHODS: A questionnaire according to the DELPHI method was sent to experts in the field (paediatric pulmonologists and infectious disease specialists) in France with the purpose of reaching a consensus on the conservative antibiotic treatment of pleural empyema in children. Two rounds were completed as part of this DELPHI process. RESULTS: Our work has shown that in the absence of clinical signs of severity, the prescription of an intravenous monotherapy is consensual but there is no agreement on the choice of drug to use. A consensus was also reached on treatment adjustment based on the results of blood cultures, the non-systematic use of a combination therapy, the need for continued oral therapy and the lack of impact of pleural drainage on infection control. On the other hand, after the second round of DELPHI, there was no consensus on the duration of intravenous antibiotic therapy and on the treatment of severe pleural empyema, especially when caused by Staphylococci. CONCLUSIONS: The result of this work highlights the needed for new French recommendations based on the evolution of microbial epidemiology in the post PCV13 era.
Assuntos
Antibacterianos/uso terapêutico , Técnica Delphi , Empiema Pleural/tratamento farmacológico , Empiema Pleural/epidemiologia , Pediatria , Idade de Início , Antibacterianos/classificação , Gestão de Antimicrobianos/métodos , Gestão de Antimicrobianos/normas , Criança , Consenso , Empiema Pleural/microbiologia , Prova Pericial/estatística & dados numéricos , Feminino , França/epidemiologia , Humanos , Masculino , Testes de Sensibilidade Microbiana/estatística & dados numéricos , Pediatria/métodos , Pediatria/normas , Derrame Pleural/tratamento farmacológico , Derrame Pleural/epidemiologia , Padrões de Prática Médica/estatística & dados numéricos , Infecções Respiratórias/epidemiologia , Infecções Respiratórias/microbiologia , Infecções Respiratórias/terapiaRESUMO
La ascitis quilosa posoperatoria (AQP) se debe a acumulación de líquido rico en triglicéridos en la cavidad peritoneal tras una lesión en la cisterna del quilo o en sus afluentes. Es infrecuente verla después de una hepatectomía. Se presenta el caso de un varón de 44 años con adenocarcinoma a 16 cm del margen anal T3N1, con metástasis que ocupaba casi la totalidad del lóbulo hepático derecho. Luego de quimioterapia se realizó hepatectomía derecha, observándose al cuarto día postoperatorio líquido del drenaje endotorácico de aspecto lechoso, con triglicéridos 223 mg/dL y 77 mg/dL de triglicéridos séricos. Se inició dieta sin grasas, hiperproteica, con ácidos grasos de cadena media y octreótide (100 microgramos subcutáneos cada 8 horas), con resolución del cuadro. En conclusión, la complicación quilosa puede tratarse exitosamente con un abordaje menos agresivo, sin suprimir la ingesta oral, utilizando octreótide subcutáneo, dieta exenta de grasas, suplementada con proteínas y ácidos grasos de cadena media.
Postoperative chylous ascites is an intraperitoneal collection of lymphatic fluid enriched with long-chain triglycerides that results from injury of the cisterna chyli or its main tributaries. This complication is rare after liver resections. Here, we report on the case of a 44 year-old man with a T3N1 rectal adenocarcinoma 16 cm above the anal margin, with metastatic compromise of almost the entire right liver lobe. Following chemotherapy, he underwent right liver resection. On postoperative day four, the thoracic drain evidenced milky fluid containing triglyceride 223 mg/dL with serum triglycerides 77 mg/dL. A fat-free diet was indicated with fat-free protein supplements, medium chain triglycerides and octreotide (100 μg subcutaneously every 8 hours), with complete resolution. In conclusion, postoperative chylous complications may be treated successfully by a less aggressive approach, with oral diet, subcutaneous octreotide, fat-free diet supplemented with proteins and medium chain fatty acids.