Optimal Conduit Diameter Selection in Coronary Bypass Grafting Using Saphenous Vein.

BACKGROUND: Predictors of long-term saphenous vein graft (SVG) patency following coronary artery bypass grafting (CABG) include harvesting technique, degree of proximal coronary stenosis, and target vessel diameter and runoff. The objective of this study was to evaluate the association between vein graft diameter and long-term survival. METHODS: Patients undergoing primary CABG (2000-2017) at Flinders Medical Centre, Adelaide, Australia, were categorised into three groups according to average SVG diameter (<3.5 mm [small], 3.5-4 mm [medium], >4 mm [large]). Survival data was obtained from the Australian Institute of Health and Welfare National Death Index. To determine the association of SVG diameter with long-term survival we used Kaplan-Meier survival analysis and Cox proportional hazard models adjusted for preoperative variables associated with survival. RESULTS: Vein graft diameter was collected in 3,797 patients. Median follow-up time was 7.6 years (interquartile range, 3.9-11.8) with 1,377 deaths. SVG size >4 mm was associated with lower rates of adjusted survival up to 4 years postoperatively (hazard ratio 1.48; 95% confidence interval 1.05-2.1; p=0.026). CONCLUSIONS: Vein graft diameter >4mm was found to be associated with lower rates of survival following CABG.

Mating Disruption as a Suppression Tactic in Programs Targeting Regulated Lepidopteran Pests in US.

Mating disruption, the broadcast application of sex-attractant pheromone to reduce the ability of insects to locate mates, has proven to be an effective method for suppressing populations of numerous moth pests. Since the conception of mating disruption, the species-specificity and low toxicity of pheromone applications has led to their consideration for use in area-wide programs to manage invasive moths. Case histories are presented for four such programs where the tactic was used in the United States: Pectinophora gossypiella (pink bollworm), Lymantria dispar (gypsy moth), Epiphyas postvittana (light brown apple moth), and Lobesia botrana (European grapevine moth). Use of mating disruption against P. gossypiella and L. botrana was restricted primarily to agricultural areas and relied in part (P. gossypiella) or wholly (L. botrana) on hand-applied dispensers. In those programs, mating disruption was integrated with other suppression tactics and considered an important component of overall efforts that are leading toward eradication of the invasive pests from North America. By contrast, L. dispar and E. postvittana are polyphagous pests, where pheromone formulations have been applied aerially as stand-alone treatments across broad areas, including residential neighborhoods. For L. dispar, mating disruption has been a key component in the program to slow the spread of the infestation of this pest, and the applications generally have been well tolerated by the public. For E. postvittana, public outcry halted the use of aerially applied mating disruption after an initial series of treatments, effectively thwarting an attempt to eradicate this pest from California. Reasons for the discrepancies between these two programs are not entirely clear.

Genetic structure, admixture and invasion success in a Holarctic defoliator, the gypsy moth (Lymantria dispar, Lepidoptera: Erebidae).

Characterizing the current population structure of potentially invasive species provides a critical context for identifying source populations and for understanding why invasions are successful. Non-native populations inevitably lose genetic diversity during initial colonization events, but subsequent admixture among independently introduced lineages may increase both genetic variation and adaptive potential. Here we characterize the population structure of the gypsy moth (Lymantria dispar Linnaeus), one of the world's most destructive forest pests. Native to Eurasia and recently introduced to North America, the current distribution of gypsy moth includes forests throughout the temperate region of the northern hemisphere. Analyses of microsatellite loci and mitochondrial DNA sequences for 1738 individuals identified four genetic clusters within L. dispar. Three of these clusters correspond to the three named subspecies; North American populations represent a distinct fourth cluster, presumably a consequence of the population bottleneck and allele frequency change that accompanied introduction. We find no evidence that admixture has been an important catalyst of the successful invasion and range expansion in North America. However, we do find evidence of ongoing hybridization between subspecies and increased genetic variation in gypsy moth populations from Eastern Asia, populations that now pose a threat of further human-mediated introductions. Finally, we show that current patterns of variation can be explained in terms of climate and habitat changes during the Pleistocene, a time when temperate forests expanded and contracted. Deeply diverged matrilines in Europe imply that gypsy moths have been there for a long time and are not recent arrivals from Asia.

Identification of a potential third component of the male-produced pheromone of Anoplophora glabripennis and its effect on behavior.

The Asian longhorned beetle, Anoplophora glabripennis, is considered to be one of the most serious invasive pests of deciduous trees in North America. An efficient monitoring trap is needed to detect and delimit new introductions and assess population densities of established infestations. Previous studies on A. glabripennis have shown that males produce a two-component aggregation pheromone that consists of a 1:1 blend of 4-(n-heptyloxy)butan-1-ol and 4-(n-heptyloxy)butanal. Moderate attraction in field trapping studies suggested that there may be additional chemical cues missing. Volatiles from male A. glabripennis were examined to identify other potential pheromone components. Gas chromatographic / electroantennographic (GC/EAD) analyses of male aerations detected a consistent EAD-active response to a previously unidentified compound. This compound was identified as (3E,6E)-α-farnesene. Both male and female beetles were antennally responsive to this sesquiterpene, and both sexes were attracted to it in olfactometer bioassays at different doses. When (3E,6E)-α-farnesene was combined with 4-(n-heptyloxy)butan-1-ol and 4-(n-heptyloxy)butanal, attraction of both sexes increased compared to assays using 4-(n-heptyloxy)butan-1-ol and 4-(n-heptyloxy)butanal alone.

Improving detection tools for emerald ash borer (Coleoptera: Buprestidae): comparison of multifunnel traps, prism traps, and lure types at varying population densities.

The emerald ash borer, Agrilus planipennis Fairmaire (Coleoptera: Buprestidae), is a serious invasive pest of North American ash (Fraxinus spp.) that has caused devastating mortality since it was first identified in North America in 2002. In 2012, we conducted field trapping assays that tested the efficacy of purple prism and fluon-coated green multifunnel (Lindgren funnel) traps. Traps were baited with combinations of several lures that were previously shown to be attractive to A. planipennis: manuka oil--a sesquiterpene-rich oil, (3Z)-hexenol--a green leaf volatile, or (3Z)-dodecen-12-olide [= (3Z)-lactone], a sex pheromone. Eighty-nine blocks (trap lines) were tested throughout nine states along the outer edges of the currently known A. planipennis infestation in North America. Trap catch was highest on fluon-coated green multifunnel traps, and trap detections at sites with low A. planipennis population density ranged from 72 to 76% for all trap and lure types tested. (3Z)-hexenol and (3Z)-lactone baited traps functioned as well as (3Z)-hexenol and manuka oil-baited traps. Independent of the lure used, detection rates on green fluon-coated multifunnel traps were comparable with glued purple prism traps in areas with low A. planipennis population densities.

Improving detection tools for the emerald ash borer (Coleoptera: Buprestidae): comparison of prism and multifunnel traps at varying population densities.

The current emerald ash borer survey trap used in the United States is a prism trap constructed from a stock purple corrugated plastic. In recent years, several colors (particularly shades of green and purple) have been shown to be more attractive to the emerald ash borer than this stock color. Our goal was to determine if plastics produced with these colors and incorporated into prism traps can improve and serve as a new alternative to plastics already in use for the emerald ash borer survey. The plastics were tested in moderate to heavily infested areas in Michigan in two initial studies to test their effectiveness at catching the emerald ash borer. Because results from studies performed in heavily infested sites may not always correspond with what is found along the edges of the infestation, we compared trap catch and detection rates (recording at least one catch on a trap over the course of the entire trapping season) of several trap types and colors at sites outside the core of the currently known emerald ash borer infestation in a nine-state detection tool comparison study. Two of the new plastics, a (Sabic) purple and a medium-dark (Sabic) green were incorporated into prism traps and tested alongside a standard purple prism trap and a green multifunnel trap. In areas with lower emerald ash borer density, the new purple (Sabic) corrugated plastic caught more beetles than the current purple prism trap, as well as more than the medium-dark green (Sabic) prism and green multifunnel traps. Sabic purple traps in the detection tools comparison study recorded a detection rate of 86% compared with 73, 66, and 58% for the standard purple, Sabic green, and green multifunnel traps, respectively. These detection rates were reduced to 80, 63, 55, and 46%, respectively, at low emerald ash borer density sites.

JMJD6 is a driver of cellular proliferation and motility and a marker of poor prognosis in breast cancer.

INTRODUCTION: We developed an analytic strategy that correlates gene expression and clinical outcomes as a means to identify novel candidate oncogenes operative in breast cancer. This analysis, followed by functional characterization, resulted in the identification of Jumonji Domain Containing 6 (JMJD6) protein as a novel driver of oncogenic properties in breast cancer. METHODS: Through microarray informatics, Cox proportional hazards regression was used to analyze the correlation between gene expression and distant metastasis-free survival (DMFS) of patients in 14 independent breast cancer cohorts. JMJD6 emerged as a top candidate gene robustly associated with poor patient survival. Immunohistochemistry, siRNA-mediated silencing, and forced overexpression of JMJD6 in cell-based assays elucidated molecular mechanisms of JMJD6 action in breast cancer progression and shed light on the clinical breast cancer subtypes relevant to JMJD6 action. RESULTS: JMJD6 was expressed at highest levels in tumors associated with worse outcomes, including ER- and basal-like, Claudin-low, Her2-enriched, and ER+ Luminal B tumors. High nuclear JMJD6 protein was associated with ER negativity, advanced grade, and poor differentiation in tissue microarrays. Separation of ER+/LN- patients that received endocrine monotherapy indicated that JMJD6 is predictive of poor outcome in treatment-specific subgroups. In breast cancer cell lines, loss of JMJD6 consistently resulted in suppressed proliferation but not apoptosis, whereas forced stable overexpression increased growth. In addition, knockdown of JMJD6 in invasive cell lines, such as MDA-MB231, decreased motility and invasion, whereas overexpression in MCF-7 cells slightly promoted motility but did not confer invasive growth. Microarray analysis showed that the most significant transcriptional changes occurred in cell-proliferation genes and genes of the TGF-ß tumor-suppressor pathway. High proliferation was characterized by constitutively high cyclin E protein levels. The inverse relation of JMJD6 expression with TGF-ß2 could be extrapolated to the breast cancer cohorts, suggesting that JMJD6 may affect similar pathways in primary breast cancer. CONCLUSIONS: JMJD6 is a novel biomarker of tumor aggressiveness with functional implications in breast cancer growth and migration.

Quantification of the internal mammary artery size in Aboriginal and Torres Strait islanders.

BACKGROUND: Variation in size of the internal mammary artery has been demonstrated in ethnic groups, but not reported in Aboriginal patients. We hypothesised that the left internal mammary artery is smaller in Aboriginal patients compared to non-Aboriginal patients and aimed to determine the impact on survival following coronary artery bypass graft (CABG) surgery. METHODS: Left internal mammary artery size was compared between Aboriginal (n = 345) and non-Aboriginal (n = 1819) in 2343 patients undergoing CABG at Flinders Medical Centre from January 2010 to June 2021. To determine the association with-survival we used Kaplan-Meier survival analysis and Cox proportional hazard models adjusted for preoperative variables. RESULTS: There was a significant difference in left internal mammary artery (LIMA) size-Aboriginal 1.8 ± 0.4 mm; non-Aboriginal 2.1 ± 0.4 mm (P < 0.001)-and left anterior descending (LAD) artery size-Aboriginal 1.7 ± 0.3 mm; non-Aboriginal 1.9 ± 0.3 mm (P < 0.001). Aboriginal patients were more likely to have the LIMA discarded (9.3% vs. 0.4%) and to receive a LAD vein graft (17% versus 3%) (P < 0.001). There was no difference in 30-day mortality or survival <5 years. CONCLUSION: This study supports the hypothesis that the left internal mammary artery is smaller in Aboriginal patients compared to non-Aboriginal patients. Although Aboriginal patients were more likely to receive a venous conduit to the LAD, we observed no difference in survival up to 5 years. This data contrasts with reported outcomes of other ethnic groups.

Efficacy of multifunnel traps for capturing emerald ash borer (Coleoptera: Buprestidae): effect of color, glue, and other trap coatings.

Tens of thousands of adhesive-coated purple prism traps are deployed annually in the United States to survey for the invasive emerald ash borer, Agrilus planipennis Fairmaire (Coleoptera: Buprestidae). A reusable, more user-friendly trap is desired by program managers, surveyors, and researchers. Field assays were conducted in southeastern Michigan to ascertain the feasibility of using nonsticky traps as survey and detection tools for emerald ash borer. Three nonsticky trap designs, including multifunnel (Lindgren), modified intercept panel, and drainpipe (all painted purple) were compared with the standard purple prism trap; no statistical differences in capture of emerald ash borer adults were detected between the multifunnel design and the prism. In subsequent color comparison assays, both green- and purple-painted multifunnel traps (and later, plastic versions of these colors) performed as well or better than the prism traps. Multifunnel traps coated with spray-on adhesive caught more beetles than untreated traps. The increased catch, however, occurred in the traps' collection cups and not on the trap surface. In a separate assay, there was no significant difference detected between glue-coated traps and Rain-X (normally a glass treatment)-coated traps, but both caught significantly more A. planipennis adults than untreated traps.

Evaluation of pheromone-baited traps for winter moth and Bruce spanworm (Lepidoptera: Geometridae).

We tested different pheromone-baited traps for surveying winter moth, Operophtera brumata (L.) (Lepidoptera: Geometridae), populations in eastern North America. We compared male catch at Pherocon 1C sticky traps with various large capacity traps and showed that Universal Moth traps with white bottoms caught more winter moths than any other trap type. We ran the experiment on Cape Cod, MA, where we caught only winter moth, and in western Massachusetts, where we caught only Bruce spanworm, Operophtera bruceata (Hulst) (Lepidoptera: Geometridae), a congener of winter moth native to North America that uses the same pheromone compound [(Z,Z,Z)-1,3,6,9-nonadecatetraene] and is difficult to distinguish from adult male winter moths. With Bruce spanworm, the Pherocon 1C sticky traps caught by far the most moths. We tested an isomer of the pheromone [(E,Z,Z)-1,3,6,9-nonadecatetraene] that previous work had suggested would inhibit captures of Bruce spanworm but not winter moths. We found that the different doses and placements of the isomer suppressed captures of both species to a similar degree. We are thus doubtful that we can use the isomer to trap winter moths without also catching Bruce spanworm. Pheromone-baited survey traps will catch both species.

Atypical Nodular Pulmonary Kappa Light-Chain Deposition.

We report a case of an incidental positron emission tomography avid right middle lobe lesion which was increasing in size. Due to concerns regarding malignancy, the patient underwent right middle lobectomy. Microscopic examination showed a 12 × 10 × 10 mm poorly circumscribed lesion composed of eosinophilic material. The material labelled strongly for kappa light chains; however, Congo red stain was only weakly positive and without "apple-green" positive birefringence under polarised light. Electron microscopy revealed fibrillar amyloid-like material. The features were those of kappa light-chain deposition.

Optimization of trap color for emerald ash borer (Coleoptera: Buprestidae).

Field assays were performed to determine the optimal color for Agrilus planipennis Fairmaire (Coleoptera: Buprestidae) traps. Previous studies have found that more A. planipennis are caught on purple or green traps than traps of other colors. In three studies, we evaluated various shades of purple, wavelengths of green (500-570 nm), and greens of different reflectance (from 9 to 66%). In all tests, traps of corrugated plastic in standard, commercially available purple (currently used to survey A. planipennis) and a customized green color were used as bases for comparison. Among purple traps, a paint color previously shown to be generally attractive to buprestids caught significantly more A. planipennis adults than traps coated with paints containing more blue or red, or traps constructed of the standard purple plastic. Among traps with maximum reflectance at varying green wavelengths, those ranging in wavelength from 525 to 540 nm caught significantly more adult A. planipennis than traps of other wavelengths. In the 530-540 nm range of the electromagnetic spectrum, there was no significant difference among traps in the 23-66% reflectance range, but traps painted with a peak reflectance of 49% caught more beetles than purple or the custom green plastic traps. Male to female ratio was highest on green traps.

Laboratory and field response of the emerald ash borer (Coleoptera: Buprestidae), to selected regions of the electromagnetic spectrum.

Retinal sensitivity of Agrilus planipennis Fairmaire (Coleoptera: Buprestidae) was examined with an aim to improve trap efficacy for the beetle. Electroretinogram (ERG) recordings from dark-adapted compound eyes of male and female were measured at different wavelengths across the spectrum ranging from 300 to 700 nm. The spectral sensitivity curves revealed peaks in the UV (340 nm), the violet/purple (420-430 nm), blue (460 nm), and green (540-560 nm) regions of the spectrum. Females were sensitive to red regions of the spectrum (640-670 nm), whereas males were not. A spectrophotometer was used to measure the wavelength and reflectance for ash foliage, purple corrugated plastic traps, as well as the elytra and abdomen of adult A. planipennis. Traps were painted using colors based on ERG and spectrophotometer measurements and compared with purple corrugated plastic traps currently used by the USDA-APHIS-PPQ-EAB National Survey. In a field assay conducted along the edges of several A. planipennis-infested ash stands, there were no significant differences in trap catch among green, red, or purple treatments. Dark blue traps caught significantly fewer A. planipennis than red, light green, or dark purple traps. In a second assay where purple and green treatments were placed in the mid canopy of ash trees (approximately 13 m in height), trap catch was significantly higher on green treatments. We hypothesize that when placed in the mid-canopy, green traps constitute a foliage-type stimulus that elicits food-seeking and/or host seeking behavior by A. planipennis.

Frequent decreased expression of candidate tumor suppressor gene, DEC1, and its anchorage-independent growth properties and impact on global gene expression in esophageal carcinoma.

Previous studies showed that expression of the novel candidate tumor suppressor gene, DEC1 (Deleted in Esophageal Cancer 1), is reduced in esophageal carcinoma and suppresses cancer cell growth in vitro and tumor growth in vivo in nude mice. This study shows that DEC1 gene expression was downregulated in 100% of 16 esophageal squamous cell carcinoma (ESCC) cell lines and 52 and 45%, respectively, of esophageal tumor specimens from Hong Kong and a high-risk ESCC region of Henan, China. Using epitope tagging, the DEC1 protein was localized to both the cytoplasm and nucleus of the cell. In 3D Matrigel culture, no significant difference in colony numbers formed was observed for DEC1 stable transfectants, as compared to vector-alone transfectant controls. However, significantly smaller colony sizes were observed for the DEC1 transfectants. In in vitro cell migration, invasion and soft agar assays of DEC1 transfectants, only the soft agar assay showed statistically significant differences in colony numbers with the vector-alone controls, indicating that DEC1 may be involved in anchorage-independent cell growth. In addition, the global gene expression affected by DEC1 in tumor-suppressive stable transfectants was investigated using cDNA oligonucleotide microarray hybridization. Three candidate genes, TFPI-2, GDF15 and DUSP6, were identified through this approach; they are downregulated in tumor segregants of DEC1 stable transfectants, ESCC cell lines and esophageal tumors and have a potential role in tumor growth and progression. These studies show that DEC1 is involved in esophageal cancer development and help elucidate its functional role in tumor development.

Sex pheromone of browntail moth, Euproctis chrysorrhea (L.): synthesis and field deployment.

The browntail moth, Euproctis chrysorrhea (L.), is native to Eurasia, where periodic outbreaks result in defoliation of forest, shade, and ornamental trees. In addition to the damage caused by defoliation, human contact with larval urticating hairs often results in severe dermatitis. Hence, tools for monitoring and controlling the moth populations are desirable. The female-produced sex pheromone of the browntail moth was identified previously, but the synthesis had not been published. This paper reports the synthesis of the pheromone of the browntail moth, (7Z,13Z,16Z,19Z)-docosatetraenyl isobutyrate, using in a key step a Wittig olefination of (6Z)-13-(tetrahydo-2H-pyran-2-yloxy)tridecenal. Field trapping studies were conducted with rubber septa and string formulations of the pheromone and included dose-response, pheromone purity, and dispenser-aging trials. It was found that traps baited with 250 microg of pheromone of 91-94% isomeric purity (main impurity presumably being the 13E isomer) on rubber septa are suitable for monitoring moth populations during the entire flight season.

Influence of trap placement and design on capture of the emerald ash borer (Coleoptera: Buprestidae).

The key to an effective pest management program for the emerald ash borer, Agrilus planipennis Fairmaire (Coleoptera Buprestidae), is a survey program equipped with tools for detecting and delimiting populations. We studied the effects of trap design, color, and placement on the efficacy of sticky traps for capturing the emerald ash borer. There were significant differences in trap catch along a transect gradient from wooded to open field conditions, with most beetles being caught along the edge, or in open fields, 15-25 m outside an ash (Fraxinus spp. L.) (Oleaceae) woodlot. Greater emerald ash borer catch occurred on purple traps than on red or white traps. Traps placed in the mid-canopy of ash trees (13 m) caught significantly more beetles than those placed at ground level. We also describe a new trap design, a three-sided prism trap, which is relatively easy to assemble and deploy.

Assessing Flight Potential of the Invasive Asian Longhorned Beetle (Coleoptera: Cerambycidae) With Computerized Flight Mills.

The Asian longhorned beetle, Anoplophora glabripennis (Motschulsky) (Coleoptera: Cerambycidae: Lamiinae), is an invasive woodborer that poses a serious threat to urban and natural landscapes. In North America, this beetle is a quarantine pest, and populations are subject to eradication efforts that consist of the identification, removal, and destruction of infested host material, and removal or prophylactic treatment of high-risk host plant species. To enhance Asian longhorned beetle eradication protocols in landscapes with extensive host availability, we assessed the dispersal potential of male and female adults of varying age, mating, and nutritional status using computerized flight mills. In total, 162 individuals were tethered to computerized flight mills for a 24-h trial period to collect information on total distance flown, flight times and velocities, and number and duration of flight bouts. Adult Asian longhorned beetles (in all treatments) flew an average of 2,272 m within a 24-h period, but are capable of flying up to 13,667 m (8.5 miles). Nutrition and age had the greatest impacts on flight, with Asian longhorned beetle adults >5 d of age that had fed having greater overall flight performance than any other group. However, mating status, sex, and body size (pre-flight weight and elytron length) had a minimal effect on flight performance. This information will be useful for refining quarantine zones surrounding areas of infestation, and for providing greater specificity as to the risk the Asian longhorned beetle poses within invaded regions.

Genome of the Asian longhorned beetle (Anoplophora glabripennis), a globally significant invasive species, reveals key functional and evolutionary innovations at the beetle-plant interface.

BACKGROUND: Relatively little is known about the genomic basis and evolution of wood-feeding in beetles. We undertook genome sequencing and annotation, gene expression assays, studies of plant cell wall degrading enzymes, and other functional and comparative studies of the Asian longhorned beetle, Anoplophora glabripennis, a globally significant invasive species capable of inflicting severe feeding damage on many important tree species. Complementary studies of genes encoding enzymes involved in digestion of woody plant tissues or detoxification of plant allelochemicals were undertaken with the genomes of 14 additional insects, including the newly sequenced emerald ash borer and bull-headed dung beetle. RESULTS: The Asian longhorned beetle genome encodes a uniquely diverse arsenal of enzymes that can degrade the main polysaccharide networks in plant cell walls, detoxify plant allelochemicals, and otherwise facilitate feeding on woody plants. It has the metabolic plasticity needed to feed on diverse plant species, contributing to its highly invasive nature. Large expansions of chemosensory genes involved in the reception of pheromones and plant kairomones are consistent with the complexity of chemical cues it uses to find host plants and mates. CONCLUSIONS: Amplification and functional divergence of genes associated with specialized feeding on plants, including genes originally obtained via horizontal gene transfer from fungi and bacteria, contributed to the addition, expansion, and enhancement of the metabolic repertoire of the Asian longhorned beetle, certain other phytophagous beetles, and to a lesser degree, other phytophagous insects. Our results thus begin to establish a genomic basis for the evolutionary success of beetles on plants.

Life-threatening pleural hemorrhage following intrapleural enzyme therapy and successful treatment with fibrin-thrombin sealant pleurodesis: a case report.

INTRODUCTION: Intrapleural fibrinolytic enzyme therapy is a potentially surgery-sparing treatment for poorly resolving parapneumonic effusion and empyema. It is safe in the majority of patients, however the most significant risk associated with this treatment is severe bleeding secondary to pleural hemorrhage. Contraindications for intrapleural enzyme therapy are not widely agreed upon and little is known about how to treat this difficult and potentially lethal hemorrhagic complication. CASE PRESENTATION: An independent 82-year-old Caucasian man presented to hospital with an empyema complicating community-acquired pneumonia and coincidental pulmonary embolus. He was initially commenced on intravenous antibiotics, pleural drainage and anticoagulation, however failed to improve significantly and was commenced on intrapleural fibrinolytic enzyme therapy. Shortly after, he suffered severe pleural hemorrhage that was uncontrollable despite emergency thoracotomy and washout. Subsequent hemostasis was achieved after re-exploration and application of topical fibrin-thrombin sealant spray. The patient survived and was discharged home. CONCLUSIONS: Intrapleural enzyme therapy can be effective in loculated parapneumonic effusion and empyema, but massive pleural hemorrhage can complicate its use. Pleural hemorrhage appears to be associated with anticoagulation or coagulopathy, and can be difficult to manage. This case adds to the body of data on bleeding complications following intrapleural enzyme therapy, and to the best of our knowledge is the first report of fibrin-thrombin sealant use in this setting.