Clinical Features and Prognosis of Nontuberculous Mycobacterial Pleuritis.

BACKGROUND: While nontuberculous mycobacterial (NTM) pleuritis rarely complicates pulmonary NTM infection, high mortality has been reported in case reports and small studies. OBJECTIVES: The purpose of this study was to clarify the clinical features and treatment outcomes of pulmonary NTM infection cases accompanied by NTM pleuritis. METHODS: Medical records of 1,044 patients with pulmonary NTM disease were retrospectively reviewed to select patients complicated by NTM-proven pleuritis. We investigated clinical characteristics, pathogens, pleural effusion examinations, radiographic findings, treatments, and clinical course of the NTM pleuritis patients. RESULTS: Among 1,044 cases with pulmonary NTM, NTM pleuritis occurred in 15 cases (1.4%). The mean age was 69 years with a performance status of mostly 2 or better (80.0%), and 6 cases (40.0%) were complicated by pneumothorax. Subpleural cavities were radiologically detected in 11 cases (73.3%), and extrapulmonary air-fluid level was detected in 14 cases (93.3%). Eleven patients were treated with combinations of 2-4 antimycobacterial drugs, including clarithromycin, and 2 patients were treated with isoniazid, rifampicin, and ethambutol. Chest tube drainage was performed in 11 cases, and surgical approach was added in 6 cases. The pleural effusion of 2 patients treated with only antimycobacterial medications gradually deteriorated. Two patients died from NTM pleuritis, and 1 patient died from pneumonitis during a mean of 1.8 years of follow-up. CONCLUSIONS: Comorbid NTM pleuritis was difficult to treat by medical therapy alone and resulted in a poor prognosis. In addition to antimycobacterial agents, chest tube drainage and surgical procedures in the early stages should be considered to treat NTM pleuritis.

Long-Term Prognosis and Causes of Death After Pleural Infections.

BACKGROUND AND AIMS: The development of pleural infection may imply a worse state of health and prognosis. The objective of this study was to ascertain the long-term survival and causes of death after pleural infections and to compare them to those of matched controls. MATERIAL AND METHODS: Altogether 191 patients treated for pleural infections at a single University Hospital between January 2000 and December 2008 and 1910 age- and gender-matched controls were included. Survival data and the causes of death for non-survivors were obtained from national databases and compared between the groups. RESULTS: The etiology of pleural infection was pulmonary infection in 70%, procedural complication in 9%, trauma in 5%, malignancy in 4%, other in 7%, and unknown in 5% of patients. The course of treatment was surgical in 82%, drainage only in 12%, and conservative in 5% of included patients. The median follow-up time was 11 years. Mortality rates were 8.4% versus 0.8% during the first 90 days, p < 0.001, and 46.6% versus 24.5% overall, p < 0.001, in patients and controls, respectively. Mortality was significantly higher in patients with pulmonary infection, procedural complication, or malignancy as the etiology of pleural infection. In multivariable analysis, advanced age, previous malignancies, institutional care, alcoholism, and malignant etiology for the infection were associated with inferior survival. Deaths caused by malignancies, respiratory diseases, and digestive diseases were significantly more common in patients than in controls. CONCLUSION: Long-term survival in patients with pleural infections is significantly inferior to that of age and gender-matched controls.

Early life indicators predict mortality, illness, reduced welfare and carcass characteristics in finisher pigs.

The objective of this study was to investigate associations between early life indicators, lactation management factors and subsequent mortality, health, welfare and carcass traits of offspring. A total of 1016 pigs from a batch born during one week were used. During lactation, number of liveborn piglets, stillborn and mummies, sow parity, number of times cross-fostered, weaning age, birth and weaning body weight (BW) were collected. Mortality was recorded throughout the offspring production cycle. Prior to slaughter, pigs were scored for lameness (1=non-lame to 3=severely lame). At slaughter, tail lesions were scored (0=no lesion to 4=severe lesion) and cold carcass weight (CCW), lean meat%, presence of pericarditis and heart condemnations were recorded. Additionally, lungs were scored for pleurisy (0=no lesions to 4=severely extended lesions) and enzootic pneumonia (EP) like lesions. There was an increased risk of lameness prior to slaughter for pigs born to first parity sows (P<0.05) compared with pigs born to older sows. Sow parity was a source of variation for cold carcass weight (P<0.05) and lean meat% (P<0.05). Pigs born in litters with more liveborn pigs were at greater risk of death and to be lame prior to slaughter (P<0.05). Pigs that were cross-fostered once were 11.69 times, and those that were cross-fostered ≥2 times were 7.28, times more likely to die compared with pigs that were not cross-fostered (P<0.05). Further, pigs that were cross-fostered once were at greater risk of pericarditis and heart condemnations compared with pigs that were not cross-fostered (P<0.05). Pigs with a birth BW of <0.95kg were at higher mortality risk throughout the production cycle. There was an increased risk of lameness, pleurisy, pericarditis and heart condemnations (P<0.05) for pigs with lower weaning weights. Additionally, heavier pigs at weaning also had higher carcass weights (P<0.05). There was an increased risk of lameness for pigs weaned at a younger age (P<0.05). Males were 2.27 times less likely to receive a score of zero for tail biting compared with female pigs. Results from this study highlight the complex relationship between management, performance and disease in pigs. They confirm that special attention should be given to lighter weight pigs and pigs born to first parity sows and that cross-fostering should be minimised.

[ЕNDOSCOPIC METHODS OF TREATMENT OF SUBACUTE AND CHRONIC INFLAMMATORY PLEURAL DISEASES].

Own experience of the endoscopic methods usage in diagnosis and treatment of chronic pleural diseases in 343 patients, оperated, using videothoracoscopy and video-assisted thoracoscopy, was presented. Postoperative lethality have constituted 0.29%. Application of endoscopic methods in treatment of chronic pleural diseases was highly effective and miniinvasive.

[APPLICATION OF RADIOFREQUENCY ABLATION WHILE PERFORMANCE OF VIDEOTHORACOSCOPIC OPERATIONS FOR PULMONARY AND PLEURAL TUMORS].

In the clinic radio­frequency ablation (RFA) in videothoracoscopic operations (VTHO) was performed in 56 patients. Primary peripheral pulmonary cancer (PC) was revealed in 7 patients, metastatic pulmonary affection ­ in 12, pleural affection with exudate ­ in 37. Small­cell PC was diagnosed in 11 patients, a squamous­cell one ­ in 18, and glandular ­ in 27. VTHO, using RFA technology, is indicated in primary or metastatic PC without possibility to perform radical intervention due to the process spread, patient's age, presence of severe concurrent diseases; refusal of patient from surgical treatment. Positive result was achieved in 54 patients. Duration of pleural drainage was 3 days at average, the patient stationary stay ­ 4 days. Insufficient experience of application of VTHO with RFA do not permit to estimate late follow­up results objectively. Yet, 25 patients, in whom metastatic pleurisy was revealed, have survived more than 9 mo, in peripheral PC one patient died as a result of pulmonary thromboembolism, and the rest of patients have survived from 1 yr to 1.5 yrs.

Predicting Long-Term Outcomes in Pleural Infections. RAPID Score for Risk Stratification.

RATIONALE: Pleural infections are associated with significant morbidity and mortality. The recently developed RAPID (renal, age, purulence, infection source, and dietary factors) score consists of five clinical factors that can identify patients at risk for increased mortality. OBJECTIVES: The objective of this study was to further validate the RAPID score in a diverse cohort, identify factors associated with mortality, and provide long-term outcomes. METHODS: We evaluated a single-center retrospective cohort of 187 patients with culture-positive pleural infections. Patients were classified by RAPID scores into low-risk (0-2), medium-risk (3-4), and high-risk (5-7) groups. The Social Security Death Index was used to determine date of death. All-cause mortality was assessed at 3 months, 1 year, 3 years, and 5 years. Clinical factors and comorbid conditions were evaluated for association. MEASUREMENTS AND MAIN RESULTS: Three-month mortality for low-, medium-, and high-risk groups was 1.5, 17.8, and 47.8%, respectively. Increased odds were observed among medium-risk (odds ratio, 14.3; 95% confidence interval, 1.8-112.6; P = 0.01) and high-risk groups (odds ratio, 53.3; 95% confidence interval, 6.8-416.8; P < 0.01). This trend continued at 1, 3, and 5 years. Factors associated with high-risk scores include gram-negative rod infections, heart disease, diabetes, cancer, lung disease, and increased length of stay. CONCLUSIONS: When applied to a diverse patient cohort, the RAPID score predicts outcomes in patients up to 5 years and may aid in long-term risk stratification on presentation.

Survival in Patients With Malignant Pleural Effusions Who Developed Pleural Infection: A Retrospective Case Review From Six UK Centers.

OBJECTIVE: Malignant pleural effusion (MPE) incidence is increasing, and prognosis remains poor. Indwelling pleural catheters (IPCs) relieve symptoms but increase the risk of pleural infection. We reviewed cases of pleural infection in patients with IPCs for MPE from six UK centers between January 1, 2005, and January 31, 2014. METHODS: Survival in patients with pleural infection was compared with 788 patients with MPE (known as the LENT [pleural fluid lactate dehydrogenase, Eastern Cooperative Oncology Group performance status, serum neutrophil to lymphocyte ratio, and tumor type] cohort) and with national statistics. RESULTS: Of 672 IPCs inserted, 25 (3.7%) became infected. Most patients (20 of 25) had mesothelioma or lung cancer. Median survival in the pleural infection cohort appeared longer than in the LENT cohort, although this result did not achieve significance (386 days vs 132 days; hazard ratio, 0.67; P = .07). Median survival with mesothelioma and pleural infection was twice as long as national estimates for mesothelioma survival (753 days vs < 365 days) and double the median survival of patients with mesothelioma in the LENT cohort (339 days; 95% CI, nonoverlapping). Survival with lung and breast cancer did not differ significantly between the groups. Sixty-one percent of patients experienced early infection. There was no survival difference between patients with early and late infection (P = .6). CONCLUSIONS: This small series of patients with IPCs for MPE suggests pleural infection may be associated with longer survival, particularly in patients with mesothelioma. Results did not achieve significance, and a larger study is needed to explore this relationship further and investigate whether the local immune response, triggered by infection, is able to modulate mesothelioma progression.

[Experience of various parietal pleurectomies with decortication of lungs in pleural lesions].

During 2006-2012 years different types of parietal pleurectomy (PE) with lung decortication (LD) were performed for 135 patients. Among them: 42 (31.1%)--had standart PE with LD (with performing usual thoracotomy); 34 (25.2%)--had video-assisted thoracic surgery (VATS) PE with LD; 36 (26.7%)--videothoracoscopy (VTS) PE with LD; 23 (17.0%)--standart PE with LD combined with lung resection. Common effectiveness of surgical treatment was 96.3%, mortality level--1.5%, postoperative complication level--8.9%. On the early stage of pleural diseases VATS PE with LD and VTS PE with LD are more preferable. To unclear and difficult cases for performing standart PE with LD we consider that operation should begin by VTS pleural space investigation. In some cases minithoracotomy is possible with performing VATS PE with LD or standart PE with LD (performing usual thoracotomy).

Long-term results of lung decortication in patients with trapped lung secondary to coronary artery bypass grafting.

PURPOSE: To evaluate long-term results of decortications in patients with symptomatic restrictive pleurisy and trapped lung after coronary bypass grafting. METHODS: Twenty consecutive patients undergoing lung decortications for trapped lung after coronary bypass grafting were prospectively evaluated. Pulmonary function tests were used as objective criteria, and quality of life was assessed by the Medical Research Council dyspnea scale. A p value <0.05 was considered significant. RESULTS: Twenty patients, 3 women and 17 men, with a median age of 59 years were evaluated. The median time interval between coronary bypass grafting and decortications was 9.3 months. The mean preoperative forced expiratory volume in one second and forced vital capacity were 63.8% ± 7.4% and 50.5% ± 6.6% of the predicted value, respectively, and the improvement rates after decortications were 14.97% ± 6.3% and 17.62% ± 6.38%, respectively. Dyspnea scores improved after decortications (p <0.05). The median follow-up was 25 months. After surgery, 3 patients developed superficial wound infections, and out of 7 patients with prolonged air leaks, 2 underwent re-operation. After surgery, one patient died on day 34 and another, after 3 years. CONCLUSION: Lung decortications, re-expanding the affected lung, ensures symptom remission and improves quality of life of patients with trapped lung after coronary bypass grafting in the long-term.

Sex differences in resident immune cell phenotype underlie more efficient acute inflammatory responses in female mice.

Females are protected against mortality arising from severe sepsis; however, the precise mechanisms that confer this survival advantage in females over males are unclear. Resident leukocytes in resting tissues have a significant influence on circulating cytokine levels and recruitment of blood leukocytes during acute inflammatory responses. Whether the phenotype of resident leukocytes is distinct in females is unknown. In the present study, we show that the numbers of leukocytes occupying the naive peritoneal and pleural cavities is higher in female than in male mice and rats, comprising more T and B lymphocytes and macrophages. The altered immune cell composition of the female peritoneum is controlled by elevated tissue chemokine expression. Female resident macrophages also exhibit greater TLR expression and enhanced phagocytosis and NADPH oxidase-mediated bacterial killing. However, macrophage-derived cytokine production is diminished by proportionally more resident immunomodulatory CD4+ T lymphocytes. Ovarian hormones regulate macrophage phenotype, function, and numbers, but have no significant impact on T-lymphocyte populations in females. We have identified a fundamental sex difference in phenotype of resident leukocytes. We propose that the distinct resident leukocyte population in females allows aggressive recognition and elimination of diverse infectious stimuli without recruitment of circulating neutrophils or excessive cytokine production.

Non-tuberculous mycobacterial pleurisy: an 8-year single-centre experience in Taiwan.

OBJECTIVE: To investigate the clinical characteristics and outcomes of patients with pleurisy due to non-tuberculous mycobacteria (NTM), which are currently unclear. DESIGN: From 2000 to 2007, patients with NTM and Mycobacterium tuberculosis isolated from pleural effusion (PE) samples were identified and compared. RESULTS: Thirty-five NTM patients and 140 tuberculosis (TB) patients were reviewed. Patients with NTM pleurisy were less likely to have lung involvement and receive anti-mycobacterial treatment compared with those with tuberculous pleurisy. NTM pleurisy had a higher PE leukocyte count and a lower percentage of lymphocytes. M. avium complex (MAC) was the most common pathogen in NTM pleurisy. Patients with MAC pleurisy were younger and tended to have more extra-pleural involvement and immune dysfunction. One-year mortality in the NTM pleurisy group was 37%, and anti-NTM treatment was associated with better survival. Patients with additional diagnostic evidence were more likely to receive anti-NTM treatment. CONCLUSION: NTM pleurisy is common and has a high 1-year mortality rate. Anti-NTM treatment may provide better 1-year survival and should be considered once NTM pleurisy is diagnosed.

[Mechanisms and causes of death in 143 Vietnamese HIV-infected patients hospitalized for tuberculosis]. / Evolutions fatales chez les patients vietnamiens co-infectés par le virus VIH et la tuberculose BAAR (+) au cours ou au décours immédiat de leur hospitalisation.

OBJECTIVE OF THE STUDY: To know the mechanisms and causes of death in Vietnamese VIH-infected patients hospitalized for tuberculosis. METHODS: Retrospective analysis of a monocentric cohort of 143 consecutive co infected patients admitted to Pham Ngoc Thach Hospital, in Ho Chi Minh City, between January 2004 and November 2004. MAIN RESULTS: All the patients were HIV-infected and AFB smear positive. The CD4 T lymphocyte count was 55/mm3 and the body mass index was 15.8 +/- 2 kg/m2. During the first three months after hospital admission and tuberculosis diagnosis, the percentage of deaths was 28.7% (41/143). The mechanisms of deaths were: progressive cachexia, acute respiratory failure, cardiogenic or bacteremic shock, coma and unexpected cardio respiratory arrest. The causes of death were tuberculosis (particularly mechanical complications such as compressive pneumothorax, pericarditis or pleuritis), metabolic disorders (mainly hyponatrémie and dyskaliema) and associated infection. In multivariate analysis, two parameters (available at admission) were predictive of short-term death: anemia (p=0.024) and hyponatrémie (p=0.026). CONCLUSION: The short term mortality of co infected patients with AIDS and tuberculosis remains high in developing countries. However, some causes of death such as compressive pneumothorax-pleuritis-pericarditis, metabolic disorder or even associated opportunistic infection i. e. pneumocystosis may be prevented or cured. Consequently, such patients must be carefully monitored and more particularly those with severe anemia and/or hyponatrémie at admission. Similarly appropriate diagnostic algorithms must be used in case of unfavorable evolution particularly to diagnose curable complication.

Survival study by organ disorders in 306 Japanese patients with systemic lupus erythematosus: results from a single center.

Survival rate and causes of death according to the period of diagnosis and four accompanying organ disorders were analyzed in 306 Japanese patients with systemic lupus erythematosus. The survival rate was gradually improved, and the survival rate during 5- and 10-year periods of the patients diagnosed in 1990-2004 was 94 and 92%, 20-year period of those in 1980-1989 was 77%, 30-year period of those in 1975-1979 was 71%, respectively. Survival rate of those with serositis, pulmonary hypertension, and positive family history tended to be reduced, while that of the cases with neuropsychiatric disorder and renal disorder was significantly reduced. Overlapping of these organ disorders was an important factor for a poor prognosis. Bronchopneumonia and cerebrovascular accidents were frequent causes of death, and treatment for anti-phospholipid antibody syndrome and life-style diseases such as hypertension and arteriosclerosis was thought to be important for a good outcome.

[Thoracic esophageal neoplasm-therapeutical problems and post-surgery evolution]. / Neoplasmul de esofag toracic--probleme terapeutice si evolutie postoperatorie.

The authors are presenting a few considerations on Thoracic Esophageal Neoplasm, as resulted from an 18-cases study performed on patients that were operated between 1994-1999. The esophageal resection rate was of 50%, as follows: 7 Esophageal Resections and 2 Superior Polar Esogastric Resections. The digestive transit was reestablished by means of intrathoracic transposition of the stomach (6 cases) or of the right ileo-colon (2 cases). In one of the cases an Esogastric Anastomosis was performed at the neck level (cervical-right). Immediate post-op mortality after Esophageal Resection (1 case) was due to an acute respiratory distress syndrome (ARDS). The post-op complications were as follow: one anastomotic fistula associated with a purulent pleurisy, 4 non-infectious pulmonary complications and 2 cardiac complications (paroxysmal supraventricular tachycardia). The Discussions and Conclusions of the present work are presenting samples of surgical techniques, post-op complications and prognosis.

Interpreting the Health Care Financing Administration's mortality statistics.

In this article, the methodology used by the Health Care Financing Administration in the 1992 release of 1990 mortality statistics is described, and the performance of one outlier hospital is evaluated as a case study. The study hospital is compared to all other hospitals, and to a smaller cohort of 200-to-299-bed minor teaching hospitals, in terms of predicted and observed mortality rates and mortality model determinants. Proportionately more patients treated in the study hospital were women and had cerebrovascular degeneration or chronic renal disease; fewer patients had cardiovascular disease. Substantially more patients from this hospital were transfers from a skilled nursing facility. Fewer patients were admitted through the emergency department. Although patients tended to be more seriously ill overall compared with other hospitals in the country, observed mortality rates were still higher than predicted. Possible explanations for the discrepancy were coding inconsistencies, inability to control adequately for the severity of illness of transfers from skilled nursing facilities, or quality of care problems.

Pulmonary embolism in patients attending the accident and emergency department with pleuritic chest pain.

A series of 92 patients presenting to an accident and emergency department with pleuritic chest pain is described. Only one of the patients had a diagnosis of pulmonary embolus. All the patients were followed up over a period of 3 months. During this time none of them suffered from mortality or morbidity which could be related to pulmonary embolism. No evidence was obtained during this study that a more aggressive approach to such patients is required in order to achieve the diagnosis.

[Complications after reoperation hepatectomy]. / Oslozhneniia posle rezektsii pecheni pri povtornoi operatsii.

The main cause of lethal outcomes after resection of the liver in reoperations is hemorrhage and hepatic insufficiency. Among most frequent specific complications are right-side pleurisy, formation of the residual cavity and sequestration. Complications are often observed in combinations and require active therapy. Ultrasonic scanning is a leading method of diagnosing complications after resection of the liver.