Lobar Collapse Therapy Using Endobronchial Valves as a New Complementary Approach to Treat Cavities in Multidrug-Resistant Tuberculosis and Difficult-to-Treat Tuberculosis: A Case Series.

BACKGROUND: The poor treatment outcomes of multidrug-resistant tuberculosis (TB) and the emergence of extensively drug-resistant TB and extremely and totally drug-resistant TB highlight the urgent need for new antituberculous drugs and other adjuvant treatment approaches. OBJECTIVES: We have treated cavitary tuberculosis by the application of endobronchial one-way valves (Zephyr®; Pulmonx Inc., Redwood City, Calif., USA) to induce lobar volume reduction as an adjunct to drug treatment. This report describes the feasibility, effectiveness and safety of the procedure. METHODS: Patients with severe lung destruction, one or more cavities or those who were ineligible for surgical resection and showed an unsatisfactory response to standard drug treatments were enrolled. During bronchoscopy, endobronchial valves were implanted in the lobar or segmental bronchi in order to induce atelectasis and reduce the cavity size. RESULTS: Four TB patients and 1 patient with atypical mycobacteriosis were treated. The mean patient age was 52.6 years. Complete cavity collapses were observed on CT scans in 4 of the 5 cases. All patients showed improvements in their clinical status, and sputum smears became negative within 3-5 months. There were no severe short- or long-term complications. The valves were removed in 3 of the 5 patients after 8 months on average; there was no relapse after 15 months of follow-up. CONCLUSION: These data suggest that endobronchial valves are likely to be useful adjuncts to the treatment of therapeutically difficult patients. More data are required to confirm our findings.

Therapeutic Pneumothorax and the Nobel Prize.

At the turn of the 20th century, the epidemic proportions of tuberculosis puzzled great parts the scientific community. Thus it is not surprising that well-known scholars who worked on particularly promising solutions to fight the disease were nominated for the Nobel Prize for Physiology or Medicine, perhaps the most prestigious benchmark of scientific excellence. The authors have gathered files on the Italian phtisiologist Carlo Forlanini (1847 to 1918) at the Nobel Prize archive for Physiology or Medicine in Solna, Sweden. Drawing on these files and contemporary publications, the authors discuss the origin of artificial pneumothorax for treating pulmonary tuberculosis, show how it became an international gold standard operation, and trace why the Nobel committee finally chose not to award Forlanini. Twenty Nobel Prize nominations for Forlanini were submitted from 1912 to 1919 exclusively by Italian scholars. In 1913 and 1914, Forlanini was on the shortlist of the Nobel Committee and thus one of the prime candidates for the prestigious prize. Important aspects of the rise, fall, and revival of the artificial pneumothorax from 1815 to 2015 are highlighted along with its benefits and risks.

Bolshevik disease and Stalinist terror: on the historical casuistry of artificial pneumothorax.

From its initial development by Carlo Forlanini at the end of the nineteenth century until the advent of antibiotics in the 1940s, artificial pneumothorax was one of the most widely used treatments for pulmonary tuberculosis. However, there were strongly held reservations about this therapy because of its risks and side effects. In the Soviet Union under Stalin, such uncertainties became instruments of political denunciation. The leading Soviet pulmonary physician Volf S. Kholtsman (1886-1941) was alleged to have used the so-called 'aristocratic therapy' of artificial pneumothorax to kill prominent Bolsheviks. Drawing on documents from Stalin's personal Secretariat, this historical study of the pneumothorax scandal contributes to the cultural history of tuberculosis, showing how it was instrumentalised for political purposes.

The history of surgery for pulmonary tuberculosis.

Thoracic surgical procedures evolved from surgical management of tuberculosis; lung resections, muscle flaps, and thoracoscopy all began with efforts to control the disease. The discovery of antituberculosis drugs in 1944 to 1946 made sanatorium therapy and collapse therapy in all its forms obsolete and changed thoracic surgery dramatically. Currently, management of tuberculosis is primarily medical, and surgery has a minimal role. Today surgery is usually only performed in patients with tuberculosis when the diagnosis is necessary, who have complications or sequelae of the disease, or who have active disease resistant to therapy.

[Brief history of the development of artificial pneumothorax].

Artificial pneumothorax (AP), was one kind of surgery for pulmonary tuberculosis which injects the air into the pleural cavity by needle tubes to form the artificial pneumothorax. It was applied in a clinic by the Italian physician Carlo Forlanini in 1894. In the subsequent 20 years, this therapy has not been paid attention to in medical circles until 1912 when it received recognition and gradually became the primary therapy of pulmonary tuberculosis in Europe and America. AP began to be used in pulmonary tuberculosis from 1928 to 1930 in Shanghai, China, then throughout the whole country. In the 1950s, with the appearance of streptomycin, streptomycin and rifampicin, AP gradually withdrew from the front-line of clinical practice and became a thing of the past.

Brice Clarke (1895-1975) and the control of tuberculosis in Northern Ireland.

Among the problems facing Northern Ireland after its foundation in 1920, one of the most daunting was the prevalence of tuberculosis, a chronic communicable disease with highest mortality among young women and men in the prime of life. Over a quarter of a century, legislative changes tardily responded, and in spite of, or because of its magnitude, Brice Clarke (1895-1975) devoted himself to the challenge. After decorated service in the Great War of 1914-19 he returned to finish his medical studies in Queen's University Belfast and held hospital appointments until he became Chief Tuberculosis Officer for Belfast and soon afterwards Director of Tuberculosis Services in Northern Ireland. For twenty years he was an enthusiastic proponent of collapse therapy, and even before the new chemotherapy hastened the natural decline in the tuberculosis epidemic he trumpeted the value of properly equipped chest clinics and generously funded welfare schemes. His garden at Hillsborough could not contain him in retirement; he set off on a slow boat to Japan in 1962, and returned to pen biographical sketches of famous consumptives until his death in 1975 at the age of 80.

Tuberculosis, bronchiectasis, and infertility: what ailed George Orwell?

In the last and most productive years of his life, George Orwell struggled with pulmonary tuberculosis, dying at the dawn of the era of chemotherapy. His case history illustrates clinical aspects of tuberculosis with contemporary relevance: the role of poverty in its spread, the limited efficacy of monotherapy, the potential toxicity of treatment, and the prominence of cachexia as a terminal symptom. Orwell's ordeals with collapse therapy may have influenced the portrayal of the tortures of Winston Smith in the novel 1984. I discuss unifying diagnoses for Orwell's respiratory problems and apparent infertility, including tuberculous epididymitis, Young syndrome, immotile cilia syndrome, and cystic fibrosis.

[Thoracoplasty: the current role]. / La toracoplastica: il ruolo attuale.

The Authors report a retrospective analysis of 29 patients who underwent thoracoplasty between 1990 and 1999. The mean follow-up period was 30 months. The median age was 55 years. The peri-operative mortality rate was 6.8%. The control of space obliteration, space infection and closure of the bronchopleural fistula was achieved in 27 patients. This article also discusses surgical history of thoracoplasty, technique adopted and its current application.

The history of thoracoscopic surgery.

The necessity for thoracoscopy became apparent with the adhesions that limited the success of Forlanini's introduction in 1882 of artificial pneumothorax in the treatment of pulmonary tuberculosis. The first thoracoscopy, using a modified cystoscope, was performed by H. C. Jacobaeus, a professor of medicine, not surgery, in Stockholm, publishing in 1910. Thoracoscopy and division of adhesions (intrapleural pneumonolysis) then spread all over the world, with reports of series of 1,000 or more cases in spite of a significant incidence of complications. Its use declined rapidly after the introduction of streptomycin in 1945, becoming then confined to relatively minor diagnostic procedures except in a few European centers. The advent of video-assisted thoracoscopes and the development of ancillary instruments has allowed a new explosion of thoracoscopic surgery. Surgeons, in whose hands the procedure now rests, should nevertheless be aware of the five unacceptable thoracoscopic disasters--wrong side, kebab lung, "clotted hemothorax," artificial lunchothorax, and aorto-pleuro-cutaneous fistula.