Intrapleural use of tissue plasminogen activator and DNase in pleural infection.

BACKGROUND: More than 30% of patients with pleural infection either die or require surgery. Drainage of infected fluid is key to successful treatment, but intrapleural fibrinolytic therapy did not improve outcomes in an earlier, large, randomized trial. METHODS: We conducted a blinded, 2-by-2 factorial trial in which 210 patients with pleural infection were randomly assigned to receive one of four study treatments for 3 days: double placebo, intrapleural tissue plasminogen activator (t-PA) and DNase, t-PA and placebo, or DNase and placebo. The primary outcome was the change in pleural opacity, measured as the percentage of the hemithorax occupied by effusion, on chest radiography on day 7 as compared with day 1. Secondary outcomes included referral for surgery, duration of hospital stay, and adverse events. RESULTS: The mean (±SD) change in pleural opacity was greater in the t-PA-DNase group than in the placebo group (-29.5±23.3% vs. -17.2±19.6%; difference, -7.9%; 95% confidence interval [CI], -13.4 to -2.4; P=0.005); the change observed with t-PA alone and with DNase alone (-17.2±24.3 and -14.7±16.4%, respectively) was not significantly different from that observed with placebo. The frequency of surgical referral at 3 months was lower in the t-PA-DNase group than in the placebo group (2 of 48 patients [4%] vs. 8 of 51 patients [16%]; odds ratio for surgical referral, 0.17; 95% CI, 0.03 to 0.87; P=0.03) but was greater in the DNase group (18 of 46 patients [39%]) than in the placebo group (odds ratio, 3.56; 95% CI, 1.30 to 9.75; P=0.01). Combined t-PA-DNase therapy was associated with a reduction in the hospital stay, as compared with placebo (difference, -6.7 days; 95% CI, -12.0 to -1.9; P=0.006); the hospital stay with either agent alone was not significantly different from that with placebo. The frequency of adverse events did not differ significantly among the groups. CONCLUSIONS: Intrapleural t-PA-DNase therapy improved fluid drainage in patients with pleural infection and reduced the frequency of surgical referral and the duration of the hospital stay. Treatment with DNase alone or t-PA alone was ineffective. (Funded by an unrestricted educational grant to the University of Oxford from Roche UK and by others; Current Controlled Trials number, ISRCTN57454527.).

Imaging of the pleura.

Pleural disease is a problem of global significance which causes significant morbidity and mortality. Pleural disease is usually first suspected on chest x-ray but further imaging, often ultrasound, is usually required as part of the diagnostic work-up. Complex imaging with computed tomography (CT), magnetic resonance imaging (MRI), and positron emission tomography (PET)-CT are less often performed but are routinely required in patients with mesothelioma and occasionally required in patients with pleural infection and other pleural diseases. Cross-sectional imaging may be used to suggest the diagnosis of pleural disease, quantify disease severity, guide biopsy, and even predict prognosis. This review will focus on the contributions of CT, MRI, and PET to the management of pleural disease with discussion of their relative strengths and weaknesses.

Incidence of deep vein thrombosis associated with peripherally inserted central catheters in adults with cystic fibrosis.

PURPOSE: Peripherally inserted central catheters (PICCs) are commonly used in patients with cystic fibrosis (CF) to administer intravenous antibiotics for pulmonary exacerbations. The aim of this study was to determine the incidence of PICC-related deep vein thrombosis (DVT) in a large group of adults with CF with and without Burkholderia cepacia complex (BCC) infection, and to investigate the association between PICC-related DVT and preinsertion serum erythrocyte sedimentation rate (ESR). MATERIALS AND METHODS: This was a retrospective cohort study of all patients with PICCs inserted at a single institution during a 6-year period. A total of 524 adults with CF were treated in the clinic over this time period, with 147 (28.1%) having one or more PICCs inserted. Symptomatic venous thromboses were confirmed by Doppler ultrasound. Patients were classified as BCC-positive or BCC-negative, and preinsertion blood test results were analyzed. RESULTS: A total of 376 PICCs were inserted in 147 patients, with 12 patients (8.2%) developing symptomatic PICC-related DVT. Five additional subjects (3.4%) were diagnosed with asymptomatic PICC-related DVT. BCC-positive patients had a higher overall incidence of PICC-related DVT (20.9%) than BCC-negative patients (7.7%; P = .02). Preinsertion serum ESRs were higher in patients who subsequently developed PICC-related DVT (mean +/- SE, 54.4 mm/h +/- 7.2) compared with those without DVT (38.4 mm/h +/- 2.5; P < .05). CONCLUSIONS: The incidence of symptomatic PICC-related DVT was 3.7% per PICC. BCC-positive patients had a higher overall incidence of DVT than BCC-negative patients. Higher preinsertion ESRs in patients who developed PICC-related DVT suggest that systemic inflammation may be a risk factor for subsequent PICC-related DVT.

Pleural procedures and pleuroscopy.

Pleural procedures are commonly performed by physicians from a range of specialities. These procedures vary in complexity, from relatively straightforward pleural aspiration to more challenging procedures such as pleuroscopy. After appropriate training, even complex pleural procedures have a low risk of complications. Nevertheless, an appreciation of procedural risks is essential for physician training and forms the crux of a valid patient consent process. This review presents a systematic evaluation of the potential complications of common pleural procedures.

Computer-aided detection for the identification of pulmonary nodules in pediatric oncology patients: initial experience.

BACKGROUND: Computer-aided detection (CAD) has been shown to increase the sensitivity for detection of pulmonary nodules in adults. This study reports initial findings utilizing a CAD system for the detection of pediatric pulmonary nodules. OBJECTIVE: To assess the performance of CAD and pediatric radiologists in the detection of pediatric pulmonary nodules. MATERIALS AND METHODS: CT scans from a series of pediatric patients with known primary tumors and lung nodules were analyzed by four radiologists and a commercially available CAD system. IRB approval was obtained. Sensitivities were calculated for detection according to nodule size and location. RESULTS: In 24 children (age 3-18 years) 173 nodules were identified. Overall the sensitivity of CAD was 34%, but the sensitivity of CAD for detection of nodules 4.0 mm or larger was 80%. Overall radiologist sensitivity ranged from 68% to 79%. There were 0.9 CAD false-positives and 0.3-2.4 radiologist false-positives per study. CONCLUSION: CAD in our pediatric oncology patients had good sensitivity for detection of lung nodules 4 mm and larger with a low number of false-positives. However, the sensitivity was considerably less for nodules smaller than 4 mm.

Course and variation of the intercostal artery by CT scan.

BACKGROUND: It is conventionally taught that the intercostal artery is shielded in the intercostal groove of the superior rib. The continuous course and variability of the intercostal artery, and factors that may influence them, have not been described in a large number of arteries in vivo. METHODS: Maximal intensity projection reformats in the coronal plane were produced from CT scan pulmonary angiograms to identify the posterolateral course of the intercostal artery (seventh to 11th rib spaces). A novel semiautomated computer segmentation algorithm was used to measure distances between the lower border of the superior rib, the upper border of the inferior rib, and the position of the intercostal artery when exposed in the intercostal space. The position and variability of the artery were analyzed for association with clinical factors. RESULTS: Two hundred ninety-eight arteries from 47 patients were analyzed. The mean lateral distance from the spine over which the artery was exposed within the intercostal space was 39 mm, with wide variability (SD, 10 mm; 10th-90th centile, 28-51 mm). At 3 cm lateral distance from the spine, 17% of arteries were shielded by the superior rib, compared with 97% at 6 cm. Exposed artery length was not associated with age, sex, rib space, or side. The variability of arterial position was significantly associated with age (coefficient, 0.91; P < .001) and rib space number (coefficient, - 2.60; P < .001). CONCLUSIONS: The intercostal artery is exposed within the intercostal space in the first 6 cm lateral to the spine. The variability of its vertical position is greater in older patients and in more cephalad rib spaces.

Impact of lung transplantation on serum lipids in adults with cystic fibrosis.

BACKGROUND: Cystic fibrosis (CF) is an inherited condition that causes progressive respiratory failure and is the third most common indication for adult bilateral lung transplantation. Post-transplant hyperlipidemia commonly affects lung transplant recipients, but the impact of lung transplantation on serum lipids in the adult CF population is not well studied. The aim of this study was to examine the impact of lung transplantation on the prevalence of hyperlipidemia in CF adults. METHODS: We retrospectively analyzed prospectively collected data in 108 CF adults undergoing bilateral sequential lung transplantation from 1996 to 2007 at our institution. RESULTS: The prevalence of hypercholesterolemia (>5.2 mmol/liter) and hypertriglyceridemia (>2.2 mmol/liter) increased significantly after lung transplant (14.8% vs 32.4%, p = 0.002; 8.3% vs 41.7%, p < 0.0001, respectively). Cyclosporine A (CsA) use was associated with significantly higher post-transplant total and LDL cholesterol compared with tacrolimus use. Post-transplant calculated Framingham risk score was <10% in all but 1 subject. CONCLUSION: Hyperlipidemia was common in our cohort of post-lung transplant CF adults, with a higher prevalence in those receiving CsA. Despite these findings, calculated cardiovascular risk remained low and none of these subjects developed clinically evident cardiovascular disease.