Intrapleural Fibrinolytic Therapy With Alteplase for the Management of Multiloculated Malignant Pleural Effusion: A Case Series.

Malignant pleural effusion refers to the presence of fluid in the pleural space due to an underlying malignancy. Malignant pleural effusion is sometimes accompanied by the formation of fibrous adhesions resulting in a multiloculated effusion. This diminishes the efficacy of drainage and makes successful pleurodesis impossible, leaving the patients with severe shortness of breath. In the process of freeing the pleural space from fluid-filled loculations, intrapleural application of fibrinolytic is being investigated as a possible therapeutic approach. Here, we report four cases of adult patients hospitalized for malignant pleural effusions who were treated with intrapleural fibrinolytic therapy at the Institute for Pulmonary Diseases of Vojvodina, Republic of Serbia.

Electric vs. harmonic scalpel in treatment of primary focal hyperhidrosis with thoracoscopic sympathectomy.

BACKGROUND: Hyperhidrosis is defined as excessive sweating beyond the physiologic needs of a person. Palmar hyperhidrosis in the adolescent period may have an impact on school work and may cause psychological problems. Thoracoscopic sympathectomy is now used routinely to treat patients with disabling primary hyperhidrosis or facial blushing. PATIENTS AND METHODS: From January 2008 to December of 2009 bilateral thoracoscopic sympathectomy Th2-Th4 was performed to 79 patients aged from 17 to 55, who suffered from palmar, axillar or craniofacial hyperhidrosis. For the first 39 patients (group A) thoracoscopic sympathectomy was performed using electric scalpel and for the next 40 patients (group B) thoracoscopic sympathectomy was performed using harmonic scalpel. RESULTS: Based on our results we did not find any significant differences between electric or harmonic scalpel usages for thoracoscopic sympathectomy. Moreover, there was no significant difference between complications and the severity of pain, with slightly higher intensity of pain with harmonic scalpel usage. Both electric and harmonic scalpel provided adequate treatment for primary hyperhidrosis, with the fact that non-disposable electric scalpel costs were less than that of the disposable harmonic scalpel. CONCLUSIONS: Sympathectomy should be preferred for palmar hyperhidrosis treatment, as it is much technically shorter, simpler to implement, and also easier to learn. Thoracoscopic sympathectomy is safe and effective for the treatment of primary palmar hyperhidrosis in the adolescent period without any major side effects.

Lung abscess-etiology, diagnostic and treatment options.

Lung abscess is a type of liquefactive necrosis of the lung tissue and formation of cavities (more than 2 cm) containing necrotic debris or fluid caused by microbial infection. It can be caused by aspiration, which may occur during altered consciousness and it usually causes a pus-filled cavity. Moreover, alcoholism is the most common condition predisposing to lung abscesses. Lung abscess is considered primary (60%) when it results from existing lung parenchymal process and is termed secondary when it complicates another process, e.g., vascular emboli or follows rupture of extrapulmonary abscess into lung. There are several imaging techniques which can identify the material inside the thorax such as computerized tomography (CT) scan of the thorax and ultrasound of the thorax. Broad spectrum antibiotic to cover mixed flora is the mainstay of treatment. Pulmonary physiotherapy and postural drainage are also important. Surgical procedures are required in selective patients for drainage or pulmonary resection. In the current review we will present all current information from diagnosis to treatment.

Pulmonary arteriovenous malformation-etiology, clinical four case presentations and review of the literature.

Pulmonary arteriovenous malformation (PAVM) is a rare clinical condition with abnormal direct communication between the branches of pulmonary artery and vein. It may occur as an isolated anomaly or in association with hereditary hemorrhagic telangiectasia (HHT). Although these vascular pulmonary pathologies are quite uncommon, they are the important part of the differential diagnosis of common pulmonary problems such as hypoxemia and pulmonary nodules. The diagnosis of PAVM in patients remains a diagnostic challenge to the emergency physician. The most common clinical signs of PAVM are recurrent episodes of epistaxis and hemoptysis, so surgical resection is deemed the best curative option to avoid further episodes and recurrence of hemoptysis. Quite often the diagnosis is established after pathohistological examinations. We report a case of a female patient with a massive recurrent hemoptysis and without pathologic radiological findings which would suggest to PAVM and who was successfully treated with lobectomy.

Pneumothorax as a complication of central venous catheter insertion.

The central venous catheter (CVC) is a catheter placed into a large vein in the neck [internal jugular vein (IJV)], chest (subclavian vein or axillary vein) or groin (femoral vein). There are several situations that require the insertion of a CVC mainly to administer medications or fluids, obtain blood tests (specifically the "central venous oxygen saturation"), and measure central venous pressure. CVC usually remain in place for a longer period of time than other venous access devices. There are situations according to the drug administration or length of stay of the catheter that specific systems are indicated such as; a Hickman line, a peripherally inserted central catheter (PICC) line or a Port-a-Cath may be considered because of their smaller infection risk. Sterile technique is highly important here, as a line may serve as a port of entry for pathogenic organisms, and the line itself may become infected with organisms such as Staphylococcus aureus and coagulase-negative Staphylococci. In the current review we will present the complication of pneumothorax after CVC insertion.

Semi-Fowler vs. lateral decubitus position for thoracoscopic sympathectomy in treatment of primary focal hyperhidrosis.

BACKGROUND AND OBJECTIVE: The aim of this study is to compare usefulness of Semi-Fowler position vs. lateral decubitus position for thoracoscopic sympathectomy in treatment of primary focal hyperhidrosis. MATERIALS AND METHODS: From January 2009 to January 2010, 263 consecutive patients with palmar and axillar hyperhidrosis underwent thoracoscopic sympathectomy Th2-Th4. Patients were divided into two groups: group A (n=133) underwent thoracoscopic sympathectomy through lateral decubitus using double lumen endotracheal intubation, and group B (n=130) underwent thoracoscopic sympathectomy through Semi-Fowler supine position (semi sitting with arm abducted) using single lumen endotracheal intubation without insufflation of CO2, but with short apnea period. All operations were performed through two 5 mm operating ports, videothoracoscopic camera 0° and endoscopic ultrasound activated harmonic scalpel. RESULTS: There were 107 males and 156 females with median age 30.31±8.35 years. Two groups were comparable in gender, age, severity of sweating. All operations were successfully performed with no complications or perioperative morbidity. For group A average operation time for both sides was 31.2±3.87 min and for group B average time was 14.19±4.98 min. In group B apnea period per one lung lasts 2.86±1.15 min and during that period observed saturation was 92.65%±5.66% without significant cardiorespiratory disturbances. Pleural drains were taken off on operation table after forced manually lung reexpansion. Patients were discharged from hospital for few hours, after the operation and radiologic confirmation of complete lung reexpansion. CONCLUSIONS: Based on this data (shorter operating time, lack of incomplete lung collapse, insignificant apnea and better reexpansion of lungs) we concluded that thoracoscopic sympathectomy through Semi-Fowler supine position is highly effective and easy to perform for primary hyperhidrosis.

Penetrating trauma.

Pneumothorax occurs when air enters the pleural space. Currently there is increasing incidence of road traffic accidents, increasing awareness of healthcare leading to more advanced diagnostic procedures, and increasing number of admissions in intensive care units are responsible for traumatic (non iatrogenic and iatrogenic) pneumothorax. Pneumothorax has a clinical spectrum from asymptomatic patient to life-threatening situations. Diagnosis is usually made by clinical examination and imaging techniques. In our current work we focus on the treatment of penetrating trauma.

Tube thoracostomy; chest tube implantation and follow up.

Pneumothorax is an urgent medical situation that requires urgent treatment. We can divide this entity based on the etiology to primary and secondary. Chest tube implantation can be performed either in the upper chest wall or lower. Both thoracic surgeons and pulmonary physicians can place a chest tube with minimal invasive techniques. In our current work, we will demonstrate chest tube implantation to locations, methodology and tools.

Effect of 12-monoketocholic acid on modulation of analgesic action of morphine and tramadol.

This work is concerned with the potential promotive action of 12-monoketocholic acid (12-MKC) on the analgesic effect of morphine and tramadol. The investigation was carried out on laboratory Wistar rats divided into five test groups, each treated with either morphine (2 mg/kg), tramadol (9.6 mg/kg), 12-MKC (2 mg/kg), morphine + 12-MKC, or tramadol + 12-MKC, the control group receiving physiological solution (2 mg/kg). The effect of 12-MKC on the analgesic action of morphine and tramadol was determined by radiation heat method. Morphine and tramadol, given in equimolar doses, did not show significant difference in the degree of analgesia. In combination with morphine, 12-MKC increased significantly the analgesic effect compared with the group treated with morphine alone. However, 12-MKC caused no change in the action of tramadol. The 5-day intravenous application of 12-MKC in combination with the two analgesics caused no changes in the biochemical parameters nor pathohistological changes in the liver parenchyma of tested animals.