Necessity of centralisation of EBUS.

In the study of Bauwens et al. endobronchial ultrasound (EBUS) was provocated as first step procedure in the staging of PET mediastinal hot spots in lung cancer patients. In case of negative findings a surgical procedure should be undertaken. We certainly agree that in case of a negative finding a surgical procedure should be performed, however, we disagree that the first step procedure should be EBUS. In our opinion the first step procedure in a standard clinical practice should be a standard transbronchial needle aspiration (TBNA).

Pleural drainage and pleurodesis: implementation of guidelines in four hospitals.

The aim of the present study was to evaluate the implementation of the 2003 Dutch guideline on the diagnosis and treatment of malignant pleural effusions, and the potential effect of the implementation on the clinical outcome of pleurodesis. All patients with malignant pleural effusion who had a pleural drain placed with the intention of performing pleurodesis were registered prospectively in four centres. Details of the procedure and fluid recurrence and survival data were noted. Patients with a proven malignancy (n = 100) were entered into the registration database. Diagnostic guideline recommendations were followed in 60-70% of the patients. Surprisingly, pleurodesis was performed in only 75% of the patients, mainly due to the presence of a trapped lung. All pleurodeses were performed using talc, according to the guideline. Follow-up revealed fluid recurrence in 27 (36%) patients after a mean follow-up of 17 days (range 2-285 days); 14 patients with successful pleurodesis died with a median survival of 61 days (range 13-174 days). Systemic treatment following pleurodesis and good apposition of the pleural surfaces during drainage were good prognostic factors. Despite reasonable-to-good adherence to the guideline, the number of successful pleurodeses was low. Better predictors of a good pleurodesis outcome are needed.

Toxicokinetics of nortriptyline and amitriptyline: two case reports.

Two cases are presented of intentional intoxications with the tricyclic antidepressants (TCAs) nortriptyline (NT) and amitriptyline (AT). The peak plasma concentrations were 2290 microg/L and 2900 microg/L, respectively. The active metabolites E-10-hydroxynortriptyline (EHNT) and Z-10-hydroxynortriptyline (ZHNT) profiles were quite different as monitored for 5 to 10 days after presumed drug intake. In conclusion, these cases illustrate that (1) metabolite formation and elimination after intake of an overdose dose of NT and AT are stereoselective, and (2) NT and EHNT toxicokinetics and toxicodynamics are quite different. It also shows that a patient with a severe TCA overdose can still survive if he or she receives appropriate and quick supportive care, even if the prognostic markers QRS time, coma grade, and serum TCA levels predict poor outcome.

[Patient with a lung abscess, primarily treated with drainage followed by antibiotics]. / Een patiënt met een longabces, primair behandeld met drainage en aanvullend met antibiotica.

A 45-year-old woman presented herself with coughing, nocturnal sweating, weight loss, and chest pain, left laterally. In the previous 5 months she had been treated twice with antibiotics due to a suspected pneumonia. With the help of a CT scan, 2 subpleural lung abscesses were diagnosed. The primary treatment was CT-guided drainage, as a result of which the largest abscess was emptied and a microbiological diagnosis could be established. Subsequently, the patient made a quick recovery with the help of specific antibiotics. It might be better to drain lung abscesses, especially subpleural ones, at an early stage rather than wait for the results of a trial treatment with antibiotics.