More isn't always better: antibiotic duration after surgical decortication in pleural empyema.

Background: While ample high-level evidence supports the limited use of antibiotics post-source control in intraabdominal infections, there is a paucity of available data in guiding antibiotic duration for intrathoracic infections. This study aims to analyze patient outcomes among those who have undergone surgical decortication for parapneumonic pleural empyema, comparing cases managed with infectious disease (ID) specialists against those without, and to identify predictive factors influencing antibiotic duration post-source control. We hypothesized that antibiotic duration would vary depending on the involvement of ID specialists. Methods: A retrospective chart review was completed on patients with parapneumonic pleural empyemas who underwent surgical decortication at a single tertiary center from January 2011 to March 2021. Differences in patient characteristics and outcomes for those whose antibiotics were managed by ID or not were compared with Wilcoxon two-sample tests and Fisher's exact tests. Linear regression was used to evaluate for significant factors predictive of antibiotic duration. Results: A total of 116 patients underwent surgical decortication for pleural empyema of parapneumonic etiology. ID specialists were involved with antibiotic management in 62 (53.4%) cases, while the remaining cases were not managed by ID. Demographics and patient comorbidities were similar between both groups. Growth of preoperative fluid cultures was higher in patients managed by ID (40.3% vs. 20.4%, P=0.03). Postoperatively, patients managed by ID had longer durations of antibiotics (28.7 vs. 20.9 days, P<0.001) and were more likely to be on IV antibiotics than patients not managed by ID (59.7% vs. 38.9%, P=0.04). However, postoperative outcomes were similar, including rates of disease recurrence, readmission, and 30-day mortality. Linear regression revealed length of antibiotics was significantly dependent on preoperative ventilator status [estimate: 16.346; 95% confidence interval (CI): 6.365-26.326; P=0.002], growth of preoperative pleural fluid cultures (estimate: 10.203; 95% CI: 2.502-17.904; P=0.01), and ID involvement (estimate: 8.097; 95% CI: 1.003-15.191; P=0.03). Conclusions: Antibiotic duration for pleural empyema managed with surgical decortication is significantly dependent on ID involvement, preoperative growth of cultures, and preoperative ventilator status. However, outcomes, including disease recurrence and 30-day mortality, were similar between patients regardless of ID involvement and longer length of antibiotics, raising the question of what the adequate duration of antibiotics is for patients who receive appropriate source control for pleural empyema. Further study with randomized control trials should be conducted to provide high-level evidence regarding length of antibiotics in this patient population.

The safety and prognostic evaluation of subsequent aortic surgery after thoracic endovascular aortic repair: a retrospective cohort study.

Background: Thoracic endovascular aortic repair (TEVAR) is a widely employed clinical procedure for treating various aortic pathologies. However, some patients require subsequent surgical interventions post-TEVAR, particularly due to life-threatening complications such as aortic dissection. This study aimed to evaluate the safety and prognosis associated with additional aortic surgeries following TEVAR. Methods: A retrospective analysis was conducted on 21 patients who underwent aortic surgery after TEVAR at Guangdong Provincial People's Hospital between September 2016 and August 2020. By compiling and reviewing perioperative data, we assessed surgical-related complications and survival rates. Results: Among the 21 patients, 95.2% were male, with an average age of 53 years. Preoperative comorbidities included hypertension in 15 individuals, abdominal aortic aneurysm in one patient, and coronary heart disease in two patients. The primary complications of TEVAR were stent leakage and retrograde aortic dissection, with the latter being the predominant type in subsequent aortic surgeries. The mean duration of aortic clamping during surgery was 130.0 minutes, with a deep hypothermic circulatory arrest time of 8.5 minutes. Postoperatively, two patients suffered in-hospital mortality, one developed renal dysfunction, four required re-entry into the operating room for further treatment, and the average length of hospital stay was 20 days. Following discharge, 14.3% of patients experienced complications, with central nervous system symptoms being the most prevalent. Kaplan-Meier survival analysis indicated a 5-year survival rate of 85.7%. Conclusions: Aortic surgical intervention following TEVAR is a safe therapeutic approach that can improve patient prognosis. However, meticulous management of the perioperative period is crucial for reducing the risk of complications and improving survival rates. This study provides valuable insights into aortic surgery post-TEVAR, but large-scale research is needed to validate these findings.

Mirror, Mirror on the Wall; He Had a "Bypass" After All!

How to cite this article: Magoon R, Jose J, Kumar M. Mirror, Mirror on the Wall; He Had a "Bypass" After All! Indian J Crit Care Med 2024;28(7):706-707.

Evaluating the efficacy of percutaneous puncture biopsy guided by contrast-enhanced ultrasound for peripheral pulmonary lesions.

BACKGROUND: The incidence and mortality of lung cancer have increased annually. Accurate diagnosis can help improve therapeutic efficacy of interventions and prognosis. Percutaneous lung biopsy is a reliable method for the clinical diagnosis of lung cancer. Ultrasound-guided percutaneous lung biopsy technology has been widely promoted and applied in recent years. AIM: To investigate the diagnostic value of contrast-enhanced ultrasound (CEUS)-guided percutaneous biopsy in peripheral pulmonary lesions. METHODS: We retrospectively collected data on 237 patients with peripheral thoracic focal lesions who underwent puncture biopsy at Wuxi People's Hospital. The patients were randomly divided into two groups: The CEUS-guided before lesion puncture group (contrast group) and conventional ultrasound-guided group (control group). Analyze the diagnostic efficacy of the puncture biopsy, impact of tumor size, and number of puncture needles and complications were analyzed and compared between the two groups. RESULTS: Accurate pathological results were obtained for 92.83% (220/237) of peripheral lung lesions during the first biopsy, with an accuracy rate of 95.8% (113/118) in the contrast group and 89.9% (107/119) in the control group. The difference in the area under the curve (AUC) between the contrast and the control groups was not statistically significant (0.952 vs 0.902, respectively; P > 0.05). However, when the lesion diameter ≥ 5 cm, the diagnostic AUC of the contrast group was higher than that of the control group (0.952 vs 0.902, respectively; P < 0.05). In addition, the average number of puncture needles in the contrast group was lower than that in the control group (2.58 ± 0.53 vs 2.90 ± 0.56, respectively; P < 0.05). CONCLUSION: CEUS guidance can enhance the efficiency of puncture biopsy of peripheral pulmonary lesions, especially for lesions with a diameter ≥ 5 cm. Therefore, CEUS guidance has high clinical diagnostic value in puncture biopsy of peripheral focal lung lesions.

Differential responses to thrombospondin-1 and PDGF-BB in smooth muscle cells from atherosclerotic coronary arteries and internal thoracic arteries.

Atherosclerosis is rare in internal thoracic arteries (ITA) even in patients with severe atherosclerotic coronary artery (ACA) disease. To explore cellular differences, ITA SMC from 3 distinct donors and ACA SMC from 3 distinct donors were grown to sub-confluence and growth arrested for 48 h. Proliferation and thrombospondin-1 (TSP1) production were determined using standard techniques. ITA SMC were larger, grew more slowly and survived more passages than ACA SMC. ACA SMC had a more pronounced proliferative response to 10% serum than ITA SMC. Both ACA SMC and ITA SMC proliferated in response to exogenous TSP1 (12.5 µg/ml and 25 µg/ml) and platelet derived growth factor-BB (PDGF-BB; 20 ng/ml) but TSP1- and PDGF-BB-induced proliferation were partially inhibited by anti-TSP1 antibody A4.1, microRNA-21(miR-21)-3p inhibitors and miR-21-5p inhibitors in each of the 3 ACA SMC lines, but not in any of the ITA SMC lines. PDGF-BB stimulated TSP1 production in ACA SMC but not in ITA SMC but there was no increase in TSP1 levels in conditioned media in either SMC type. In summary, there are significant differences in morphology, proliferative capacity and in responses to TSP1 and PDGF-BB in SMC derived from ITA compared to SMC derived from ACA.

Integrated proteomic and metabolomic profiling of lymph after trauma-induced hypercoagulopathy and antithrombotic therapy.

BACKGROUND: Routine coagulation tests are not widely accepted diagnostic criteria of trauma-induced hypercoagulopathy (TIH) due to insensitivity. Lymphatic vessels drain approximately 10% of the interstitial fluid into the lymphatic system and form lymph. SUBJECTIVE: The purpose of this study was to identify the potential lymph biomarkers for TIH. METHODS: Eighteen male Sprague-Dawley rats were randomly assigned to the sham (non-fractured rats with sham surgery and vehicle treatment), the VEH (fractured rats with vehicle treatment) and the CLO (fractured rats with clopidogrel treatment) group. Thoracic duct lymph was obtained to perform proteomics and untargeted metabolomics. RESULTS: A total of 1207 proteins and 16,695 metabolites were identified. The top 5 GO terms of lymph proteomics indicated that oxidative stress and innate immunity were closely associated with TIH and antithrombotic therapy. The top 5 GO terms of lymph metabolomics showed that homocystine and lysophosphatidylcholine were the differential expressed metabolites (DEMs) between the sham and VEH groups, while cholic acid, docosahexaenoic acid, N1-Methyl-2-pyridone-5-carboxamide, isoleucine and testosterone are the DEMs between the VEH and CLO group. CONCLUSIONS: This study presents the first proteomic and metabolomic profiling of lymph after TIH and antithrombotic therapy, and predicts the possible lymph biomarkers for TIH.

Revolutionizing thoracic surgery education: a bibliometric analysis of the past decade's literature.

OBJECTIVES: Thoracic surgery is a complex field requiring advanced technical skills and critical decision-making. Surgical education must evolve to equip trainees with proficiency in new techniques and technologies. METHODS: This bibliometric analysis systematically reviewed 113 articles on thoracic surgery skills training published over the past decade, retrieved from databases including Web of Science. Publication trends, citation analysis, author and journal productivity, and keyword frequencies were evaluated. RESULTS: The United States contributed the most publications, led by pioneering institutions. Simulation training progressed from basic to sophisticated modalities and virtual reality emerged with transformative potential. Minimally invasive techniques posed unique learning challenges requiring integrated curricula. CONCLUSION: Ongoing investments in educational research and curriculum innovations are imperative to advance thoracic surgery training through multidisciplinary strategies. This study provides an evidentiary foundation to optimize training and address the complexities of modern thoracic surgery.

Minimally invasive and robotic-assisted approaches applied to pediatric surgical oncology.

The management of pediatric tumors is complex, with surgery, chemotherapy, and radiotherapy being cornerstones in their treatment. Tumor removal is increasingly performed by a minimally invasive approach, which allows for quicker postoperative recovery and less postoperative pain. The goal of this report is to give an overview of minimally invasive surgical approaches for common pediatric tumors, with a focus on technical considerations and postoperative outcomes.

Fibroblast Activation Protein-Directed Imaging Outperforms 18F-FDG PET/CT in Malignant Mesothelioma: A Prospective, Single-Center, Observational Trial.

The fibroblast activation protein (FAP) is highly expressed in tumor and stromal cells of mesothelioma and thus is an interesting imaging and therapeutic target. Previous data on PET imaging with radiolabeled FAP inhibitors (FAPIs) suggest high potential for superior tumor detection. Here, we report the data of a large malignant pleural mesothelioma cohort within a 68Ga-FAPI46 PET observational trial (NCT04571086). Methods: Of 43 eligible patients with suspected or proven malignant mesothelioma, 41 could be included in the data analysis of the 68Ga-FAPI46 PET observational trial. All patients underwent 68Ga-FAPI46 PET/CT, contrast-enhanced CT, and 18F-FDG PET/CT. The primary study endpoint was the association of 68Ga-FAPI46 PET uptake intensity and histopathologic FAP expression. Furthermore, secondary endpoints were detection rate and sensitivity, specificity, and positive and negative predictive values as compared with 18F-FDG PET/CT. Datasets were interpreted by 2 masked readers. Results: The primary endpoint was met, and the association between 68Ga-FAPI46 SUVmax or SUVpeak and histopathologic FAP expression was significant (SUVmax: r = 0.49, P = 0.037; SUVpeak: r = 0.51, P = 0.030).68Ga-FAPI46 and 18F-FDG showed similar sensitivity by histopathologic validation on a per-patient (100.0% vs. 97.3%) and per region (98.0% vs. 95.9%) basis. Per-region analysis revealed higher 68Ga-FAPI46 than 18F-FDG specificity (81.1% vs. 36.8%) and positive predictive value (87.5% vs. 66.2%). Conclusion: We confirm an association of 68Ga-FAPI46 uptake and histopathologic FAP expression in mesothelioma patients. Additionally, we report high sensitivity and superior specificity and positive predictive value for 68Ga-FAPI46 versus 18F-FDG.

Efficacy of an expandable prosthesis placement after left pneumonectomy for soft tissue ewing sarcoma in a five-year-old child: 10 years follow-up.

We report the case of a five-year-old girl who underwent left pneumonectomy for Ewing sarcoma of the lung. Two expandable prosthesis were placed in the left hemi-thorax to prevent post-pneumectomy syndrome and to protect the heart from radiotherapy. With a follow-up of 10 years, the procedure proved to be effective both on PPS and on cardiac protection.

Pneumonectomy following penetrating trauma with ECMO as postoperative support: case report - (Lung trauma and ECMO).

BACKGROUND: Penetrating thoracic injuries have a significant risk of morbi-mortality. Despite the advancements in damage control methods, a subset of patients with severe pulmonary vascular lesions and bronchial injuries persists. In some of these cases, post-traumatic pneumonectomy is required, and perioperative extracorporeal membrane oxygenation (ECMO) support may be required due to right ventricular failure and respiratory failure. CASE DESCRIPTION: A male was brought to the emergency department (ED) with a penetrating thoracic injury, presenting with massive right hemothorax and active bleeding that required ligation of the right pulmonary hilum to control the bleeding. Subsequently, he developed right ventricular dysfunction and ARDS, necessitating a dynamic hybrid ECMO configuration to support his condition and facilitate recovery. CONCLUSIONS: Penetrating thoracic injuries with severe pulmonary vascular lesions may need pneumonectomy to control bleeding. ECMO support reduces the associated mortality by decreasing the complications rate. A multidisciplinary team is essential to achieve good outcomes in severe compromised patients.

Time to surgical stabilization of rib fractures: does it impact outcomes?

Objectives: Rib fractures are common, morbid, and potentially lethal. Intuitively, if interventions to mitigate downstream effects of rib fractures can be implemented early, likelihood of developing these complications should be reduced. Surgical stabilization of rib fractures (SSRF) is one therapeutic intervention shown to be useful for mitigating complications of these common fractures. Our aim was to investigate for association between time to SSRF and complications among patients with isolated rib fractures undergoing SSRF. Methods: The 2016-2019 American College of Surgeons Trauma Quality Improvement Program (TQIP) database was queried to identify patient >18 years with isolated thoracic injury undergoing SSRF. Patients were divided into three groups: SSRF ≤2 days, SSRF >2 days but <3 days, and SSRF >3 days. Poisson regression, and adjusting for demographic and clinical covariates, was used to evaluate the association between time to SSRF and the primary endpoint, in-hospital complications. Quantile regression was used to evaluate the effects of time to SSRF on the secondary endpoints, hospital and intensive care unit (ICU) length of stay (LOS). Results: Out of 2185 patients, 918 (42%) underwent SSRF <2 days, 432 (20%) underwent SSRF >2 days but <3 days, and 835 (38%) underwent SSRF >3 days. Hemothorax was more common among patients undergoing SSRF >3 days, otherwise all demographic and clinical variables were similar between groups. After adjusting for potential confounding, SSRF >3 days was associated with a threefold risk of composite in-hospital complications (adjusted incidence rate ratio: 3.15, 95% CI 1.76 to 5.62; p<0.001), a 4-day increase in total hospital LOS (change in median LOS: 4.09; 95% CI 3.69 to 4.49, p<0.001), and a nearly 2-day increase in median ICU LOS (change in median LOS: 1.70; 95% CI 1.32 to 2.08, p<0.001), compared with SSRF ≤2 days. Conclusion: Among patients undergoing SSRF in TQIP, earlier SSRF is associated with less in-hospital complications and shorter hospital stays. Standardization of time to SSRF as a trauma quality metric should be considered. Level of evidence: Level II, retrospective.

Pulmonary contusion with hemoptysis from lacrosse ball strike: A case report.

Lacrosse, a sport of increasing popularity, is played with netted sticks and a firm rubber ball propelled at speeds frequently reaching over 100 miles/hour. While lacrosse injuries have been previously described, little published literature exists on lacrosse balls causing pulmonary contusion. We present a case of a 17-year-old male lacrosse player athlete who suffered a lacrosse ball strike to the left posterolateral chest, leading to a clinical presentation of local bruising, shortness of breath, and hemoptysis. Despite delayed arrival to the emergency room, where imaging revealed pulmonary contusion, multidisciplinary supportive management led to favorable clinical outcome with no residual effect on athletic ability and quality of life. Although pulmonary contusion may be a rare injury in the setting of thoracic trauma from lacrosse ball strikes, prompt evaluation and a high index of suspicion can rule out more life-threatening processes and ensure an excellent clinical prognosis.

Droopy Shoulder Syndrome: A Gateway to Thoracic Outlet Syndrome.

Droopy shoulder syndrome (DSS) manifests as discomfort or abnormal sensations in the neck, shoulder, chest, and upper limbs, resulting from tension on the brachial plexus caused by abnormally low shoulder positioning. This case report examines the presentation and management of a patient with DSS, a rare but crucial precursor to thoracic outlet syndrome (TOS). The patient, a 22-year-old male, presented with progressive pain and tingling in his left upper limb, shoulder, chest, and neck. Comprehensive examination and imaging studies led to a diagnosis of DSS. Physical therapy prevented progression to full-blown TOS, highlighting the importance of early recognition and intervention. This case underscores the diagnostic challenges and therapeutic strategies essential for managing this syndrome, preventing complications, and restoring patient function.

Posterior thoracic antedisplacement and fusion surgery for a special type of ossification of the posterior longitudinal ligament in the thoracic spine: indications and preliminary clinical results of 2-year follow-up.

OBJECTIVES: To describe a novel technique, posterior thoracic antedisplacement and fusion (PTAF), for a special type of ossification of the posterior longitudinal ligament in the thoracic spine (T-OPLL), and to evaluate its safety and efficacy. METHODS: From July to December 2020, five consecutive patients with beak-type T-OPLL located at the thoracic vertebral body (VB) level underwent PTAF surgery. Their demographic data, radiological parameters, perioperative complications, and surgery-related findings were recorded and analyzed. The surgical outcomes were assessed using a modified Japanese Orthopedic Association (mJOA) scale, and the recovery rate (RR) was calculated using the Hirabayashi's method. RESULTS: All patients were followed up for at least two years. The mean thickness of OPLL was 9.4 ± 1.0 mm, and the OPLL spinal canal occupying ratio was 67.7% ± 8.5%. Postoperatively, the mean antedisplacement distance of OPLL was 8.1 ± 1.8 mm, and the average shortened distance of the spinal column was 6.0 ± 1.13 mm. The mean operation time and blood loss were 158.2 ± 26.3 min and 460 ± 89.4 mL, respectively. Perioperative complications were cerebrospinal fluid leakage and instrument failure, 2 cases each. The mean mJOA score was increased from 3.6 ± 2.9 before surgery to 9.4 ± 3.0 at the last follow-up, and the average RR was 84.2 ± 30.5%. CONCLUSION: The preliminary clinical outcomes indicate that PTAF is a safe and effective method for the treatment of beak-type T-OPLL, which has its apex located at the VB level and has a high spinal canal occupation ratio.

Radiological presentation of active pulmonary tuberculosis in kidney transplant recipients: a retrospective study of four cases and a review of the literature.

Although kidney transplantation is the best therapeutic option for patients with chronic kidney disease, the immunosuppression required greatly increases susceptibility to infections that are responsible for high post-transplant mortality. Pulmonary tuberculosis (TB) represents a major cause of such infections, and its early diagnosis is therefore quite important. In view of that, we researched the manifestations of active pulmonary TB in kidney transplant recipients, through chest X-ray and computed tomography (CT), as well as determining the number of cases of active pulmonary TB occurring over a 3.5-year period at our institution. We identified four cases of active pulmonary TB in kidney transplant recipients. The CT scans provided information complementary to the chest X-ray findings in all four of those cases. We compared our CT findings with those reported in the literature. We analyzed our experience in conjunction with an extensive review of the literature that was nevertheless limited because few studies have been carried out in lowand middle-income countries, where the incidence of TB is higher.

Apesar de o transplante renal ser a melhor opção terapêutica para pacientes com doença renal crônica, a imunodepressão decorrente desse tratamento eleva muito a suscetibilidade desses pacientes a infecções, responsáveis por altas taxas de mortalidade pós-operatórias. A tuberculose (TB) pulmonar é uma significativa causa dessas infecções, sendo muito importante o seu diagnóstico precoce. Assim, nós pesquisamos as manifestações da TB pulmonar ativa nessa população de transplantados renais por meio de radiografias simples e tomografia computadorizada (TC) do tórax, também para estabelecer o número de casos de TB pulmonar ativa em nossa instituição após levantamento de 3,5 anos. Encontramos quatro casos de TB pulmonar ativa em pacientes transplantados renais. A TC forneceu informações adicionais em relação às radiografias de tórax em 100% dos casos analisados. Comparamos os nossos achados de TC com os relatados na literatura. Somamos a experiência obtida com extensa revisão da literatura, ainda limitada nessa questão, com poucos estudos realizados em países em desenvolvimento onde a incidência de TB é maior.

Accuracy of an artificial intelligence algorithm for detecting moderate-to-severe vertebral compression fractures on abdominal and thoracic computed tomography scans.

Objective: To describe the accuracy of HealthVCF, a software product that uses artificial intelligence, in the detection of incidental moderate-to-severe vertebral compression fractures (VCFs) on chest and abdominal computed tomography scans. Materials and Methods: We included a consecutive sample of 899 chest and abdominal computed tomography scans of patients 51-99 years of age. Scans were retrospectively evaluated by the software and by two specialists in musculoskeletal imaging for the presence of VCFs with vertebral body height loss > 25%. We compared the software analysis with that of a general radiologist, using the evaluation of the two specialists as the reference. Results: The software showed a diagnostic accuracy of 89.6% (95% CI: 87.4-91.5%) for moderate-to-severe VCFs, with a sensitivity of 73.8%, a specificity of 92.7%, and a negative predictive value of 94.8%. Among the 145 positive scans detected by the software, the general radiologist failed to report the fractures in 62 (42.8%), and the algorithm detected additional fractures in 38 of those scans. Conclusion: The software has good accuracy for the detection of moderate-to-severe VCFs, with high specificity, and can increase the opportunistic detection rate of VCFs by radiologists who do not specialize in musculoskeletal imaging.

Objetivo: Descrever a acurácia do software HealthVCF na detecção incidental de fraturas compressivas de corpos vertebrais moderadas a graves em exames de tomografia computadorizada do tórax e abdome. Materiais e Métodos: Foram incluídos 899 exames consecutivos de pacientes com idades entre 51 e 99 anos. As imagens foram retrospectivamente avaliadas pelo software e por dois radiologistas especializados em musculoesquelético que investigaram fraturas compressivas de corpos vertebrais com perda da altura somática > 25%. A análise comparativa foi realizada entre o software e um radiologista geral, usando a avaliação do especialista como referência. Resultados: O software apresentou uma acurácia de 89,6% (IC 95%: 87,4­91,5%) para fraturas compressivas moderadas a graves, com sensibilidade de 73,8%, especificidade de 92,7% e valor preditivo negativo de 94,8%. Entre as 145 tomografias positivas detectadas pelo software, o radiologista geral deixou de relatar as fraturas em 62 (42,8%) e o algoritmo detectou fraturas adicionais em 38 dessas tomografias. Conclusão: O software possui boa acurácia na detecção de fraturas compressivas moderadas a graves, com alta especificidade, podendo aumentar a taxa de detecção oportunística dessas fraturas por radiologistas não especializados em musculoesquelético.