Lung abscess: the non-conservative management: a narrative review.

Background and Objective: Systemic antibiotics are the best treatment options for lung abscesses. However, up to 37% of lung abscesses do not respond to antibiotics and may require additional interventions. Percutaneous transthoracic tube drainage (PTTD), endoscopic catheter drainage (ECD) and surgical resection are additional options available when first line therapy with systemic antibiotics are unsuccessful. In this narrative review, we summarize all available interventional procedures, techniques, complications, safety, and contraindications. Methods: A literature search was performed using Medline/PubMed from January 1980 to October 2023. Key words: "lung abscess", "pulmonary abscess", "endoscopic drainage", "percutaneous drainage", "tube drainage". Pediatric patients were excluded from this study. Key Content and Findings: PTTD and ECD are fairly safe procedures. Performing PTTD or ECD without delay may shorten the duration of hospital stay. This may lower the burden on health care. Moreover, draining abscesses may relieve discomfort in the clinical symptoms associated with abscesses. The primary factor in choosing ECD over PTTD is the location of the abscess, and the presence of a bronchial airway leading to the abscess for successful ECD. ECD has lower rate of complications and mortality; and similar success rate compared to PTTD. While mortality has been reported with PTTD, ECD appears to be safer according to present data. Conclusions: PTTD and ECD are safe procedures, with low complication rates. ECD has a lower complication rate than PTTD does.

A Case of an Intraoperative Iatrogenic Methanol Exposure.

BACKGROUND ThinPrep Cytolyt is a methanol-based cell preservation solution frequently used to fix tissue samples immediately following endobronchial ultrasound-guided fine-needle aspiration. Currently, no published reports describe an iatrogenic exposure to Cytolyt. We report the only known case of an accidental intraoperative administration of a methanol solution, with corresponding plasma concentrations, and successful treatment with fomepizole. CASE REPORT A 70-year-old woman with a history of stage IIIA rectal adenocarcinoma was referred for evaluation of a newly identified lung mass. During the procedure, a bronchoalveolar lavage (BAL) of the right upper lobe was performed. After BAL, the proceduralist was informed that the syringe used to instill fluid for the BAL contained Cytolyt rather than saline. The Department of Medical Toxicology was contacted immediately, and the patient received a 15 mg/kg dose of fomepizole. The first plasma methanol level, before fomepizole administration, was elevated to 21 mg/dL. The methanol level was 13 mg/dL 3 h after fomepizole treatment and even lower thereafter; therefore, no additional fomepizole was required. The patient did not develop signs of systemic toxicity and was discharged on hospital day 3. CONCLUSIONS Following methanol exposures, patients can exhibit metabolic acidosis, with potential for blindness, hemodynamic instability, and possibly death if untreated. Fomepizole (4-methylpyrazole) inhibits alcohol dehydrogenase and is a mainstay of treatment. Preventing medical errors is key in ensuring optimal patient care and decreasing adverse events. Providers using CytoLyt and any similar products should be aware of this potential error and approach the possibility of methanol toxicity as they would other routes of methanol exposure.

A Distinct Difference Between Air and Mucosal Temperatures in Human Respiratory Tract.

Extensive evidence indicates that several types of temperature-sensitive ion channels are abundantly expressed in the sensory nerves innervating airway mucosa. Indeed, airway temperature is known to play an important role in regulating respiratory functions. However, the actual airway mucosal temperature and its dynamic changes during the respiratory cycle have not been directly measured. In previous studies, airway tissue temperature was often estimated by indirect measurement of the peak exhaled breath temperature (PEBT). In view of the poor thermal conductivity of air, we believe that the airway tissue temperature cannot be accurately determined by the exhaled air temperature, and this study aimed to test this hypothesis. We applied a miniature rapid-response temperature probe to measure directly the mucosal temperatures of trachea, major, lobar, and segmental bronchi in eight human subjects during a bronchoscopy procedure. Unlike the air temperature in the airway lumen, the mucosal temperature in these airway segments remained relatively stable and did not exhibit the phasic changes synchronous with respiratory cycles. The airway mucosal temperature increased progressively from the extra-thoracic trachea (35.7 ± 0.2°C) toward the segmental bronchus (36.9 ± 0.2°C). Most importantly, the temperatures measured directly at the mucosa of all these airway segments were substantially higher than the PEBT (31.7 ± 0.8°C). The recent findings of a close association between an increased PEBT and airway tissue inflammation have revealed the implication and potential of incorporating the PEBT measurement in the future clinical diagnosis of airway inflammation. Therefore, it is imperative to recognize this distinct difference in temperature between airway mucosa and exhaled air.

Anticoagulation in ECMO patients: an overview.

Extracorporeal membrane oxygenation (ECMO) is a form of cardiorespiratory support, and is being increasingly used to support refractory heart and respiratory failure. It involves draining blood from the vascular system, which is then circulated outside the body by a mechanical pump and then later reinfused back into the circulation. The blood that is circulated outside the body comes in contact with a large surface area of non-endothelial biosurface. This exposure leads to a pro-thrombotic state, and hence anticoagulation is required. Unfractionated heparin is the most commonly used anticoagulation in most ECMO centers, but it does require close monitoring. Despite the advances made, hemostasis remains a challenge for physicians who manage patients on ECMO.

Concurrent Intrapleural Instillation of Tissue Plasminogen Activator and DNase for Pleural Infection. A Single-Center Experience.

RATIONALE: Treatment of pleural infection with instillation of intrapleural tissue plasminogen activator (tPA) and human recombinant DNase (DNase) has been proven to decrease the length of hospital stay, decrease surgical referral, and improve drainage. The optimal dosage, administration, timing, and frequency of the regimen remain unclear. It is unknown if the two drugs can be administered immediately one after the other (referred to as concurrent) instead of instilling them separately with a 1- to -2-hour interval in between. OBJECTIVES: To assess the safety and efficacy of concurrent instillation of intrapleural tPA/DNase guided by radiographic and clinical response in patients with pleural infection. METHODS: We conducted a retrospective cohort study. Consecutive patients with pleural infection who received concurrent tPA/DNase were included. The initiation and number of doses of tPA/DNase therapy were based on pleural fluid drainage, clinical response, and radiographic findings. MEASUREMENTS AND MAIN RESULTS: Seventy-three patients received concurrent tPA/DNase therapy. Treatment was successful in 90.4% of them; 80.8% were effectively treated with fewer than six doses of therapy (median, 2; interquartile range [IQR], 1-3.5); and 71.2% received their first dose of tPA/DNase within 24 hours after chest tube insertion. The median hospital stay from the first dose of tPA/DNase to discharge was 7 days (IQR, 5-11 d). The volume of pleural fluid drained increased from a median of 295 ml (IQR, 97.5-520 ml) 24 hours before treatment to a median of 1,102 ml (IQR, 627-2,200 ml) 72 hours following therapy (P < 0.001). Nonfatal pleural bleeding occurred in 5.4%, 15.1% had chest pain, and 2.7% died as a result of pleural infection. CONCLUSIONS: This cohort study shows that early administration of concurrent tPA/DNase in patients with pleural infection is relatively safe and effective. Given the high cost of therapy, it is feasible to guide therapy on the basis of clinical and radiographic response.

Pill aspiration presenting as an endobronchial tumor.

Tracheobronchial foreign body aspiration is a major cause of morbidity and mortality. The incidence of foreign body aspiration decreases significantly with increasing age, resulting in atypical presentations in adults. A high index of suspicion is required in adults presenting with respiratory symptoms. We present a rare case of a foreign body (pill) aspiration in an elderly female mimicking an obstructing endobronchial lesion.

The use of CP-EBUS-TBNA in the diagnosis of chondrosarcoma in a patient With Maffucci syndrome.

We report a case of a 52-year-old white woman with Maffucci syndrome, a rare skeletal disorder characterized by multiple cartilage-forming tumors (enchondromas). She was referred for evaluation of an enlarging pulmonary nodule. Her positron emission tomography-computed tomography scan revealed a low-density, tubular lesion in the superior segment of the left lower lobe of the lung. She underwent a convex-probe endobronchial ultrasound (CP-EBUS)-guided transbronchial needle aspiration (TBNA) that confirmed metastatic chondrosarcoma. Although CP-EBUS-TBNA has become an established tool for diagnosing and staging of non-small cell lung cancer, analysis of samples from rare tumors such as sarcomas by cytology alone is often inadequate and histologic confirmation using more invasive procedures is often required. Interestingly in our case, the diagnosis of chondrosarcoma was established from the cytology specimen obtained with a 21-G needle without the need for further tissue sampling. Moreover, the location of the lesion was the superior segment of the left lower lobe, an area typically not accessible by CP-EBUS, due to the size of the airway. Considering together, the successful diagnosis of a rare tumor such as sarcomas by CP-EBUS-TBNA modality indicates the growing importance of this minimally invasive technology.

Endobronchial fibroepithelial polyp.

Benign airway tumors are rare and represent only 1.9% of pulmonary tumors. Fibroepithelial polyps are common benign lesions in the skin, uterus, and neck; however, it is rare in the tracheobronchial tree with only sporadic case reports. The etiology is unclear, but it is thought to be due to inflammation or infection, especially in smokers and in patients with chronic obstructive pulmonary disease. In this case report, we describe a rare case of endobronchial fibroepithelial polyp and the utility of an interventional endobronchial therapeutic approach.

Emerging trends in enteric fever in Nepal: 9124 cases confirmed by blood culture 1993-2003.

This was a retrospective study in an urban hospital in Kathmandu, Nepal to determine the changing burden of salmonella septicaemia, the proportion of Salmonella paratyphi A, and the emergence of drug-resistant organisms. The participants were outpatients and inpatients over the period 1993-2003, and the main outcome measures were blood culture isolates and antibiotic sensitivity testing. The results showed that of 82467 blood cultures performed, a bacterium was isolated from 12252. Salmonella accounted for 9124 (74.5%) of the positive blood cultures: 6447 (70.7%) were Salmonella enterica serotype Typhi (S. typhi) and 2677 (29.3%) were Paratyphi A (S. paratyphi A). In comparing the period 1997-2000 to the period 2001-2003, we found that, as a proportion of total blood cultures taken, salmonella septicaemia more than doubled, from 6.2 to 13.6% (P<0.001). From the first half of the study (1993-1998) to the second half (1999-2003), S. paratyphi A as a proportion of all salmonella isolates rose from 23 to 34% (P<0.001), which paralleled its increased resistance to ciprofloxacin. Despite the introduction of new antibiotics, enteric fever continues to grow as a cause for hospital presentation in Nepal. Salmonella paratyphi A contributes an increasingly large proportion of cases, and ciprofloxacin resistance is also emerging more rapidly in S. paratyphi A.

Preliminary analysis of 64 slices helical CT perfusion imaging of pancreatic tumors / 中华胰腺病杂志

Objective To describe the hemodynamic characteristics of normal pancreas and pancreatic tumors by 64 slices helical CT perfusion imaging, to evaluate the role of CT perfusion in the diagnosis of pancreatic tumors. Methods Perfusion CT scan was performed in 149 patients, including 36 patients with normal pancreas, 105 patients with pancreatic tumors and 8 patients with duodenal papillary carcinoma. The parameters including blood flow (BF) ,blood volume (BV) and permeability surface area product (PS) were measured. Results The mean value of BF, BV and PS of normal pancreas were (135.24±48.36) ml· min-1·kg-1, (200.55±54.96)ml/kg and (49.75±24.27) ml·min-1·kg-1, respectively. Pancreatic carcinoma has a lower BF, BV and PS,whieh were 31.77±19.36 ml·min-1· kg-1, (66.84±39.49)ml/kg and (37.64±27.14) ml·min-1·kg-1, respectively. The aforementioned parameters in pancreatic cysts were close to zero. The parameters in pancreatic carcinoma were significantly lower than those in normal pancreas(P<0.05); the BF and BV in duodenal papillary carcinoma were significantly lower than those in normal pancreas(P<0.05), while the value of PS was not significantly different from that in normal pancreas; the aforementioned parameters in pancreatic cysts were significantly different from those in normal pancreas(P <0.01). Conclusions In perfu sion CT, normal pancreas was an organ with symmetrical BF,BV and PS. Pancreatic carcinoma was a tumor with low perfusion and decreased PS. Duodenal papillary carcinoma had decreased BF and BV with no significant change in PS. Pancreatic cyst had no blood perfusion. The 64 slice helical CT peffusion imaging was invaluable in differential diagnosis of pancreatic tumors.

Salmonella enterica serovar Paratyphi A and S. enterica serovar Typhi cause indistinguishable clinical syndromes in Kathmandu, Nepal.

BACKGROUND: Enteric fever is a major global problem. Emergence of antibacterial resistance threatens to render current treatments ineffective. There is little research or public health effort directed toward Salmonella enterica serovar Paratyphi A, because it is assumed to cause less severe enteric fever than does S. enterica serovar Typhi. There are few data on which to base this assumption, little is known of the serovar's antibacterial susceptibilities, and there is no readily available tolerable vaccination. METHODS: A prospective study was conducted of 609 consecutive cases of enteric fever (confirmed by blood culture) to compare the clinical phenotypes and antibacterial susceptibilities in S. Typhi and S. Paratyphi A infections. Variables independently associated with either infection were identified to develop a diagnostic rule to distinguish the infections. All isolates were tested for susceptibility to antibacterials. RESULTS: Six hundred nine patients (409 with S. Typhi infection and 200 with S. Paratyphi A infection) presented during the study period. The infections were clinically indistinguishable and had equal severity. Nalidixic acid resistance, which predicts a poor response to fluoroquinolone treatment, was extremely common (75.25% of S. Paratyphi A isolates and 50.5% of S. Typhi isolates; P < .001). S. Paratyphi A was more likely to be resistant to ofloxacin (3.6% vs. 0.5%; P = .007) or to have intermediate susceptibility to ofloxacin (28.7% vs. 1.8%; P < .001) or ciprofloxacin (39.4% vs. 8.2%; P < .001). MICs for S. Paratyphi A were higher than for S. Typhi (MIC of ciprofloxacin, 0.75 vs. 0.38 microg/mL [P < .001]; MIC of ofloxacin, 2.0 vs. 0.75 microg/mL [P < .001]). CONCLUSIONS: The importance of S. Paratyphi A has been underestimated. Infection is common, the agent causes disease as severe as that caused by S. Typhi and is highly likely to be drug resistant. Drug resistance and lack of effective vaccination suggest that S. Paratyphi A infection may become a major world health problem.

Enteric (typhoid) fever in travelers.

The incidence of enteric (typhoid) fever in travelers is estimated to be approximately 3-30 cases per 100,000 travelers to developing countries. Recently, it is become clear that travelers who are visiting friends and relatives, especially travelers to the Indian subcontinent, seem to be the most vulnerable to enteric fever and require special attention for prevention. Recent concerns are the increasing incidence of paratyphoid fever in Asia, which is not covered by available typhoid vaccines, and the emergence of infections caused by antibiotic-resistant strains (including strains resistant to fluoroquinolones). Typhoid vaccination is recommended for most travelers to moderate- to high-risk countries. Because of the nonspecific clinical presentation of enteric fever, a high index of suspicion is important in febrile travelers who have traveled to areas of endemicity.