Intrapleural Thrombolytics as First Line Therapy for Complicated Parapneumonic Effusions and Empyema in Patients with Prohibitive Surgical Risk: A Cases Series.

OBJECTIVE: In complicated parapneumonic effusion or Empyema, approximately 25% of patients require surgical intervention which can be associated with a mortality risk of almost 20%. However, the use combination of rt-tPA and DNase in elderly patients with prohibitive surgical risk has improved outcomes. The main goal of our study is to highlight the utility of intrapleural thrombolysis in patients with prohibitive risk for surgery. METHODS: A retrospective record review study of patients (n=23) with complicated parapneumonic pleural effusion or empyema treated with tPA and DNase from January 1st of 2015 to March 18th, 2019 at VACHCS. Data collected to describe the outcome of intrapleural thrombolytics included demographic, pleural fluid analysis, surgical risk assessment, diagnosis and initiation treatment day, doses, chest imaging, drainage rate, chest tube size and average days in place, inflammatory markers, microbiology, antibiotics, and complications. RESULTS: Only 21.7% of patients were considered surgical candidates. Seventy-four percent had a 30-day post-surgical mortality risk of > 2.5% using the National Surgery Office (NSO) risk calculator. Post-operative inpatient stay was 99.7% and estimated post operative ICU stay average was >80%. Primary outcome (pleural drainage improvement) obtained in 73.9%. Most common serious complications included sepsis (52.2%) and nonserious was residual hydropneumothorax (47.8%). CONCLUSION: This study demonstrates that administration of intrapleural thrombolytics through a percutaneous pleural catheter achieved successful drainage safely and without the need for surgical interventions in a selected group of advanced age, elderly patients with pleural infections who were deemed to be high surgical risk.

Lung Cancer Screening in Community-Based Practice in Puerto Rico: A Survey of Puerto Rico Pulmonologists.

OBJECTIVE: Lung Cancer (LC) in Puerto Rico (PR) is the fifth most common malignancy (5.2%), the third most common among men (5.9%) and the fifth among women (4.6%), with a mortality of 11.3%. Despite current data demonstrating the importance and clinical value for lung cancer screening LDCT Screening among high risk patients remains low regardless of the potential to prevent thousands of lung cancer deaths per year. Due to significant disparities in health care in PR it is believed that LDCT use for lung cancer screening in PR is not been enforced in the private sector. METHODS: A self-administered anonymous survey was provided to a group of pulmonologists at the annual meeting of the PR Pneumology Society. The survey contained questions regarding characteristics of their practice and implementation of lung cancer screening. Provided information was tabulated in percentages. RESULTS: A total of 31 pulmonologists participated in the administration of the survey. Most participants had their medical practice in the metropolitan area (52%), which is the most populated area with best access to physicians and health care services. The sample from the north area comprised 19% of the subjects. All respondents were affiliated to health care institutions. As most of them served 1-3 health care centers (96%) with access to specialized equipment such as Chest CT. Most of the physicians (99%) had availability of chest CT scan within 1 hour from their practices and 97% were aware of the U.S. Preventive Services Task Force lung cancer screening recommendations. Their age range was 41 and over (55%). Despite the above there were discrepancies when asked about lung cancer screening implementation. Sixteen (16) percent did not perform lung cancer screening at all, and 77% that performed screening, reported limitations to it. CONCLUSION: This data suggests that although lung cancer screening has shown to reduce mortality and is recommended by the USPTF, it is not been conducted appropriately in PR. The main limitation identified was what the health insurance had to offer rather than lack of health insurance. Other factor to take in consideration is the lack of a comprehensive screening program for Lung Cancer anywhere in the island. In addition, costs associated with staff and implementation were noted as a significant barrier among the surveyed pulmonologists.