Early percutaneous catheter drainage in protecting against prolonged fever among patients with pyogenic liver abscess: a retrospective cohort study.

BACKGROUND: Percutaneous catheter drainage (PCD) has been viewed as first-line treatment for pyogenic liver abscess (PLA), yet detailed guidance is lacking for best practice of PCD. This study investigated characteristics of patients with PLA who had received PCD, identified factors associated with prolonged fever, and aimed to evaluate the relationship between timing of PCD and clinical improvement. METHODS: This was a retrospective study of patients with PLA who had undergone PCD over a 7-year period. PCD performed when the liquefaction degree of abscesses was less than 30% and/or within 1 week after fever onset was defined as early PCD. Patients were grouped and analysed based on the timing of PCD (early vs. delayed). Factors associated with prolonged fever were also analysed using univariate and multivariate logistic regression. RESULTS: Among 231 patients with PLA, 81 treated with PCD were included in the study after exclusion. The size of abscesses ranged from 3.4 to 16 cm in diameter. Interestingly, the abscesses were predominantly multiloculated in this cohort (82.7%). The most common pathogen isolated from pus was Klebsiella pneumoniae (60.5%), followed by Escherichia coli (8.6%). The duration of fever was significantly shortened with early PCD as compared to delayed PCD intervention (p = .042). No statistical differences were found between the two groups with regard to catheter adjustment and salvage drainage. Maximum body temperature and diameter of abscess > 7.5 cm were found to be associated with prolonged fever while early PCD was inversely related to prolonged fever. Multivariate analysis suggested that early PCD treatment was an independent protective factor of prolonged fever (p = .030). CONCLUSIONS: Large abscesses with loculation could be successfully treated with PCD, and early PCD protected patients with PLA from prolonged fever. Our findings suggest that early intervention should be provided if PCD is indicated in clinical practice.KEY MESSAGESLarge abscesses and multiloculated abscesses can be treated with percutaneous catheter drainage.Early percutaneous catheter drainage is identified as a protective factor of prolonged fever among patients with pyogenic liver abscesses.Early intervention should be provided if percutaneous catheter drainage is indicated for pyogenic liver abscesses.

Update on Novel Targeted Therapy for Pleural Organization and Fibrosis.

Pleural injury and subsequent loculation is characterized by acute injury, sustained inflammation and, when severe, pathologic tissue reorganization. While fibrin deposition is a normal part of the injury response, disordered fibrin turnover can promote pleural loculation and, when unresolved, fibrosis of the affected area. Within this review, we present a brief discussion of the current IPFT therapies, including scuPA, for the treatment of pathologic fibrin deposition and empyema. We also discuss endogenously expressed PAI-1 and how it may affect the efficacy of IPFT therapies. We further delineate the role of pleural mesothelial cells in the progression of pleural injury and subsequent pleural remodeling resulting from matrix deposition. We also describe how pleural mesothelial cells promote pleural fibrosis as myofibroblasts via mesomesenchymal transition. Finally, we discuss novel therapeutic targets which focus on blocking and/or reversing the myofibroblast differentiation of pleural mesothelial cells for the treatment of pleural fibrosis.

Morphological changes in chronic subdural hematomas following upfront middle meningeal artery embolization: sequence, timing, and association with outcomes.

OBJECTIVE: Middle meningeal artery embolization (MMAE) is an increasingly utilized approach for the treatment of chronic subdural hematomas (CSDHs). The course of morphological progression of CSDHs following MMAE is poorly understood. Herein, the authors aimed to describe these morphological changes and assess their prognostic significance for the outcomes on follow-up. METHODS: A single-institution retrospective cohort study of CSDH cases treated by upfront MMAE, without prior or adjunctive surgical evacuation, was performed. Clinical outcomes, complications, and the need for rescue surgery on follow-up were recorded. Hematomas were categorized into 6 morphological subtypes. All baseline and follow-up head CT scans were assessed for CSDH structural appearance, density, and loculation. Changes in CSDH size were quantified via 3D reconstruction for volumetric measurement. RESULTS: Overall, 52 CSDHs in 45 patients treated with upfront MMAE were identified. Hematomas were followed for a mean of 92.9 days. Volume decreased by ≥ 50% in 79.6% of the CSDHs. The overall rescue surgery rate was 9.6%. A sequence of morphological changes after MMAE was identified. Hematomas that diverged from this sequence (5.4%) all progressed toward treatment failure and required rescue surgery. The CSDHs were categorized into early, intermediate, and late stages based on the baseline morphological appearance. Progression from early to intermediate and then to late stage took 12.7 and 30.0 days, respectively, on average. The volume of early/intermediate- and late-stage hematomas decreased by ≥ 50%, a mean of 78.2 and 47.6 days after MMAE, respectively. Early- and intermediate-stage hematomas showed a trend toward more favorable outcomes compared with late-stage hematomas. The density of homogeneous hypodense hematomas (HSDHs) transiently increased immediately after MMAE (p < 0.001). A marked decrease in density and volume 1 to 3 weeks after MMAE in HSDHs was detected, the lack of which indicated an eventual need for rescue surgery. In HSDHs, a baseline mean density of < 20 HU, and a lower density than baseline by 1 month post-MMAE were predictors of favorable outcomes. The baseline hematoma volume, axial thickness, midline shift, and loculation were not correlated with MMAE outcomes. Loculated, trabecular, and laminar hematomas, which are known to have unfavorable surgical outcomes, had MMAE outcomes similar to those of other "surgical" hematomas. CONCLUSIONS: The current study was the first to describe the nature, sequence, and timing of morphological changes of CSDHs after MMAE treatment and has identified structural features that can predict treatment outcomes.

Novel OCT findings in choroidal osteoma: brief report.

The aim of this article is to report the presence of choroidal loculation of fluid and choroidal cavern in a case of choroidal osteoma, previously undescribed in this disease.

Endoscopic treatment of brain abscess.

BACKGROUND: Treatment of brain abscess is still a subject of controversy. The main treatment is surgical, although medical therapy alone can be used for selected cases. The treatment of choice is aspiration, which may be performed with the aid of an endoscope or by freehand technique, with or without stereotactic or intraoperative ultrasound guidance. Excision is valuable in some cases. We are reporting our results of endoscopic approach in 12 patients. METHODS: This study included 12 patients of brain abscesses treated between January 2015 and January 2018. All the cases except those with small abscesses (<3.0 cm in diameter) were included in the study. Rigid endoscope was used. Follow-up CT scan was done in all cases within 7 and 30 days after surgery. Follow-up periods ranged between 3 and 6 months. RESULTS: There were 11 patients with a history of chronic otitis media and one patient who suffered from congenital cyanotic heart disease. Glasgow Coma Score (GCS) was 5 in one patient, 13 in two cases, and 14-15 in 9 cases. There were one cerebellar, six temporal, and five frontal abscesses. All the patients recovered completely except one who died (GCS 5). There was no procedure-related complication. Hospital stay ranged from 14 to 45 days with an average of 28 days. The endoscopy aided visualization of multiloculations and septation in eight patients which allowed the opening of the septations and complete evacuation. CONCLUSION: Endoscopic aspiration is safe, easy, and represents an effective way of treatment of brain abscess through proper visualization. It can be used for ensuring the complete aspiration of contents, control of any bleeding point, and also for multiloculated abscess to identify and open the septations which may not be possible in stereotactic or any other guided aspirations.

Loculations and Associated Risk Factors of Childhood Pleural Tuberculosis.

Background: Pleural loculation in childhood pleural tuberculosis (TB) remains a problem in practice, it is usually associated with failure drainage. Therefore, to improve the management of childhood pleural TB, a retrospective study was conducted to identify the risk factors associated with loculated effusion in childhood pleural TB. Methods: Between January 2006 and December 2019, consecutive children (≤15 years old) with tuberculous pleural effusion (definite and possible) were included for further analysis. The demographic, clinical, laboratory, and radiographic features were collected from the medical records. Univariate and multivariate logistic regressions were used to explore the factors associated with the presence of pleural loculation in children with pleural TB. Results: A total of 154 children with pleural TB (definite, 123 cases; possible, 31 cases) were included in our study and then were classified as loculated effusion (n = 27) and non-loculated effusion (n = 127) groups by chest X-ray or ultrasonography. Multivariate analysis revealed that male gender (age-adjusted OR = 3.903, 95% CI: 1.201, 12.683), empyema (age-adjusted OR = 4.499, 95% CI: 1.597, 12.673), peripheral monocytes ≤0.46 × 109/L (age-adjusted OR = 4.122, 95% CI: 1.518, 11.193) were associated with the presence of loculated effusion in children with pleural TB. Conclusion: In conclusion, several characteristics, such as male gender, empyema, and peripheral monocyte count have been identified as risk factors for pleural loculation in children with pleural TB. Our findings may be helpful to improve the management of pleural loculation in childhood pleural TB.

Obstruction of Ventriculoperitoneal Shunt After Myelography-Report of a Unique Case and Its Treatment.

BACKGROUND: Myelography, frequently supplanted by noninvasive, efficient magnetic resonance imaging, remains a useful technique when evaluating the spinal canal in nerve root avulsion, radiation therapy treatment planning, cerebrospinal fluid (CSF) loculation, and CSF leak. Myelography is achieved through a lumbar puncture and instillation of nonionic, water-soluble intrathecal iohexol (Omnipaque, GE Healthcare, Marlborough, Massachusetts, USA) contrast. The aim of the study was to highlight a possible complication of obstruction of a shunt valve due to an increased viscosity of the CSF after intrathecal Omnipaque contrast administration during myelography. CASE DESCRIPTION: The authors report a case of myelography that resulted in obstruction of a ventriculoperitoneal (VP) shunt. A 23-year-old female with significant medical history of neurofibromatosis type I, obstructive hydrocephalus, anterior cervical diskectomy and fusion, and VP shunt placement underwent diagnostic computed tomography after myelography with Omnipaque contrast to assess possible CSF loculation and cord impingement from her cervical instrumentation. The patient experienced somnolence after myelography from obstruction of the VP shunt, with marked ventriculomegaly demonstrated by computed tomography of the head. A shunt tap and shunt pumping regimen resulted in resolution of the obstruction and hydrocephalus, with return to neurologic baseline. CONCLUSIONS: This is a recent case of VP shunt obstruction after myelography, of which previous cases reported are decades old. A shunt pumping regimen may be a nonoperative, effective mean for similar mechanical obstructions of VP shunts for restoration of flow and patency of the shunt system in these patients. We encourage physicians to consider the possibility of shunt obstruction after diagnostic myelography. Caution and close observation should be considered in patients undergoing myelography with a programmable VP shunt.

Very low-dose intrapleural tPA for indwelling pleural catheter-associated symptomatic fluid loculation.

Indwelling pleural catheters (IPCs) are effective management options for malignant pleural effusion. Symptomatic fluid loculation is a recognized complication of IPC use and is usually managed with intrapleural instillation of fibrinolytic drugs, such as tissue plasminogen activator (tPA). A previous multicentre observational study showed significant heterogeneity among centres in their dosing regimen for tPA (from 2 to 20 mg) in treating symptomatic loculations. Potential pleural bleeding, especially in high-risk patients, often deters clinicians from initiating intrapleural fibrinolytic therapy. Lower doses of tPA may reduce bleeding risks. This case report describes the successful use of 0.5 mg (the lowest reported dose) of tPA in a patient with significant bleeding risks whose IPC was complicated by symptomatic loculation.

Fibrin turnover and pleural organization: bench to bedside.

Recent studies have shed new light on the role of the fibrinolytic system in the pathogenesis of pleural organization, including the mechanisms by which the system regulates mesenchymal transition of mesothelial cells and how that process affects outcomes of pleural injury. The key contribution of plasminogen activator inhibitor-1 to the outcomes of pleural injury is now better understood as is its role in the regulation of intrapleural fibrinolytic therapy. In addition, the mechanisms by which fibrinolysins are processed after intrapleural administration have now been elucidated, informing new candidate diagnostics and therapeutics for pleural loculation and failed drainage. The emergence of new potential interventional targets offers the potential for the development of new and more effective therapeutic candidates.

Different characteristics of tuberculous pleural effusion according to pleural fluid cellular predominance and loculation.

BACKGROUND: Tuberculous pleural effusion (TPE) exhibits different characteristics according to pleural fluid cellular predominance or whether the pleural fluid is free-flowing or loculated. However, its categorization based on either of these factors alone may be insufficient to properly reflect the heterogeneous manifestation of TPE. We evaluated the characteristics of the four TPE groups classified according to cellular predominance and whether the fluid is free-flowing or loculated. METHODS: A cohort of 375 patients with TPE was retrospectively reviewed. Clinical, radiological, and laboratory findings were compared between neutrophilic and lymphocytic TPE, and between free-flowing and loculated effusion for both neutrophilic and lymphocytic TPE. RESULTS: Lymphocytic TPE and neutrophilic TPE were observed in 336 (90%) and 39 (10%) patients, respectively. Pleural fluid loculation was present in 36% and 31% of the patients in the lymphocytic and neutrophilic groups, respectively. A few parameters of the laboratory findings between neutrophilic and lymphocytic TPE patients showed significant differences. However, these significant differences were prominently observed when comparing free-flowing and loculated subgroups of the respective neutrophilic and lymphocytic groups. Pleural fluid pH, lactate dehydrogenase, and adenosine deaminase levels were significantly different among the four subgroups. The neutrophilic loculated subgroup exhibited the most intense pleural inflammation and the highest mycobacterial yields when compared to the other subgroups. However, the percentage of neutrophils in the pleural fluid was not positively associated with the probability of culture-positive effusion. CONCLUSIONS: The heterogeneous manifestation of TPE would be better characterized by using a classification system based on combined pleural fluid cellular predominance and loculation, with the neutrophilic loculated subgroup contributing to most of the clinically significant differences.

Neutrophilic Loculated Tuberculous Pleural Effusion: Incidence, Characteristics and Differentiation From Complicated Parapneumonic Effusion.

OBJECTIVES: Tuberculous pleural effusion (TPE) is generally characterized by lymphocytic exudative effusion, either free-flowing or loculated. However, patients can also have neutrophilic loculated TPE, although little data are available concerning the incidence and characteristics of this form of TPE. It is important to differentiate between neutrophilic loculated TPE and complicated parapneumonic effusion (PPE), which also shows neutrophilic loculated effusion but needs a different management approach. The present study evaluated the incidence and characteristics of neutrophilic loculated TPE and differentiated it from complicated PPE. MATERIALS AND METHODS: Between 2009 and 2014, a cohort of patients with TPE was retrospectively reviewed in a South Korean referral hospital. Clinical, laboratory, computed tomography and pleural fluid findings of patients with neutrophilic loculated TPE were compared to those of patients with neutrophilic free-flowing TPE and complicated PPE, respectively. RESULTS: Neutrophilic TPE was observed in 33 (10%) out of 344 patients with TPE. Of these, 10 (30%) patients exhibited loculation of the pleural fluid. These patients showed distinct pleural fluid characteristics. The classical pleural fluid biomarker levels were more intense than those observed in 23 patients with neutrophilic free-flowing TPE, but similar to those of 54 patients with complicated PPE. A high mycobacterial burden was observed in the pleural fluid, and favorable outcomes were achieved with antituberculosis drug administration alone. Nodular parenchymal lesions and pleural fluid adenosine deaminase levels were independent discriminators of neutrophilic loculated TPE and PPE. CONCLUSIONS: These results may be helpful to understand and manage patients with neutrophilic loculated TPE and differentiate them from patients with complicated PPE.

Analysis of risk factors for complicated parapneumonic effusion in children / 临床儿科杂志

Objective To investigate the related risk factors of complicated parapneumonic effusion (CPPE) in children. Method The clinical data of 88 children with parapneumonic effusion (PPE) were retrospectively analyzed from January 2013 to April 2015. According to the treatment effect of antibiotics, CPPE group and uncomplicated parapneumonic effusion (UPPE) group were divided. The univariate analysis of clinical and laboratory parameters was performed between two groups. Then the multifactor logistic regression was performed further. The receiver operator characteristic (ROC) curve was draw. Results The univariate analysis indicated that the risk factors were the formation of loculation and serum CD3+ and CD19+ levels (Z=2.030~7.457, P30%and the formation of loculation.

Relevant factors for developing loculation after parapneumonic pleural effusion in children / 中华实用儿科临床杂志

Objective To identify the relevant factors for the loculation clinically in children with parapneumonic pleural effusion (PPE).Methods The clinical data of 172 children with PPE were retrospectively reviewed from January 2012 to March 2015 in Children's Hospital of Hebei Province.Based on the findings of chest ultrasound, the subjects were divided into 2 groups, the loculation group (78 cases) and the control group (94 cases).The comparison was made between the 2 groups in gender, age, course of disease and fever before admitting into hospital, the location of the effusion, white blood cells (WBC) and the percentage of neutrophils (N), blood platelet (PLT) ,lactate dehydrogenase (LDH),C-reactive protein (CRP), mycoplasma (MP), the routine and biochemical examination of pleural fluid, including white cell count (WBCp), the percentage of polymorphonuclear cell (PMN), lactate dehydrogenase (LDHp) ,glucose (GLU) ,adenosine deaminase (ADA) ,lactic acid (LAC) and C-reactive protein (CRPp).If the result of single factor regression showed P ＜ 0.01, the indicators were analyzed by the multifactor Logistic regression.The receiver operator characteristic (ROC) curve was drawn to evaluate the prediction ability of Logistic regression models.Results (1) The result of single factor regression indicated that the risk factors included age, WBC, PLT, LDH, MP, WBCp, PMN, GLU and LAC (all P ＜ 0.05).(2) The result of multifactor Logistic regression showed that the factors included PLT (OR =3.437,P =0.007), LDH (OR =0.306, P =0.006), GLU (OR =0.324, P =0.037), MP (OR =0.375 ,P =0.022) and LAC (OR =3.656, P =0.003).(3) The area under the ROC curve was 0.876, P =0.000,which indicated that the regression models had over medium diagnostic accuracy.Conclusions When PLT ＞ 434.5 × 109/L,LDH ＜400 U/L,non MP infection,GLU ＜6.11 mmol/L and LAC ＞3.83 mmol/L,it may indicate that the formation of loculation for the PPE children.