Respiratory chest pain: diagnosis and treatment

Rehabilitation for Functioning and Quality of Life in Patients with Malignant Pleural Mesothelioma: A Scoping Review

Malignant pleural mesothelioma (MPM) represents a significant clinical challenge due to limited therapeutic options and poor prognosis. Beyond mere survivorship, setting up an effective framework to improve functioning and quality of life is an urgent need in the comprehensive management of MPM patients. Therefore, this study aims to review the current understanding of MPM sequelae and the effectiveness of rehabilitative interventions in the holistic approach to MPM. A narrative review was conducted to summarize MPM sequelae and their impact on functioning, disability, and quality of life, focusing on rehabilitation interventions in MPM management and highlighting gaps in knowledge and areas for further investigation. Our findings showed that MPM patients experience debilitating symptoms, including fatigue, dyspnea, pain, and reduced exercise tolerance, decreasing quality of life. Supportive and rehabilitative interventions, including pulmonary rehabilitation, physical exercise improvement, psychological support, pain management, and nutritional supplementation, seem promising approaches in relieving symptoms and improving quality of life but require further research. These programs emphasize the pivotal synergy among patient-tailored plans, multidisciplinary team involvement, and disease-specific focus. Despite advancements in therapeutic management, MPM remains a challenging disease with limited effective interventions that should be adapted to disease progressions. Rehabilitative strategies are essential to mitigate symptoms and improve the quality of life in MPM patients. Further research is needed to establish evidence-based guidelines for rehabilitative interventions tailored to the unique needs of MPM patients.

Ultrasound-guided erector spinae nerve block for relief of chest pain from pneumonia in the emergency department

Erector spinae plane blocks (ESPB) have shown to provide meaningful chest wall anesthesia and reduce opioid consumption after thoracic surgery. Emergency physicians often use erector spinae plane blocks in the emergency department (ED) for rib fractures when acetaminophen, non-steroidal anti-inflammatory (NSAID), and opioids fail to control pain. They have also demonstrated successful pain management for conditions like herpes zoster, renal colic, burns, and acute pancreatitis for ED patients. With low reported rates of complication and relatively easy landmarks to identify, erector spinae plane blocks are an appealing regional anesthetic technique for emergency physicians to utilize for uncontrolled pain. We present the case of a 58-year-old male presenting to the ED with chest pain from pneumonia which remained unmanageable after acetaminophen, NSAID, and opioid administration. An ultrasound-guided erector spinae plane block was performed in the ED and the patient had a significant reduction in his chest pain.

Comprehensive Pulmonary Rehabilitation for Patients with Malignant Pleural Mesothelioma: A Feasibility Pilot Study

Malignant pleural mesothelioma (MPM) represents a significant health burden, with limited treatment options and poor prognosis. Despite advances in pharmacological and surgical interventions, the role of rehabilitation in MPM management remains underexplored. This study aims to assess the feasibility of a tailored pulmonary rehabilitation intervention addressing physical and respiratory function in MPM patients. A prospective pilot study was conducted on surgically treated MPM patients referred to a cardiopulmonary rehabilitation service. The intervention comprised multidisciplinary educational sessions, physical rehabilitation, and respiratory physiotherapy. Feasibility was evaluated based on dropout rates, adherence to the rehabilitation program, safety, and patient-reported outcomes. Twelve patients were initially enrolled, with seven completing the study. High adherence to physical (T1: 93.43%, T2: 82.56%) and respiratory (T1: 96.2%, T2: 92.5%) rehabilitation was observed, with minimal adverse events reported. Patient satisfaction remained high throughout the study (GPE scores at T1: 1.83 ± 1.17; T2: 2.0 ± 1.15), with improvements noted in physical function, pain management, and health-related quality of life. However, some issues, such as time constraints and lack of continuous supervision, were reported by participants. This pilot study demonstrates the feasibility and potential benefits of a tailored pulmonary rehabilitation intervention in MPM patients. Despite its promising outcomes, further research with larger samples is warranted to validate its efficacy and integrate rehabilitation as a component into the multidisciplinary management of MPM.

Beyond breathing: Systematic review of global chronic obstructive pulmonary disease guidelines for pain management

CONTEXT

Patients with chronic obstructive pulmonary disease (COPD) experience pain as both symptom and comorbidity. There has been no evaluation of the recommendations for pain management in updated clinical practice guidelines (CPGs).

OBJECTIVES

Update the evidence on pain management, determine alignment of pain management recommendations with best-practice, and advocate for optimal pain management in patients with COPD.

METHODS

PubMed, Guideline International Network, Guideline Portal, Agency for Healthcare Research and Quality, National Institute for Healthcare Excellence, Scottish International Guidelines Network, Institute of Medicine, grey literature, national websites, and bibliographies were searched. CPGs available online for stable COPD produced by organizations representing reputable knowledge of COPD management were included. CPGs unavailable online, not translatable into English, or not including techniques within the defined scope were excluded. Researchers performed frequency counts for the verbatim terms "pain," "physical activity," "exercise," "rehabilitation," "physical therap(ist)/(y), "physiotherap(ist)/(y)," recorded context, and collected recommendations for pain management/treatment when present.

RESULTS

Of 32 CPGs, 24 included "pain" verbatim. Of these, 13 included recommendations for pain treatment/management. Common recommendations included opioids, pharmacological management, further medical assessment, and surgical intervention. Two CPGs referred to palliative care, one CPG discussed treating cough, and one discussed massage, relaxation, and breathing.

CONCLUSIONS

Pain management recommendations vary and are not aligned with evidence. Pain should be addressed in patients with COPD, whether directly or indirectly related to the disease. Reduction of variability in pain management and the disease burden is necessary. Pain management should include referrals to providers who can maximize benefit of their services.

Navigating Compassion: A Comprehensive Review of Palliative Care in Respiratory Medicine

Palliative care has emerged as a crucial aspect of comprehensive healthcare, particularly in respiratory medicine. This review navigates the intricate landscape of palliative care in the context of respiratory diseases, including chronic obstructive pulmonary disease (COPD), idiopathic pulmonary fibrosis (IPF), and lung cancer. The exploration begins with a comprehensive examination of palliative care's definition, significance, and purpose in respiratory medicine. It progresses to understanding common respiratory diseases, their impact on patients' quality of life, and the nuances of disease progression and prognosis. Delving into the principles of palliative care, the review highlights the importance of a patient- and family-centered approach, emphasizing the multidisciplinary collaboration required for holistic care. Symptom management takes center stage, with a detailed exploration of dyspnea, cough, and pain, covering pharmacological and non-pharmacological interventions. The psychosocial and spiritual dimensions are then unveiled, recognizing the psychological impact of respiratory diseases and the significance of addressing spiritual needs with cultural sensitivity. Communication in palliative care is explored through breaking lousy news, advance care planning, and shared decision-making. The section acknowledges the complex considerations surrounding end-of-life care, including recognizing the end-of-life phase, establishing care goals, and withdrawing life-sustaining therapies. Recognizing the indispensable role of caregivers, the review underscores the importance of caregiver support. It delineates strategies for providing emotional and practical support alongside a crucial focus on self-care for caregivers who shoulder the responsibilities of providing palliative care. As the exploration concludes, the challenges in implementing palliative care in respiratory medicine are outlined, from late referrals to communication barriers. However, the review also envisions a future marked by innovation, with emerging approaches, such as telehealth and personalized medicine, offering promising avenues for improvement. Research gaps and areas for improvement are identified, emphasizing the need for a collaborative effort to enhance the quality of palliative care for individuals facing respiratory diseases. The review culminates in a call to action, urging early palliative care integration, investment in education and training, research initiatives, advocacy for accessible services, and collaboration across disciplines. By heeding this call, healthcare providers, researchers, and policymakers can collectively contribute to the evolution and enhancement of palliative care in the challenging landscape of respiratory medicine.

Procedure-related pain during CT-guided percutaneous transthoracic needle biopsies of lung lesions: a prospective study

BACKGROUND

The existing data on the degree of pain in patients during CT-guided percutaneous transthoracic needle biopsy (PTNB) of lung lesions are limited and the factors related to pain are unclear. In this study, we aimed to evaluate the prevalence and severity of pain reported during PTNB and to identify factors associated with increased reported pain.

METHODS

Patients who underwent PTNB from April 2022 to November 2022 were prospectively evaluated using the numeric rating scale, which assesses subjective pain based on a 0-10 scoring system (0 = no pain; 10 = the worst pain imaginable). The scale divides the scores into three categories: mild pain (1-3 points), moderate pain (4-6 points), and severe pain (7-10 points). Pain scores from 4 to 10 were considered significant pain. Demographic data of patients, lesion characteristics, biopsy variables, complications, the patient's subjective feelings, and pathological result data were analyzed by multivariable logistic regression analysis to identify variables associated with significant pain.

RESULTS

We enrolled 215 participants who underwent 215 biopsy procedures (mean age: 64.5 ± 9.3 years, 123 were men). The mean procedure-related pain score was 2 ± 2. Overall, 20% (43/215) of participants reported no pain (score of 0), 67.9% (146/215) reported pain scores of 1-3, 11.2% (24/215) reported scores of 4-6, and 0.9% (2/215) reported scores of 7 or higher. Furthermore, non-significant pain (scores of 0-3) was reported during 87.9% (189/215) of the procedures. In the adjusted model, significant pain was positively associated with lesions ≥ 34 mm (p = 0.001, odds ratio [OR] = 6.90; 95% confidence interval [CI]: 2.18, 21.85), a needle-pleural angle ≥ 77° (p = 0.047, OR = 2.44; 95% CI: 1.01, 5.89), and a procedure time ≥ 26.5 min (p = 0.031, OR = 3.11; 95% CI: 1.11, 8.73).

CONCLUSIONS

Most participants reported no pain or mild pain from CT-guided percutaneous transthoracic needle biopsies of lung lesions. However, those with a larger lesion, a greater needle-pleural angle, and a longer procedure time reported greater pain.

Thrombosis and thromboembolism: Brighton collaboration case definition and guidelines for data collection, analysis, and presentation of immunization safety data

This is a Brighton Collaboration case definition of thrombosis and thromboembolism to be used in the evaluation of adverse events following immunization, and for epidemiologic studies for the assessment of background incidence or hypothesis testing. The case definition was developed by a group of experts convened by the Coalition for Epidemic Preparedness Innovations (CEPI) in the context of active development of SARS-CoV-2 vaccines. The case definition format of the Brighton Collaboration was followed to develop a consensus definition and defined levels of certainty, after an exhaustive review of the literature and expert consultation. The document underwent peer review by the Brighton Collaboration Network and by selected expert reviewers prior to submission.

The effect of cold application on pain in patients with chest tubes before deep breathing and coughing exercises: A randomized controlled study

BACKGROUND

Pain control is very important to ensure the comfort of patients and increase their quality of life.

OBJECTIVES

The purpose of this randomized controlled trial was to examine the effects of cold therapy in patients with chest tube before deep breathing and coughing exercises.

METHODS

The study participants were patients with chest tubes, who were treated at a training and research hospital in Turkey between May 2, 2017, and October 24, 2019. Seventy patients participated in the study in accordance with the inclusion criteria. The intervention group, patient identification form, and visual analogue scale were used to collect data. Cold therapy was applied for the intervention group before deep breathing and coughing exercises, and not for the control group.

RESULTS

The pain rates of the intervention group participants were lower (3.31) after the deep breathing and coughing exercises, than the rates (4.24) before the exercises (p<0.01). The pain rate (5.29) among the control group participants after the deep breathing and coughing exercises was significantly higher than those before (3.47) the exercises (p<0.01).

CONCLUSIONS

The study revealed that cold therapy before deep breathing and coughing exercises effectively relieves pain in patients with chest tubes.

Cardiopulmonary-related patient-reported outcomes in a randomized clinical trial of radiation therapy for breast cancer

Background

Long-term prospective patient-reported outcomes (PRO) after breast cancer adjuvant radiotherapy is scarce. TomoBreast compared conventional radiotherapy (CR) with tomotherapy (TT), on the hypothesis that TT might reduce lung-heart toxicity.

Methods

Among 123 women consenting to participate, 64 were randomized to CR, 59 to TT. CR delivered 50 Gy in 25 fractions/5 weeks to breast/chest wall and regional nodes if node-positive, with a sequential boost (16 Gy/8 fractions/1.6 weeks) after lumpectomy. TT delivered 42 Gy/15 fractions/3 weeks to breast/chest wall and regional nodes if node-positive, 51 Gy simultaneous-integrated-boost in patients with lumpectomy. PRO were assessed using the European Organization for Research and Treatment of Cancer questionnaire QLQ-C30. PRO scores were converted into a symptom-free scale, 100 indicating a fully symptom-free score, 0 indicating total loss of freedom from symptom. Changes of PRO over time were analyzed using the linear mixed-effect model. Survival analysis computed time to > 10% PRO-deterioration. A post-hoc cardiorespiratory outcome was defined as deterioration in any of dyspnea, fatigue, physical functioning, or pain.

Results

At 10.4 years median follow-up, patients returned on average 9 questionnaires/patient, providing a total of 1139 PRO records. Item completeness was 96.6%. Missingness did not differ between the randomization arms. The PRO at baseline were below the nominal 100% symptom-free score, notably the mean fatigue-free score was 64.8% vs. 69.6%, pain-free was 75.4% vs. 75.3%, and dyspnea-free was 84.8% vs. 88.5%, in the TT vs. CR arm, respectively, although the differences were not significant. By mixed-effect modeling on early ≤2 years assessment, all three scores deteriorated, significantly for fatigue, P ≤ 0.01, without effect of randomization arm. By modeling on late assessment beyond 2 years, TT versus CR was not significantly associated with changes of fatigue-free or pain-free scores but was associated with a significant 8.9% improvement of freedom from dyspnea, P = 0.035. By survival analysis of the time to PRO deterioration, TT improved 10-year survival free of cardiorespiratory deterioration from 66.9% with CR to 84.5% with TT, P = 0.029.

Conclusion

Modern radiation therapy can significantly improve long-term PRO.

Trial registration

Trial registration number ClinicalTrials.govNCT00459628, April 12, 2007 prospectively.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12885-021-08916-z.

The effectiveness and safety of local pleural anesthesia for pain control in patients undergoing CT-guided transthoracic needle biopsy

OBJECTIVES

To evaluate the effectiveness and safety of pleural anesthesia for CT-guided transthoracic needle biopsy (TNB).

METHODS

This retrospective study was performed between March 2019 and August 2019 in a tertiary care hospital. Patients undergoing CT-guided TNB received either (a) pleural and skin anesthesia (pleural anesthesia group) or (b) skin anesthesia only (skin anesthesia group). Pain score was reported on a 0-5 numeric rating scale, and pain scores 3-5 were classified as significant pain. The relationship between pleural anesthesia and pain score, significant pain, and pneumothorax was assessed by using multivariable linear and logistic regression models.

RESULTS

A total of 111 patients (67 men, 66.0 ± 11.4 years) were included (pleural anesthesia group, 38; skin anesthesia group, 73). Pleural anesthesia group reported lower pain score (1.4 ± 1.0 vs. 2.3 ± 1.1, p < 0.001) and less frequent significant pain (18.4% [7/38] vs. 42.5% [31/73], p = 0.020) than skin anesthesia group. Pain score was negatively associated with pleural anesthesia (β = -0.93, p < 0.001) and positively associated with procedure time (β = 0.06, p < 0.001). Significant pain was negatively associated with pleural anesthesia (p = 0.004, adjusted odds ratio [OR] = 0.21 [95% confidence interval: 0.07, 0.61]) and positively associated with procedure time (p < 0.001, adjusted OR = 1.15 [95% confidence interval: 1.07, 1.24]). Pleural anesthesia was not associated with pneumothorax or chest tube placement (p = 0.806 and 0.291, respectively).

CONCLUSION

Pleural anesthesia reduces subjective pain without increasing the risk of pneumothorax.

KEY POINTS

• Local pleural anesthesia is a simple method that can be added to the conventional skin anesthesia for CT-guided transthoracic needle biopsy. • The addition of local pleural anesthesia can effectively reduce pain compared to the conventional skin anesthesia method. • This procedure is not associated with an increased risk of pneumothorax or chest tube placement.

Neurological Causes of Chest Pain

PURPOSE OF REVIEW

Chest pain is a very common presenting complaint among patients in the hospital, a large proportion of whom have non-cardiac chest pain (NCCP). Neurological causes of NCCP have not been previously reviewed although several causes have been identified.

RECENT FINDINGS

Chest pain has been reported as a symptom of multiple neurological conditions such as migraine, epilepsy, and multiple sclerosis, with varying clinical presentations. The affected patients are often not formally diagnosed for long periods of time due to difficulties in recognizing the symptoms as part of neurological disease processes. This paper will briefly summarize well-known etiologies of chest pain and, then, review neurological causes of NCCP, providing an overview of current literature and possible pathophysiologic mechanisms.

Chest pain management: use of troponins in internal medicine wards

OBJECTIVES

To probe the reference biomarkers used to manage chest pain (CP) by Italian internists.

METHODS

Two hundred and fifty-seven doctors registered as members of the Federation of Associations of Hospital Doctors on Internal Medicine of the Campania Region (FADOI-Campania) were surveyed by means of Google Forms platform. Each participant was asked to report his/her sex, age, and location and hospital size (beds in hospital) in which he/she worked. Furthermore, they were asked to indicate the reference biomarker he/she usually employed in the management of patients with CP, choosing from four possible answers. In line with national and international guidelines, cardiac troponins are the gold standard biomarkers.

RESULTS

Eighty-two internists (30 females) completed the survey. Interestingly, only 30.5% of participants indicated the cardiac troponins as reference biomarker. Moreover, internists working in medium-sized hospitals appeared to prefer the simultaneous measurement of cardiac troponins and Creatine Kinase MB Isoenzyme.

CONCLUSIONS

Given the economic impact of performing inappropriate examinations and the frequency of the CP symptom and associated diseases, rethinking pathways in a multidisciplinary and shared fashion can promote optimization and appropriateness, and therefore stop wastefulness.

Pleurisy Can Cause Chest Wall Tenderness: A Case Report

Stab-like localized chest pain, aggravated by breathing, is compatible with pleuritic pain or with aching related to chest wall abnormalities. Local tenderness inflicted by palpation helps to differentiate pleuritic from musculoskeletal chest pain and serves as a principal accessory manoeuvre in the algorithm of chest pain evaluation. Herein, we report the case of a 27-year-old patient with pulmonary thromboembolism and right lower lobe consolidation/atelectasis. The patient presented with right-sided chest pain, radiating to the shoulder, related to pleural irritation, yet associated with confounding intense chest wall tenderness and guarding, also involving the costovertebral angle. We propose that spinal reflex-related chest wall tenderness was involved, similar to peritoneal signs evoked by irritation of the parietal peritoneum. This case report illustrates that localized chest wall tenderness and guarding, triggered by palpation, may not serve as unequivocal indicators of musculoskeletal pain, and could be unrecognized features of pleuritic chest pain also.

LEARNING POINTS

Pleuritic chest pain may be associated with local tenderness and guarding.These unrecognized features of pleurisy supposedly reflect a spinal reflex, initiated by nociceptors in the parietal pleura.Local pain inflicted upon palpation and guarding may not serve as unequivocal indicators of musculoskeletal chest pain.

Recognition of pulmonary pathology in a patient presenting with shoulder pain

BACKGROUND

. Shoulder pain is a common symptom of musculoskeletal disorder about the shoulder. However, shoulder pain can also be symptomatic of other non- musculoskeletal disease. Careful assessment of the clinical presentation is essential in differential diagnosis and decisions to treat or refer.

CASE DESCRIPTION

. A 56-year-old male preseted with shoulder pain and a previous diagnosis of subacromial impingement of the left shoulder. The shoulder pain increased with effort, was present at night making it difficult to sleep and became disabling for the patient in work and activities of daily living. In addition, the patient reported left thoracic pain and increasing episodes of dry coughing, shortness of breath, fever and unusual generalized fatigue. Physical examination did not reveal a musculoskeletal concern about the patient's shoulder. An increased body temperature was detected and when combined with auscultation and thorax percussion led the physiotherapist to hypothesize pulmonary involvement, later reinforced by the evocation of the patient's symptoms while measuring his peak expiratory flow.

DISCUSSION

. An underlyng serious pathology can be easily masked by shoulder pain. Physiotherapists need to consider that when a patient presents with a cluster of history and physical examination findings that are negative for mechanical shoulder pain, other systems must be considered as the source of presenting symptoms. Through the identification of risk factors and red flag findings, the physiotherapist can identify the need for referral.

Chest pain in patients with COPD: the fascia's subtle silence

COPD is a progressive condition that leads to a pathological degeneration of the respiratory system. It represents one of the most important causes of mortality and morbidity in the world, and it is characterized by the presence of many associated comorbidities. Recent studies emphasize the thoracic area as one of the areas of the body concerned by the presence of pain with percentages between 22% and 54% in patients with COPD. This article analyzes the possible causes of mediastinal pain, including those less frequently taken into consideration, which concern the role of the fascial system of the mediastinum. The latter can be a source of pain especially when a chronic pathology is altering the structure of the connective tissue. We conclude that to consider the fascia in daily clinical activity may improve the therapeutic approach toward the patient.

Respiratory effects of biomass fuel combustion on rural fish smokers in a Nigerian fishing settlement: a case control study

BACKGROUD

The aim was to study the prevalence of respiratory symptoms and assess the lung function of fish smokers in Nigeria.

METHODS

A case control study was done among fish smokers in Nigeria. Women aged 15 years or older (n=210) involved in fish smoking and equal number of matched controls were interviewed on respiratory symptoms and their peak expiratory flow rate (PEFR) measured. Data was analysed using chi square test, student's t-test and odd ratios.

RESULTS

Both groups were similar in their personal characteristics. The test group had significantly increased occurrence of sneezing (153; 72.86%), catarrh (159; 75.71%), cough (138; 65.71%) and chest pain (59; 28.10%) compared with the control group, odds ratio (OR) 2.49, 95% confidence interval CI (1.62-3.82), P < 0.001), OR 3.77,95% CI (2.44- 5.85), P < 0.001, OR 3.38, 95% CI (2.22-5.15), P < 0.001, and OR 6.45,95% CI (3.22-13.15), P < 0.001, respectively. The mean PEFR of 321±58.93 L/min among the fish smokers was significantly lower than 400±42.92 L/min among the controls (p = 0.0001).

CONCLUSION

Fish smokers have increased risk of respiratory symptoms and reduced pulmonary function. There is a need for protective equipment and periodic evaluation.

Appendicitis complicated by appendiceal metastasis via peritoneal dissemination from lung cancer

Peritoneal disseminations from lung cancer are difficult to detect during the patient's clinical course. Therefore, complications of this condition are unclear. We report a case in which peritoneal dissemination from lung cancer complicated appendicitis. A 74-year-old man with lung cancer who was receiving maintenance therapy presented at our hospital because of abdominal pain. It was the seventh day after the 14th cycle of maintenance therapy with bevacizumab. He was diagnosed with acute appendicitis. The resected appendix showed acute appendicitis complicated by appendiceal metastasis from lung cancer. Adenocarcinoma was observed predominantly in the serous membrane from the neck to the tail of the appendix. The distribution of the adenocarcinoma was diffuse. Peritoneal dissemination was considered the route of metastasis. He was admitted to the palliative care unit 10 months after appendectomy. Appendiceal metastasis via peritoneal dissemination from lung cancer complicated appendicitis in our patient who had been receiving bevacizumab.

Percutaneous CT-guided lung interventions-local pleural anesthesia

Local pleural anesthesia during percutaneous lung interventions is an important part of the procedure that has not been standardized in the literature. Significant pain can be experienced during lung biopsies, which may affect the outcome of intervention. We describe a step-by-step method of anesthesia targeting the most sensitive anatomical structure involved: the parietal pleura.

The irregular diaphragmatic pleural interface: a novel sonographic sign facilitating the diagnosis of pneumonia

Pneumonia, a disease that has been reported to be the sixth leading cause of death in the United States, has worsening mortality with delays in diagnosis. As the history and physical examination are excessively inaccurate in the diagnosis of pneumonia, we often rely on chest radiography to rule in or out disease. However, it is found to lack sufficient accuracy when computed tomography is used as the reference standard. Sonography has emerged as a viable alternative to chest radiography in the diagnosis of pneumonia. Here, we describe a novel sonographic sign that can be used to assist in the diagnosis of pneumonia.

Diagnostic tools of pleural effusion

Pleural effusion is not a rare disease in Korea. The diagnosis of pleural effusion is very difficult, even though the patients often complain of typical symptoms indicating of pleural diseases. Pleural effusion is characterized by the pleural cavity filled with transudative or exudative pleural fluids, and it is developed by various etiologies. The presence of pleural effusion can be confirmed by radiological studies including simple chest radiography, ultrasonography, or computed tomography. Identifying the causes of pleural effusions by pleural fluid analysis is essential for proper treatments. This review article provides information on the diagnostic approaches of pleural effusions and further suggested ways to confirm their various etiologies, by using the most recent journals for references.

Prevalence of depression in patients with chest pain and non-obstructive coronary artery disease

Many studies have demonstrated the prevalence of depression in patients with coronary artery disease (CAD), but few have examined this relation in those with chest pain who do not have obstructive CAD on angiography. The aim of this study was to compare the prevalence of depression amongst patients with chest pain in the presence or absence of obstructive CAD and a healthy control group without chest pain. This prospectively designed, observational cohort study used 2 independent data sets: (1) The Queen Elizabeth Hospital Coronary Angiogram Database (n = 1,144), consisting of 819 patients with obstructive CAD and 325 patients with nonobstructive CAD (NoCAD), all of whom had chest pain and (2) the North West Adelaide Health Study (NWAHS; n = 3,168), a population-based biomedical cohort, from which patients with chest pain were excluded. The presence of depression was determined by a previously validated method using the Short Form 36. The prevalence of depression differed among the 3 groups, with 63% in those with NoCAD, 53% in those with CAD, and only 24% in the healthy NWAHS cohort. Analysis of the angiography cohort revealed age, gender, antidepressant medication, previous myocardial infarction, previous airway disease, Short Form 36 physical summary score, Seattle Angina Questionnaire physical limitation score, and NoCAD on angiography to be independent predictors of depression. In conclusion, these findings highlight the importance of screening for depression in patients with NoCAD.

Acid-sensing by airway afferent nerves

Inhalation of acid aerosol or aspiration of acid solution evokes a stimulatory effect on airway C-fiber and Aδ afferents, which in turn causes airway irritation and triggers an array of defense reflex responses (e.g., cough, reflex bronchoconstriction, etc.). Tissue acidosis can also occur locally in the respiratory tract as a result of ischemia or inflammation, such as in the airways of asthmatic patients during exacerbation. The action of proton on the airway sensory neurons is generated by activation of two different current species: a transient (rapidly activating and inactivating) current mediated through the acid-sensing ion channels, and a slowly activating and sustained current mediated through the transient receptor potential vanilloid type 1 (TRPV1) receptor. In view of the recent findings that the expression and/or sensitivity of TRPV1 are up-regulated in the airway sensory nerves during chronic inflammatory reaction, the proton-evoked irritant effects on these nerves may play an important part in the manifestation of various symptoms associated with airway inflammatory diseases.

Pleural disease in the emergency department

Emergency department presentations of pleural-based diseases are common, with severity ranging from mild to life threatening. The acute assessment, diagnosis, and treatment of pleural disease are critical as urgent invasive maneuvers such as thoracocentesis and thoracostomy may be indicated. The emergency physician must have a systematic approach to these conditions that allows for rapid recognition, diagnosis, and definitive management. This article focuses on nontraumatic pleural disease, including diagnostic and treatment considerations of pleural effusion, empyema, primary spontaneous pneumothorax, secondary spontaneous pneumothorax, pediatric pneumothorax, spontaneous hemothorax, and spontaneous tension pneumothorax.

A retrospective study of pulmonary infarction in patients with systemic lupus erythematosus from southern Taiwan

Since large-scale reports of pulmonary infarction in systemic lupus erythematosus (SLE) are limited, a retrospective study was performed for this manifestation in 773 hospitalized patients in southern Taiwan from 1999 to 2009. Pulmonary infarction was defined as the presence of pulmonary embolism, persistent pulmonary infiltrates, and characteristic clinical symptoms. Demographic, clinical, laboratory, and radiological images data were analyzed. There were 12 patients with pulmonary embolism and 9 of them had antiphospholipid syndrome (APS). Six patients (19 to 53 years, average 38.2 ± 12.6) with 9 episodes of lung infarction were identified. All cases were APS and four episodes had coincidental venous thromboembolism. There were four episodes of bilateral infarction and seven episodes of larger central pulmonary artery embolism. Heparin therapy was routinely prescribed and thrombolytic agents were added in two episodes. Successful recovery was noted in all patients. In conclusion, there was a 0.8% incidence of pulmonary infarction in patients with SLE, all with the risk factor of APS. Differentiation between pulmonary infarction and pneumonia in lupus patients should be made; they have similar chest radiography with lung consolidation but require a different clinical approach in management. Although this report is a retrospective study with relatively small numbers of lupus patients with lung infarcts, our observation might provide beneficial information on the clinical features and radiological presentations during the disease evolution of pulmonary infarction in SLE with APS.