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Zia MA. Streptokinase: An Efficient Enzyme in Cardiac Medicine. Protein Pept Lett 2020; 27:111-119. [PMID: 31612811 DOI: 10.2174/0929866526666191014150408] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/18/2018] [Revised: 04/22/2019] [Accepted: 08/06/2019] [Indexed: 01/27/2023]
Abstract
An imbalance in oxygen supply to cardiac tissues or formation of thrombus leads to deleterious results like pulmonary embolism, coronary heart disease and acute cardiac failure. The formation of thrombus requires clinical encounter with fibrinolytic agents including streptokinase, urokinase or tissue plasminogen activator. Irrespective to urokinase and tissue plasminogen activator, streptokinase is still a significant agent in treatment of cardiovascular diseases. Streptokinase, being so economical, has an important value in treating cardiac diseases in developing countries. This review paper will provide the maximum information to enlighten all the pros and cons of streptokinase up till now. It has been concluded that recent advances in structural/synthetic biology improved SK with enhanced half-life and least antigenicity. Such enzyme preparations would be the best thrombolytic agents.
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Affiliation(s)
- Muhammad A Zia
- Enzyme Biotechnology Laboratory, Department of Biochemistry, University of Agriculture, Faisalabad-38040,Pakistan
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2
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Do H, Nguyen Q, Nguyen L, Nguyen L. Single Trocar Thoracoscopic Surgery for Pleural Empyema in Children. J Laparoendosc Adv Surg Tech A 2020. [PMID: 32326810 DOI: 10.1089/lap.2019.0637] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/12/2022] Open
Abstract
Aim: To present outcomes of single trocar thoracoscopic surgery in the treatment of pleural empyema (PE) in children. Patients and Methods: The thoracoscopic surgery was performed using a single trocar inserted through the fifth intercostal space. A conventional rigid scope with a working channel was used. Pleural fluid was aspirated, followed by debridement and ablation of all septa using one instrument through the working channel. Results: Sixty patients from 1 month to 14 years of age underwent surgery without any intraoperative complications or death. The mean operative time was 67 ± 21 minutes. There was no conversion to open thoracotomy. Postoperative complications occurred in 4 patients. Reoperation was required in 1 patient. Mean duration of postoperative hospitalization was 15 ± 9 days. Follow-up was obtained in 57 patients and resulted in normal clinical and chest X-ray findings in all patients. Conclusion: Single trocar thoracoscopic operation is safe, feasible, and effective in the treatment of PE in children. A future study with control group is required to draw accurate conclusions.
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Affiliation(s)
- Hung Do
- Urological Department and General Surgical Department, National Children's Hospital, Hanoi, Vietnam
| | - Quang Nguyen
- Urological Department and General Surgical Department, National Children's Hospital, Hanoi, Vietnam
| | - Liem Nguyen
- Pediatric Surgical Department, Vinmec International Hospital, Hanoi, Vietnam
| | - Linh Nguyen
- Urological Department and General Surgical Department, National Children's Hospital, Hanoi, Vietnam
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3
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Ramasli Gursoy T, Sismanlar Eyuboglu T, Onay ZR, Aslan AT, Tapisiz Aktas A, Tezer H, Boyunaga O, Budakoglu II. Pleural Thickening after Pleural Effusion: How can we Follow-Up in Children? J Trop Pediatr 2020; 66:85-94. [PMID: 31204435 DOI: 10.1093/tropej/fmz036] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/14/2022]
Abstract
INTRODUCTION No clear information exists about the factors affecting pleural thickening following parapneumonic effusion in children. We aimed to investigate factors that affect the resolving time of pleural thickening after parapneumonic effusion. METHODS Between the years of 2007-18, 91 patients, which were followed due to diagnosis of pleural thickening after parapneumonic effusion, were assessed. Ages, complaints, physical examination findings, laboratory results, chest x-ray and ultrasonography findings, treatments, duration of treatment and recovery time of the patients were examined terms in of pleural thickening resolving time. RESULTS The mean age of patients was 7.5 ± 5.0 years. Pleural thickening resolving time was 151 ± 6.8 days. The resolving time for pleural thickening was delayed with older ages, longer duration of complaints, fever before hospital admission and treatment, lower oxygen saturation at the time of admission, crackles in the physical examination, higher white blood cell count and pleural fluid density (p = 0.018, p = 0.001, p = 0.021, p = 0.020, p = 0.024, p = 0.025, p = 0.021, p = 0.019). In addition, the amount of effusion measured by thorax ultrasonography, fibrinolytic usage, and complications had a role in the delayed resolving time (p = 0.034, p = 0.001, p = 0.034). Pleural thickening resolved in 80% of the patients. CONCLUSION In this report, 80% of pleural thickening, following parapneumonic effusion resolved within 5 months. Patients who do not have a complication during follow-up are not required to monitor with frequent chest x-ray. Patients with a higher amount of pleural effusion, complications and need for fibrinolytic treatment should be followed more carefully.
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Affiliation(s)
- Tugba Ramasli Gursoy
- Department of Pediatric Pulmonology, Gazi University Faculty of Medicine, Ankara, Turkey
| | - Tugba Sismanlar Eyuboglu
- Department of Pediatric Pulmonology, Dr Sami Ulus Maternity and Children Research and Training Hospital, 06080 Ankara, Turkey
| | - Zeynep Reyhan Onay
- Department of Pediatric Pulmonology, Gazi University Faculty of Medicine, Ankara, Turkey
| | - Ayse Tana Aslan
- Department of Pediatric Pulmonology, Gazi University Faculty of Medicine, Ankara, Turkey
| | - Anil Tapisiz Aktas
- Department of Pediatric Infectious Disease, Gazi University Faculty of Medicine, Ankara, Turkey
| | - Hasan Tezer
- Department of Pediatric Infectious Disease, Gazi University Faculty of Medicine, Ankara, Turkey
| | - Oznur Boyunaga
- Department of Radiology, Gazi University Faculty of Medicine, Ankara, Turkey
| | - Irem Isil Budakoglu
- Department of Medical Education, Gazi University Medicine Faculty, Ankara, Turkey
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4
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Mathew JL, Soni V, Singh M, Mittal P, Singhi S, Gautam V, Sodhi KS, Jayashree M, Vaidya P. Intrapleural streptokinase is effective and safe for children with multi-loculated empyema regardless of the time from disease onset. Acta Paediatr 2018; 107:2165-2171. [PMID: 29782063 DOI: 10.1111/apa.14408] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/19/2018] [Revised: 04/24/2018] [Accepted: 05/16/2018] [Indexed: 11/30/2022]
Abstract
AIM This study compared the efficacy of administering intrapleural streptokinase to children with multi-loculated empyema within 14 days or at any time after disease onset. METHODS We studied children under 12 years with multi-loculated empyema who were admitted to a teaching hospital in Chandigarh, India, from July 2013 to June 2017. They received antibiotics, pleural drainage and intrapleural streptokinase. The first group received three doses within 14 days of disease onset, the second received three doses regardless of time after onset and the third group received four to six doses regardless of time after onset. The three phases lasted 18, 18 and 12 months, respectively. RESULTS Of 195 children, 133 (68%) received streptokinase within 14 days, 46 (24%) beyond 14 days and 16 (8%) did not receive it. There was no difference in surgical decortication (14/133 versus 7/46, p > 0.05) and median hospitalisation duration (15 versus 14 days, p > 0.05) between administration before versus after 14 days. Median hospitalisation was shorter with four to six doses than three doses (11 versus 16 days, p < 0.01). CONCLUSION Intrapleural streptokinase was effective for multi-loculated empyema even when it was administered more than 14 days after disease onset and four to six doses were superior to three doses.
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Affiliation(s)
- Joseph L. Mathew
- Department of Paediatrics; Advanced Paediatrics Centre; Postgraduate Institute of Medical Education and Research; Chandigarh India
| | - Vimlesh Soni
- Department of Paediatrics; Advanced Paediatrics Centre; Postgraduate Institute of Medical Education and Research; Chandigarh India
| | - Meenu Singh
- Department of Paediatrics; Advanced Paediatrics Centre; Postgraduate Institute of Medical Education and Research; Chandigarh India
| | - Piyush Mittal
- Department of Paediatrics; Advanced Paediatrics Centre; Postgraduate Institute of Medical Education and Research; Chandigarh India
| | - Sunit Singhi
- Department of Paediatrics; Advanced Paediatrics Centre; Postgraduate Institute of Medical Education and Research; Chandigarh India
- Department of Paediatrics; Medanta, The Medicity; Gurgaon India
| | - Vikas Gautam
- Department of Medical Microbiology; Postgraduate Institute of Medical Education and Research; Chandigarh India
| | - Kushaljit S. Sodhi
- Department of Radiodiagnosis and Imaging; Postgraduate Institute of Medical Education and Research; Chandigarh India
| | - Muralidharan Jayashree
- Department of Paediatrics; Advanced Paediatrics Centre; Postgraduate Institute of Medical Education and Research; Chandigarh India
| | - Pankaj Vaidya
- Department of Paediatrics; Advanced Paediatrics Centre; Postgraduate Institute of Medical Education and Research; Chandigarh India
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5
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Feola GP, Hogan MJ, Baskin KM, Cahill AM, Connolly BL, Crowley JJ, Charles JA, Heran MK, Marshalleck FE, Sierre S, Towbin RB, Walker TG, Silberzweig JE, Censullo M, Dariushnia SR, Gemmete JJ, Weinstein JL, Nikolic B. Quality Improvement Standards for the Treatment of Pediatric Empyema. J Vasc Interv Radiol 2018; 29:1415-1422. [DOI: 10.1016/j.jvir.2018.04.027] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/24/2017] [Revised: 04/24/2018] [Accepted: 04/26/2018] [Indexed: 01/14/2023] Open
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6
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Espinosa CM, Fallat ME, Woods CR, Weakley KE, Marshall GS. An Approach to the Management of Pleural Empyema with Early Video-assisted Thoracoscopic Surgery and Early Transition to Oral Antibiotic Therapy. Am Surg 2016. [DOI: 10.1177/000313481608200412] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
Practice variation exists in the management of children with bacterial pneumonia complicated by empyema. The success of video-assisted thoracoscopic surgery (VATS) versus chest tube insertion for drainage and fibrinolysis may be dependent on the stage of disease. There is little published experience with early transition to oral (PO) antibiotics, and many children are treated with intravenous (IV) antibiotics at home. To describe a cohort of children with pneumonia and empyema in a primarily rural state managed with early VATS and transition to PO antibiotics. This was a retrospective medical record review of children managed by the pediatric infectious diseases and surgery services at Kosair Children's Hospital from 2008 through 2012. Sixty-one children met inclusion criteria. The majority underwent VATS on the first or second hospital day. No organism was identified in 67 per cent of cases. All patients received IVantibiotics at admission and all were discharged on PO antibiotics. The median time to transition was five days (interquartile range [IQR], 4–6), and the median duration of PO therapy was 16 days (IQR, 14–21). Ninety-eight per cent did not require further IV therapy. There were no deaths and clinical outcomes were good. In conclusion, children with pneumonia and empyema can be managed effectively with early VATS and early transition from IV to PO antibiotic therapy.
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Affiliation(s)
- Claudia M. Espinosa
- Departments of Pediatrics and University of Louisville School of Medicine, Louisville, Kentucky
| | - Mary E. Fallat
- Departments of Surgery, University of Louisville School of Medicine, Louisville, Kentucky
| | - Charles R. Woods
- Departments of Pediatrics and University of Louisville School of Medicine, Louisville, Kentucky
| | - Kathryn E. Weakley
- Departments of Pediatrics and University of Louisville School of Medicine, Louisville, Kentucky
| | - Gary S. Marshall
- Departments of Pediatrics and University of Louisville School of Medicine, Louisville, Kentucky
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7
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Affiliation(s)
- Mohamed A Hendaus
- Hamad Medical Corporation, Doha, Qatar Weill-Cornell Medical College, Ar-Rayyan, Qatar
| | - Ibrahim A Janahi
- Hamad Medical Corporation, Doha, Qatar Weill-Cornell Medical College, Ar-Rayyan, Qatar
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Hanson SJ, Havens PL, Simpson PM, Nugent ML, Wells RG. Intrapleural alteplase decreases parapneumonic effusion volume in children more than saline irrigation. Pediatr Pulmonol 2015; 50:1328-35. [PMID: 25847131 DOI: 10.1002/ppul.23184] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/24/2014] [Revised: 01/16/2015] [Accepted: 01/21/2015] [Indexed: 11/06/2022]
Abstract
OBJECTIVE In this prospective, double-blind, randomized crossover trial, we determined the effect of intrapleural fibrinolysis with alteplase compared to that of normal saline irrigation on the thoracostomy tube output and pleural effusion volume in children with complicated parapneumonic effusion. METHODS Twenty seven children, median age 3.5 years, referred to the interventional radiology service for thoracostomy tube drainage of a parapneumonic effusion were studied. Seventeen patients with pleural fluid thickness greater than 2 cm or >20% ipsilateral chest volume after 8 hr of thoracostomy tube drainage entered the treatment arm. They were randomized to receive alteplase 0.1 mg/kg twice a day on days 1 and 3, or on days 2 and 4, with normal saline irrigation on the alternate days. Daily pleural fluid volume measured by low dose chest computed tomography (CT) and thoracostomy tube output was compared between the saline and alteplase groups. RESULTS Compared to normal saline irrigation, alteplase irrigation resulted in increased thoracostomy tube drainage and to a greater decline in pleural fluid volume. Earlier alteplase administration resulted in increased fluid mobilization compared to administration later in the hospital course. There were no bleeding complications. CONCLUSIONS Intrapleural fibrinolysis with alteplase safely increases pleural drainage and decreases the volume of pleural inflammatory debris compared to intrapleural administration of normal saline. The benefit of intrapleural alteplase on decreasing the volume of pleural inflammatory debris occurs for up to 72 hr with repeated twice daily dosing.
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Affiliation(s)
- Sheila J Hanson
- Medical College of Wisconsin, Children's Hospital of Wisconsin, Milwaukee, Wisconsin
| | - Peter L Havens
- Medical College of Wisconsin, Children's Hospital of Wisconsin, Milwaukee, Wisconsin
| | - Pippa M Simpson
- Medical College of Wisconsin, Children's Hospital of Wisconsin, Milwaukee, Wisconsin
| | - Melodee L Nugent
- Medical College of Wisconsin, Children's Hospital of Wisconsin, Milwaukee, Wisconsin
| | - Robert G Wells
- Medical College of Wisconsin, Children's Hospital of Wisconsin, Milwaukee, Wisconsin
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Experience with an evidence-based protocol using fibrinolysis as first line treatment for empyema in children. J Pediatr Surg 2013; 48:1312-5. [PMID: 23845624 DOI: 10.1016/j.jpedsurg.2013.03.029] [Citation(s) in RCA: 29] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/15/2013] [Accepted: 03/08/2013] [Indexed: 11/23/2022]
Abstract
INTRODUCTION We previously reported a prospective, randomized trial comparing video-assisted thoracoscopic decortication (VATS) to fibrinolysis for the treatment of empyema. In that study no advantages to VATS were identified, although VATS resulted in significantly higher hospital charges. We subsequently implemented the algorithm from the trial utilizing primary fibrinolytic therapy in all children diagnosed with empyema. In this study, we reviewed our experience to examine the clinical efficacy of this protocol. METHODS After IRB approval, we conducted a retrospective review of all children diagnosed with empyema as all were treated with the fibrinolysis protocol utilized in the prospective trial since the completion of the trial. RESULTS In 102 consecutive patients treated with fibrinolysis, 16 patients (15.7%) required subsequent VATS. No patients were treated with initial VATS. No major side effects were seen from fibrinolytic therapy. Mean operative time for VATS after fibrinolysis was 62 minutes. The length of stay after VATS was 5.9 days. CONCLUSIONS The results of an evidence-based protocol using fibrinolysis to treat empyema have replicated the results of the trial that led to the implementation of the protocol. The pediatric empyema population can be successfully treated without an operation in the majority of cases.
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10
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Islam S, Calkins CM, Goldin AB, Chen C, Downard CD, Huang EY, Cassidy L, Saito J, Blakely ML, Rangel SJ, Arca MJ, Abdullah F, St Peter SD. The diagnosis and management of empyema in children: a comprehensive review from the APSA Outcomes and Clinical Trials Committee. J Pediatr Surg 2012; 47:2101-10. [PMID: 23164006 DOI: 10.1016/j.jpedsurg.2012.07.047] [Citation(s) in RCA: 125] [Impact Index Per Article: 10.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/06/2012] [Revised: 07/23/2012] [Accepted: 07/25/2012] [Indexed: 11/16/2022]
Abstract
The aim of this study is to review the current evidence on the diagnosis and management of empyema. The American Pediatric Surgical Association Outcomes and Clinical Trials Committee compiled 8 questions to address. A comprehensive review was performed on each topic. Topics included the distinction between parapneumonic effusion and empyema, the optimal imaging modality in evaluating pleural space disease, when and how pleural fluid should be managed, the first treatment option and optimal timing in the management of empyema, the optimal chemical debridement agent for empyema, therapeutic options if chemical debridement fails, therapy for parenchymal abscess or necrotizing pneumonia and duration of antibiotic therapy after an intervention. The evidence was graded for each topic to provide grade of recommendation where appropriate.
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Affiliation(s)
- Saleem Islam
- University of Florida College of Medicine, Gainesville, FL, USA
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Fitzsimons E, Thomson A. Intrapleural Fibrinolytics in the Management of Empyema. PEDIATRIC ALLERGY IMMUNOLOGY AND PULMONOLOGY 2012. [DOI: 10.1089/ped.2011.0138] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 10/28/2022]
Affiliation(s)
- Emma Fitzsimons
- Department of Paediatrics, Oxford University Hospital NHS Trust, Oxford, England
| | - Anne Thomson
- Paediatric Respiratory Medicine, Oxford University Hospitals NHS Trust, Oxford, England
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12
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Goldin AB, Parimi C, LaRiviere C, Garrison MM, Larison CL, Sawin RS. Outcomes associated with type of intervention and timing in complex pediatric empyema. Am J Surg 2012; 203:665-673. [DOI: 10.1016/j.amjsurg.2012.01.005] [Citation(s) in RCA: 26] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/07/2011] [Revised: 01/12/2012] [Accepted: 01/12/2012] [Indexed: 10/28/2022]
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Krenke K, Peradzyńska J, Lange J, Ruszczyński M, Kulus M, Szajewska H. Local treatment of empyema in children: a systematic review of randomized controlled trials. Acta Paediatr 2010; 99:1449-53. [PMID: 20456264 DOI: 10.1111/j.1651-2227.2010.01863.x] [Citation(s) in RCA: 23] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/28/2022]
Abstract
UNLABELLED The aim of the study is to systematically evaluate data from randomized controlled trials (RCTs) on the efficacy of using intrapleural fibrinolytic agents in the treatment of complicated parapneumonic effusions or empyema in children. The Cochrane Library, MEDLINE and EMBASE databases were searched in July 2009. Four RCTs, involving 194 children, were included. In two RCTs, intrapleural fibrinolytic treatment was compared with normal saline. One of these RCTs showed a significantly reduced hospital stay in those treated with urokinase compared with those treated with normal saline. Otherwise, no fibrinolytic agent had an effect on any other outcome. Two RCTs that compared fibrinolytic treatment with video-assisted thoracoscopic surgery (VATS) revealed no benefit of VATS. CONCLUSION There is little evidence that intrapleural fibrinolysis is more effective than normal saline in the local treatment of complicated parapneumonic effusions or empyema in children. There is no evidence that VATS is more effective than fibrinolytic treatment. Only a limited number of trials were available for analysis, so some caution must be exercised in interpreting the strength of the evidence presented.
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Affiliation(s)
- Katarzyna Krenke
- Department of Paediatric Pneumonology and Allergy, The Medical University of Warsaw, Poland.
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Pericardiectomy for pleuropericardial effusion complicating bacterial pneumonia. Case Rep Med 2010; 2010:715953. [PMID: 20585369 PMCID: PMC2878687 DOI: 10.1155/2010/715953] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/22/2010] [Accepted: 04/11/2010] [Indexed: 11/20/2022] Open
Abstract
Severe pericardial effusion is a rare complication of bacterial pneumonia and it usually disappears under medical treatment. Herein we report a case of a girl with a congenital immunodeficient syndrome and bacterial pneumonia, who developed recurrent and life-threatening pericardial effusion refractory to medical treatment. She was finally treated with pericardiectomy.
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Carter E, Waldhausen J, Zhang W, Hoffman L, Redding G. Management of children with empyema: Pleural drainage is not always necessary. Pediatr Pulmonol 2010; 45:475-80. [PMID: 20425855 DOI: 10.1002/ppul.21200] [Citation(s) in RCA: 11] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/11/2022]
Abstract
BACKGROUND There is considerable variation in the management of pediatric empyema, and there are no clear criteria for when to perform pleural drainage. Our study aims were: (1) to retrospectively review our experience with an empyema treatment strategy that started with intravenously administered (IV) antibiotics alone in medically stable patients with procession to pleural drainage only if there was no clinical improvement after 48 hr, and (2) to identify predictors for undergoing pleural drainage. METHODS We performed a retrospective review of 182 previously healthy children, 1-18 years old, hospitalized with empyema from December 1996 through December 2008. The primary outcome measures were the proportion of patients requiring pleural drainage procedures and hospital length of stay (LOS). RESULTS Ninety-five children (52%) received antibiotics alone, and 87 (45%) underwent drainage procedures (21 chest tube alone, 57 VATS/thoracotomy, and 8 chest tube followed by VATS/thoracotomy); only 4 received fibrinolytics. Mean (standard deviation) LOS was significantly shorter in the antibiotics alone group, 7.0 (3.5) versus 11 (4.0) days. The strongest predictors of undergoing pleural drainage were admission to the intensive care unit and large effusion size (>(1/2) thorax filled). CONCLUSIONS Some children with empyema can be treated with IV antibiotics alone and have reasonably short LOS. At our institution, those that required intensive care or had large effusions with mediastinal shift were more likely to require pleural drainage.
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Affiliation(s)
- Edward Carter
- Department of Pediatrics, University of Washington, Seattle, Washington, USA.
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16
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Wang JN, Shin JW, Chang TY, Wang JY, Wu JM. Decreased proinflammatory cytokines production in children with complicated parapneumonic pleural effusion after intrapleural fibrinolytic treatment. Inflammation 2009; 32:410-8. [PMID: 19731002 DOI: 10.1007/s10753-009-9150-2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/28/2022]
Abstract
Intrapleural fibrinolytic therapy (IFT) provides clinical benefit in the treatment of complicated pleural parapneumonic effusion (CPE). Whether IFT influences the proinflammatory cytokines production and fibrinlytic activity is currently unclear. Therefore, we collected pleural effusion samples from CPE patients with IFT (study group) and patients without IFT (control group). A membrane human inflammatory cytokines array kit was used to compare the difference of targeted cytokine production between these two groups. Enzyme-linked immunosorbent assay (ELISA) methods were used for quantitative analysis of targeted cytokines and fibrinolytic enzymes. The results showed there were no significant differences between the study (n = 16) and control (n = 14) groups in patients' demographic data. After fibrinolytic therapy, the patients in the study group had significant lower plasminogen activator inhibitor (PAI) level (732.36+/-254.09 ng/mL vs 1,509.36+/-1,340.11 ng/mL, p<0.05) and higher urokinase plasminogen activator (u-PA) level (75.56+/-41.70 ng/mL vs 6.87+/-5.07 ng/mL, p<0.05) than they did before treatment. Moreover, the tissue inhibitors of metalloproteinase-2 (TIMP-2) (1,560.03+/-403.49 pg/mL vs 3,686.45+/-1,263.83 pg/mL, p<0.05) and inflammatory chemokine, regulated on activation normal T-cell expressed and secreted/chemokine (C-C motif) ligand 5 (RANTES), (293.58+/-212.93 pg/mL vs 749.27+/-53.79 pg/mL, p<0.05), were also significantly lower in the study group after fibrinolytic therapy, but not in the control group. In conclusion, intrapleural fibrinolytic treatment with urokinase could enhance fibrinolytic activity and decrease TIMP-2 and RANTES production.
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Affiliation(s)
- Jieh-Neng Wang
- Institute of Clinical Medicine, National Cheng Kung University Medical College, Tainan 70421, Taiwan
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Efficacy of video-assisted thoracoscopic surgery in managing childhood empyema: a large single-centre study. J Pediatr Surg 2009; 44:337-42. [PMID: 19231530 DOI: 10.1016/j.jpedsurg.2008.10.083] [Citation(s) in RCA: 36] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/03/2008] [Accepted: 10/23/2008] [Indexed: 11/22/2022]
Abstract
BACKGROUND/PURPOSE A randomised controlled trial evaluating the role of video-assisted thoracoscopic surgery (VATS) in childhood empyema reported a failure rate of 16.6%. Our aim is to determine the outcome of VATS in a large series of children managed by 3 paediatric surgeons experienced in endoscopic surgery. METHOD A retrospective study of all children with empyema admitted under the care of the 3 surgeons between February 2004 and February 2008 was undertaken. Recorded details included demographic data, mode of presentation, preoperative investigations, operative details, antibiotic usage, microbiological data, postoperative course, follow-up data and complications. RESULTS 114 children (69 boys, 45 girls) had VATS for empyema. Their median age was 5 (0.2-15) years. The pleural cavity was drained for a median of 4 (2-13) days. Median postoperative hospital stay was 7 (4-36) days. Median follow-up was 8 (1-24) months. There were 8 (7%) treatment failures: 5 conversions to thoracotomy and 3 recurrent empyemas. There were 7 complications (6%): air leak (n = 6) and lung injury (n = 1). 104 (91%) children had full resolution of symptoms. There were no deaths. CONCLUSION Video-assisted thoracoscopic surgery has a better outcome in childhood empyema than reported in a recent randomised trial and it has an important role in the management of this condition.
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18
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St. Peter SD, Tsao K, Harrison C, Jackson MA, Spilde TL, Keckler SJ, Sharp SW, Andrews WS, Holcomb GW, Ostlie DJ, Holcomb GW, Ostlie DJ. Thoracoscopic decortication vs tube thoracostomy with fibrinolysis for empyema in children: a prospective, randomized trial. J Pediatr Surg 2009; 44:106-11; discussion 111. [PMID: 19159726 PMCID: PMC3086274 DOI: 10.1016/j.jpedsurg.2008.10.018] [Citation(s) in RCA: 193] [Impact Index Per Article: 12.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/30/2008] [Accepted: 10/07/2008] [Indexed: 01/24/2023]
Abstract
PURPOSE Management of empyema has been debated in the literature for decades. Although both primary video-assisted thoracoscopic surgery (VATS) and tube thoracostomy with pleural instillation of fibrinolytics have been shown to result in early resolution when compared to tube thoracostomy alone, there is a lack of comparative data between these modes of management. Therefore, we conducted a prospective, randomized trial comparing VATS to fibrinolytic therapy in children with empyema. METHODS After Institutional Review Board approval, children defined as having empyema by either loculation on imaging or more than 10,000 white blood cells/microL were treated with VATS or fibrinolysis. Based on our retrospective data using length of postoperative hospitalization as the primary end point, a sample size of 36 patients was calculated for an alpha of .5 and a power of 0.8. Fibrinolysis consisted of inserting a 12F chest tube followed by infusion of 4 mg tissue plasminogen activator mixed with 40 mL of normal saline at the time of tube placement followed by 2 subsequent doses 24 hours apart. RESULTS At diagnosis, there were no differences between groups in age, weight, degree of oxygen support, white blood cell count, or days of symptoms. The outcome data showed no difference in days of hospitalization after intervention, days of oxygen requirement, days until afebrile, or analgesic requirements. Video-assisted thoracoscopic surgery was associated with significantly higher charges. Three patients (16.6%) in the fibrinolysis group subsequently required VATS for definitive therapy. Two patients in the VATS group required ventilator support after therapy, one of whom required temporary dialysis. No patient in the fibrinolysis group clinically worsened after initiation of therapy. CONCLUSIONS There are no therapeutic or recovery advantages between VATS and fibrinolysis for the treatment of empyema; however, VATS resulted in significantly greater charges. Fibrinolysis may pose less risk of acute clinical deterioration and should be the first-line therapy for children with empyema.
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Affiliation(s)
- Shawn D. St. Peter
- Center for Prospective Clinical Trials, Department of Pediatric Surgery, Children’s Mercy Hospital, Kansas City, MO 64108, USA
,Corresponding author. Tel.: +1 816 983 6479; fax: +1 816 983 6885. .
| | - Kuojen Tsao
- Center for Prospective Clinical Trials, Department of Pediatric Surgery, Children’s Mercy Hospital, Kansas City, MO 64108, USA
| | - Christopher Harrison
- Department of Infectious Disease, Children’s Mercy Hospital, Kansas City, MO 64108, USA
| | - Mary Ann Jackson
- Center for Prospective Clinical Trials, Department of Pediatric Surgery, Children’s Mercy Hospital, Kansas City, MO 64108, USA
| | - Troy L. Spilde
- Center for Prospective Clinical Trials, Department of Pediatric Surgery, Children’s Mercy Hospital, Kansas City, MO 64108, USA
| | - Scott J. Keckler
- Center for Prospective Clinical Trials, Department of Pediatric Surgery, Children’s Mercy Hospital, Kansas City, MO 64108, USA
| | - Susan W. Sharp
- Center for Prospective Clinical Trials, Department of Pediatric Surgery, Children’s Mercy Hospital, Kansas City, MO 64108, USA
| | - Walter S. Andrews
- Center for Prospective Clinical Trials, Department of Pediatric Surgery, Children’s Mercy Hospital, Kansas City, MO 64108, USA
| | - George W. Holcomb
- Center for Prospective Clinical Trials, Department of Pediatric Surgery, Children’s Mercy Hospital, Kansas City, MO 64108, USA
| | - Daniel J. Ostlie
- Center for Prospective Clinical Trials, Department of Pediatric Surgery, Children’s Mercy Hospital, Kansas City, MO 64108, USA
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Roberts JE, Bezack BJ, Winger DI, Pollack S, Shah RA, Cataletto M, Katz DS, Montoya-Iraheta C, Schroeder SA, Quintos-Alagheband ML. Association between parapneumonic effusion and pericardial effusion in a pediatric cohort. Pediatrics 2008; 122:e1231-5. [PMID: 18984649 DOI: 10.1542/peds.2008-0171] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/24/2022] Open
Abstract
OBJECTIVE Associations between pleural and pericardial effusions have been described in malignancy and autoimmune disorders. Bacterial pneumonia is the most frequent cause of parapneumonic effusion; however, knowledge of the relationship between parapneumonic effusion and the presence of pericardial fluid in children is limited. We examined this relationship. METHODS We performed a retrospective chart review of pediatric patients who were admitted to our institution during a 6-year period with a diagnosis of either parapneumonic effusion or empyema and who had undergone an echocardiogram, a computed tomography scan of the thorax, or both. All demographic, clinical, radiographic, and laboratory data of these patients were collected, and statistical analysis was done with Student's t tests and chi2 analyses. RESULTS We reviewed the charts of 59 children with parapneumonic effusions. Forty-eight underwent 2-dimensional echocardiography, chest computed tomography scan, or both. Of these 48 patients, 54.2% (n=26) were found to have a concomitant pericardial effusion. The majority of patients with pericardial effusions had left-sided pleural disease. Patients with pericardial effusions had more symptomatic days before hospitalization, lower pleural fluid albumin levels, elevated serum white blood cell counts, elevated pleural fluid white blood cell and absolute neutrophil counts, and an increased incidence of surgical intervention. One patient had evidence of hemodynamic compromise that required pericardiocentesis. CONCLUSIONS We found a high incidence of pericardial effusions in pediatric patients with parapneumonic effusions. Leukocytosis, higher pleural fluid leukocyte and neutrophil counts, and a propensity for surgical intervention suggest a prognostic relationship between pericardial effusions and more severe parapneumonic disease. The majority of these pericardial collections resolve with treatment of the underlying pleural disease.
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Affiliation(s)
- Jon E Roberts
- Department of Pediatrics, Winthrop-University Hospital, 120 Mineola Blvd, Suite 210, Mineola, NY 11501, USA.
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20
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Antibiothérapie des pleuropneumopathies de l’enfant : quelles leçons tirer des études cliniques publiées et propositions thérapeutiques. Arch Pediatr 2008; 15 Suppl 2:S84-92. [DOI: 10.1016/s0929-693x(08)74222-2] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/18/2022]
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21
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Aydoğan M, Aydoğan A, Ozcan A, Tugay M, Gokalp AS, Arisoy ES. Intrapleural streptokinase treatment in children with empyema. Eur J Pediatr 2008; 167:739-44. [PMID: 17710434 DOI: 10.1007/s00431-007-0580-2] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/30/2007] [Revised: 07/10/2007] [Accepted: 07/11/2007] [Indexed: 10/22/2022]
Abstract
Our aim was to compare intrapleural streptokinase (SK) treatment and simple tube drainage in the treatment of children with complicated parapneumonic pleural effusion. A retrospective review of medical records included patient demographics, clinical presentation, biochemical and microbial studies of pleural effusion, radiographic evaluation of chest tube drainage, use of fibrinolytic agents and type of surgical intervention. During the 2.5-year period (1999-2002), 53 children (29 M, 24 F) with complicated parapneumonic effusions or empyema were identified. Closed tube drainage and antibiotic treatment were administered to patients with a diagnosis of complicated parapneumonic effusion (n = 24) until October 2000; after that time point, intrapleural streptokinase was added to this regimen (n = 29). The median age at the time of presentation was 2.5 years (range: 5 months-14.6 years). There were no significant differences in terms of clinical outcomes between the two groups. The average length of hospital stay was 19.1 +/- 5.5 and 21.9 +/- 11.2 days for the drainage and streptokinase groups, respectively; the time to afebrile state after admission was 5.8 +/- 4.1 and 7.6 +/- 7.5 days. The percentage of patients who eventually required surgical intervention was 8.3% for the drainage group and 20.6% for the streptokinase group. In conclusion, in the treatment of complicated parapneumonic effusions or empyema, the adjunctive treatment with intrapleural SK does not significantly reduce durations of fever, chest tube drainage and hospital stay, and the need for surgery, regardless of the stage of the disease, compared to simple closed tube drainage.
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Affiliation(s)
- Metin Aydoğan
- Department of Pediatric Allergy, School of Medicine, Kocaeli University, Kocaeli, Turkey.
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22
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Abstract
Pneumonias in children can be complicated by pleural effusions, empyema and abscesses. The incidence of these complications is increasing, correlated to an increased virulence of the pneumococcal bacterium. These complications may prolong morbidity and lead to decreased pulmonary function. Traditionally, patients were treated medically with antibiotics, and refractory complications were treated surgically with large bore chest tube placement and thoracotomy. Improvements included instilling fibrinolytics into the chest tubes and video-assisted thoracoscopic surgery, which expedited recovery and improved outcomes. Image guided techniques from interventional radiology have been developed as an alternative to treat these patients with minimal invasiveness. These therapies have achieved high success and low complication rates, and are the preferred first-line procedures when available.
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Affiliation(s)
- Mark J Hogan
- Section of Vascular and Interventional Radiology, Nationwide Children's Hospital, Departmentof Radiology, 700 Children's Drive, Columbus, OH 43205, USA.
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23
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Abstract
Pneumonia with associated complex pleural disease is a cause of significant morbidity among hospitalized children. The management of this patient population continues to be a challenge and varies even among single institutions. The article presented here reviews the management goals for pediatric patients hospitalized with complex parapneumonic effusions and provides updated summaries of both medical and surgical therapies.
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Affiliation(s)
- Sarah C McBride
- Children's Hospital Boston, Harvard Medical School, Boston, Massachusetts, USA.
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24
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Desrumaux A, François P, Pascal C, Cans C, Croizé J, Gout JP, Pin I. [Epidemiology and clinical characteristics of childhood parapneumonic empyemas]. Arch Pediatr 2007; 14:1298-303. [PMID: 17631988 DOI: 10.1016/j.arcped.2007.06.008] [Citation(s) in RCA: 16] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/16/2007] [Revised: 06/04/2007] [Accepted: 06/19/2007] [Indexed: 11/23/2022]
Abstract
UNLABELLED Several studies have reported an increasing incidence of childhood parapneumonic empyemas in various countries. AIM OF THE STUDY The aim of our study was to estimate the annual incidence of complicated community-acquired pneumonias in children during a 9-year period in a French area and to describe the epidemiological and clinical characteristics of these complications. POPULATION AND METHODS We have listed the children from 28 days to 15 years old, hospitalized in the 2 children hospitals of the Isere district for a community-acquired pneumonia complicated with a pleural empyema or a pulmonary abscess from 1995 to 2003. RESULTS During the study period, 90 children were hospitalized for a complicated pneumonia including 83 pleural empyemas and 7 isolated lung abscess. The average number of cases was 4 per year from 1995 to 1998 then increased since 1999 to reach 34 cases in 2003, according to a linear model (P<0,001). The incidence of the complicated pneumonia, plotted to the paediatric population of the area has gone up from 0.5 per 100000 to 13 per 100000 children between 1995 and 2003. CONCLUSION The incidence of the complicated pneumonias in children increased since 1999 in a French area. Additional investigations are necessary to identify the causes of this increase.
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Affiliation(s)
- A Desrumaux
- Département de pédiatrie, CHU de Grenoble, 38043 Grenoble, France
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25
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Noukoua Tchuisse C, Ghaye B, Dondelinger RF. Imaging and Treatment of Thoracic Fluid and Gas Collections. Emerg Radiol 2007. [DOI: 10.1007/978-3-540-68908-9_19] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/19/2022]
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Dikensoy O, Zhu Z, Na MJ, Liao H, Donnelly E, Light RW. Intrapleural heparin or heparin combined with human recombinant DNase is not effective in the treatment of empyema in a rabbit model. Respirology 2007; 11:755-60. [PMID: 17052304 DOI: 10.1111/j.1440-1843.2006.00934.x] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/27/2022]
Abstract
OBJECTIVE AND BACKGROUND The aim of this study was to investigate the effectiveness of intrapleural heparin or heparin combined with human recombinant DNase in the treatment of empyema. METHODS Empyema was induced in rabbits with an intrapleural injection of 10(9)Pasteurella multicoda organisms in infusion agar via a surgically placed chest tube. Once empyema was verified, a blinded investigator administered drugs via the chest tube. There were three treatment groups each with six rabbits. One group was given 1000 IU heparin, a second group was given 1000 IU heparin plus 1 mg of human recombinant DNase via chest tube and the control group received saline. The rabbits received treatment every 12 h for a total of six treatments and the volume of each treatment was 3 mL. The animals were sacrificed at day 10 and the amount of empyema and pleural thickening was scored macroscopically on a scale of 0-6. RESULTS The total volume of pleural effusion aspirated was significantly higher in the heparin group (25.8+/-10.7 mL) compared with either saline (8+/-8.9) or heparin plus human recombinant DNase (6.8+/-6.1) groups (P=0.003). The mean empyema and pleural thickening scores did not differ significantly between the groups (P=0.8, P=0.5 respectively). A weak correlation was found between total volume of aspirated pleural fluid and pleural parameters of white blood cell counts and LDH levels (r=0.546 and P=0.02, r=0.631 and P=0.02 respectively). CONCLUSION The intrapleural administration of 1000 IU heparin alone or in combination with 1 mg of human recombinant DNase is no more effective than saline in the treatment of empyema in rabbits. Intrapleural heparin significantly increased the drainage of pleural fluid compared with the combination and saline group.
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Affiliation(s)
- Oner Dikensoy
- Pulmonary Division, St. Thomas Hospital and Vanderbilt University, Nashville, TN, USA.
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27
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Blanc P, Dubus JC, Bosdure E, Minodier P. Pleurésies purulentes communautaires de l'enfant. Où en sommes-nous? Arch Pediatr 2007; 14:64-72. [PMID: 17118634 DOI: 10.1016/j.arcped.2006.10.001] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/28/2006] [Accepted: 10/10/2006] [Indexed: 11/24/2022]
Abstract
Community-acquired pleural infection is a life-threatening complication of pneumonia in children. It seems to be more prevalent actually. This pathology is associated with an high morbidity and frequently requires prolonged hospitalization and invasives procedures. However, there is no consensus on its management in pediatrics, especially because of the lack of trials. To improve the quality of the future studies and to compare the series, a child-adapted classification is required. To date, in attempt of evidence, chest drainage or thoracocentesis-thoracoscopy are questionable. For treatment, high regimens of synergic and intravenously-delivered antibiotics seem to be the better choice.
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Affiliation(s)
- P Blanc
- Médecine infantile, hôpital Nord, chemin des Bourelly, 13915 Marseille cedex 20, France.
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28
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Martins S, Valente S, David TN, Pereira L, Barreto C, Bandeira T. Derrame pleural complicado na criança – Abordagem terapêutica. REVISTA PORTUGUESA DE PNEUMOLOGIA 2007. [DOI: 10.1016/s0873-2159(15)30337-8] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/23/2022] Open
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Leung C, Chang YC. Video-assisted thoracoscopic surgery in a 1-month-old infant with pleural empyema. J Formos Med Assoc 2006; 105:936-40. [PMID: 17098695 DOI: 10.1016/s0929-6646(09)60179-0] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022] Open
Abstract
Pleural empyema is a frequent complication of bacterial pneumonia in childhood but is rare in neonates. Various modalities of treatment from intravenous antibiotics, chest tube drainage, intrapleural fibrinolytic agent installation, video-assisted thoracostomy to surgical decortication have been suggested to treat different stages of empyema in children, but management of progressive empyema in neonates is still at the stage of antimicrobial therapy and tube thoracostomy. Here, we report a 1-month-old infant with staphylococcal pneumonia complicated with multiloculated empyema who was successfully treated with video-assisted thoracoscopic surgery (VATS) after 4 days of chest tube drainage and parenteral antibiotics. The patient's condition improved rapidly after the operation and the antimicrobial therapy was continued for 3 weeks. He was asymptomatic and thriving at follow-up 1 year later. Chest radiography at 1 month was free of any lesion. This case suggests that VATS can be a safe and effective treatment for neonatal empyema.
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Affiliation(s)
- Cheung Leung
- Division of Neonatology, Department of Pediatrics, Far Eastern Memorial Hospital, Panchiao, Taipei, Taiwan.
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30
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Wang JN, Yao CT, Yeh CN, Liu CC, Wu MH, Chuang HY, Wu JM. Once-daily vs. twice-daily intrapleural urokinase treatment of complicated parapneumonic effusion in paediatric patients: A randomised, prospective study. Int J Clin Pract 2006; 60:1225-30. [PMID: 16981967 DOI: 10.1111/j.1742-1241.2006.01110.x] [Citation(s) in RCA: 10] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/27/2022] Open
Abstract
To evaluate the effective dose frequency (once daily vs. twice daily) of intrapleural urokinase treatment in children who required tube thoracostomy for drainage of a complicated parapneumonic effusion, we designed a randomised prospective study in a tertiary medical centre in Taiwan. From June 2002 to January 2005, 30 paediatric patients with complicated parapneumonic effusion who had received chest tube drainage were randomised 1 : 1 to the once-daily (urokinase 5000-6000 IU/kg/dose) or twice-daily (urokinase 2500-3000 IU/kg/dose) treatment. We compared clinical manifestations and outcomes in both groups. There were no differences in pleural effusion characteristics between the groups. Six patients had Streptococcus pneumoniae, one had Staphylococcus aureus, one had Group A Streptococcus, and 22 had unknown pathogens. There were no significant differences between the once- vs. twice-daily group in the amount of drained pleural fluid (564.9 +/- 422.1 ml vs. 560.5 +/- 198.6 ml, respectively), fever duration after chest tube insertion (4.3 +/- 3.2 days vs. 5.3 +/- 2.7 days), or total admission days (14.3 +/- 3.9 days vs. 14.6 +/- 3.0 days) (p > 0.05 for all). Only two patients (one in each group) required the surgery. Thus, we found that both once- and twice-daily administration of urokinase were similarly efficacious, and resulted in good clinical outcomes. Both obviated the need for surgery in most (93%) cases of pneumonia with complicated parapneumonic effusion in this series. A larger, multicentre study is necessary to verify our findings.
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Affiliation(s)
- J-N Wang
- The Institute of Clinical Medicine, College of Medicine, National Cheng Kung University, Tainan, Taiwan
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31
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Kalfa N, Allal H, Lopez M, Saguintaah M, Guibal MP, Sabatier-Laval E, Forgues D, Counil F, Galifer RB. Thoracoscopy in pediatric pleural empyema: a prospective study of prognostic factors. J Pediatr Surg 2006; 41:1732-7. [PMID: 17011279 DOI: 10.1016/j.jpedsurg.2006.05.066] [Citation(s) in RCA: 28] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
Abstract
PURPOSE The indications for thoracoscopy remain imprecise in cases of pleural empyema. This study aimed to identify preoperative prognostic factors to help in the surgical decision. METHODS From 1996 to 2004, 50 children with parapneumonic pleural empyema underwent thoracoscopy either as the initial procedure (n = 26) or after failure of medical treatment (n = 24). Using multivariate analysis, we tested the prognostic value of clinical and bacteriological data, the ultrasonographic staging of empyema, and the delay before surgery. Outcome measures were technical difficulties, postoperative complications, time to apyrexia, duration of drainage, and length of hospitalization. RESULTS The clinical and bacterial data did not significantly predict the postoperative course. Echogenicity and the presence of pleural loculations at ultrasonography were not independent significant prognostic factors. A delay between diagnosis and surgery of more than 4 days was significantly correlated (P < .05) with more frequent surgical difficulties, longer operative time, more postoperative fever, longer drainage time, longer hospitalization, and more postoperative complications, such as bronchopleural fistula, empyema relapse, and persistent atelectasia. CONCLUSION The main prognostic factor for thoracoscopic treatment of pleural empyema is the interval between diagnosis and surgery. A 4-day limit, corresponding to the natural process of empyema organization, is significant. The assessment of loculations by ultrasonography alone is not sufficient to predict the postoperative course.
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Affiliation(s)
- Nicolas Kalfa
- Visceral Pediatric Surgery Department, Lapeyronie-Arnaud de Villeneuve Hospital, Montpellier Cedex 5 34295, France
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Kurt BA, Winterhalter KM, Connors RH, Betz BW, Winters JW. Therapy of parapneumonic effusions in children: video-assisted thoracoscopic surgery versus conventional thoracostomy drainage. Pediatrics 2006; 118:e547-53. [PMID: 16908618 DOI: 10.1542/peds.2005-2719] [Citation(s) in RCA: 94] [Impact Index Per Article: 5.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/24/2022] Open
Abstract
OBJECTIVE Controversy surrounds the optimal treatment of parapneumonic effusions. This trial of pediatric patients with community-acquired pneumonia and associated parapneumonic processes compared primary video-assisted thoracoscopic surgery with conventional thoracostomy drainage. DESIGN A prospective, randomized trial was conducted at DeVos Children's Hospital (Grand Rapids, MI) between November 2003 and May 2005. All of the patients under 18 years of age with large parapneumonic effusions were approached for enrollment in the study. After enrollment, each patient was randomly assigned to receive either video-assisted thoracoscopic surgery or thoracostomy tube drainage of the effusion. Subsequent therapies (fibrinolysis, imaging, and further drainage procedures) were similar for each group per protocol. RESULTS Eighteen patients were enrolled in the study: 10 in video-assisted thoracoscopic surgery and 8 in conventional thoracostomy. The groups were demographically similar. No mortalities were encountered in either group, and everyone was discharged from the hospital with acceptable outcomes. Yet, there were multiple variables that demonstrated statistical difference. Hospital length of stay, number of chest tube days, narcotic use, number of radiographic procedures, and interventional procedures were all less in the patients who underwent primary video-assisted thoracoscopic surgery. In addition, no patient in the video-assisted thoracoscopic surgery group required fibrinolytic therapy, which was also statistically different from the thoracostomy drainage group. CONCLUSIONS The outcomes of this study strongly suggest that primary video-assisted thoracoscopic surgery for evacuation of parapneumonic effusions is superior to conventional thoracostomy drainage.
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Affiliation(s)
- Beth A Kurt
- Department of Pediatrics, DeVos Children's Hospital, 100 Michigan St NE, MC 117, Grand Rapids, Michigan 49503, USA
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Suchar AM, Zureikat AH, Glynn L, Statter MB, Lee J, Liu DC. Ready for the Frontline: Is Early Thoracoscopic Decortication the New Standard of Care for Advanced Pneumonia with Empyema? Am Surg 2006. [DOI: 10.1177/000313480607200806] [Citation(s) in RCA: 18] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
Video-assisted thoracoscopic decortication (VATD) has been established as an effective and potentially less morbid alternative to open thoracotomy for the management of empyema. However, the timing and role of VATD for advanced pneumonia with empyema is still controversial. In assessing surgical outcome, the authors reviewed their VATD experience in children with empyema or empyema with necrotizing pneumonia. The charts of 42 children who underwent VATD at our institution between July 2001 and July 2005 were retrospectively reviewed for surgical outcome. For purposes of analysis, patients were cohorted into four classes with increasing severity of pneumonia: 1 (-) intraoperative pleural fluid cultures, (-) necrotizing pneumonia, 18 (43%); 2 (+) pleural fluid cultures, (-) necrotizing pneumonia, 10 (24%); 3 (-) pleural fluid cultures, (+) necrotizing pneumonia, 6 (14%); 4 (+) pleural fluid cultures, (+) necrotizing pneumonia, 8 (19%). A P value of <0.05 via Student's t test or Fischer's exact analysis was considered an indicator of significant difference in the comparison of group outcomes. VATD was successfully completed in all 42 patients with no mortality and without significant morbidity (82% had less than 20 cc blood loss). There was found to be no significant difference (p = NS) in time to surgical discharge (removal of chest tube) among all groups. Hospital length of stay postsurgery was found to be significantly increased between 1 and 4 (6 days vs 9 days; P = 0.038). 14/14 (100%) of children with necrotizing pneumonia were found to have evidence of lung parenchymal preservation with improved aeration on follow-up CT scan and/or chest x-rays. The authors conclude that early VATD in children with advanced pneumonia with empyema is indicated to avoid unnecessarily lengthy hospitalization and prolonged intravenous antibiotic therapy. Furthermore, early VATD can be safely performed in various stages of advanced pneumonia with empyema, promoting lung salvage, and accelerating clinical recovery.
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Affiliation(s)
- Adam M. Suchar
- University of Chicago Comer Children's Hospital, Chicago, Illinois
| | - Amer H. Zureikat
- University of Chicago Comer Children's Hospital, Chicago, Illinois
| | - Loretto Glynn
- University of Chicago Comer Children's Hospital, Chicago, Illinois
| | - Mindy B. Statter
- University of Chicago Comer Children's Hospital, Chicago, Illinois
| | - Jongin Lee
- University of Chicago Comer Children's Hospital, Chicago, Illinois
| | - Donald C. Liu
- University of Chicago Comer Children's Hospital, Chicago, Illinois
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Ozkan OS, Ozmen MN, Akhan O. Percutaneous management of parapneumonic effusions. Eur J Radiol 2006; 55:311-20. [PMID: 15885958 DOI: 10.1016/j.ejrad.2005.03.004] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/02/2005] [Revised: 03/07/2005] [Accepted: 03/10/2005] [Indexed: 11/28/2022]
Abstract
Parapneumonic effusions continue to be a significant source of morbidity and mortality. Treatment at earlier stages before fibrous peel and loculations occur has a much better prognosis. Using image guidance, addition of intracavitary fibrinolytic instillation, close follow-up with drainage of residual or new collections are some of the other factors that improve prognosis. In this article, we discussed treatment strategies, percutaneous management of parapneumonic effusions, its alternatives and results.
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Affiliation(s)
- Orhan S Ozkan
- Department of Radiology, Hacettepe University School of Medicine, 06100 Sihhiye/Ankara, Turkey
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Abstract
PURPOSE OF REVIEW Transthoracic ultrasound has received increased interest from chest physicians in recent years. Modern ultrasound devices are user friendly, inexpensive, lightweight, and portable, which makes them suited for outpatient settings as well as for bedside investigation of the severely ill. Ultrasound is set to become a practical and essential tool for the pulmonologist in the near future. RECENT FINDINGS An ever-increasing number of articles are aimed at describing and refining how ultrasound can be utilised by chest physicians in daily practice. Only basic ultrasound skills are required to assess pleural effusions and perform ultrasound-guided thoracocentesis. Sonographic assistance with insertion of chest drains as well as identification or biopsy of thoracic masses are more complex, and advanced skills are required for the investigation of pneumothorax and thromboembolic disease. SUMMARY The current literature documents the progress in the application of ultrasound for the practicing chest physician. In this article the authors describe the most recent developments and follow up with some simple but essential advice for the novice venturing into chest ultrasound.
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Affiliation(s)
- Andreas H Diacon
- Department of Internal Medicine, Tygerberg Academic Hospital and University of Stellenbosch, Cape Town, South Africa.
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Avansino JR, Goldman B, Sawin RS, Flum DR. Primary operative versus nonoperative therapy for pediatric empyema: a meta-analysis. Pediatrics 2005; 115:1652-9. [PMID: 15930229 DOI: 10.1542/peds.2004-1405] [Citation(s) in RCA: 152] [Impact Index Per Article: 8.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/24/2022] Open
Abstract
OBJECTIVE The optimal treatment of children with empyema remains controversial. The purpose of this review was to compare reported results of nonoperative and primary operative therapy for the treatment of pediatric empyema. METHODS A systematic comprehensive review of the scientific literature was conducted with the PubMed (National Library of Medicine) database for the period from 1981 to 2004. This reproducible search identified all publications dealing with treatment of empyema in the pediatric population (<18 years of age). A meta-analysis was performed with studies with adequate data summaries for > or =1 of the outcomes of interest for both treatment groups. RESULTS Sixty-seven studies were reviewed. Data were aggregated from reports of children initially treated nonoperatively (3418 cases from 54 studies) and of children treated with a primary operative approach (363 cases from 25 studies). The populations were similar in age. Patients who underwent primary operative therapy had a lower aggregate in-hospital mortality rate (0% vs 3.3%), reintervention rate (2.5% vs 23.5%), length of stay (10.8 vs 20.0 days), duration of tube thoracostomy (4.4 vs 10.6 days), and duration of antibiotic therapy (12.8 vs 21.3 days), compared with patients who underwent nonoperative therapy. In 8 studies for which meta-analysis was possible, patients who received primary operative therapy were found to have a pooled relative risk of failure of 0.09, compared with those who did not. Meta-analysis could not be performed for any of the other outcome measures investigated in this review. Similar complication rates were observed for the 2 groups (5% vs 5.6%). CONCLUSIONS These aggregate results suggest that primary operative therapy is associated with a lower in-hospital mortality rate, reintervention rate, length of stay, time with tube thoracostomy, and time of antibiotic therapy, compared with nonoperative treatment. The meta-analysis demonstrates a significantly reduced relative risk of failure among patients treated operatively.
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Affiliation(s)
- Jeffrey R Avansino
- Department of Surgery, University of Washington, Box 356410, Seattle, WA 98105, USA.
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Abstract
PURPOSE OF REVIEW Complicated parapneumonic effusion and empyema continue to account for significant morbidity and mortality, and uncertainties remain regarding their optimal management. This review describes recent advances in this field, as well as areas for future research. RECENT FINDINGS Recent advances have addressed the pathogenesis, bacteriology, and treatment of pleural infection. Key areas for research in the development of empyema include the interplay between inflammatory and coagulation cascades and development of fibrosis within the pleural space. The varied bacteriology of empyema has been more clearly defined, and in particular the differences between community- and hospital-acquired infection highlighted. Studies of treatment have focused particularly on the roles of intrapleural fibrinolytics and surgery. SUMMARY Increased understanding of the pathogenesis of empyema may ultimately yield novel therapeutic targets. Comprehensive descriptions of the bacteriology of empyema aids antibiotic choice, and the use of intrapleural DNase shows promise in facilitating drainage of infected pleural fluid. Uncertainties remain, such as the role of intrapleural fibrinolytics and the optimal timing of surgical intervention.
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Affiliation(s)
- Stephen J Chapman
- Oxford Pleural Diseases Unit, Oxford Centre for Respiratory Medicine, Churchill Hospital, Oxford, UK.
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