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De Vera CJ, Emerine RL, Girard RA, Sarva K, Jacob J, Azghani AO, Florence JM, Cook A, Norwood S, Singh KP, Komissarov AA, Florova G, Idell S. A Novel Rabbit Model of Retained Hemothorax with Pleural Organization. Int J Mol Sci 2023; 25:470. [PMID: 38203639 PMCID: PMC10779131 DOI: 10.3390/ijms25010470] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/01/2023] [Revised: 12/08/2023] [Accepted: 12/22/2023] [Indexed: 01/12/2024] Open
Abstract
Retained hemothorax (RH) is a commonly encountered and potentially severe complication of intrapleural bleeding that can organize with lung restriction. Early surgical intervention and intrapleural fibrinolytic therapy have been advocated. However, the lack of a reliable, cost-effective model amenable to interventional testing has hampered our understanding of the role of pharmacological interventions in RH management. Here, we report the development of a new RH model in rabbits. RH was induced by sequential administration of up to three doses of recalcified citrated homologous rabbit donor blood plus thrombin via a chest tube. RH at 4, 7, and 10 days post-induction (RH4, RH7, and RH10, respectively) was characterized by clot retention, intrapleural organization, and increased pleural rind, similar to that of clinical RH. Clinical imaging techniques such as ultrasonography and computed tomography (CT) revealed the dynamic formation and resorption of intrapleural clots over time and the resulting lung restriction. RH7 and RH10 were evaluated in young (3 mo) animals of both sexes. The RH7 recapitulated the most clinically relevant RH attributes; therefore, we used this model further to evaluate the effect of age on RH development. Sanguineous pleural fluids (PFs) in the model were generally small and variably detected among different models. The rabbit model PFs exhibited a proinflammatory response reminiscent of human hemothorax PFs. Overall, RH7 results in the consistent formation of durable intrapleural clots, pleural adhesions, pleural thickening, and lung restriction. Protracted chest tube placement over 7 d was achieved, enabling direct intrapleural access for sampling and treatment. The model, particularly RH7, is amenable to testing new intrapleural pharmacologic interventions, including iterations of currently used empirically dosed agents or new candidates designed to safely and more effectively clear RH.
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Affiliation(s)
- Christian J. De Vera
- Department of Cellular and Molecular Biology, School of Medicine, The University of Texas Health Science Center at Tyler, 11937 US HWY 271, Tyler, TX 75708, USA; (C.J.D.V.); (R.L.E.); (R.A.G.); (K.S.); (J.J.); (J.M.F.); (A.A.K.); (G.F.)
| | - Rebekah L. Emerine
- Department of Cellular and Molecular Biology, School of Medicine, The University of Texas Health Science Center at Tyler, 11937 US HWY 271, Tyler, TX 75708, USA; (C.J.D.V.); (R.L.E.); (R.A.G.); (K.S.); (J.J.); (J.M.F.); (A.A.K.); (G.F.)
| | - René A. Girard
- Department of Cellular and Molecular Biology, School of Medicine, The University of Texas Health Science Center at Tyler, 11937 US HWY 271, Tyler, TX 75708, USA; (C.J.D.V.); (R.L.E.); (R.A.G.); (K.S.); (J.J.); (J.M.F.); (A.A.K.); (G.F.)
| | - Krishna Sarva
- Department of Cellular and Molecular Biology, School of Medicine, The University of Texas Health Science Center at Tyler, 11937 US HWY 271, Tyler, TX 75708, USA; (C.J.D.V.); (R.L.E.); (R.A.G.); (K.S.); (J.J.); (J.M.F.); (A.A.K.); (G.F.)
| | - Jincy Jacob
- Department of Cellular and Molecular Biology, School of Medicine, The University of Texas Health Science Center at Tyler, 11937 US HWY 271, Tyler, TX 75708, USA; (C.J.D.V.); (R.L.E.); (R.A.G.); (K.S.); (J.J.); (J.M.F.); (A.A.K.); (G.F.)
| | - Ali O. Azghani
- Department of Biology, The University of Texas at Tyler, 3900 University Blvd, Tyler, TX 75799, USA;
| | - Jon M. Florence
- Department of Cellular and Molecular Biology, School of Medicine, The University of Texas Health Science Center at Tyler, 11937 US HWY 271, Tyler, TX 75708, USA; (C.J.D.V.); (R.L.E.); (R.A.G.); (K.S.); (J.J.); (J.M.F.); (A.A.K.); (G.F.)
| | - Alan Cook
- Department of Surgery, School of Medicine, The University of Texas Health Science Center at Tyler, 11937 US HWY 271, Tyler, TX 75708, USA; (A.C.); (S.N.)
| | - Scott Norwood
- Department of Surgery, School of Medicine, The University of Texas Health Science Center at Tyler, 11937 US HWY 271, Tyler, TX 75708, USA; (A.C.); (S.N.)
| | - Karan P. Singh
- Department of Epidemiology and Biostatistics, School of Medicine, The University of Texas Health Science Center at Tyler, 11937 US HWY 271, Tyler, TX 75708, USA;
| | - Andrey A. Komissarov
- Department of Cellular and Molecular Biology, School of Medicine, The University of Texas Health Science Center at Tyler, 11937 US HWY 271, Tyler, TX 75708, USA; (C.J.D.V.); (R.L.E.); (R.A.G.); (K.S.); (J.J.); (J.M.F.); (A.A.K.); (G.F.)
| | - Galina Florova
- Department of Cellular and Molecular Biology, School of Medicine, The University of Texas Health Science Center at Tyler, 11937 US HWY 271, Tyler, TX 75708, USA; (C.J.D.V.); (R.L.E.); (R.A.G.); (K.S.); (J.J.); (J.M.F.); (A.A.K.); (G.F.)
| | - Steven Idell
- Department of Cellular and Molecular Biology, School of Medicine, The University of Texas Health Science Center at Tyler, 11937 US HWY 271, Tyler, TX 75708, USA; (C.J.D.V.); (R.L.E.); (R.A.G.); (K.S.); (J.J.); (J.M.F.); (A.A.K.); (G.F.)
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Abdul Hamid MF, Hasbullah AHH, Mohamad Jailaini MF, Nik Abeed NN, Ng BH, Haron H, Md Ali NA, Ismail MI, Nik Ismail NA, Abdul Rahman MR, Ban AYL. Retrospective review comparing intrapleural fibrinolytic therapy (alteplase) and surgical intervention in complex pleural effusion. BMC Pulm Med 2022; 22:439. [PMID: 36419155 PMCID: PMC9685928 DOI: 10.1186/s12890-022-02239-w] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/04/2022] [Accepted: 11/14/2022] [Indexed: 11/25/2022] Open
Abstract
Background Intrapleural fibrinolytic therapy (IPFT) is one of the treatment options for complex pleural effusion. In this study, the IPFT agent used was alteplase, a tissue plasminogen activator (t-PA). This study aims to determine the difference in the outcome of patients with complex pleural effusion between IPFT and surgery in terms of radiological improvement, inflammatory parameters, length of stay, and post-intervention complications.
Methods A retrospective review of patients with complex pleural effusion treated at Universiti Kebangsaan Malaysia Medical Center from January 2012 to August 2020 was performed. Patient demographics, chest imaging, drainage chart, inflammatory parameters, length of hospital stay, and post-intervention and outcome were analyzed. Results Fifty-eight patients were identified (surgical intervention, n = 18; 31% and IPFT, n = 40, 69%). The mean age was 51.7 ± 18.2 years. Indication for surgical intervention was pleural infection (n = 18; 100%), and MPE (n = 0). Indications for IPFT was pleural infection (n = 30; 75%) and MPE (n = 10; 25%). The dosages of t-PA were one to five doses of 2–50 mg. The baseline chest radiograph in the IPFT group was worse than in the surgical intervention group. (119.96 ± 56.05 vs. 78.19 ± 55.6; p = 0.029) At week 1, the radiological success rate for IPFT and surgical intervention were 27% and 20%, respectively, and at weeks 4–8, the success rate was 56% and 80% respectively. IPFT was associated with lesser complications; fever (17.5%), chest pain (10%), and non-life-threatening bleeding (5%). Conclusion IPFT was comparable to surgery in radiological outcome, inflammatory parameters, and length of stay with lesser reported complications.
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Affiliation(s)
- Mohamed Faisal Abdul Hamid
- grid.240541.60000 0004 0627 933XRespiratory Unit, Department of Medicine, Faculty of Medicine, Universiti Kebangsaan Malaysia Medical Centre (UKMMC), Jalan Yaacob Latif, Bandar Tun Razak, Cheras, 56000 Kuala Lumpur, Malaysia ,grid.240541.60000 0004 0627 933XHeart and Lung Institute, Faculty of Medicine, Universiti Kebangsaan Malaysia Medical Centre (UKMMC), Jalan Yaacob Latiff, Bandar Tun Razak, Cheras, 56000 Kuala Lumpur, Malaysia
| | - Ahmad Hadyan Husainy Hasbullah
- grid.240541.60000 0004 0627 933XRespiratory Unit, Department of Medicine, Faculty of Medicine, Universiti Kebangsaan Malaysia Medical Centre (UKMMC), Jalan Yaacob Latif, Bandar Tun Razak, Cheras, 56000 Kuala Lumpur, Malaysia
| | - Mas Fazlin Mohamad Jailaini
- grid.240541.60000 0004 0627 933XRespiratory Unit, Department of Medicine, Faculty of Medicine, Universiti Kebangsaan Malaysia Medical Centre (UKMMC), Jalan Yaacob Latif, Bandar Tun Razak, Cheras, 56000 Kuala Lumpur, Malaysia ,grid.240541.60000 0004 0627 933XHeart and Lung Institute, Faculty of Medicine, Universiti Kebangsaan Malaysia Medical Centre (UKMMC), Jalan Yaacob Latiff, Bandar Tun Razak, Cheras, 56000 Kuala Lumpur, Malaysia
| | - Nik Nuratiqah Nik Abeed
- grid.240541.60000 0004 0627 933XRespiratory Unit, Department of Medicine, Faculty of Medicine, Universiti Kebangsaan Malaysia Medical Centre (UKMMC), Jalan Yaacob Latif, Bandar Tun Razak, Cheras, 56000 Kuala Lumpur, Malaysia ,grid.240541.60000 0004 0627 933XHeart and Lung Institute, Faculty of Medicine, Universiti Kebangsaan Malaysia Medical Centre (UKMMC), Jalan Yaacob Latiff, Bandar Tun Razak, Cheras, 56000 Kuala Lumpur, Malaysia
| | - Boon Hau Ng
- grid.240541.60000 0004 0627 933XRespiratory Unit, Department of Medicine, Faculty of Medicine, Universiti Kebangsaan Malaysia Medical Centre (UKMMC), Jalan Yaacob Latif, Bandar Tun Razak, Cheras, 56000 Kuala Lumpur, Malaysia ,grid.240541.60000 0004 0627 933XHeart and Lung Institute, Faculty of Medicine, Universiti Kebangsaan Malaysia Medical Centre (UKMMC), Jalan Yaacob Latiff, Bandar Tun Razak, Cheras, 56000 Kuala Lumpur, Malaysia
| | - Hairulfaizi Haron
- grid.240541.60000 0004 0627 933XCardiothoracic Unit, Department of Surgery, Faculty of Medicine, Universiti Kebangsaan Malaysia Medical Centre (UKMMC), Jalan Yaacob Latiff, Bandar Tun Razak, Cheras, 56000 Kuala Lumpur, Malaysia ,grid.240541.60000 0004 0627 933XHeart and Lung Institute, Faculty of Medicine, Universiti Kebangsaan Malaysia Medical Centre (UKMMC), Jalan Yaacob Latiff, Bandar Tun Razak, Cheras, 56000 Kuala Lumpur, Malaysia
| | - Nur Ayub Md Ali
- grid.240541.60000 0004 0627 933XCardiothoracic Unit, Department of Surgery, Faculty of Medicine, Universiti Kebangsaan Malaysia Medical Centre (UKMMC), Jalan Yaacob Latiff, Bandar Tun Razak, Cheras, 56000 Kuala Lumpur, Malaysia ,grid.240541.60000 0004 0627 933XHeart and Lung Institute, Faculty of Medicine, Universiti Kebangsaan Malaysia Medical Centre (UKMMC), Jalan Yaacob Latiff, Bandar Tun Razak, Cheras, 56000 Kuala Lumpur, Malaysia
| | - Muhammad Ishamuddin Ismail
- grid.240541.60000 0004 0627 933XCardiothoracic Unit, Department of Surgery, Faculty of Medicine, Universiti Kebangsaan Malaysia Medical Centre (UKMMC), Jalan Yaacob Latiff, Bandar Tun Razak, Cheras, 56000 Kuala Lumpur, Malaysia ,grid.240541.60000 0004 0627 933XHeart and Lung Institute, Faculty of Medicine, Universiti Kebangsaan Malaysia Medical Centre (UKMMC), Jalan Yaacob Latiff, Bandar Tun Razak, Cheras, 56000 Kuala Lumpur, Malaysia
| | - Nik Azuan Nik Ismail
- grid.240541.60000 0004 0627 933XDepartment of Radiology, Faculty of Medicine, Universiti Kebangsaan Malaysia Medical Centre (UKMMC), Jalan Yaacob Latiff, Bandar Tun Razak, Cheras, 56000 Kuala Lumpur, Malaysia
| | - Mohd Ramzisham Abdul Rahman
- grid.240541.60000 0004 0627 933XCardiothoracic Unit, Department of Surgery, Faculty of Medicine, Universiti Kebangsaan Malaysia Medical Centre (UKMMC), Jalan Yaacob Latiff, Bandar Tun Razak, Cheras, 56000 Kuala Lumpur, Malaysia ,grid.240541.60000 0004 0627 933XHeart and Lung Institute, Faculty of Medicine, Universiti Kebangsaan Malaysia Medical Centre (UKMMC), Jalan Yaacob Latiff, Bandar Tun Razak, Cheras, 56000 Kuala Lumpur, Malaysia
| | - Andrea Yu-Lin Ban
- grid.240541.60000 0004 0627 933XRespiratory Unit, Department of Medicine, Faculty of Medicine, Universiti Kebangsaan Malaysia Medical Centre (UKMMC), Jalan Yaacob Latif, Bandar Tun Razak, Cheras, 56000 Kuala Lumpur, Malaysia ,grid.240541.60000 0004 0627 933XHeart and Lung Institute, Faculty of Medicine, Universiti Kebangsaan Malaysia Medical Centre (UKMMC), Jalan Yaacob Latiff, Bandar Tun Razak, Cheras, 56000 Kuala Lumpur, Malaysia
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Janowak CF, Becker BR, Philpott CD, Makley AT, Mueller EW, Droege CA, Droege ME. Retrospective Evaluation of Intrapleural Tissue Plasminogen Activator With or Without Dornase Alfa for the Treatment of Traumatic Retained Hemothorax: A 6-Year Experience. Ann Pharmacother 2022; 56:10600280221077383. [PMID: 35184602 DOI: 10.1177/10600280221077383] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022] Open
Abstract
BACKGROUND Intrapleural fibrinolytic instillation is second-line treatment for retained hemothorax. Dornase alfa (DNase) has demonstrated efficacy in parapneumonic effusion, but the lack of deoxyribonucleoproteins limits direct extrapolation to traumatic retained hemothorax treatment. OBJECTIVE This study evaluated the effectiveness of intrapleural tissue plasminogen activator (tPA) with and without DNase in the treatment of retained traumatic hemothorax. METHODS This retrospective cohort study included patients aged 16 years and older admitted to a level 1 trauma center from January 2013 through July 2019 with retained hemothorax and one or more intrapleural tPA instillations. Exclusion criteria were tPA for other indications or concomitant empyema. The primary endpoint was treatment failure defined as the need for operative intervention. RESULTS Fifty patients were included (tPA alone: 28; tPA with DNase: 22). Baseline characteristics were similar between groups, including time to diagnosis (6.5 [interquartile range (IQR), 4-15.5] days vs 6 [IQR, 6.3-10.8] days, P = 0.52). Median tPA dose per treatment (6 [IQR, 6-6.4] mg vs 10 [IQR, 8.4-10] mg, P < 0.001) and cumulative tPA (18 [IQR, 6.5-24] mg vs 30 [IQR, 29.5-40], P < 0.001) dose were significantly lower in the tPA alone group. Treatment failure was similar between groups. Chest tube output, retained hemothorax reduction, and bleeding incidences were similar between groups. Multivariate logistic regression demonstrated no significant risk factors for treatment failure. CONCLUSIONS AND RELEVANCE Dornase alfa added to tPA may not reduce the need for operation to treat retained hemothorax. Further studies should be directed at optimal tPA dose determination and economic impact of inappropriate DNase use.
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Affiliation(s)
- Christopher Francis Janowak
- Section of General Surgery, Department of Surgery, University of Cincinnati College of Medicine, Cincinnati, OH, USA
| | - Bradley Robert Becker
- IngenioRX, Inc, Morristown, NJ, USA
- Univeristy of Cincinnati James L. Winkle College of Pharmacy, Cincinnati, OH, USA
| | - Carolyn Dosen Philpott
- Univeristy of Cincinnati James L. Winkle College of Pharmacy, Cincinnati, OH, USA
- UC Health - University of Cincinnati Medical Center, Cincinnati, OH, USA
| | - Amy Teres Makley
- Section of General Surgery, Department of Surgery, University of Cincinnati College of Medicine, Cincinnati, OH, USA
| | - Eric William Mueller
- Univeristy of Cincinnati James L. Winkle College of Pharmacy, Cincinnati, OH, USA
- UC Health - University of Cincinnati Medical Center, Cincinnati, OH, USA
| | - Christopher Allen Droege
- Univeristy of Cincinnati James L. Winkle College of Pharmacy, Cincinnati, OH, USA
- UC Health - University of Cincinnati Medical Center, Cincinnati, OH, USA
| | - Molly Elizabeth Droege
- Univeristy of Cincinnati James L. Winkle College of Pharmacy, Cincinnati, OH, USA
- UC Health - University of Cincinnati Medical Center, Cincinnati, OH, USA
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Karandashova S, Florova G, Idell S, Komissarov AA. From Bedside to the Bench—A Call for Novel Approaches to Prognostic Evaluation and Treatment of Empyema. Front Pharmacol 2022; 12:806393. [PMID: 35126140 PMCID: PMC8811368 DOI: 10.3389/fphar.2021.806393] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/31/2021] [Accepted: 12/31/2021] [Indexed: 11/13/2022] Open
Abstract
Empyema, a severe complication of pneumonia, trauma, and surgery is characterized by fibrinopurulent effusions and loculations that can result in lung restriction and resistance to drainage. For decades, efforts have been focused on finding a universal treatment that could be applied to all patients with practice recommendations varying between intrapleural fibrinolytic therapy (IPFT) and surgical drainage. However, despite medical advances, the incidence of empyema has increased, suggesting a gap in our understanding of the pathophysiology of this disease and insufficient crosstalk between clinical practice and preclinical research, which slows the development of innovative, personalized therapies. The recent trend towards less invasive treatments in advanced stage empyema opens new opportunities for pharmacological interventions. Its remarkable efficacy in pediatric empyema makes IPFT the first line treatment. Unfortunately, treatment approaches used in pediatrics cannot be extrapolated to empyema in adults, where there is a high level of failure in IPFT when treating advanced stage disease. The risk of bleeding complications and lack of effective low dose IPFT for patients with contraindications to surgery (up to 30%) promote a debate regarding the choice of fibrinolysin, its dosage and schedule. These challenges, which together with a lack of point of care diagnostics to personalize treatment of empyema, contribute to high (up to 20%) mortality in empyema in adults and should be addressed preclinically using validated animal models. Modern preclinical studies are delivering innovative solutions for evaluation and treatment of empyema in clinical practice: low dose, targeted treatments, novel biomarkers to predict IPFT success or failure, novel delivery methods such as encapsulating fibrinolysin in echogenic liposomal carriers to increase the half-life of plasminogen activator. Translational research focused on understanding the pathophysiological mechanisms that control 1) the transition from acute to advanced-stage, chronic empyema, and 2) differences in outcomes of IPFT between pediatric and adult patients, will identify new molecular targets in empyema. We believe that seamless bidirectional communication between those working at the bedside and the bench would result in novel personalized approaches to improve pharmacological treatment outcomes, thus widening the window for use of IPFT in adult patients with advanced stage empyema.
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Affiliation(s)
- Sophia Karandashova
- Department of Pediatrics, University of California San Francisco, San Francisco, CA, United States
| | - Galina Florova
- Department of Cellular and Molecular Biology, The University of Texas Health Science Center at Tyler, Tyler, TX, United States
| | - Steven Idell
- Department of Cellular and Molecular Biology, The University of Texas Health Science Center at Tyler, Tyler, TX, United States
| | - Andrey A. Komissarov
- Department of Cellular and Molecular Biology, The University of Texas Health Science Center at Tyler, Tyler, TX, United States
- *Correspondence: Andrey A. Komissarov,
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Imburgio S, Tavakolian K, Mararenko A, Tasnim T, Khan T, Costanzo E. Empyema Versus Lung Abscess: A Case Report. J Investig Med High Impact Case Rep 2022; 10:23247096221139268. [DOI: 10.1177/23247096221139268] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/19/2022] Open
Abstract
Lung abscesses and empyemas are 2 forms of pulmonary infection that can present with similar clinical features. However, empyemas are associated with higher morbidity and mortality, necessitating the need to distinguish one from the other. Plain radiographs can sometimes provide clues to help differentiate the 2 pathologies but more often than not, a computed tomography scan is required to confirm the diagnosis. Correct diagnosis is essential, as the goal standard therapeutic intervention for empyemas may be contraindicated in patients with lung abscesses. Empyemas require percutaneous or surgical drainage in combination with antibiotics, while lung abscesses are generally treated with antibiotics alone as drainage can be associated with various complications. We present a case of a 65-year-old man with parapneumonic empyema diagnosed with characteristic findings on chest computed tomography and treated with surgical drainage and antibiotics. We hope to improve patient outcomes by highlighting the classical radiographic findings that help distinguish empyema and abscess.
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Affiliation(s)
- Steven Imburgio
- Jersey Shore University Medical Center, Neptune City, NJ, USA
| | | | - Anton Mararenko
- Jersey Shore University Medical Center, Neptune City, NJ, USA
| | - Tasfia Tasnim
- Jersey Shore University Medical Center, Neptune City, NJ, USA
| | - Taimoor Khan
- Jersey Shore University Medical Center, Neptune City, NJ, USA
| | - Eric Costanzo
- Jersey Shore University Medical Center, Neptune City, NJ, USA
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Bhalla AS, Jana M, Naranje P, Singh SK, Banday I. Challenges in Image-Guided Drainage of Infected Pleural Collections: A Review. JOURNAL OF CLINICAL INTERVENTIONAL RADIOLOGY ISVIR 2021. [DOI: 10.1055/s-0041-1734374] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/20/2022] Open
Abstract
AbstractInfected pleural fluid collections (IPFCs) commonly occur as a part of bacterial, fungal, or tubercular pneumonia or due to involvement of pleura through hematogenous route. Management requires early initiation of therapeutic drugs, as well as complete drainage of the fluid, to relieve patients’ symptoms and prevent pleural fibrosis. Image-guided drainage plays an important role in achieving these goals and improving outcomes. Intrapleural fibrinolytic therapy (IPFT) is also a vital component of the management. The concepts of image-guided drainage procedures, IPFT, and nonexpanding lung are discussed in this review.
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Affiliation(s)
- Ashu S. Bhalla
- Department of Radiodiagnosis, All India Institute of Medical Sciences, Ansari Nagar, New Delhi, Delhi, India
| | - Manisha Jana
- Department of Radiodiagnosis, All India Institute of Medical Sciences, Ansari Nagar, New Delhi, Delhi, India
| | - Priyanka Naranje
- Department of Radiodiagnosis, All India Institute of Medical Sciences, Ansari Nagar, New Delhi, Delhi, India
| | - Swish K. Singh
- Department of Radiodiagnosis, All India Institute of Medical Sciences, Ansari Nagar, New Delhi, Delhi, India
| | - Irshad Banday
- Department of Radiodiagnosis, All India Institute of Medical Sciences, Ansari Nagar, New Delhi, Delhi, India
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Cain CJ, Margolis M, Lazar JF, Henderson H, Hamm M, Malouf S, Khaitan PG. Short and long-term outcomes of surgical intervention for empyema in the post-fibrinolytic era. J Cardiothorac Surg 2021; 16:187. [PMID: 34215289 PMCID: PMC8254344 DOI: 10.1186/s13019-021-01566-z] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/20/2021] [Accepted: 06/17/2021] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND Open window thoracostomy (OWT) is indicated for patients with bronchopleural fistula (BPF) or trapped lung in the setting of empyema refractory to non-surgical interventions. We investigated the role of OWT in the era of minimally invasive surgeries, endobronchial valves and fibrinolytic therapy. METHODS A retrospective chart review of all patients who underwent OWT at a single institution from 2010 to 2020 was performed. Indications for the procedure as well as operative details and morbidity and mortality were evaluated to determine patient outcomes for OWT. RESULTS Eighteen patients were identified for the study. The most common indication for OWT was post-resectional BPF (n = 9). Prior to OWT, n = 11 patients failed other surgical or minimally invasive interventions. Patient comorbidities were quantified with the Charlson Comorbidity index (n = 11 score ≥ 5, 10-year survival ≤21%). Three (16.7%) patients died < 30 days post-operatively and 12 (66%) patients were deceased by the study's end (overall survival 24.0 ± 32.2 months). Mean number of ribs resected were 2.5 ± 1.2 (range 1-6) with one patient having 6 ribs removed. Patients were managed with negative pressure wound therapy (n = 9) or Kerlix packing (n = 9). Eleven patients (61.6%) underwent delayed closure (mean time from index surgery to closure 4.8 ± 6.7 months). CONCLUSIONS Our study illustrates the significant comorbidities of patients undergoing OWT, the poor outcomes therein, and pitfalls associated with this procedure. We show that negative pressure wound therapy can be utilized as potential way to obliterate the pleural space and manage an open chest in the absence of an airleak; however, OWT procedures continue to be extremely morbid.
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Affiliation(s)
- Caitlin J Cain
- Department of General Surgery, Georgetown University School of Medicine, Medstar Washington Hospital Center, 110 Irving Street, NW (G253), Washington DC, 20010, USA
| | - Marc Margolis
- Department of General Surgery, Georgetown University School of Medicine, Medstar Washington Hospital Center, 110 Irving Street, NW (G253), Washington DC, 20010, USA.,Division of Thoracic Surgery, Georgetown University School of Medicine, Medstar Washington Hospital Center, 110 Irving Street, NW (G253), Washington DC, 20010, USA
| | - John F Lazar
- Department of General Surgery, Georgetown University School of Medicine, Medstar Washington Hospital Center, 110 Irving Street, NW (G253), Washington DC, 20010, USA.,Division of Thoracic Surgery, Georgetown University School of Medicine, Medstar Washington Hospital Center, 110 Irving Street, NW (G253), Washington DC, 20010, USA
| | - Hayley Henderson
- Division of Thoracic Surgery, Georgetown University School of Medicine, Medstar Washington Hospital Center, 110 Irving Street, NW (G253), Washington DC, 20010, USA
| | - Margaret Hamm
- Division of Thoracic Surgery, Georgetown University School of Medicine, Medstar Washington Hospital Center, 110 Irving Street, NW (G253), Washington DC, 20010, USA
| | - Stefanie Malouf
- Division of Thoracic Surgery, Georgetown University School of Medicine, Medstar Washington Hospital Center, 110 Irving Street, NW (G253), Washington DC, 20010, USA
| | - Puja Gaur Khaitan
- Department of General Surgery, Georgetown University School of Medicine, Medstar Washington Hospital Center, 110 Irving Street, NW (G253), Washington DC, 20010, USA. .,Division of Thoracic Surgery, Georgetown University School of Medicine, Medstar Washington Hospital Center, 110 Irving Street, NW (G253), Washington DC, 20010, USA.
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Hutchinson AH, Fakhouri EW, Raudales J. Recurrent Large Volume Malignant Pleural Effusion in a Patient With Renal Cell Carcinoma. Cureus 2021; 13:e13593. [PMID: 33815993 PMCID: PMC8009455 DOI: 10.7759/cureus.13593] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/12/2022] Open
Abstract
Malignant pleural effusion (MPE) due to renal cell carcinoma (RCC) is extremely rare, accounting for only 1%-2% of all malignant pleural effusions. This paper presents a case report of a 56-year-old male who presented with a chief complaint of bilateral flank pain with dyspnea and was diagnosed with RCC via immunopathologic pleural fluid analysis and who persistently had recurrent large volume pleural effusion. A 56-year-old male who had a recent admission for dyspnea secondary to a right-sided pleural effusion underwent thoracentesis and returned to the hospital for his worsening shortness of breath. He was found to have recurrent pleural effusion. Thoracentesis studies revealed an exudative pleural effusion positive for malignant cells showing adenocarcinoma, which had an immunopathologic profile (WT-1 and PAX8) favoring an adenocarcinoma of kidney origin. The patient underwent chest tube placement, followed by chemical pleurodesis with 4.3 L of bloody fluid drained immediately. Subsequent x-rays taken while the chest tube was in place showed worsening reaccumulating pleural effusion. A repeat CT scan showed a large right pleural effusion with loculated collections. The patient then underwent right video-assisted thoracoscopic surgery, which revealed a loculated effusion with pleural carcinomatosis that was biopsy-positive for RCC. This report presents a rare case displaying how RCC pleural carcinomatosis can cause a patient to present with dyspnea secondary to a pleural effusion, which was revealed to be RCC upon fluid cytology and immunohistopathology studies. This case demonstrates that RCC can cause recurrent large volume MPE, which has not been widely reported in contemporary literature.
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Affiliation(s)
- Akil H Hutchinson
- Internal Medicine, NewYork-Presbyterian Brooklyn Methodist Hospital, Brooklyn, USA
| | - Eddie W Fakhouri
- Internal Medicine, NewYork-Presbyterian Brooklyn Methodist Hospital, Brooklyn, USA
| | - Juan Raudales
- Internal Medicine, NewYork-Presbyterian Brooklyn Methodist Hospital, Brooklyn, USA
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9
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Chaddha U, Agrawal A, Feller-Kopman D, Kaul V, Shojaee S, Maldonado F, Ferguson MK, Blyth KG, Grosu HB, Corcoran JP, Sachdeva A, West A, Bedawi EO, Majid A, Mehta RM, Folch E, Liberman M, Wahidi MM, Gangadharan SP, Roberts ME, DeCamp MM, Rahman NM. Use of fibrinolytics and deoxyribonuclease in adult patients with pleural empyema: a consensus statement. THE LANCET RESPIRATORY MEDICINE 2021; 9:1050-1064. [PMID: 33545086 DOI: 10.1016/s2213-2600(20)30533-6] [Citation(s) in RCA: 20] [Impact Index Per Article: 6.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Received: 09/15/2020] [Revised: 11/09/2020] [Accepted: 11/10/2020] [Indexed: 02/06/2023]
Abstract
Although our understanding of the pathogenesis of empyema has grown tremendously over the past few decades, questions still remain on how to optimally manage this condition. It has been almost a decade since the publication of the MIST2 trial, but there is still an extensive debate on the appropriate use of intrapleural fibrinolytic and deoxyribonuclease therapy in patients with empyema. Given the scarcity of overall guidance on this subject, we convened an international group of 22 experts from 20 institutions across five countries with experience and expertise in managing adult patients with empyema. We did a literature and internet search for reports addressing 11 clinically relevant questions pertaining to the use of intrapleural fibrinolytic and deoxyribonuclease therapy in adult patients with bacterial empyema. This Position Paper, consisting of seven graded and four ungraded recommendations, was formulated by a systematic and rigorous process involving the evaluation of published evidence, augmented with provider experience when necessary. Panel members participated in the development of the final recommendations using the modified Delphi technique. Our Position Paper aims to address the existing gap in knowledge and to provide consensus-based recommendations to offer guidance in clinical decision making when considering the use of intrapleural therapy in adult patients with bacterial empyema.
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Affiliation(s)
- Udit Chaddha
- Division of Pulmonary, Critical Care and Sleep Medicine, Icahn School of Medicine at Mount Sinai, New York, NY, USA.
| | - Abhinav Agrawal
- Division of Pulmonary, Critical Care and Sleep Medicine, Donald and Barbara Zucker School of Medicine at Hofstra-Northwell, New Hyde Park, NY, USA
| | - David Feller-Kopman
- Department of Otolaryngology-Head and Neck Surgery, Johns Hopkins University, Baltimore, MD, USA
| | - Viren Kaul
- Department of Pulmonary and Critical Care Medicine, Crouse Health-SUNY Upstate Medical University, Syracuse, NY, USA
| | - Samira Shojaee
- Department of Medicine, Division of Pulmonary and Critical Care Medicine, Virginia Commonwealth University, Richmond, VA, USA
| | - Fabien Maldonado
- Division of Allergy, Pulmonary and Critical Care Medicine, Vanderbilt University Medical Center, Nashville, TN, USA
| | - Mark K Ferguson
- Section of Thoracic Surgery, University of Chicago Medical Center, Chicago, IL, USA
| | - Kevin G Blyth
- Institute of Cancer Sciences and Glasgow Pleural Disease Unit, University of Glasgow, Glasgow, UK
| | - Horiana B Grosu
- The University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | - John P Corcoran
- Interventional Pulmonology Service, University Hospitals Plymouth NHS Trust, Plymouth, UK
| | - Ashutosh Sachdeva
- Division of Pulmonary and Critical Care Medicine, University of Maryland, Baltimore, MD, USA
| | - Alex West
- Guy's and St Thomas' NHS Foundation Trust, London, UK
| | - Eihab O Bedawi
- Oxford Centre for Respiratory Medicine, Oxford University Hospitals NHS Trust, Oxford, UK; Oxford Respiratory Trials Unit, University of Oxford, Oxford, UK
| | - Adnan Majid
- Department of Surgery, Division of Thoracic Surgery and Interventional Pulmonology, Beth Israel Deaconess Medical Center, Massachusetts General Hospital Harvard Medical School, Boston, MA, USA
| | - Ravindra M Mehta
- Department of Pulmonary and Critical Care, Apollo Hospitals, Bangalore, India
| | - Erik Folch
- Complex Chest Disease Center, Beth Israel Deaconess Medical Center, Massachusetts General Hospital Harvard Medical School, Boston, MA, USA
| | - Moishe Liberman
- Division of Thoracic Surgery, University of Montreal, Montreal, QC, Canada
| | - Momen M Wahidi
- Department of Medicine, Division of Pulmonary, Allergy and Critical Care, Duke University Medical Center, Durham, NC, USA
| | - Sidhu P Gangadharan
- Department of Surgery, Division of Thoracic Surgery and Interventional Pulmonology, Beth Israel Deaconess Medical Center, Massachusetts General Hospital Harvard Medical School, Boston, MA, USA
| | - Mark E Roberts
- Sherwood Forest Hospitals NHS Foundation Trust, Sutton-in-Ashfield, UK
| | - Malcolm M DeCamp
- Division of Cardiothoracic Surgery, University of Wisconsin, Madison, WI, USA
| | - Najib M Rahman
- Oxford Respiratory Trials Unit, University of Oxford, Oxford, UK
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10
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Holsen MR, Tameron AM, Evans DC, Thompson M. Intrapleural Tissue Plasminogen Activator for Traumatic Retained Hemothorax. Ann Pharmacother 2019; 53:1060-1066. [DOI: 10.1177/1060028019846122] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022] Open
Abstract
Objective: To describe the efficacy, safety, dosing regimen, and administration technique of intrapleural alteplase for the treatment of retained hemothorax. Data Sources: A PubMed, EMBASE, and Google Scholar search (January 2000 to February 2019) was conducted with the search terms intrapleural, fibrinolytic, fibrinolysis, alteplase, tissue plasminogen activator, and hemothorax. Study Selection and Data Extraction: Articles were included if they described the use of intrapleural alteplase in adult patients with a retained hemothorax; single patient case reports and abstracts were excluded. Data Synthesis: A total of 6 retrospective reviews and 1 meta-analysis were identified for inclusion. A variety of dosing strategies have been defined for the administration of intrapleural alteplase ranging from 6 to 100 mg, volume of fluid from 50 to 120 mL of normal saline, and the number of total doses has ranged from 1 to 8 over the treatment course. A majority of studies showed a greater than 80% success rate and less than 7% bleeding rate. Relevance to Patient Care and Clinical Practice: Because of the paucity of data for use of alteplase in retained hemothorax and administration of a high-risk medication, this review provides dosing and administration recommendations based on reported safety and efficacy. Conclusion: Administration of intrapleural alteplase should be considered in patients with retained hemothorax as an alternative to surgical intervention. In contrast to intrapleural alteplase administration for other indications such as empyema, higher doses and volumes of alteplase are recommended for retained hemothorax.
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Affiliation(s)
- Maya R. Holsen
- The Ohio State University Wexner Medical Center, Columbus, OH, USA
| | | | - David C. Evans
- The Ohio State University Wexner Medical Center, Columbus, OH, USA
| | - Molly Thompson
- The Ohio State University Wexner Medical Center, Columbus, OH, USA
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11
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Cargill TN, Hassan M, Corcoran JP, Harriss E, Asciak R, Mercer RM, McCracken DJ, Bedawi EO, Rahman NM. A systematic review of comorbidities and outcomes of adult patients with pleural infection. Eur Respir J 2019; 54:13993003.00541-2019. [PMID: 31391221 PMCID: PMC6860993 DOI: 10.1183/13993003.00541-2019] [Citation(s) in RCA: 35] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/18/2019] [Accepted: 07/19/2019] [Indexed: 11/09/2022]
Abstract
Background Pleural infection remains an important cause of mortality. This study aimed to investigate worldwide patterns of pre-existing comorbidities and clinical outcomes of patients with pleural infection. Methods Studies reporting on adults with pleural infection between 2000 and 2017 were identified from a search of Embase and MEDLINE. Articles reporting exclusively on tuberculous, fungal or post-pneumonectomy infection were excluded. Two reviewers assessed 20 980 records for eligibility. Results 211 studies met the inclusion criteria. 134 articles (227 898 patients, mean age 52.8 years) reported comorbidity and/or outcome data. The majority of studies were retrospective observational cohorts (n=104, 78%) and the most common region of reporting was East Asia (n=33, 24%) followed by North America (n=27, 20%). 85 articles (50 756 patients) reported comorbidity. The median (interquartile range (IQR)) percentage prevalence of any comorbidity was 72% (58–83%), with respiratory illness (20%, 16–32%) and cardiac illness (19%, 15–27%) most commonly reported. 125 papers (192 298 patients) reported outcome data. The median (IQR) length of stay was 19 days (13–27 days) and median in-hospital or 30-day mortality was 4% (IQR 1–11%). In regions with high-income economies (n=100, 74%) patients were older (mean 56.5 versus 42.5 years, p<0.0001), but there were no significant differences in prevalence of pre-existing comorbidity nor in length of hospital stay or mortality. Conclusion Patients with pleural infection have high levels of comorbidity and long hospital stays. Most reported data are from high-income economy settings. Data from lower-income regions is needed to better understand regional trends and enable optimal resource provision going forward. In pleural infection, patients from higher-income countries tend to be older with more comorbidities and are more likely to be referred for fibrinolytic treatment in comparison to patients from lower-income countrieshttp://bit.ly/2K2M5HL
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Affiliation(s)
- Tamsin N Cargill
- Oxford Centre for Respiratory Medicine, Oxford University Hospitals NHS Trust, Oxford, UK.,Joint first authors
| | - Maged Hassan
- Oxford Centre for Respiratory Medicine, Oxford University Hospitals NHS Trust, Oxford, UK .,Joint first authors
| | - John P Corcoran
- Interventional Pulmonology Service, Respiratory Medicine Dept, University Hospitals Plymouth, Plymouth, UK
| | - Elinor Harriss
- Bodleian Health Care Libraries, University of Oxford, Oxford, UK
| | - Rachelle Asciak
- Oxford Centre for Respiratory Medicine, Oxford University Hospitals NHS Trust, Oxford, UK
| | - Rachel M Mercer
- Oxford Centre for Respiratory Medicine, Oxford University Hospitals NHS Trust, Oxford, UK
| | - David J McCracken
- Oxford Centre for Respiratory Medicine, Oxford University Hospitals NHS Trust, Oxford, UK
| | - Eihab O Bedawi
- Oxford Centre for Respiratory Medicine, Oxford University Hospitals NHS Trust, Oxford, UK
| | - Najib M Rahman
- Oxford Centre for Respiratory Medicine, Oxford University Hospitals NHS Trust, Oxford, UK
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