Aspergilloma mimicking a lung cancer

INTRODUCTIONPulmonary aspergillosis occurs in the parenchymal cavities or ectatic airways. It rarely affects healthy people with an intact immune response. There have been few reports describing an aspergilloma mimicking a lung cancer.PRESENTATION OF CASEWe experienced the case of an asymptomatic healthy 71-year-old female who was admitted with an abnormal lung shadow. Chest CT revealed an irregularly shaped solid lung nodule in the left upper lobe, which increased in size during the follow-up at a regional hospital. The pathology of the bronchial biopsy was negative for malignant cells, and the cultures were negative. Because a lung cancer was strongly suspected, video-assisted thoracic surgery was performed. Aspergillus was detected by a pathological study of the excised specimen, with no evidence of lung cancer.DISCUSSIONIt is difficult to make an accurate diagnosis of aspergilloma by imaging findings in healthy people with an intact immune response, and therefore a surgical resection allows both the pathological diagnosis and treatment to be performed concurrently.CONCLUSIONAn aspergilloma presenting a mass shadow on imaging may mimic a lung cancer in healthy people with intact immune response.     

Pulmonary aspiration

Pulmonary aspiration is defined as the inhalation of oropharyngeal or gastric content into the airway below the vocal cords. The mechanisms of injury related to aspiration can be divided into three groups: particle related, acid related and bacterial. Clinical signs suggestive of aspiration are: diffuse rales, wheezing, tachypnoea and low grade pyrexia. Investigations include: fibreoptic bronchoscopy, bronchoalveolar lavage and protected brush specimens. Imaging used includes chest X-ray and computed tomography. Initial management consists of administration of 100% oxygen and strategies to minimise the risk of further aspirate contaminating the airway. The decision to continue with surgery depends on the extent of the aspiration, the patient's premorbid condition and the urgency of the procedure. Elective surgery is most likely to be abandoned or postponed. In the emergency situation modification of the surgical procedure to one that is less complex or lengthy should be considered. The patient in ICU receives supportive treatment. Ventilatory lung protective strategies should be used to limit further lung injury. Seventy per cent of aspiration pneumonitis do not develop bacterial superinfection so antibiotics are not needed unless confirmed by bronchial culture.     

Destroyed lung due to aspiration of phenolphthalein

A 76-year-old female, presented with a recurrent cough and haemoptysis after an aspiration of a 'grain de Valls'. Chest radiography and computed tomography demonstrated an atelectasis of the medial segment of the right middle pulmonary lobe. Bronchoscopy was negative for any malignancy but the onco-PET-scan showed a pathologic hypermetabolic lesion in the right middle lobe. A lobectomy was performed and pathology revealed a 'destroyed lung' with images of foreign body reactions and microabscesses without any sign of malignancy. Postoperatively, clinical improvement with complete resolution of the symptoms was observed. With this case report we demonstrate the irritative and clastogenic characteristics of phenolphtalein, the main active ingredient of the 'grain de Valls'. This case also illustrates an example of a false positive PET-scan.     

全胸腔镜下肺叶切除治疗肺结核空洞内继发曲菌球26例

目的探讨全胸腔镜下肺叶切除治疗肺结核空洞内继发曲菌球的安全性、可行性。方法2009年4月～2013年12月全胸腔镜下以肺叶切除为主手术治疗26例肺结核空洞内继发曲菌球。采取3个切口：观察孔在腋中线第7或8肋间;主操作孔在腋前线第4或5肋间,应用切口保护器,不使用肋骨牵开器;辅助操作孔在与观察孔同一肋间的肩胛下角线（即第7或8肋间）。在全胸腔镜下完成解剖性肺叶切除,用内镜切割缝合器处理血管和支气管,术中遇到特殊情况则中转开胸。结果2例中转开胸：1例因胸膜粘连致密,1例因出血。余24例在全胸腔镜下完成解剖性肺叶切除,包括右肺上叶6例,右肺上叶＋下叶背段2例,右肺中叶1例,右肺下叶4例,左肺上叶4例,左肺下叶5例,左肺下叶＋上叶舌段2例。手术时间（152．3±57．2）min;术中出血量（336．3±106．5）mI,术后引流液总量（820．5±570．8）ml;术后带管时间（7．3±3．5）d;术后住院时间（9．4±3．7）d。围手术期无死亡。术后并发症4例：肺漏气3例,其中2例持续引流12～15d后愈合拔管,1例重新置入胸腔闭式引流管,接负压吸引,术后19d后愈合拔管;切口延迟愈合1例,给予清创缝合,10d后切口愈合良好拆线。26例随访5—60个月,平均27．6月,无复发、死亡。结论全胸腔镜下肺叶切除治疗肺结核空洞内继发曲菌球安全、可行。     

袋鼠肠内营养电子泵在鼻饲患者中的应用

目的观察袋鼠肠内营养电子泵在鼻饲患者中的应用效果。方法将120例老年鼻饲患者随机分为两组各60例。对照组应用普通肠内营养泵鼻饲,观察组应用袋鼠肠内营养电子泵,鼻饲3个月后对两组鼻饲效果进行比较。结果观察组鼻饲期间胃潴留、腹泻发生率显著低于对照组(P<0.05,P<0.01);其营养支持效果显著优于对照组(P<0.01)。结论应用袋鼠肠内营养电子泵控制鼻饲液输注,能有效预防鼻饲并发症发生,提高肠内营养支持的效果,促进胃肠功能恢复。     

Routine intraoperative aspiration of gallbladder during laparoscopic cholecystectomy

Background Technical modifications and methods for gallbladder dissection to minimize the risk of gallbladder perforation during laparoscopic cholecystectomy (LC) are described. The authors aimed to investigate the effects of gallbladder aspiration during LC on the operative and postoperative course of patients. Methods For this study, 200 patients undergoing LC for symptomatic cholelithiasis were randomly divided into two groups. Gallbladders were aspirated before dissection in group A (n = 100), and they were not aspirated in group B (n = 100). Operative and postoperative data on the patients were collected. Results The rate of gallbladder perforation was significantly lower in group A than in group B (p = 0.0003). The operative time was significantly shorter in group A (46.70 ± 15.93 min) than in group B (60.75 ± 22.09 min) (p = 0.047). Postoperative complications were more numerous in group B. The hospital stay was significantly longer in group B (1.55 ± 0.81 days) than in group A (1.3 ± 0.5 days; p = 0.004). Conclusion The findings demonstrate the advantages of gallbladder aspiration in elective cases.     

Prevention of tracheal aspiration using the pressure-limited tracheal tube cuff

A new design of tracheal tube cuff, the pressure-limited cuff, used with a constant-pressure inflation system, was compared with a high-volume low-pressure cuffed tracheal tube for leakage of dye placed in the subglottic space into the trachea. Patients requiring ventilation on the intensive care unit were randomly allocated into two groups, one for each type of cuff, and blue food dye was instilled daily via a fine catheter above the cuff into the subglottic space. There were eight patients in the high-volume low-pressure group and seven in the pressure-limited cuff group. Dye leaked into the trachea in seven (87%) of the high-volume low-pressure group compared with none (0%) of the pressure-limited cuff group (p < 0.01). This study demonstrates that the pressure-limited cuffed tracheal tube, in combination with a constant-pressure inflation device, prevents leakage of fluid into the lungs that occurs with high-volume low-pressure cuffs in the critically ill, intubated patient.     

Septic arthritis of the knee: the use and effect of antibiotics prior to diagnostic aspiration

Septic arthritis of the native knee joint and total knee arthroplasty both cause diagnostic and treatment issues. There is no gold standard test to diagnose a joint infection and the use of joint aspiration is commonly relied on. It is widely accepted by orthopaedic surgeons that antibiotics should be withheld until aspiration has been performed to increase the odds of identifying an organism. Patients often present to other specialties that may not be as familiar with these principles. Our study found that 25 (51%) of the 49 patients treated for septic arthritis of the native or prosthetic knee in our unit over a 3-year period had received antibiotics prior to discussion or review by the on-call orthopaedic service. Patients were significantly less likely to demonstrate an organism on initial microscopy (entire cohort: p = 0.001, native knees: p = 0.006, prosthetic knees: p = 0.033) or on subsequent culture (entire cohort: p = 0.001, native knees: p = 0.017, prosthetic knees: p = 0.012) of their aspirate if they had received antibiotics. The sensitivity of microscopy in all patients dropped from 58% to 12% when patients had received antibiotics (native knees: 46% to 0%, prosthetic knees: 72% to 27%). The sensitivity of the culture dropped from 79% to 28% in all patients when the patient had received antibiotics (native knees: 69% to 21%, prosthetic knees: 91% to 36%). This study demonstrated how the management of patients with suspected cases of septic arthritis of the knee may be compromised by empirical administration of antibiotics. These patients were significantly less likely to demonstrate an organism on microscopy and culture of their initial aspirate. There is a significant high false negative rate associated with knee aspiration with prior administration of antibiotic therapy.     

细针针吸细胞学检查在乳腺疾病诊断中的应用

统计六年来乳腺细针针吸细胞学检查结果，探讨其在临床上应用价值。对５９４例具有病理诊断的乳腺细针针吸细胞学检查结果采用国际通用准确性统计标准统计。结果：５９４例中３８３例乳腺恶性肿瘤细胞学检查敏感性９０．５％，假奶性９．５％，２１１例乳腺良性疾患中特异性为９９．５％，假阳性０．４８％。我们认为乳腺细针针吸细胞学检查具有相当高的精确度及应用价值。     

湿细针穿刺细胞学检查对乳腺癌的诊断意义

目的探讨乳腺癌术前最佳病理学诊断方法. 方法对68例怀疑乳腺癌者用 7号针头、10 ml注射器进行湿细针穿刺细胞学检查. 结果 19例穿刺阳性找到癌细胞,无假阳性.余49例穿刺阴性中46例行乳腺区段切除, 1例术后石蜡切片为乳腺纤维肉瘤,其余均为良性病变;3例未行手术者随访 11～ 20个月均未发现乳腺癌.敏感性95.0%(19/20),特异性100%(48/48),准确率98.5%(67/68),假阴性率5.0%(1/20),假阳性率为0(0/48). 19例穿刺阳性无一例出现针道种植癌.无任何并发症. 结论湿细针穿刺细胞学检查具有安全、经济、方便、快速、痛苦小、准确率高的特点,可作为诊断乳腺癌的首选方法.     

Pneumonia due to aspiration of povidone-iodine during anesthesia--a case report]

We report a case of pneumonia secondary to aspiration of povidone-iodine, which was used as an oral antiseptic. The patient was 17 y.o. female (body weight: 70 kg) who underwent a transsphenoidal resection of pituitary adenoma. Although she had a history of asthma during her childhood, no asthmatic attacks occurred for the past 10 yrs. After satisfactory anesthesia induction and tracheal intubation, 60 ml of 0.7% povidone-iodine solution was used to clean the oral cavity by a surgeon. Insufficient sealing by the cuff occurred after suturing the tube, which had made a needle hole in the cuff. Arterial oxygen saturation dropped to 90% and an increased resistance in the lungs was noted. The trachea was reintubated and she was transferred to the ICU. Her chest X-ray revealed signs of pneumonia and atelectasis in the right upper lobe. Mechanical ventilation with PEEP and periodical bronchial toilet were performed during her stay in the ICU for 42 hrs. A week was needed for the improvement of her X-ray findings. Although povidone-iodine is thought to be safe and affective antiseptics, severe complications from its aspiration may occur in patients whose airways are sensitive as observed in this case.     

预防气管切开鼻饲患者误吸的循证护理

目的采用循证护理方案预防气管切开鼻饲患者发生误吸。方法针对9例颅内肿瘤开颅切除术后患者的护理问题,计算机检索防止此类患者发生误吸的最佳实践证据,应用于该组患者并评价效果。结果该组患者在循证护理期间未发生误吸。结论采用循证方法提出的护理方案能有效防止气管切开并鼻饲患者发生误吸。     

不同胃肠减压方式对颅脑损伤患者鼻饲反流误吸的影响

目的比较持续和间断两种胃肠减压方式降低颅脑损伤患者鼻饲反流、误吸的效果,为临床实施最佳胃肠减压方式提供依据。方法将入选的45例颅脑损伤患者随机分为持续胃肠减压组(持续组,23例)和间断胃肠减压组(间断组,22例),连续干预7d。每日收集两组咽喉部及支气管分泌物各6次,检测分泌物中的胃蛋白酶,比较两组反流、误吸、电解质紊乱及胃液pH异常发生情况。结果持续组反流、误吸发生率分别是12.63%和8.80%,间断组分别是19.37%和12.99%,两组比较,差异有统计学意义(均P<0.01);两组血电解质紊乱发生率及胃液pH值比较,差异无统计学意义(均P>0.05)。结论持续胃肠减压能有效降低颅脑损伤患者鼻饲期间反流、误吸的发生,短期的持续胃肠减压并不会增加电解质紊乱及胃液pH值异常发生率。     

Scintigraphic method to detect silent aspiration during sleep in postsurgical patients with oral cancer

BACKGROUND: A simple method to detect silent aspiration during sleep has not been established in postsurgical oral cancer patients. METHODS: Radioactive paste consisting of (99m)TcO(4) (-) and carboxylmethylcellulose was prepared and placed in a maxillary prosthesis with a cavity in the palatal space. The patient was requested to wear this appliance during sleep, and the following morning the patient was subjected to scintigraphic scanning. Both the anterior and posterior aspects of the thorax were scanned using a Shimazu Medical gamma camera with window settings adjusted to a low energy collimator at 500 kilocounts per image. RESULTS: Silent aspiration that had not been detected by videofluoroscopic examination was clearly demonstrated by the scintigraphic method, showing aspiration of radioactive paste during sleep in the left thorax of the patient. CONCLUSIONS: The method reported for establishing aspiration is simple and reliable to assess silent aspiration during sleep in patients with oral cancer.     

Ultrasound to guide the individual medical decision by evaluating the gastric contents and risk of aspiration: A literature review

Pulmonary aspiration of gastric contents is one of the most terrible complications following general anesthesia. It is important for patients to prevent this complication by obeying the preoperative fasting protocol strictly. At present, it has been reported by many studies that bedside ultrasound, as a non-invasive and convenient method, could be used to evaluate gastric contents qualitatively and quantitatively. With the advantages of reliability, accuracy and repeatability, it can greatly reduce the risk of aspiration and ensure patients' life security. But most of the data were acquired from the healthy volunteers. For the gastrointestinal disorder, the pregnant women, obesity, children, the elderly and diabetes patients, the accuracy and reliability of ultrasound to predict the risk of aspiration remains to be identified by more further studies. For these patients with increasing risk of aspiration, I-AIM (Indication, Acquisition, Interpretation, Medical decision-making) framework plays an important role in ensuring the safety of patients. It is crucial to make appropriate clinical decisions by evaluating the gastric contents with ultrasound.     

Clear cell adenocarcinoma of the lung: The wolf in sheep’s clothing

Clear cell adenocarcinoma of the lung is a rare tumour with good prognosis, predominantly composed of clear cells. A young lady presented with a large, cystic lesion in the right lower lobe suggestive of hydatid cyst. In the hospital she developed acute toxemia, and was therefore taken for emergency thoracotomy and right lower lobectomy. Post operatively she expired, due to sepsis. Histopathology revealed clear cell adenocarcinoma of the lung, and autopsy demonstrated metastasis in the spleen. Herein we have reported an unusually aggressive presentation of this tumour, in a young lady in whom it masqueraded as a benign cystic lesion.