Eotaxin-3 and interleukin-5 pleural fluid levels are associated with pleural fluid eosinophilia in post-coronary artery bypass grafting pleural effusions

OBJECTIVES: The primary aim of this study was to examine the association between pleural fluid (PF) eosinophilia, and the PF and serum levels of interleukin (IL)-5, eotaxin-2, eotaxin-3, and vascular cell adhesion molecule (VCAM)-1 in patients with post-coronary artery bypass grafting (CABG) pleural effusions. DESIGN: A prospective observational study. SETTING: A tertiary teaching hospital. PATIENTS AND METHODS: Thirty-eight patients with post-CABG pleural effusions were recruited into the study. An effusion that contained at least 10% eosinophils was called "eosinophilic." The PF and serum levels of the cytokines and VCAM-1 were measured using an enzyme-linked immunosorbent assay. RESULTS: (1) The number of PF eosinophils significantly correlated with the number of blood eosinophils. (2) PF IL-5 levels were significantly higher than the corresponding serum levels, and there was a significant correlation between the PF and serum IL-5 levels. PF IL-5 levels significantly correlated with the PF eosinophil count, and serum IL-5 levels significantly correlated with the number of blood eosinophils. (3) PF eotaxin-3 levels were significantly higher than serum levels, and PF eotaxin-3 levels significantly correlated with the PF eosinophil count. (4) PF VCAM-1 levels were significantly lower than the corresponding serum levels, and PF VCAM-1 levels were significantly higher in eosinophilic pleural effusions (EPEs) than in non-EPEs. CONCLUSION: In patients with post-CABG pleural effusions, IL-5 and eotaxin-3 are produced preferentially in the pleural cavity, and they are strongly associated with PF eosinophilia.     

Sentinel lymph node mapping of the pleural space

STUDY OBJECTIVES: Although the sentinel lymph node (SLN) concept has traditionally been applied to solid organs, we hypothesized that the pleural space might drain into a specific SLN group. The identification of such a nodal group could assist in the staging and treatment of pleural-based diseases, such as mesothelioma, or other lung cancers with visceral pleural invasion. The purpose of this study was to determine whether the pleural space has an SLN group. DESIGN: Sixteen rats underwent right or left pleural space injection of a novel lymph tracer, quantum dots (QDs), which have a hydrodynamic diameter of 15 nm and fluoresce in the near-infrared (NIR) spectrum. Nodal uptake of the entire thorax was imaged with a custom system that simultaneously acquired color video, NIR fluorescence of the QDs, and a merged picture of the two in real-time. Six pigs underwent right or left pleural space injection of QDs and similar imaging. MEASUREMENTS AND RESULTS: In the rat, the QDs drained solely to the highest superior mediastinal lymph node group, corresponding to lymph node station 1, according the regional lymph node classification for lung of the American Joint Committee on Cancer. In one rat, the injection of QDs in the left pleural space resulted in migration to the contralateral station 1 lymph node group. The injection of QDs in the right or left pleural space of the pig resulted in migration solely to the ipsilateral highest superior mediastinal lymph node group. CONCLUSIONS: NIR fluorescence imaging in two species demonstrated that the highest superior mediastinal lymph nodes of station 1 are the SLNs of the pleural space. This study also provides intraoperative feasibility and proof of the concept for identifying lymph nodes communicating with the pleural space on a patient-specific basis, in real-time, and with high sensitivity.     

Characteristics of trapped lung: pleural fluid analysis, manometry, and air-contrast chest CT

STUDY OBJECTIVES: To review the pleural fluid characteristics, pleural manometry, and radiographic data of patients who received a diagnosis of trapped lung in our pleural diseases service. DESIGN: Retrospective case series. METHODS: The procedure records of 247 consecutive patients who underwent pleural manometry at the Medical University of South Carolina between October 2002 and November 2005 were reviewed. Eleven patients in whom a diagnostic pneumothorax was introduced were identified. Manometry data, radiographic findings, pleural fluid analysis, final clinical diagnosis, and information regarding the initial pleural insult were retrieved from the medical record. RESULTS: All 11 patients had a clinical diagnosis of trapped lung. The causes of trapped lung were attributed to coronary artery bypass graft surgery, uremia, thoracic radiation, pericardiotomy, spontaneous bacterial pleuritis and repeated thoracentesis, and complicated parapneumonic effusion. Mean pleural fluid pH was 7.30, pleural fluid lactate dehydrogenase (LDH) was 124 IU/L, and pleural fluid total protein was 2.9 g/dL. Pleural fluid was paucicellular with mononuclear cell predominance. Pleural space elastance was increased in all cases and ranged from 19 to 149 cm H(2)O/L of pleural fluid removed. All demonstrated abnormal visceral pleural thickness on air-contrast chest CT. CONCLUSIONS: Trapped lung is a clinical entity characterized by the presence of a restrictive visceral pleural peel that was first described in 1967. The pleural fluid is paucicellular, LDH is low, and protein may be in the exudative range. The elevated total pleural fluid protein may be related to factors other than active pleural inflammation or malignancy and does not exclude the diagnosis.     

Prevalence and predictors of symptoms in the terminal stage of lung cancer: A community study

BACKGROUND: There is little knowledge concerning the prevalence and predictors of symptoms in the terminal stage of lung cancer. METHODS: We examined, retrospectively, all cases of lung cancer diagnosed from 1990 to 1996 in a defined hospital area in Norway. All medical records from general practitioners, nursing homes, and hospitals were investigated. A total of 271 cases were diagnosed, and 247 of 253 deaths (98%) were analyzed. RESULTS: In the terminal 8 weeks, pain was recorded in 85% of the patients, psychological symptoms (anxiety, insomnia, and/or depression) in 71%, dyspnea in 54%, neurologic symptoms in 28%, cough in 24%, nausea in 21%, and hemoptysis in 9%. Young age (p = 0.02) and small cell lung carcinoma (p = 0.03) were risk factors for psychological symptoms. Terminal dyspnea was more frequent in patients with stage III (p = 0.002) and nausea in stage IV (p = 0.02) at the time of diagnosis, while cough (p = 0.04) occurred more often in non-small cell lung carcinoma. Terminal pain was independent of gender, age, performance status, stage, and histology. CONCLUSION: In a community health service encompassing all lung cancer patients, pain, psychological symptoms, and dyspnea were frequent complaints in the terminal phase. Terminal dyspnea and nausea were associated with staging at the time of diagnosis, and terminal cough and nausea were associated with histology.     

Diagnosis and treatment of tuberculous pleural effusion in 2006

Tuberculous (TB) pleural effusion occurs in approximately 5% of patients with Mycobacterium tuberculosis infection. The HIV pandemic has been associated with a doubling of the incidence of extrapulmonary TB, which has resulted in increased recognition of TB pleural effusions even in developed nations. Recent studies have provided insights into the immunopathogenesis of pleural TB, including memory T-cell homing and chemokine activation. The definitive diagnosis of TB pleural effusions depends on the demonstration of acid-fast bacilli in the sputum, pleural fluid, or pleural biopsy specimens. The diagnosis can be established in a majority of patients from the clinical features, pleural fluid examination, including cytology, biochemistry, and bacteriology, and pleural biopsy. Measurement of adenosine deaminase and interferon-gamma in the pleural fluid and polymerase chain reaction for M tuberculosis has gained wide acceptance in the diagnosis of TB pleural effusions. Although promising, these tests require further evaluation before their routine use can be recommended. The treatment of TB pleural effusions in patients with HIV/AIDS is essentially similar to that in HIV-negative patients. At present, evidence regarding the use of corticosteroids in the treatment of TB pleural effusion is not clear-cut.     

Contribution of a pleural antigen assay (Binax NOW) to the diagnosis of pneumococcal pneumonia

STUDY OBJECTIVES: To determine whether the detection of pneumococcal antigen in pleural fluid augments conventional microbiological methods used for the etiologic diagnosis of pneumonia. METHODS: In this retrospective study, a rapid immunochromatographic test (ICT) [NOW Streptococcus pneumoniae assay; Binax; Scarborough, ME] was performed on pleural fluid samples from 34 patients with pneumonia due to S pneumoniae, 89 patients with effusions of nonpneumococcal origin, and 17 patients with pneumonia of unknown etiology. Data on blood cultures, pleural fluid cultures, and urinary antigen tests were recorded. RESULTS: The ICT test result was positive in 24 of 34 patients (70.6%) with pneumococcal pneumonia and negative in 83 of 89 patients (93.3%) without pneumococcal pneumonia. The sensitivity of the pleural ICT test was higher than that obtained for blood (37.5%) and pleural fluid cultures (32.3%), but lower than the detection of pneumococcal antigen in urine samples (82.1%). However, three patients with pneumococcal pneumonia and a negative ICT urine test result had a positive pleural fluid antigen detection result test. Previous antibiotic exposure did not influence pneumococcal antigen detection in either pleural fluid or urine specimens. Six additional patients with empyema due to anaerobes (three patients), Streptococcus viridans (two patients), and Enterococcus faecalis (one patient) had false-positive pleural ICT test results. Finally, the ICT assay finding was also positive in 5 of 17 patients (29.4%) with pneumonia without a definite microbiological cause. CONCLUSIONS: The ICT test performed on pleural fluid samples augments the standard diagnostic methods of blood and pleural fluid cultures, even in the case of prior antibiotic therapy, and enhances the ICT urinary antigen assay.     

Occult traumatic pneumothorax: diagnostic accuracy of lung ultrasonography in the emergency department

BACKGROUND: The role of chest ultrasonography (US) in the diagnosis of pneumothorax (PTX) has been established, but how it compares with lung CT scanning in the diagnosis of radiooccult PTX and in the determination of its topographic extension has not yet been completely evaluated. OBJECTIVE: To determine the diagnostic accuracy of chest US in the emergency department (ED) in the diagnosis of occult PTX in trauma patients and to define its ability to determine PTX extension. DESIGN: An 18-month prospective study. PATIENTS: A total of 109 conscious, spontaneously breathing patients who had been admitted to the ED for chest trauma or polytrauma. METHODS: All eligible patients underwent a standard anteroposterior supine chest radiograph (Rx) and a spiral CT lung scan within 1 h of ED admission. Lung US was carried out by an operator who was unaware of the other examination results, both for diagnosis and for the quantitative delimitation of the PTX. RESULTS: Twenty-five traumatic PTXs were detected in the 218 hemithoraxes (109 patients; 2 patients had a bilateral PTX) evaluated by spiral CT scan; of these, only 13 of 25 PTXs (52%) were revealed by chest Rx (sensitivity, 52%; specificity, 100%), while 23 of 25 PTXs (92%) were identified by lung US with one false-positive result (sensitivity, 92%; specificity, 99.4%). In 20 of 25 cases, there was agreement on the extension of the PTX between CT lung scan and lung US with a mean difference of 1.9 cm (range, 0 to 4.5 cm) in the localization of retroparietal air extension; chest Rx was not able to give quantitative results. CONCLUSIONS: Lung US scans carried out in the ED detect occult PTX and its extension with an accuracy that is almost as high as the reference standard (CT scanning).     

Predictors of heartburn during sleep in a large prospective cohort study

BACKGROUND AND AIMS: Nocturnal gastroesophageal reflux, which may result in nocturnal heartburn, has been demonstrated to be associated with a more severe form of gastroesophageal reflux disease (GERD). The aim of this study was to determine the clinical predictors of heartburn during sleep in a large prospective cohort study. METHODS: Study subjects were members of the parent cohorts from which the Sleep Heart Health Study (SHHS) recruited participants. SHHS is a multicenter, longitudinal, cohort study of the cardiovascular consequences of sleep-disordered breathing. As part of the recruitment process, parent cohort members completed a questionnaire that permitted an assessment of the relationships between heartburn during sleep, and patient demographics, sleep abnormalities, medical history, and social habits in nine community-based parent cohorts across the United States. All variables, significant at the p < 0.05 level, were included as independent variables in multivariate logistic regression models with heartburn during sleep status included as the dependent variable RESULTS: A total of 15,314 subjects completed the questions about heartburn during sleep, and of these, 3,806 subjects (24.9%) reported having this symptom. In four increasingly comprehensive multivariate models, increased body mass index (BMI), carbonated soft drink consumption, snoring and daytime sleepiness (Epworth sleepiness scale score), insomnia, hypertension, asthma, and usage of benzodiazepines were strong predictors of heartburn during sleep. In contrast, college education decreased the risk of reporting heartburn during sleep. CONCLUSIONS: Heartburn during sleep is very common in the general population. Reports of this type of symptom of GERD are strongly associated with increased BMI, carbonated soft drink consumption, snoring and daytime sleepiness, insomnia, hypertension, asthma, and usage of benzodiazepines. Overall, heartburn during sleep may be associated with sleep complaints and excessive daytime sleepiness.     

Heparin-induced skin lesions and other unusual sequelae of the heparin-induced thrombocytopenia syndrome: a nested cohort study

BACKGROUND: Heparin-induced thrombocytopenia (HIT) is caused by platelet-activating, heparin-dependent IgG antibodies (HIT-IgG). Although HIT is known to predispose the patient to thrombosis, the relationship between the formation of HIT-IgG and various other unusual clinical sequelae putatively linked with the HIT syndrome, such as heparin-induced skin lesions and acute anaphylactoid reactions following treatment with an IV heparin bolus, is not clear. METHODS: We used data from a clinical trial of postoperative heparin prophylaxis to compare the frequency of one or more predefined unusual clinical sequelae developing in 20 patients who formed platelet-activating HIT-IgG with 80 control patients who did not form HIT-IgG (nested cohort study). RESULTS: Five of the 20 patients in whom HIT-IgG developed had one or more unusual clinical sequelae, compared with none of 80 control patients (25% vs 0%, respectively; odds ratio, infinity; 95% confidence interval, 4.3 to infinity; p < 0.001). The unusual complications included heparin-induced erythematous or necrotic skin lesions (n = 4), an anaphylactoid reaction following IV heparin bolus use (n = 1), and warfarin-associated venous limb ischemia (n = 1). Thrombocytopenia, as it is conventionally defined (ie, platelet count fall to < 150 x 10(9) cells/L) developed in only one of these five patients. CONCLUSIONS: Certain unusual clinical sequelae, such as heparin-induced skin lesions, are strongly associated with the formation of HIT-IgG and should be considered as manifestations of the HIT syndrome, even in the absence of thrombocytopenia as conventionally defined.     

A case-control study of obstructive sleep apnea-hypopnea syndrome in obese and nonobese chinese children

BACKGROUND: Obesity is a risk factor for obstructive sleep apnea-hypopnea syndrome (OSAHS) in adults. However, the prevalence of OSAHS in children is not clear, and the relationship between obesity and OSAHS remains controversial. METHODS: Obese children were recruited from the endocrinology, respiratory, and ear, nose, and throat clinics. Weight-matched, age-matched, and sex-matched children were recruited as control subjects. Standard questionnaires were administered, and a standardized physical examination was carried out. Lateral neck roentgenography, sleep polysomnography, full blood count, and arterial blood gas analysis were also performed. Children with body mass index z-scores of > 1.96 were considered to be obese. An adenoidal/nasopharygeal ratio of > 0.67 was considered to constitute adenotonsillar hypertrophy (ATH). OSAHS was defined as an apnea-hypopnea index (AHI) score of > 5 or obstructive apnea index (OAI) score of > 1. RESULTS: Ninety-nine obese children and 99 control subjects were recruited into the study. Obese patients had significantly higher AHI and OAI scores, and lower sleep efficiency and minimum arterial oxygen saturation (MinSao(2)) than control subjects. The prevalence of OSAHS was significantly higher in obese children with or without the ATH groups than their nonobese counterparts (odds ratio, 1.9 vs 108, respectively; 95% confidence interval, 1.21 to 4.7 vs 6.2 to 191, respectively). Obesity, tonsillar hypertrophy, and adenoid hypertrophy were independent risk factors for OSAHS (p < 0.001, p = 0.042, and p = 0.004, respectively). There was a positive correlation between the degree of obesity and AHI (r = 0.535; p < 0.001), and an inverse correlation between obesity and MinSao(2) (r = -0.507; p < 0.001). End-tidal CO(2), Paco(2), and bicarbonate levels were within the normal range. CONCLUSIONS: Obesity is a risk factor for OSAHS, and the degree of obesity is positively correlated with the severity of OSAHS.     

A 1-year prospective study of the infectious etiology in patients hospitalized with acute exacerbations of COPD

INTRODUCTION: Infection is a major cause of acute exacerbations of COPD (AECOPDs). We aimed to study the infectious etiology related to AECOPD. METHODS: Patients admitted to an acute care hospital in Hong Kong with an AECOPD were recruited prospectively from May 1, 2004, to April 30, 2005. Sputum samples, nasopharyngeal aspirate (NPA) samples, and paired serology specimens were collected. Spirometry was performed with patients in the stable phase 2 to 3 months after hospital discharge. RESULTS: There were 643 episodes of AECOPD among 373 patients. Their mean age was 75.3 years (SD, 7.9 years) with 307 male patients. The mean FEV(1) was 40.4% predicted (SD, 18.7% predicted), and the mean FEV(1)/FVC ratio was 58.4% (SD, 16.0%). Among sputum samples from the 530 episodes of AECOPD hospital admissions that were saved, 13.0%, 6.0%, and 5.5%, respectively, had positive growth of Haemophilus influenzae, Pseudomonas aeruginosa, and Streptococcus pneumoniae. Among the 505 hospital admissions with patients who had NPA samples saved, 5.7%, 2.3%, 0.8%, and 0.8%, respectively, had influenza A, respiratory syncytial virus (RSV), influenza B, and parainfluenza 3 isolated from viral cultures. Paired serology test results revealed a fourfold rise in viral titers in 5.2%, 2.2%, and 1.4% of patients, respectively, for influenza A, RSV, and influenza B. Very severe airflow obstruction (stable-state spirometry) was associated with a higher chance of a positive sputum culture (FEV(1) >/= 30% predicted, 28.2%; FEV(1) < 30% predicted, 40.4%; p = 0.006). CONCLUSION: H influenzae and influenza A were the most common etiologic agents in patients who were hospitalized with AECOPDs. More severe airflow obstruction was associated with a higher chance of a positive sputum culture finding.     

Exudative pleural effusion following thoracoscopic pulmonary vein isolation for paroxysmal atrial fibrillation

Surgical treatments for atrial fibrillation are gaining popularity. We present a case of post-cardiac injury syndrome following thoracoscopic pulmonary vein isolation.