Early use of intrapleural fibrinolytics in the management of postpneumonic empyema. A prospective study.

OBJECTIVE: A prospective randomized study was conducted in order to analyze the role of fibrinolytics in the treatment of complicated parapneumonic effusion. METHODS: From 2001 to 2004, 127 consecutive patients were managed for thoracic empyema. In all cases the cause was bacterial pneumonia. Seventy patients were managed with sole tube thoracostomy (group A) and 57 with combination of tube thoracostomy and streptokinase instillation (group B). Groups were statistically compared for the age, gender, duration of symptoms, quality of pleural fluid, chest imaging, complete drainage, length of hospital stay and mortality. Multivariate analysis was used in order to define the factors that affect outcome. RESULTS: Tube thoracostomy was successful in 47 (67.1%) cases (group A), while fibrinolysis led to a favorable outcome in 50 cases (87.7%) (P<0.05). The length of stay in thoracic surgical department was significantly longer for group A (P<0.001). Mortality rate in group A was significantly higher (P<0.001). Multiple regression analysis disclosed as sole independent favorable factor for pleural drainage, the use of fibrinolysis during the course of chest tube drainage (P=0.006, odds ratio 4.29, 95% CI 1.51-12.14). CONCLUSIONS: Fibrinolytic agents are a useful adjunct in the management of complicated parapneumonic effusions. Intrapleural fibrinolytics, if used early in the fibrinopurulent stage of a parapneumonic effusion, decrease the rate of surgical interventions (VATS or open decortcation) and the length of hospital stay with minor associated morbidity.     

Factors associated with cardiac rhythm disturbances in the early post-pneumonectomy period: a study on 259 pneumonectomies.

OBJECTIVE: To identify predisposing factors associated with cardiac rhythm disturbances during the early post-pneumonectomy period (first 7 postoperative days). MATERIALS AND METHODS: During the study period (1995-1999), 259 pneumonectomies were performed for malignant (244 cases) or benign disease (15 cases). Postoperative monitoring of patients included continuous arterial pressure - rhythm monitoring and pulse oximetry. Cardiac rhythm disturbances during the intensive care unit stay were detected on the monitor screen and recorded with a 12-lead electrocardiogram. Cardiac rhythm disturbances associated with electrolytes or fluid balance abnormality, mediastinal deviation or surgical postoperative complications were excluded from the study. Age of patients, preexisting cardiac disease, side of pneumonectomy, intrapericardial procedures, stage of the malignant disease, expected postoperative FEV(1)<1200 ml, intraoperative transfusions of packed red cells, elevated right heart pressures, low postoperative serum magnesium levels and long operative times were considered as predisposing factors for the development of post-pneumonectomy cardiac rhythm disturbances. Statistical analysis has been made using logistic regression analysis, Student t-test and chi-square test. RESULTS: Cardiac rhythm disturbances were detected in 49 patients (18.91%). Atrial fibrillation/flutter (31 cases), supraventricular tachycardia (14 cases), and premature ventricular contractions (four cases) were the observed rhythm disturbances. Right pneumonectomy versus left pneumonectomy (P<0.0001) and intrapericardial pneumonectomy versus standard pneumonectomy (P<0.0001) were identified as strong predisposing factors for the establishment of post-pneumonectomy cardiac rhythm disturbances. Patients who established post-pneumonectomy cardiac rhythm disturbances had significantly higher (P=0.024) right ventricular systolic pressure (42.50+/-15.50 mmHg) when compared with patients who had postoperative sinus rhythm (29.07+/-7.71 mmHg) and had also longer operative times than patients who did not develop rhythm disturbances (P=0.015). Mortality rate in patients who developed post-pneumonectomy rhythm disturbances was 20.40%. CONCLUSIONS: Cardiac rhythm disturbances observed early after pneumonectomy are mainly of supraventricular origin, complicating right and intrapericardial pneumonectomies, patients with elevated right heart pressures and long operative times, and are associated with high mortality rates.     

Pros and cons of perfusion balloons in failed angioplasty

Prolonged inflation with perfusion balloons is commonly used in failed angioplasty. The objective of this study was to determine the angiographic outcome of 59 consecutive patients treated with prolonged inflation with perfusion balloons as the primary treatment for failed angioplasty. Angiographic success (< 50% stenosis and normal flow) was achieved in 41%. Angiographic success was greater in the left anterior descending coronary artery (67% versus 33% for non-left anterior descending involvement, P = .044) and was less in complex dissections (25% versus 75% for no dissection or simple dissections, P = .025). Angiographic deterioration occurred in 37.5% of the successful group and 77% of the unsuccessful group (P = .002) and was more frequent in the right coronary artery (88% versus 50% for non-right coronary involvement, P = .007) and complex dissections (92% versus 38% for no dissection or simple dissections, P = .0001). Thus, in a group of patients with unsuccessful outcome following conventional balloon angioplasty, success with the perfusion balloon was modest. Furthermore, angiographic deterioration was frequently observed following unsuccessful prolonged inflation.     

Burnout Evaluation and Potential Predictors in a Greek Cohort of Mental Health Nurses

Background

Job burnout is one of the most serious occupational health hazards, especially, among mental health nurses. It has been attributed among others to staff shortages, health service changes, poor morale and insufficient employee participation in decision-making.

Posttraumatic Transdiaphragmatic Intercostal Hernia: Report of a Case and Review of the Literature

Intercostal hernias are rare, and usually occur following injuries of the thoracic wall. The scope of this report is to present a case of a 53-year-old obese patient that developed a transdiaphragmatic intercostal hernia. The patient presented with a palpable, sizeable, reducible mass in the right lateral thoracic wall, with evident bowel sounds in the area, 6 months after a motor-vehicle accident. On computed tomography (CT), the hernia sac contained part of the liver and part of the ascending colon. A surgical repair of the defect was performed, using a prosthetic patch. The patient''s postoperative course was uneventful and she remains recurrence free at 12 months after surgery. Intercostal hernias should be suspected following high-impact injuries of the thoracic wall, and CT scans will facilitate the diagnosis of intercostal hernia. We consider the surgical repair of the defect, with placement of a prosthetic mesh, as the treatment of choice to ensure a favorable outcome.Key words: Hernia, Transdiaphragmatic, Intercostal, Abdominal, MeshThe herniation of abdominal contents through the thoracic wall, as a result of the disruption of diaphragmatic and/or intercostal muscles, is an uncommon clinical entity.^1–3 This condition is usually reported to occur following penetrating or blunt injuries of the thoracic wall.⁴ However, there are several cases that have been described to be a consequence of a coughing–spell rib fracture, usually in patients with other predisposing factors such as chronic obstructive pulmonary disease, asthma, advanced age, or osteoporosis.^1,3,4The present report describes a case of a middle-aged obese patient that developed a transdiaphragmatic intercostal hernia involving the liver and the ascending colon 6 months after a traumatic incident. The underlying mechanism, the anatomical and diagnostic considerations, as well as the treatment options are also discussed.     

Reliability among clinicians diagnosing low back-related leg pain

Purpose

To investigate agreement and reliability among clinicians when diagnosing low back-related leg pain (LBLP) in primary care consulters.

Methods

Thirty-six patients were assessed by one of six physiotherapists and diagnosed as having either leg pain due to nerve root involvement (sciatica) or referred leg pain. Assessments were video recorded. In part one, the physiotherapists each viewed videos of six patients they had not assessed. In part two, videos were viewed by another six health professionals. All clinicians made an independent differential diagnosis and rated their confidence with diagnosis (range 50–100 %).

Results

In part one agreement was 72 % with fair inter-rater reliability (K = 0.35, 95 % CI 0.07, 0.63). Results for part two were almost identical (K = 0.34, 95 % CI 0.02, 0.69). Agreement and reliability indices improved as diagnostic confidence increased.

Conclusion

Reliability was fair among clinicians from different backgrounds when diagnosing LBLP but improved substantially with high confidence in clinical diagnosis.