Recurrent Effusion Research Articles

Flexion Instability After Total Knee Arthroplasty.

Flexion instability after total knee arthroplasty (TKA) is caused by an increased flexion gap compared with extension gap. Patients present with recurrent effusions, subjective instability (especially going downstairs), quadriceps weakness, and diffuse periretinacular pain. Manual testing for laxity in flexion is commonly done to confirm a diagnosis, although testing positions and laxity grades are inconsistent. Nonsurgical treatment includes quadriceps strengthening and bracing treatment. The mainstays to surgical management of femoral instability involve increasing the posterior condylar offset, decreasing the tibial slope, raising the joint line in combination with a thicker polyethylene insert, and ensuring appropriate rotation of implants. Patient outcomes after revision TKA for flexion instability show the least amount of improvement when compared with revisions for other TKA failure etiologies. Future work is needed to unify reproducible diagnostic criteria. Advancements in biomechanical analysis with motion detection, isokinetic quadriceps strength testing, and computational modeling are needed to advance the collective understanding of this underappreciated failure mechanism.

Intracavitary chemotherapy with epidermal growth factor receptor-tyrosine kinase inhibitor (EGFR-TKI) is not superior to TKI monotherapy in controlling malignant pleural effusion recurrence in EGFR-mutated lung cancer patients.

Epidermal growth factor receptor (EGFR) mutated non-small cell lung cancer (NSCLC) patients benefit from EGFR-tyrosine kinase inhibitors (TKIs) therapy. There are few studies comparing the efficacy between intrapleural chemotherapy combination with TKIs and TKIs alone in controlling re-accumulation of malignant pleural effusions (MPEs). The purpose of the study was to determine if patients with EGFR-mutated NSCLC and MPEs would benefit from intrapleural chemotherapeutics with an oral EGFR-TKI than EGFR-TKI alone. We evaluated EGFR-mutated lung cancer patients with MPEs in Zhejiang Cancer Hospital. We evaluated the efficacy. Progression-free survival (PFS) and overall survival (OS) was evaluated by Kaplan-Meier method. One hundred one NSCLC patients with MPEs at the time of diagnosis were included. We divided the patients into two groups. The overall response rate (ORR) with respect to MPE recurrence between the TKI alone and combination therapy groups was 65.5% (38/58) and 58.1% (25/43) (P=0.449). The disease control rate was 89.7% (52/58) and 86.0% (37/43) (P=0.579), respectively. The PFS in the TKI alone and TKI plus intrapleural drugs was 10.3 and 9.9 months, respectively (P=0.746). The intrapleural PFS was 11.4 and 11.0 months for the TKI alone and combination groups, respectively (P=0.188). The OS was 24.9 and 22.6 months (P=0.543), respectively. Hematologic toxicity and chest pain were more frequent in the combination therapy than TKI alone groups. Intrapleural chemotherapy with TKI did not improve the efficacy of controlling MPEs in patients with EGFR-mutated NSCLC, but may increase adverse events, which are typical side effects of chemotherapy. We could treat these patients with TKI drugs alone combined with pleural effusion drainage.

Single-trocar thoracoscopic pericardio-pleural fenestration under local anesthesia for malignant pleural effusion: a case report

BackgroundPericardio-pleural fenestration by video-assisted thoracoscopic surgery is an efficient procedure for malignant pericardial effusion, but requires general anesthesia with single-lung ventilation.Case presentationA 43-year-old woman was referred with complaints of deteriorating dyspnea and orthopnea. Chest computed tomography revealed right massive pleural effusion and pericardial effusion. Echocardiography demonstrated collapse of both the right atrium and right ventricle due to cardiac tamponade. Semi-rigid thoracoscopic pleural biopsy and pericardio-pleural fenestration were successfully performed under local anesthesia via a single trocar, because surgical procedures under general anesthesia with single-lung ventilation might have been intolerable for the patient. Adequate biopsy specimens of pleura and pericardium and immediate relief of serious symptoms were obtained without perioperative complications. No recurrence of pleural or pericardial effusion was observed for 3 months postoperatively.ConclusionThoracoscopic pericardio-pleural fenestration under local anesthesia via a single trocar is feasible as an alternative approach in critically ill patients, allowing effective pericardial drainage, evaluation of the pleural cavity, and accurate biopsies of the pericardium and parietal pleura simultaneously.

Bacterial Pericarditis Causing Cardiac Tamponade in a Patient with No Primary Source of Infection

Introduction Bacterial Pericarditis is a rare entity accounting for Case Description 73 year old male with history of coronary artery disease presents with pleuritic chest pain and dyspnea since 2 days. On arrival, he was hemodynamically stable. EKG showed changes consistent with acute pericarditis. Echo showed moderate pericardial effusion without tamponade and normal systolic/diastolic function. Patient was treated with colchicine, NSAIDS could not be given due to acute kidney injury. His home dose of aspirin and clopidogrel were continued. Overnight, patient decompensated with persistent tachycardia, tachypnea and hypoxia. He started spiking fevers with worsening leucocytosis. Echo showed moderate pericardial effusion with signs of cardiac tamponade. Urgent pericardiocentesis was done and 250 mL of serosanguinous fluid was removed and a pigtail catheter was left in situ. His antiplatelet agents were discontinued to prevent hemorrhagic pericardial effusion. Methicillin sensitive Staphylococcus aureus was detected in cultures of pericardial fluid and blood. His antibiotic was deescalated to intravenous nafcillin. Echo post procedure showed small pericardial effusion with fibrinous echogenic material. His pericardial drain was not draining enough and was removed the next day. He started developing moderate left sided pleural effusion, likely an extension of pericardial inflammation. A small bore pleural catheter was placed in left pleural space for drainage. He had to undergo pericardectomy for definitive drainage and a chest tube was placed in right pleural cavity for drainage. Transesophageal echocardiogram demonstrated no further pathology. Repeat echo and CT-chest did not show any effusions, so pleural drains were removed on 6th day and patient was doing well. Discussion Purulent pericarditis presents as an acute illness characterized by fever in all patients, chest pain in 25-37% of patients. Bacterial pericarditis is usually not a primary infection, but occurs as a complication of underlying infection. Risk factors are immunosuppression, chest injuries, and chronic kidney disease with hemodialysis, diabetes mellitus and alcoholism. About 15% of patients with purulent pericarditis can develop cardiac tamponade. Typically small effusions accumulate quickly and develop tamponade. Large effusions can accumulate slowly allowing the pericardial sac to expand. Treatment is drainage of pus along with antibiotic therapy. Pericardiocentesis may be sufficient but in case of recurrent effusion or poor drainage of thick loculated fluid, pericardiotomy and pericardial window with manual lysis of adhesions and loculations allowing complete drainage is required. Survival in purulent pericarditis depends on early empiric antibiotic therapy and pericardial drainage.

Pre-EDIT: A Randomized Feasibility Trial of Elastance-Directed Intrapleural Catheter or Talc Pleurodesis in Malignant Pleural Effusion

Talc slurry pleurodesis (TSP) prevents recurrence of symptomatic malignant pleural effusion (MPE) in 71%to 78%patients. Nonexpansile lung (NEL) frequently accounts for TSP failure but is often occult predrainage, impairing selection of patients. NEL is associated with high pleural elastance (PEL), but technical limitations have hampered the development of PEL as a predictive NEL marker. We performed a single-center, randomized, controlled, open-label feasibility trial of EDIT (elastance-directed indwelling pleural catheter or TSP) management, using a novel digital manometer and a new definition of high PEL. Patients with symptomatic MPE were randomized 1:1 between EDIT and standard care (TSP). EDIT involved PEL assessment during large-volume thoracentesis; patients with high PEL (maximum PEL sustained over 250mL [MaxPEL250]≥ 14.5cm H2O/L) were allocated to immediately receive an indwelling pleural catheter; the remainder underwent immediate drain placement for TSP. The primary outcome measure was recruitment feasibility, defined a priori as 30 patients over 12months. Secondary outcomes included safety, technical reliability, and the aspiration volume required to detect high PEL. The accuracy of the PEL definition for NEL was analyzed post hoc. Thirty-one patients were randomized (one allocation failure) over 12months. PEL assessment (mean duration, 33 minutes) was successful in 13 of 15 patients (87%). No directly attributable serious adverse events occurred. High PEL was detected in seven of 13 patients (54%), associated with 100%sensitivity and 67%specificity for NEL, and was first detected at a median volume of 325mL (range, 250-800mL). A phase 3 trial testing the effect of EDIT management on symptomatic MPE recurrence following TSP is feasible. ClinicalTrials.gov; No.: NCT03319186; URL: www.clinicaltrials.gov.

Atraumatic Recurrent Knee Effusion in a Collegiate Athlete - Soccer

Atraumatic Recurrent Knee Effusion in a Collegiate Athlete - Soccer

Compare two surgical interventions for otitis media with effusion in young children

To prospectively evaluate the effect of tympanostomy tubes combined with adenoidectomy and tube insertion on treatment for otitis media with effusion in young children, and to analyze the related factors of prognosis and recurrence of the disease. The clinical and follow-up data of 184 children with otitis media with effusion who were treated in the department of Otolaryngology, Head and Neck Surgery, Beijing Children's Hospital, Capital Medical University from September 2013 to January 2015, were reviewed systematically. According to different surgical methods, they were randomly divided into the observation group in which patients were treated with tube insertion combined with adenoidectomy, and control group in which the rest underwent simple tube insertion. The curative effect, changes of air conduction hearing threshold before and after surgery, the healing time of tympanic membrane and recurrence of middle ear effusion were compared between the two groups. Influencing factors of recurrence of otitis media with effusion were analyzed, and the effect of healing time on tympanic membrane after tube removal was observed. The total effective rate of treatment in the observation group was higher than that in the control group (91.84% vs 80.23%, P < 0.05), and the air conduction hearing thresholds in two groups were decreased significantly at 3months and 6months after surgery, respectively (P < 0.05). The total effective rate of children under 4years old in the observation group was also higher than that in the control group. The duration of middle ear effusion and the recurrence rate in the observation group were shorter/lower than those in the control group (P < 0.05). Analysis showed that recurrent respiratory tract infection before surgery and retention time of ventilating tube shorter than 12months were risk factors for recurrence of otitis media with effusion, while adenoidectomy was a protective factor. Besides, the tympanic membrane healing time of the tympanic membrane tube for 1years was shorter than that of the tympanic membrane tube for more than one year (P < 0.05). The persisted perforation rate is 3.57% in less 12months of tube, as opposed to it was 12% in more 12months of tube (P < 0.05). Tube insertion combined with adenoidectomy is more effective than tympanostomy tubes in the treatment of young children with OME, and the same results were found for children under four years of age. It can significantly shorten the duration of middle ear effusion and reduce the recurrence rate after surgery. For 3-6year-old children, the upper respiratory tract infection and short ventilation tube indwelling time increase the possibility of OME recurrence, it is recommended that the ventilation tube should be retained for at least 12months.

CARDIAC TAMPONADE CONCEALED UNDER LARGE PLEURAL EFFUSION

Pericardial effusions and subsequent tamponade are not infrequent complications of thoracic malignancies. Pericardial window is a more permanent solution for malignant effusions yet depending on the approach can be associated with recurrent effusions. A 32 year old man with untreated Hodgkin's

Bayesian Semiparametric Joint Regression Analysis of Recurrent Adverse Events and Survival in Esophageal Cancer Patients.

We propose a Bayesian semiparametric joint regression model for a recurrent event process and survival time. Assuming independent latent subject frailties, we define marginal models for the recurrent event process intensity and survival distribution as functions of the subject's frailty and baseline covariates. A robust Bayesian model, called Joint-DP, is obtained by assuming a Dirichlet process for the frailty distribution. We present a simulation study that compares posterior estimates under the Joint-DP model to a Bayesian joint model with lognormal frailties, a frequentist joint model, and marginal models for either the recurrent event process or survival time. The simulations show that the Joint-DP model does a good job of correcting for treatment assignment bias, and has favorable estimation reliability and accuracy compared with the alternative models. The Joint-DP model is applied to analyze an observational dataset from esophageal cancer patients treated with chemo-radiation, including the times of recurrent effusions of fluid to the heart or lungs, survival time, prognostic covariates, and radiation therapy modality.

Evaluation of intracavitary carboplatin chemotherapy for treatment of pleural carcinomatosis in cats: a retrospective study of eight cases.

The aim of this study was to evaluate the benefit of intracavitary carboplatin chemotherapy in cats with malignant pleural effusion of epithelial origin. The medical records of cats with a cytological diagnosis of neoplastic pleural effusion of epithelial origin were reviewed at three referral institutions between January 2013 and June 2018. Only cats treated with intracavitary carboplatin chemotherapy were enrolled. Data collection included signalment, medical history, clinical signs, pleural effusion analysis, diagnostic imaging findings, intracavitary carboplatin chemotherapy protocol, adverse events, response to chemotherapy, outcome and underlying primary tumour, if possible. Eight cats met the inclusion criteria. Three cats had previous surgical removal of a tumour, including a poorly differentiated primary lung carcinoma, a uterine adenocarcinoma and a benign mammary tumour. The main clinical signs were tachypnoea and/or dyspnoea, inappetence and weight loss. Thoracic radiographs revealed marked bilateral pleural effusion in all cats. Pleural fluid analysis was consistent with a modified transudate, with malignant epithelial cells on cytology, leading to a diagnosis of pleural carcinomatosis. All cats received only one cycle of intracavitary carboplatin chemotherapy at a dose of 200-240 mg/m2. Recurrence of pleural effusion was reported in 7/8 cats within 4-15 days of chemotherapy, and death was recorded in all cats within 5-16 days, owing to recurrent pleural effusion or poor general condition. The primary cancer was suspected to be of pulmonary, mammary and pancreatic origin in four cats, two cats and one cat, respectively, and of unknown origin in the remaining cat. In this study, intracavitary carboplatin chemotherapy seems ineffective in managing neoplastic pleural effusion of epithelial origin in cats with pleural carcinomatosis. Other cytotoxic drugs and/or techniques should be investigated in the future to improve the quality of life and survival of cats with pleural carcinomatosis.

Influenza B virus infection complicated by life-threatening pericarditis: a unique case-report and literature review

BackgroundAcute pericarditis may occur frequently after viral infections. To our knowledge, influenza B virus infection complicated by pericarditis without myocardial involvement has never been reported. We report the first case of life-threatening pericarditis caused by influenza B virus infection.Case presentationA 48-years-old woman with trisomy 21 and ostium primum atrial septal defect was transferred from Cardiology to our Internal Medicine Department for severe pericardial effusion unresponsive to ibuprofen and colchicine. Based on the recent patient history of flu-like syndrome, and presence of pleuro-pericardial effusion, a viral etiology was suspected. Laboratory evaluation and molecular assay of tracheal aspirate identified influenza B virus. Therefore, the ongoing metilprednisolone and colchicine therapy was implemented with oseltamivir with progressive patient improvement and no evidence of pericardial effusion recurrence during follow-up.ConclusionsEspecially in autumn and winter periods, clinicians should include Influenza B virus infection on differential diagnosis of pericarditis with large pericardial effusion.

Pleural amyloidosis presenting as recurrent bilateral pleural effusions

Amyloidosis is a disease of insoluble protein deposition. It can affect many organ systems but less commonly found in the lung. Pleural effusions secondary to amyloidosis are rare and sparsely reported in the literature. The incidence ranges from 9 to 14 per million person-years. We present a case report of a 77-year-old female with respiratory distress and recurrent bilateral pleural effusions and known intra-abdominal amyloidosis. Initially, we attempted conservative non-operative management using tube thoracostomy drainage with lytic medications. But ultimately, she required decortication with the hope of promoting symphysis of her lung and chest wall to prevent recurrent effusions. Further investigation is warranted in this disease process, as the exact mechanism remains elusive. The same holds true regarding a standardized treatment approach due to the rarity of the disease.

Efficacy of central venous catheter in pleurodesis in refractory hepatic hydrothorax

Background Hepatic hydrothorax is an important complication of cirrhosis and portal hypertension. Recurrent hepatic hydrothorax may be difficult to manage. In cases where medical therapies, usually diuretics, have failed to adequately control symptomatic effusion, thoracentesis, thoracostomy tube drainage, and pleurodesis have been employed. Tunneled pleural catheters are used for control and long-term management of recurrent pleural effusions. The aim of management of recurrent effusion in patients with hepatic hydrothorax is to relieve symptoms, to decrease discomfort of the patient through repeated aspiration, and chemical pleurodesis to prevent recurrence. Intrapleural chemical agents including tetracycline, doxycycline, bleomycin, talc insufflations, or talc slurry are used for pleurodesis. Tetracycline is the most common agent. A central venous catheter is a thin, long flexible tube that may be inserted into the pleural space. Objectives The aim of this study is to explore the efficacy, safety, and tolerability of central venous catheter in pleurodesis by tetracycline to relieve distressing symptoms and prevent fluid re-accumulation in patients with recurrent hepatic hydrothorax. Patients and methods This study recruited 22 patients with hepatic hydrothorax to evaluate the effectiveness of the small-bore central venous line in draining the pleural cavity as well as to evaluate the effectiveness of the intrapleural tetracycline as a sclerosing agent. Results Regarding the success rate of pleurodesis in the studied patients, the procedure was successful in 16 (72.7%) cases and failed in six (27.3%) cases. Regarding the reported complications, chest pain was the most commonly reported complication followed by dyspnea, fever, and tachycardia. Conclusion Central venous catheters are small and flexible and allow the patients to move easily offering a wonderful, comfortable, and tolerable method for drainage and pleurodesis.

General Orthopaedic Roundtable: Workup of Recurrent Knee Effusions in a 57-Year-Old Male with Mild Knee Arthritis

The purpose of the JOPA Roundtable discussion is to give orthopaedic PAs insight on how each participating editorial board member treats certain orthopaedic conditions in his or her current practice. In this General Orthopaedic Roundtable, editorial board members with a general orthopaedic practice discuss the management of recurrent knee effusions in a 57-year-old male with mild knee arthritis. Participants share their knowledge and experience on the topic.

Leukopenia Induced by Anti-Tuberculosis Treatment

Our 43-years-old patient was diagnosed with pleural tuberculosis. Biological tests were ordered prior to the onset of the treatment and were all normal. After one month under treatment, he developed hematological and hepatic toxicity signs: neutropenia, cytolysis and cholestasis. After an onward investigation, rifampicin was identified as neutropenia causal treatment and pyrazinamide was avoided to prevent its hepatotoxicity. The decision of the multidisciplinary staff was to introduce a combination of three drugs: Isoniazid, Ethambutol and Ciprofloxacin for eight months while stopping Rifampicin. Chest X ray exam showed no recurrence of the pleural effusion.

Cardiac tamponade caused by acute coxsackievirus\xa0infection related pericarditis complicated by aortic stenosis in a hemodialysis patient: a case report

BackgroundPericardial effusion is observed in the majority of viral pericarditis cases; however, viral pericarditis accompanied by a large effusion resulting in cardiac tamponade is rare.Case presentationHere, we report the case of a 75-year-old hemodialysis patient with acute viral pericarditis complicated by aortic stenosis. The patient was referred with a diagnosis of aortic stenosis and pericardial effusion. The pericardial effusion had increased during the preoperative examinations, and the inflammatory reaction had progressed. We decided to abort the surgical intervention and start oral administration of anti-inflammatory agents. We subsequently performed a pericardiocentesis. High antibody titers to coxsackievirus were noted in the pericardial effusion. Since no recurrence of the pericardial effusion was observed, the patient underwent an aortic valve replacement 2 months later. The pericardium completely adhered to the heart. Pathological examination of the pericardium showed fibrous pericarditis without active inflammation.ConclusionsHere, we successfully treated a hemodialysis case with severe aortic stenosis complicated by cardiac tamponade and worsened by acute viral pericarditis. We waited for the pericarditis to resolve after administering anti-inflammatory agents and performed pericardial drainage before carrying out aortic valve replacement. The perioperative course of our case was unique and suggestive.

Long-term outcome of video-assisted thoracoscopic thoracic duct ligation and pericardectomy in dogs with chylothorax: A multi-institutional study of 39 cases.

To evaluate the long-term outcome of video-assisted thoracoscopic (VATS) thoracic duct ligation (TDL) and pericardectomy for treatment of chylothorax in dogs. Multi-institutional retrospective study. Thirty-nine client-owned dogs. Dogs were included if they had undergone a VATS TDL and pericardectomy and had at least 1-year follow-up or had died within 1 postoperative year. Medical records were evaluated, and recorded data included clinicopathological and diagnostic imaging results, surgical findings, complications, conversion rates, and long-term resolution and recurrence rates. Thirty-nine dogs met the inclusion criteria. Two dogs died intraoperatively; 1 was euthanized after severe restrictive pleuritis was diagnosed intraoperatively, and 1 underwent ventricular fibrillation and cardiac arrest during pericardectomy and could not be resuscitated. Conversion to an open approach was required in 1 of 39 (3%) dogs for TDL and 4 of 36 (11%) dogs for pericardectomy. Overall follow-up time was median 38 months (range, 3-115). Resolution of pleural effusion occurred in 35 of 37 (95%) dogs that survived the perioperative period. Late recurrence of pleural effusion was seen at 12, 12, and 19 months postoperatively in 3 of 35 (9%) dogs that survived the perioperative period and in which chylothorax had initially resolved. Successful long-term resolution of chylothorax was seen in a high proportion of dogs that underwent VATS TDL and pericardectomy, although late recurrence was sometimes seen. Video-assisted thoracoscopic thoracic duct ligation and pericardectomy are highly successful in dogs with chylothorax. Future studies should evaluate whether pericardectomy is required in dogs without evidence of pericardial disease.

BLADDER OUTLET OBSTRUCTION LEADING TO URINOTHORAX

SESSION TITLE: Disorders of the Pleura 2 SESSION TYPE: Med Student/Res Case Rep Postr PRESENTED ON: 10/09/2018 01:15 pm - 02:15 pm INTRODUCTION: Urinothorax is the presence of urine in the pleural space as a result of genitourinary (GU) trauma or obstructive uropathy. Injury in the GU tract results in urine extravasation into the peritoneal or retroperitoneal space, which then enters the pleural space via the diaphragm or lymphatics. Pleural fluid analysis greatly aids in the diagnosis. Dyspnea is often the presenting symptom. Less than seventy cases of urinothorax have been identified in the literature. CASE PRESENTATION: A 78-year old male presented with fatigue, dyspnea, suprapubic pain, and urinary incontinence for the past two weeks. Routine workup revealed AKI and hyperkalemia. The patient had a history of CVA, hypertension, hyperlipidemia and chronic kidney disease. Computed tomography (CT) of abdomen/pelvis revealed an enlarged prostate with bladder outlet obstruction and severe hydroureteronephrosis. Additionally, a large right sided pleural effusion with near collapse of the right lower lobe was noted [Figure 1]. A thoracentesis was performed and 2020 mL of simple, serous fluid was drained. The transudative fluid had a pH of 7.2, total fluid protein < 1.0 and fluid to serum creatinine ratio >1.0, highly suggestive of urinothorax. His dyspnea resolved after thoracentesis. He ultimately required bilateral percutaneous nephrostomy tubes with improvement in his renal function and no recurrence of urinothorax or other pleural effusion as seen on subsequent imaging. Given his known obstructive uropathy, no further workup was indicated for etiology of urinothorax. DISCUSSION: Urinothorax is a rare cause of pleural effusions that is caused by GU trauma, including iatrogenic instrumentation or transplant, or obstructive uropathy, including mechanical obstruction or bladder outlet obstruction. In both etiologies, the mechanism involves high pressures that result in translocation of urine into spaces that ultimately connect with the pleural space. Diagnosis involves identifying a pleural effusion and subsequently testing pleural fluid via thoracentesis. This rare and under diagnosed condition presents as the only transudative pleural effusion with pH <7.40. Other abnormal labs include a pleural fluid to serum creatinine ratio >1.0 and/or elevated LDH in pleural fluid. The fluid to serum creatinine ratio is the most specific feature of urinothorax. CT or ultrasound imaging can help discover the cause. Although there is an association with nephrostomy, our case was due to obstructive uropathy as it was diagnosed prior to intervention. CONCLUSIONS: Urinothorax is a rare condition that can result from abdominal trauma, genitourinary tract injury or obstructive uropathy. Recognition of this rare entity is important to allow for timely alleviation of obstruction, relieve symptoms, and prevent recurrence; as was the case with our patient. Reference #1: Austin, Adam & Navin Jogani, Sidharth & Bradley Brasher, Paul & Gupta Argula, Rahul & Huggins, John & Chopra, Amit. (2017). The Urinothorax: A Comprehensive Review with Case Series. The American Journal of the Medical Sciences. 354. 44-53. Reference #2: Toubes ME, Lama A, Ferreiro L, et al. Urinothorax: a systematic review. Journal of Thoracic Disease. 2017;9(5):1209-1218. https://doi.org/10.21037/jtd.2017.04.22. DISCLOSURES: No relevant relationships by Michael Bergman, source=Web Response No relevant relationships by Ryan Richard, source=Web Response No relevant relationships by Jigna Solanki, source=Web Response

Efficacy and Safety of Indwelling Pleural Catheters in Management of Hepatic Hydrothorax: A Systematic Review of Literature

Introduction: Hepatic hydrothorax (HH) is an infrequent but debilitating and therapeutically challenging complication of advanced liver cirrhosis. As evidence suggests against chest tube placement in HH many clinicians are reluctant to place indwelling pleural catheters (IPCs) for non-malignant effusions like HH as well. We aim to study the efficacy and safety of IPCs as an alternative treatment option in our systematic review. Methods: A literature search was conducted using the electronic database engines MEDLINE through PubMed, EMBASE, Ovid, Scopus and Cochrane Library (Cochrane Central Register of Controlled trialsand Cochrane Database of Systematic Reviews)from inception to April, 2018 to identify published articles and reports addressing outcomes in patients treated with an IPC for the treatment of HH [figure 1]. Risk of bias was rated for each study by using the Cochrane criteria. Results: The search strategy retrieved 370 papers out of which 4 observational studies were selected with a total of 111 patients.After insertion of IPCs for HH spontaneous pleurodesis was achieved in 16 (31.4%) out of 51 patients and mean duration to achieve spontaneous pleurodesis was 73-222 days. As far as secondary outcomes are concerned, frequency of pneumothorax during or after the procedure was 0 (0%) out of 92 patients, pain at insertion site 12 (20%) out of 60 patients, catheter blockage 2 (2.9%) out of 68 patients, pleural fluid infection 5 (4.5%) out of 111 patients and catheter site cellulitis 1 (3.1%) out of 32 patients. Re-accumulation of pleural fluid after catheter removal was mentioned in one study in which 12 (20%) out of 60 patients developed recurrence of pleural effusion. Primary and secondary end points are summarized in figure 2. Conclusion: We conclude that IPC is an acceptable therapeutic option for the management of refractory pleural effusion in patients with hepatic hydrothorax. Although TIPS and liver transplantation are gold standards for management of pleural effusion in these patients, cost and availability are major concerns with these treatment modalities. Tunneled pleural catheter is safe and efficacious alternative with a reasonable rate of spontaneous pleurodesis.969_A Figure 1. Prisma diagram showing method of study selection969_B Figure 2. showing primary and secondary end points

Aortic chemodectoma causing a lymphocyte-rich effusion in a cat

A 13-year-old neutered male domestic shorthaired cat presented to a primary care practice with a few days history of dyspnoea. Pleural effusion was diagnosed radiographically. Thoracocentesis was performed and analysis...