Pleural Research Articles

Incidence of radiographic and clinically significant pneumothorax or hemothorax after thoracic discectomy via mini-open lateral retropleural approach without prophylactic chest tube placement.

The mini-open lateral retropleural (MO-LRP) approach is an effective option for surgically treating thoracic disc herniations, but the approach raises concerns for pneumothorax (PTX). However, chest tube placement causes insertion site tenderness, necessitates consultation services, increases radiation exposure (requires multiple radiographs), delays the progression of care, and increases narcotic requirements. This study examined the incidence of radiographic and clinically significant PTX and hemothorax (HTX) after the MO-LRP approach, without the placement of a prophylactic chest tube, for thoracic disc herniation. This study was a single-institution retrospective evaluation of consecutive cases from 2017 to 2022. Electronic medical records were reviewed, including postoperative chest radiographs, radiology and operative reports, and postoperative notes. The presence of PTX or HTX was determined on chest radiographs obtained in all patients immediately after surgery, with interval radiographs if either was present. The size was categorized as large (≥ 3 cm) or small (< 3 cm) based on guidelines of the American College of Chest Physicians. PTX or HTX was considered clinically significant if it required intervention. Thirty patients underwent thoracic discectomy via the MO-LRP approach. All patients were included. Twenty patients were men (67%), and 10 (33%) were women. The patients ranged in age from 25 to 74 years. The most commonly treated level was T11-12 (n = 11, 37%). Intraoperative violation of parietal pleura occurred in 5 patients (17%). No patient had prophylactic chest tube placement. Fifteen patients (50%) had PTX on postoperative chest radiographs; 2 patients had large PTXs, and 13 had small PTXs. Both patients with large PTXs had expansion on repeat radiographs and were treated with chest tube insertion. Of the 13 patients with a small PTX, 1 required 100% oxygen using a nonrebreather mask; the remainder were asymptomatic. One patient, who had no abnormal findings on the immediate postoperative chest radiograph, developed an incidental HTX on postoperative day 6 and was treated with chest tube insertion. Thus, 3 patients (10%) required a chest tube: 2 for expanding PTX and 1 for delayed HTX. Most patients who undergo thoracic discectomy via the MO-LRP approach do not develop clinically significant PTX or HTX. PTX and HTX in this patient population should be treated with a chest tube only when there are postoperative clinical and radiographic indications.

First-in-human phase I clinical trial of RSO-021, a first-in class covalent inhibitor of mitochondrial peroxiredoxin 3 (PRX3), in patients with malignant pleural effusion due to mesothelioma and other advanced solid tumors (MITOPE).

3019 Background: Malignant cells rely on buffering oxidative stress through mitochondrial PRX3. Oxidative stress is selectively lethal to cancer cells and may be leveraged therapeutically. RSO-021 is a naturally-occurring, sulfur-rich, cyclic oligopeptide of the thiopeptide class, which covalently inactivates PRX3, leading to catastrophic oxidative stress and cell death. We conducted a phase 1 study to explore safety and identify the maximum tolerated dose (MTD) of intra-pleural RSO-021 in patients with mesothelioma, or other predominantly pleural cancer, with pleural effusion. Methods: MITOPE was a multicenter trial of weekly intrapleural RSO-021 (90, 120, and 180 mg) with a 3 + 3 dose-escalation design. The primary objective was to assess RSO-021 safety/tolerability. Secondary objectives included establishing local and systemic pharmacokinetic profiles and early anti-tumor activity. We defined dose-limiting toxicity (DLT) as grade (G) ≥3 non-hematological AEs with exceptions for some manageable G3 AEs that resolved within 72 h and complicated G4 hematological AEs or those lasting &gt;7 days. We also studied inflammatory and pharmacodynamic markers in local/systemic samples. Efficacy was assessed using mRECIST 1.1 (mesothelioma) and RECIST 1.1 (other tumors). Results: Of 15 patients treated (90 mg/wk, n=7; 120 mg/wk, n=6; 180 mg/wk, n=2), 12 (80%) had ≥3 prior anti-cancer regimens; 12 (80%) had mesothelioma. See table for AE and efficacy data. The commonest all-grade treatment-related AEs (TRAE) were fatigue (33%), pyrexia (20%), and elevated creatinine (20%). Three patients (20%) had DLTs: G3 dyspnea and G3 acute inflammatory response at 120 mg/wk; G3 dyspnea at 180 mg/wk. MTD was 90 mg/wk. Pro-inflammatory cytokines in pleural fluid/serum correlated with AEs suggestive of local inflammation. Prophylaxis mitigated local inflammatory TRAEs. PRX3 target binding in cell pellets from pleural fluid confirmed on-target activity. Systemic exposure was minimal. Disease control was 70% in 10 evaluable patients. The partial response at 90 mg/wk was a 59% reduction in mesothelioma target lesions. Median PFS at MTD was 5.7 months (95% CI, 1.4-NR). Two patients had disease control (DC) &gt;30 wks. Conclusions: Weekly intrapleural RSO-021 was safe with signs of anti-tumor activity in patients with pleural mesothelioma. Phase 2 exploration of this novel agent is ongoing at 2 doses, as a single agent and in combination. Clinical trial information: NCT05278975 . [Table: see text]

MORPHORANGENOLOGICAL CHARACTERISTICS IN EARLY DIAGNOSIS OF CHILDREN WITH INFLAMMATORY PULMONARY DISEASES

The choice of this particular topic is due to the need to study morphofunctional studies and compare them with radiological data. The literature shows that in order to improve and timely diagnosis and prevention of inflammatory diseases of the bronchopulmonary system, the director carries out radiological diagnostic methods. Morphological studies of pleural fluid can affect the diagnosis and treatment of children with pneumonia.

Exploring the efficacy and advancements of medical pleurodesis: a comprehensive review of current research.

This narrative review aims to provide an overview of medical pleurodesis techniques, and their indications and potential adverse effects. Pleurodesis is a procedure performed with the aim of obliterating the pleural space. It has indications in the management of both malignant and benign pleural effusions and pneumothorax. Various nonsurgical techniques exist to perform pleurodesis. The scope of this work is to review the different nonsurgical techniques and their indications. This narrative review was performed checking scientific databases for medical literature, focusing especially on the data derived from randomised controlled trials. Pleurodesis is an effective method to manage pleural effusions and pneumothorax, and minimally invasive techniques are now frequently used with good results. Further research is needed to assess the efficacy of new treatments and the possibility of using different techniques in association.

Phase 2 study to evaluate the novel mitochondrial PRX3 inhibitor, RSO-021, as an intrapleural monotherapy and in combination with IV paclitaxel in patients with malignant pleural effusion due to mesothelioma or another advanced solid tumor.

TPS8124 Background: Tumor cells generate elevated levels of reactive oxygen species (ROS), leading to increased expression and activity of critical ROS scavenging pathways. Peroxiredoxin 3 (PRX3) is the principal peroxide scavenging enzyme in mitochondria. RSO–021 is a novel small molecule PRX3 inhibitor that inactivates PRX3 through direct covalent adduction of active site cysteine residues, in turn inducing oxidative stress that is incompatible with tumor cell survival. Preclinical studies of RSO-021 show that it selectively inhibits mitochondrial PRX3 in vitro and is highly effective in a variety of tumor models, including mesothelioma and many solid tumors. RSO-021 has completed phase 1 evaluation in patients with advanced mesothelioma or solid tumors with predominant pleural disease and malignant pleural effusions. The phase 1 data supported weekly intrapleural dosing of RSO-021 at the 90 mg dose level, with acceptable safety and early signals of efficacy. Some patients were able to receive &gt;30 weeks of treatment. Pre- and post-dose primary prophylaxis for local inflammatory reactions to intrapleural injection was instituted during dose escalation, using corticosteroids, NSAIDS and paracetamol. It also became clear that RSO-021 should not be administered to patients with a dry pleural tap, due to risk of extravasation. Methods: The objectives of this open-label, multi-center, 4-arm phase 2 study (MITOPE) are to confirm the efficacy, safety, tolerability, and pharmacology of weekly intrapleural RSO-021 administration. Exploratory endpoints include target engagement as well as biomarkers of response and inflammation. The study explores 2 different RSO-021 doses (90 mg/wk and 45 mg/wk) per FDA Project Optimus, both as monotherapy and in combination with IV paclitaxel 175 mg/m2 every 3 weeks at until progression or limiting toxicity. Each arm at each dose has a 2-stage Simon design (12-21 patients) requiring 1 response to trigger stage 2 (null/target response rate 3%/20% and type I/type II error 0.05/0.8) for a maximum of 168 patients in the trial. Three of the 4 study arms are investigating the antitumor activity of RSO-021 monotherapy (arms 1-3) and the fourth is assessing the paclitaxel combination. Eligibility (by arm) requires: newly diagnosed treatment-naïve mesothelioma with pleural effusion; mesothelioma with pleural effusion that progressed on ≥1 standard of care (SoC) regimen; solid tumor with predominant pleural/lung disease and effusion that progressed on ≥1 SoC regimen; and breast, epithelial ovarian or non-small cell lung cancer with predominant pleural/lung disease and effusion that progressed on ≥1 SoC regimen. The first patient was treated in 4Q2023 and the trial is actively recruiting to all 4 arms at 9 UK sites. Additional sites are planned. Clinical trial information: NCT05278975 .

Comparative analysis of genetic variants in pleural fluids and solid tissue biopsies of pleural mesothelioma patients: Implications for molecular heterogeneity assessment

ObjectivesThis study aims to determine whether the sequencing of DNA extracted from pleural fluids (PFs) of Pleural Mesothelioma (PM) patients accurately represents the genetic information obtained from the solid tissue counterpart biopsies with particular attention to the identification of single nucleotide variants (SNVs). Materials and methodsSingle pleural biopsy, PFs, and blood were collected from PM patients. DNA was extracted from these samples and then subjected to Whole-Exome Sequencing. ResultsA higher number of SNVs was identified in PFs than in solid tissue biopsies (STBs). Most SNVs were detected in PFs samples but not in STBs samples, while only a few SNVs were detected in STBs samples but not in PFs samples. ConclusionThe current findings support the notion that PFs might offer a more robust depiction of cancer's molecular diversity. Nonetheless, the current outcomes challenge the assertion that liquid biopsies can encompass the entirety of intra-patient variations. Indeed, a subset of potential cancer-driver SNVs was exclusively identified in STBs. However, relying solely on STBs would have precluded the detection of significant SNVs that were exclusively present in PFs. This implies that while PFs serve as a valuable complement to STBs, they do not supplant them.

Presentation and management of delayed bronchopleural fistula after pulmonary lobectomy: a case report

BackgroundLung cancer is the second most diagnosed cancer and the leading cause of cancer deaths worldwide. Surgical lung resection is the best treatment modality in the early stages of lung cancer as well as in some locally advanced cases. Postoperative air leak is one of the most common complications after pulmonary resection with incidence ranging between 20 and 33%. The majority of air leaks seal, within 5 days after surgery, on their own by conservative management. However, at least 5% of patients still have prolonged air coming out from the residual lung at discharge. This report describes the management of a thin lady with right lung cancer who underwent a right lower lobectomy and then suffered from a delayed air leak 7 weeks after surgery and required extensive thoracic and general surgery collaboration.Case presentationA 72-year-old heavy smoker female patient diagnosed with stage I lung cancer underwent right robotic-assisted thoracoscopic surgery converted to thoracotomy because of a fused fissure, right lower lobectomy, and mediastinal lymphadenectomy presented with delayed air leak 49 days after surgery. VATS decortication and mechanical pleurodesis were done 2 weeks after unsuccessful conservative treatment. Still, the lung failed to expand four weeks later so the patient was sent to surgery; she is underweight (BMI of 18) with not many options for a big flap to fill the chest cavity empty space. Accordingly; the decision was to use multiple pedicle flaps; omentum, intercostal muscle, and serratus anterior muscle to cover the bronchopleural fistulas and fill the pleural space in addition to mechanical and chemical pleurodesis. Full expansion of the lung was obtained. The patient was discharged on Post-Operative day 5 without remnant pneumothorax.ConclusionsAir leaks After lobectomy usually presents directly postoperatively; various management options are available ranging from conservative and minimally invasive to major operative treatment. We presented what we believe was unusual delayed bronchopleural fistula post-lobectomy in a thin lady which demonstrates clearly how a delayed air leak was detected and how collaborative efforts were crucial for delivering high-quality, safe, and patient-centered care till treated and complete recovery.

Severe acute alcoholic pancreatitis complicated by distributive shock, abdominal compartment syndrome, and black pleural effusion

Severe acute pancreatitis (SAP) is a life-threatening medical emergency that can lead to multi-system organ failure and mortality. Here, we highlight a case of SAP complicated by a black pleural effusion (BPE), distributive shock, and acute abdominal compartment syndrome (ACS) requiring emergent decompressive laparotomy. BPE fluid analysis was consistent with previously reported exudative effusions from a pancreatic pseudocyst, though the computed tomography (CT) of abdomen and pelvis did not show definitive evidence of a pseudocyst. In addition, black fluid was also discovered during decompressive laparotomy for ACS. It is possible that the severely elevated intra-abdominal pressure contributed to a temporary translocation/transudation of this fluid from the abdominal cavity into the pleural space, as no re-accumulation of the BPE was observed on a follow-up CT after thoracostomy tube removal.

Ultrasound-Assisted and Ultrasound-Guided Thoracentesis: An Educational Review.

Thoracentesis is one of the most important invasive procedures in the clinical setting. Particularly, thoracentesis can be relevant in the evaluation of a new diagnosed pleural effusion, thus allowing for the collection of pleural fluid so that laboratory tests essential to establish a diagnosis can be performed. Furthermore, thoracentesis is a maneuver that can have therapeutic and palliative purposes. Historically, the procedure was performed based on a physical examination. In recent years, the role of ultrasound has been established as a valuable tool for assistance and guidance in the thoracentesis procedure. The use of ultrasound increases success rates and significantly reduces complications. The aim of this educational review is to provide a detailed and sequential examination of the procedure, focusing on the two main modalities, the ultrasound-assisted and ultrasound-guided form.

EFFICACY OF INTRAPLEURAL STREPTOKINASE IN RETAINED HEMOTHORAX

Retained hemothorax is a challenging clinical entity characterised by the accumulation of blood within the pleural cavity following chest trauma or surgery. In recent years, intrapleural streptokinase has emerged as a potential therapeutic option for managing retained hemothorax, offering a less invasive alternative to surgical interventions. However, limited data are available on the efficacy of this treatment modality in the Pakistani population. Objective: This study aimed to evaluate the effectiveness and safety of intrapleural streptokinase in resolving retained hemothorax among patients in Pakistan. Methods: A prospective observational study was conducted at a Rawalpindi Teaching Hospital in Pakistan from January 2022 to July 2023. One hundred patients meeting the inclusion criteria were enrolled in the study. Baseline demographic and clinical data were recorded, and intrapleural streptokinase therapy was administered according to standard protocols. Response to treatment was assessed through regular clinical examinations and radiological imaging over a predetermined duration. Descriptive statistics were used to summarise baseline characteristics, and inferential statistics, such as chi-square tests or t-tests, were utilised to compare outcomes between subgroups. Results: Of the 100 patients treated with intrapleural streptokinase therapy, 85% achieved successful resolution of retained hemothorax, as evidenced by complete drainage of blood from the pleural cavity and radiological confirmation of lung re-expansion. A subset of patients who did not respond to therapy required additional surgical interventions. Minor complications were observed in 10% of the study population. Conclusion: Intrapleural streptokinase therapy demonstrated promising outcomes in resolving retained hemothorax among patients in Pakistan. Despite the need for additional surgical interventions in some cases, this treatment modality's overall efficacy and safety profile supports its consideration as a first-line therapy for retained hemothorax in resource-limited settings.

Empyema associated with peritoneal dialysis peritonitis.

A 65-year-old woman on peritoneal dialysis (PD) was admitted due to abdominal pain with cloudy PD effluent. The white blood cell count in PD effluent was 5860/µL with 85% polymorphonuclear neutrophils. Therefore, she was clinically diagnosed with peritonitis. The cultures of PD effluent were negative. Initial abdominal computed tomography did not find suggest any intraabdominal pathology. The patient was treated with empirical intraperitoneal antibiotics. Because abdominal pain with cloudy PD effluent persisted, the PD catheter was removed eventually. The culture of the removed PD catheter grew Klebsiella pneumoniae. However, intermittent fever was noted over the following days and empyema developed approximately 2 weeks after PD catheter removal. The culture of pleural fluid also grew K. pneumoniae. Another computed tomography revealed multiple intraabdominal abscesses that was assumed to come from a complication of PD-associated peritonitis. We postulate that the empyema might be caused by transdiaphragmatic extension of the intraabdominal abscesses into the pleural space.

&lt;i&gt;Congenital Analbuminemia&lt;/i&gt;

Congenital analbuminemia (CAA) is a rare autosomal recessive disorder, characterized by the absence or very low level of serum albumin (human serum albumin/HSA) as a result of defect on chromosome 4 which encodes albumin. It is defined as albumin level &lt;1 g/l with normal liver function and the absence of protein loss.1,2 Estimated CAA prevalence is less than 1 in 1 million.A 10-year-old boy suffered from generalized edema that got worsened since last month. The patient had been misdiagnosed with nephrotic syndrome 2 years earlier, and then became protein-losing enteropathy. Neither cough nor diarrhea were reported. The patient had history of food allergy. Physical examination showed moderately ill condition, Glasgow Coma Scale (GCS) score E4 V5 M6, blood pressure 90/50 mmHg, pulse 120 x/min, respiratory rate 30x/min, palpebral edema, shifting dullness, undulation (+), with nonpitting edema on the extremities. Laboratory findings: leukocytosis (neutrophilia), peripheral blood smear showed hypochromic microcytic anisositosis erythrocyte. AAT serum 246 mg/dl, GGT serum: 88 U/l, iron serum 28 µg/dl, TIBC 411 µg/dl, transferrin saturation 7%, total IgE 775,90 U/ml. Serum Protein Electrophoresis (SPE) results were hypoalbuminemia (1,4 g/dl), hypogammaglobulinemia (0,21 g/dl), and total protein 2,91 g/dl. Chest X-ray showed pneumonia with minimal right pleural effusion. Overestimation of serum albumin level was caused by alpha and beta globulin that were detected as albumin in bromocresol green (BCG) methods. CAA aggravated with by allergy caused malnutrition in this patient. These data support the diagnosis of CAA with sepsis and iron deficiency anemia. Suggestion for the management consist of blood culture, procalcitonin level measurement, inguinal lymph node biopsy, DNA sequence analysis, also analysis of pleural and ascites fluid.

Chest ultrasound is better than CT in identifying septated effusion of patients with pleural disease

Septated pleural effusion is very common. The presence of septations in pleural effusion determines the local treatment strategy for such patients. Therefore, there is a pressing need for imaging techniques to assess the presence of septations. The objective of this research was to assess the diagnostic efficacy of computed tomography (CT) and chest ultrasound in identifying septated pleural effusion. We delineated the ultrasound and enhanced chest CT manifestations for diagnosing septated pleural effusions, and subsequently, we conducted a comparative analysis to assess the diagnostic efficacy of enhanced chest CT and ultrasound in identifying septated pleural effusions. Medical thoracoscopy served as the gold standard for confirming the diagnosis of septated pleural effusions. Ultrasound demonstrated a sensitivity of 82.6% (95% CI 73.3–89.7%) and a specificity of 100.0% (95% CI 98.1–NaN) for diagnosing septated pleural effusion. In comparison, enhanced chest CT exhibited a sensitivity of 59.8% (95% CI 49.0–69.9%) and a specificity of 87.0% (95% CI 81.5–91.4%). The positive predictive value for ultrasound was 100.0% (95% CI 95.3–100.0%), while for enhanced chest CT, it was 68.8% (95% CI 59.0–77.4%). Ultrasound yielded a negative predictive value of 92.3% (95% CI 87.5–NaN), and enhanced chest CT had a negative predictive value of 82.0% (95% CI 74.6–87.8%) in diagnosing septated pleural effusion. Thoracic ultrasound exhibits superior sensitivity and specificity compared to enhanced chest CT in diagnosing septated pleural effusions. Therefore, chest ultrasound is highly recommended as an adjunct for determining septated pleural effusion.

Pneumothorax risk reduction during CT-guided lung biopsy – Effect of fluid application to the pleura before lung puncture and the gravitational effect of pleural pressure

PurposeThis study investigated strategies to reduce pneumothorax risk in CT-guided lung biopsy. The approach involved administering 10 ml of 1 % lidocaine fluid in the subpleural or pleural space before lung puncture and utilizing the gravitational effect of pleural pressure with specific patient positioning. MethodWe retrospectively analyzed 72 percutaneous CT-guided lung biopsies performed at a single center between January 2020 and April 2023. These were grouped based on fluid administration during the biopsy and whether the biopsies were conducted in dependent or non-dependent lung regions. Confounding factors like patient demographics, lesion characteristics, and procedural details were assessed. Patient characteristics and the occurrence of pneumothoraces were compared using a Kurskal-Wallis test for continuous variables and a Fisher’s exact test for categorical variables. Multivariable logistic regression was used to identify potential confounders. ResultsSubpleural or pleural fluid administration and performing biopsies in dependent lung areas were significantly linked to lower peri-interventional pneumothorax incidence (n = 15; 65 % without fluid in non-dependent areas, n = 5; 42 % without fluid in dependent areas, n = 5; 36 % with fluid in non-dependent areas,n = 0; 0 % with fluid in dependent areas; p = .001). Even after adjusting for various factors, biopsy in dependent areas and fluid administration remained independently associated with reduced pneumothorax risk (OR 0.071, p<=.01 for lesions with fluid administration; OR 0.077, p = .016 for lesions in dependent areas). ConclusionsPre-puncture fluid administration to the pleura and consideration of gravitational effects during patient positioning can effectively decrease pneumothorax occurrences in CT-guided lung biopsy.

Hemodynamic features of chronic constrictive pericarditis and concomitant pleural disease: a case report

Chronic constrictive pericarditis (CP) is an uncommon form of heart failure in which a thickened and often calcified pericardium limits diastolic filling, ultimately reducing cardiac pump performance. Diagnosis can be challenging and may require integrating clinical data with meticulous echocardiographic assessment and cross-sectional cardiac imaging. If non-invasive testing is inconclusive, right heart catheterization remains the gold standard diagnostic test. Classic hemodynamic features of constrictive pericarditis may also be seen in restrictive cardiomyopathy and are often insufficient to establish the diagnosis. Therefore, the preferred hemodynamic criteria of CP include the finding of increased ventricular interdependence and intrathoracic and intracardiac pressure dissociation. However, the presence of concomitant pleural disease may interfere with the catheterization hemodynamics and decrease the accuracy of these criteria as we present in this case report.

Small Hemothoraces Not Drained on Admission: Initial Volume Predicts Need for Intervention.

Unlike large hemothoraces (HTX), small HTX after blunt trauma may be observed without drainage. We aimed to study if there were risk factors that would predict the need for intervention in initially observed small HTX. A retrospective review of patients with blunt traumatic HTX from 2016 to 2022 was performed. Patients with small HTX (pleural fluid volume <400mL on admission chest computerized tomography [CT]) were included. Patients were considered as being "initially observed" if there was no intervention for the HTX within 48hours after admission. Primary outcome was any HTX-related intervention (open, thoracoscopic or percutaneous procedures) occurring after 48hours and up to 6months after injury. Univariable and multivariable statistical analyses were employed. A P-value of <.05 was considered significant. Of 335 patients with HTX, 188 (59.6%) met inclusion criteria. Median (interquartile range) HTX volume was 90 (36-134)ml. One hundred and twenty-seven (68%) were initially observed. Of these, 31 (24%) had the primary outcome. These patients had a larger HTX volume (median, 129 vs 68mL, P = .0001), and number of rib fractures (median, 7 vs 4, P = .0002) compared to those without the primary outcome. Chest-related readmission occurred in 8 (6%) with a median of 20days from injury. Of these, 7 required an HTX-related intervention. Logistic regression analysis found that both the number of rib fractures and HTX volume independently predicted the primary outcome. For small HTX initially observed, number of rib fractures and initial volume predicted delayed HTX-related intervention.

Case report: E-FAST in Detecting Traumatic Pneumothorax. Do We Agree With The Article : Pneumothorax On E-Fast? Not So Fast

Blunt Thoracic trauma is one of the main causes of death in the world with mortality rates ranging from 15-77% and the most common case is pneumothorax where air collects in the pleural cavity due to trauma and causes partial or complete lung collapse. E-FAST examination has been accepted as a modality in diagnosing pneumothorax in trauma cases but there are many reports vary regarding the accuracy of using E-FAST, especially in diagnosing pneumothorax. This case presentation reports the case of a male patient with blunt thoracic trauma where E-FAST diagnosis provides an early diagnosis with more sensitive results compared to chest X-ray. Taking into account the operator's knowledge and the existing system, the authors still recommend using E-FAST in trauma patients to get a better diagnosis and early warning, especially in emergency conditions, the authors also suggest that in patients with stable conditions, the E-FAST examination combined with other examination modalities will obtain more accurate results.

Subpleural pulmonary nodule marking with patent blue V dye prior to surgical resection.

Subpleural located pulmonary nodules are perioperatively invisible to the surgeon. Their precise identification is conventionally possible by palpation, but often at the cost of performing a thoracotomy. The aim of the study was to evaluate the success rate and feasibility of the pre-operative CT-guided marking subpleural localized nodule using a mixture of Patent Blue V and an iodine contrast agent prior to the extra-anatomical video-assisted thoracoscopic surgery (VATS) resection in patients for whom the primary anatomical resection in terms of segmentectomy or lobectomy was not indicated. The data of consecutive patients with pulmonary nodules located ≤ 30 mm from the parietal pleura, who were indicated for VATS extra-anatomical resection between 2017 to 2023, were retrospectively reviewed and analyzed. All patients indicated for VATS resection underwent color marking of the area with the pulmonary lesion under CT-guided control immediately before the surgery. The primary outcome was the marking success. Morphological lesion characteristics, time from marking to the surgery, procedure related complications, final histology findings and 30day mortality were analyzed. Additionally, we assessed the association of the successful marking and the patient's smoking history. A total of 62 lesions were marked. The successful marking was observed in 56/62 (90.3%) patients. The median time from the lesion marking to the beginning of surgery was 75.0 (IQR 65.0-85.0) minutes. The procedure related pneumothorax was observed in 6 (9.7%) patients, intraparenchymal hematoma in 1 (1.6%) patient. No statistically significant association of the depth of the subpleural lesion's location, occurrence of complications or time from the marking to surgery and the successful marking was observed. The 30day mortality was zero. No association of smoking and successful marking was observed. The method of marking the subpleural pulmonary lesions under CT-guided control with a mixture of Patent Blue V and iodine contrast agent is a safe and effective method with minimal complications. It provides surgeons the precise visualization of the affected pulmonary parenchyma before the planned extra-anatomical VATS resection.

Ventilator-induced Lung Injury Promotes Inflammation within the Pleural Cavity.

Mechanical ventilation contributes to the morbidity and mortality of patients in intensive care, likely through the exacerbation and dissemination of inflammation. Despite the proximity of the pleural cavity to the lungs and exposure to physical forces, little attention has been paid to its potential as an inflammatory source during ventilation. Here, we investigate the pleural cavity as a novel site of inflammation during ventilator-induced lung injury. Mice were subjected to low or high tidal volume ventilation strategies for up to 3 hours. Ventilation with a high tidal volume significantly increased cytokine and total protein levels in BAL and pleural lavage fluid. In contrast, acid aspiration, explored as an alternative model of injury, only promoted intraalveolar inflammation, with no effect on the pleural space. Resident pleural macrophages demonstrated enhanced activation after injurious ventilation, including upregulated ICAM-1 and IL-1β expression, and the release of extracellular vesicles. In vivo ventilation and invitro stretch of pleural mesothelial cells promoted ATP secretion, whereas purinergic receptor inhibition substantially attenuated extracellular vesicles and cytokine levels in the pleural space. Finally, labeled protein rapidly translocated from the pleural cavity into the circulation during high tidal volume ventilation, to a significantly greater extent than that of protein translocation from the alveolar space. Overall, we conclude that injurious ventilation induces pleural cavity inflammation mediated through purinergic pathway signaling and likely enhances the dissemination of mediators into the vasculature. This previously unidentified consequence of mechanical ventilation potentially implicates the pleural space as a focus of research and novel avenue for intervention in critical care.

Genome analyses of colistin-resistant high-risk blaNDM-5 producing Klebsiella pneumoniae ST147 and Pseudomonas aeruginosa ST235 and ST357 in clinical settings

BackgroundColistin is a last-resort antibiotic used in extreme cases of multi-drug resistant (MDR) Gram-negative bacterial infections. Colistin resistance has increased in recent years and often goes undetected due to the inefficiency of predominantly used standard antibiotic susceptibility tests (AST). To address this challenge, we aimed to detect the prevalence of colistin resistance strains through both Vitek®2 and broth micro-dilution. We investigated 1748 blood, tracheal aspirate, and pleural fluid samples from the Intensive Care Unit (ICU), Neonatal Intensive Care Unit (NICU), and Tuberculosis and Respiratory Disease centre (TBRD) in an India hospital. Whole-genome sequencing (WGS) of extremely drug-resitant (XDR) and pan-drug resistant (PDR) strains revealed the resistance mechanisms through the Resistance Gene Identifier (RGI.v6.0.0) and Snippy.v4.6.0. Abricate.v1.0.1, PlasmidFinder.v2.1, MobileElementFinder.v1.0.3 etc. detected virulence factors, and mobile genetic elements associated to uncover the pathogenecity and the role of horizontal gene transfer (HGT).ResultsThis study reveals compelling insights into colistin resistance among global high-risk clinical isolates: Klebsiella pneumoniae ST147 (16/20), Pseudomonas aeruginosa ST235 (3/20), and ST357 (1/20). Vitek®2 found 6 colistin-resistant strains (minimum inhibitory concentrations, MIC = 4 μg/mL), while broth microdilution identified 48 (MIC = 32–128 μg/mL), adhering to CLSI guidelines. Despite the absence of mobile colistin resistance (mcr) genes, mechanisms underlying colistin resistance included mgrB deletion, phosphoethanolamine transferases arnT, eptB, ompA, and mutations in pmrB (T246A, R256G) and eptA (V50L, A135P, I138V, C27F) in K. pneumoniae. P. aeruginosa harbored phosphoethanolamine transferases basS/pmrb, basR, arnA, cprR, cprS, alongside pmrB (G362S), and parS (H398R) mutations. Both strains carried diverse clinically relevant antimicrobial resistance genes (ARGs), including plasmid-mediated blaNDM-5 (K. pneumoniae ST147) and chromosomally mediated blaNDM-1 (P. aeruginosa ST357).ConclusionThe global surge in MDR, XDR and PDR bacteria necessitates last-resort antibiotics such as colistin. However, escalating resistance, particularly to colistin, presents a critical challenge. Inefficient colistin resistance detection methods, including Vitek2, alongside limited surveillance resources, accentuate the need for improved strategies. Whole-genome sequencing revealed alarming colistin resistance among K. pneumoniae and P. aeruginosa in an Indian hospital. The identification of XDR and PDR strains underscores urgency for enhanced surveillance and infection control. SNP analysis elucidated resistance mechanisms, highlighting the complexity of combatting resistance.