Current opinion in pulmonary medicine
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The purpose of this review is to present a novel radiologic percutaneous transabdominal technique for treating high-output chylothorax by thoracic duct embolization, and to demonstrate that it can be potentially safer than the traditional treatment by surgical open-chest thoracic duct ligation. ⋯ We have found that two thirds of patients presenting with life-threatening chylothorax can be safely treated by percutaneous transabdominal thoracic duct blockage. When successful, this novel interventional procedure can obviate repeat major thoracic surgery and shorten hospital stays.
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Complicated parapneumonic effusion and empyema continue to account for significant morbidity and mortality, and uncertainties remain regarding their optimal management. This review describes recent advances in this field, as well as areas for future research. ⋯ Increased understanding of the pathogenesis of empyema may ultimately yield novel therapeutic targets. Comprehensive descriptions of the bacteriology of empyema aids antibiotic choice, and the use of intrapleural DNase shows promise in facilitating drainage of infected pleural fluid. Uncertainties remain, such as the role of intrapleural fibrinolytics and the optimal timing of surgical intervention.
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Lung cancer is one of the major causes of cancer-related deaths. Grim mortality figures argue powerfully for new approaches to control this disease. Chemoprevention is the use of specific natural or synthetic chemical agents to reverse, suppress, or prevent carcinogenic progression to invasive cancer. The current article focuses on the field of lung cancer chemoprevention and recent advances. Lung cancer biology and general principles of prevention strategies are also described. ⋯ The concept of chemoprevention in lung cancer is still in its infancy but one day may have a significant impact on the incidence and mortality of this leading cancer threat. An improved understanding of carcinogenesis and cancer prevention mechanisms will no doubt aid in the design of future clinical trials and in the validation of candidate agents as well as the development of new targets. Planned or ongoing trials currently are targeting important molecular markers of lung carcinogenesis and progression including cyclooxygenase-2, the ras-signaling pathway through farnesyl transferase inhibitors and the tyrosine kinase/epidermal growth factor receptor pathway. Until such studies are completed however, no drug or drug combination should be used for lung cancer prevention outside of a clinical study.
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The challenge of diagnosis and management of solitary pulmonary nodules is among the most common yet most important areas of pulmonary medicine. Ideally, the goal of diagnosis and management is to promptly bring to surgery all patients with operable malignant nodules while avoiding unnecessary thoracotomy in patients with benign disease. ⋯ In almost all patients computed tomography (CT) is the best first step. Three key questions can then help guide the workup of the SPN. These are what is the pretest probability of cancer, what is the risk of surgical complications, and does the appearance of the nodule on CT scan suggest a benign or malignant etiology. In patients with average surgical risk, positron emission tomography (PET) scan is warranted when there is discordance between pretest probability of cancer and the appearance of the nodule on CT scan. Thus, when either the patient has a low risk of cancer and the CT suggests a malignant origin, or when there is high risk of cancer and the CT appears benign, PET scan will be cost effective. In most other situations, PET scanning is only marginally more effective than CT and fine needle aspiration strategies but costs much more.
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Tobacco smoking is a leading cause of lung cancer and chronic obstructive pulmonary disease. For smokers who want to quit, nicotine replacement therapy and bupropion are frequently recommended. Currently, disagreement surrounds the extent of risk reduction from quitting, the consequences of the change of nicotine replacement therapy to over-the-counter status, and the safety and efficacy of new tobacco products being marketed by tobacco companies. This article reviews the current evidence relevant to these and other developments in smoking interventions and describes the most effective strategies that smokers can use to reduce their risk. ⋯ Health care practitioners should encourage all smokers to attempt cessation and emphasize pharmacotherapy as an important aid to quitting. Professionals who educate patients on the appropriate use of pharmacotherapy and follow-up on smokers' attempts to quit will help reduce the societal burden and personal risks of smoking.