Current opinion in pulmonary medicine
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Malignant pleural effusions are common in cancer patients with advanced disease. These patients usually present with chest pain, cough, and progressive shortness of breath, all of which may cause significant impairment in quality of life. ⋯ These procedures are usually palliative and are performed depending on patients' symptoms, underlying medical conditions, extent of disease, performance status, and prognosis. This review focuses on the diagnosis and treatment of patients with malignant pleural effusions.
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Accurate diagnosis of deep venous thrombosis and pulmonary embolism is required because treatment can be lifesaving, although inappropriate anticoagulation exposes the mother and fetus to hemorrhage and other hazards. Clinicians must be aware of which patients are at risk, as deep venous thrombosis is frequently asymptomatic. Clinical diagnosis is unreliable for deep venous thrombosis and pulmonary thromboembolism; therefore, objective tests are required. ⋯ Where doubt remains, venography, CT, and magnetic resonance imaging have a role. Ventilation-perfusion scanning is the pivotal test for pulmonary thromboembolism for pregnancy, and it need not expose the fetus to excess radiation. If the results of this test are unclear, deep venous ultrasound can guide management of suspected pulmonary thromboembolism, thus avoiding pulmonary angiography.
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Among the evolving techniques for the diagnosis of acute pulmonary embolism, contrast enhanced spiral CT takes a particularly prominent role because it is available at most centers, it images the pulmonary embolism directly, and it is minimally invasive. It has not yet been fully evaluated, however. Magnetic resonance angiography also has appeal for similar reasons. ⋯ Magnetic resonance angiography for pulmonary embolism is still in the early testing phase. Transesophageal echocardiography can image pulmonary embolism in central pulmonary arteries, but preliminary tests suggest that it has a low negative predictive value and cannot be used to exclude pulmonary embolism. Finally, it seems that a rapid and sensitive technique for measuring d-dimer may now be available, which may assist in eliminating the diagnosis of acute pulmonary embolism in a significant percentage of patients in whom the diagnosis is suspected.
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Thoracoscopy is an old technique that has been recently revived with the development of video-endoscopic technology. Video-assisted thoracic surgery (VATS) is now an established surgical approach with proven benefits in the management of pleural diseases. ⋯ It also has an established therapeutic role in the management of the fibrinopurulent phase of empyema and the treatment of hemothorax. The technique is still continually evolving, and refinement of instrumentation promises to further reduce surgical trauma in selected procedures.