Journal of thoracic disease
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Pleural disease is common with a rising case frequency. Many of these patients will be symptomatic and require diagnostic and/or therapeutic procedures. Patients with pleural disease present to a number of different medical specialties, and an equally broad range of clinicians are therefore required to have practical knowledge of these procedures. ⋯ The advent of thoracic ultrasound (TUS) has had a major influence on patient safety and the number of physicians with the necessary skill set to perform pleural procedures. As the variety and complexity of pleural interventions increases, there is increasing recognition that early specialist input can reduce the risk of complications and number of procedures a patient requires. This review looks at the means by which complications of pleural procedures arise, along with how they can be managed or ideally prevented.
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Review
Intrapleural tissue plasminogen activator and deoxyribonuclease therapy for pleural infection.
Pleural infection remains a global health burden associated with significant morbidity. Drainage of the infected pleural fluid is important but can often be hindered by septations and loculations. Intrapleural fibrinolytic therapy alone, to break pleural adhesions, has shown no convincing advantages over placebo in improving clinical outcome. ⋯ Pain can occur, especially with the first dose. Treatment is contraindicated in those with significant bleeding diathesis or a bronchopleural fistula. Future research is required to optimize dosing regimens and in refining patient selection.
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A 44-year-old non-smoking woman presented with recurrent right spontaneous pneumothorax 9 years after a right-side surgical pleurodesis via a video-assisted thoracic surgery (VATS) approach for suspected primary pneumothorax in another center. Histological examination of tissue excised during the earlier operation confirmed catamenial pneumothorax, but no further treatment was given. During the 9 years since, she had had persistent right lower chest pain and chest X-ray (CXR) had shown a "persistently elevated right diaphragm", but these had been treated as iatrogenic neuropathic pain and phrenic nerve palsy respectively. ⋯ Intra-operatively, the right half of the liver was found to have herniated into the chest via a massive fenestration (10 cm × 9 cm) in the right hemidiaphragm. The defect was repaired via a combined thoracotomy and laparotomy approach. This case serves as an advisory that in patients with persistent ipsilateral chest pain and a raised hemidiaphragm following surgery for catamenial pneumothorax, diaphragmatic fenestration and abdominal visceral herniation should be suspected amongst the differential diagnoses.