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Macrophages in tuberculosis: friend or foe.

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Tuberculosis (TB) remains one of the greatest threats to human health. The causative bacterium, Mycobacterium tuberculosis (Mtb), is acquired by the respiratory route. It is exquisitely human adapted and a prototypic intracellular pathogen of macrophages, with alveolar macrophages (AMs) being the primary conduit of infection and disease.

The outcome of primary infection is most often a latently infected healthy human host, in whom the bacteria are held in check by the host immune response. Such individuals can develop active TB later in life with impairment in the immune system. In contrast, in a minority of infected individuals, the host immune response fails to control the growth of bacilli, and progressive granulomatous disease develops, facilitating spread of the bacilli via infectious aerosols coughed out into the environment and inhaled by new hosts. The molecular details of the Mtb-macrophage interaction continue to be elucidated. However, it is clear that a number of complex processes are involved at the different stages of infection that may benefit either the bacterium or the host.

Macrophages demonstrate tremendous phenotypic heterogeneity and functional plasticity which, depending on the site and stage of infection, facilitate the diverse outcomes. Moreover, host responses vary depending on the specific characteristics of the infecting Mtb strain.

In this chapter, we describe a contemporary view of the behavior of AMs and their interaction with various Mtb strains in generating unique immunologic lung-specific responses.

Use of multidetector computed tomography to guide management of pneumothorax

imagePurpose of reviewPneumothorax, a potentially life-threatening condition, is present in about one-third of chest trauma patients. Traditionally, pneumothorax has been diagnosed and managed by use of chest radiography, which has been found inaccurate and inconsistent. With the ubiquitous application of multidetector computed tomography (MDCT) in emergency care, MDCT quantification of pneumothoraces becomes an emerging technique for accurate determination of the size of pneumothoraces. The use of MDCT quantification provides a promising means to improve pneumothorax management. Recent findingsRecent studies have demonstrated that MDCT is the gold standard for detecting pneumothorax and MDCT provides an effective imaging modality for the accurate measurement of the volume of pneumothoraces. The use of MDCT volumetric quantification of pneumothoraces has been evidenced in the improvement of performance in pneumothorax management for clinically stable chest trauma patients. SummaryThe MDCT volumetric quantification of pneumothoraces is a new concept in the care of chest trauma patients and has the potential to improve pneumothorax management. Further clinical studies are needed to establish a MDCT-based clinical guideline for pneumothorax management.

Management of malignant pleural effusions: questions that need answers

imagePurpose of reviewMalignant pleural effusion (MPE) is common. However, regardless of the differences between patients, their underlying cancer type, and pleural fluid characteristics, management options are often limited. These have not advanced significantly over the last 80 years since pleurodesis was first described. Correspondingly, patient-related outcome measures have been neglected. The evidence (or lack of) behind the current treatment recommendations is reviewed and key research questions are described. Recent findingsTalc continues to be the most effective sclerosant available for pleurodesis in MPE. A recent randomized controlled trial comparing talc pleurodesis and indwelling pleural catheter insertion as first-line therapy suggests these approaches are equally effective, and utilized a patient-based symptom score as the primary outcome. The need to acknowledge the advances in translational medicine and oncological therapies to measure patient-related trial outcomes and to target pleural fluid formation in MPE is discussed. SummaryPulmonologists should be aware of the staggering lack of progress in the evidence that supports the current ‘recommended’ management of MPE. The need for a re-think about MPE management with a focus on alternative therapeutic targets and treatment objectives should be appreciated, in order to optimize future patient care.

The increasing incidence of empyema

imagePurpose of reviewThe aim of this review is to highlight recent changes concerning the incidence of empyema. In this article we have focused on community-acquired empyema Recent findingsThe incidence of empyema seems to have been increasing both in children and adults worldwide in the past decades, mainly in healthy young adults and in older patients. The bacteriology of pleural infection is changing as well. In children, the most common microorganism that causes empyema continues to be Streptococcus pneumoniae. Interestingly, the widespread use of the seven valent conjugate vaccine has produced a replacement phenomenon with the emergence of some pneumococcal serotypes such as serotypes 1, 3 and 19A, which have a higher propensity to cause empyema. Moreover increases in the incidence of empyema due to Staphylococcus aureus have also been observed. In adults, increases in the rate of empyema due to Streptococcus milleri group and S. aureus have been reported. SummaryContinued surveillance in the epidemiology of empyema is needed. Progress in new strategies of prevention, such as a new generation of conjugate pneumococcal vaccines and protein-based vaccines, could become an important step in the control of this important complication.

Dysfunction of the diaphragm: imaging as a diagnostic tool

imageThis review summarizes the utility and efficacy of different imaging modalities in the diagnosis of diaphragmatic dysfunction.

Recent findings : Dynamic MRI of the diaphragm has been recently described in the literature as a tool allowing more detailed study of diaphragmatic dysfunction.

Summary : The diaphragm is the primary muscle of ventilation. Diaphragmatic dysfunction can be partial or complete, unilateral or bilateral. The diagnosis is difficult to establish at certain times due to diversity of presentations and severity of symptoms. There are several causes of diaphragmatic dysfunction, which adds to the complexity of diagnostic workup. In this review, the basic anatomy and function of the diaphragm and the different pathologic processes that may affect its function will be presented. These processes may originate in the brain, spinal cord, phrenic nerve or the diaphragm itself. Furthermore, this article will review the utility and efficacy of different diagnostic modalities in the diagnosis of diaphragmatic dysfunction. Most of these imaging tools have been well known for several years, including plain chest radiographs, fluoroscopy and ultrasound.

An emerging mode is magnetic resonance dynamic imaging, which is another potentially effective way of functional diaphragmatic imaging that is still not part of routine clinical practice.

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