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Capitonnage Results in Low Postoperative Morbidity in the Surgical Treatment of Pulmonary Echinococcosis

The main surgical techniques in the treatment of pulmonary echinococcosis are cystotomy alone, cystotomy and capitonnage, enucleation, and pericystectomy. Controversy persists regarding the selection of surgical technique. We reviewed our experience to identify the impact of capitonnage on outcomes.

 Methods

A single-institution retrospective analysis was made of the 308 consecutive patients with thoracic hydatid disease treated surgically during 17 years.

 Results

The most common presenting symptoms were cough and chest pain. At presentation, 69 patients (22.4%) had complicated hydatid disease, cyst rupture into bronchus in 62 and into pleural cavity in 7. Bilateral involvement occurred in 37 patients (12.0%), simultaneous hepatic cysts in 36 (11.6%), and intrathoracic extrapulmonary involvement in 14 (4.5%). Surgery consisted of cystotomy with capitonnage in 271 patients (92.2%), cystotomy and closure of bronchial openings in 20 (6.8%), and lobectomy in 3 (1.0%). Hospital mortality was zero; postoperative complications developed in 21 patients (6.8%).

 Conclusions

Cystotomy with capitonnage has a low complication rate. Pulmonary resection is best limited to patients with parenchymal destruction secondary to infection.

Safety of long-acting {beta} agonists for the treatment of asthma: clearing the air

Concerns about the safety of long-acting β2-agonist (LABA) therapy, has led to the appearance of multiple publications and recommendations.

This review critically examines the available clinical evidence and safety requirements for LABA use. On the basis of nearly 20 systematic reviews and databases, the authors conclude that LABA monotherapy significantly increases the risk of asthma-related adverse effects. We also conclude that the use of LABAs concomitantly with inhaled corticosteroids (ICS) significantly reduces asthma hospitalisations and is not associated with life-threatening events and asthma-related deaths, especially when concurrent use of LABAs and ICS can be reasonably assured (use of a single inhaler device). An appropriate clinical study would require an extremely large sample, making it impractical.

Finally, some of the new US Food and Drug Administration (FDA) recommendations have caused confusion and do not appear to be fully evidence based. Although limited by low statistical power, the evidence supports the use of LABAs plus ICS in a single inhaler device (to increase adherence and reduce the potential use of LABA monotherapy) for all patients (not only children) with moderate to severe asthma.

What's new in respiratory infections and tuberculosis 2008-2010

Over the past few years there have been an increasing number of research articles published in Thorax on respiratory tract infections (including tuberculosis) affecting children and adults. Although these articles cover a wide variety of areas, several broad themes can be discerned.

These include greater interest in viral respiratory infections (partially stimulated by the recent influenza A pandemic), improved characterisation of who is at risk of community-acquired pneumonia and mycobacterial infection, research into better diagnostics and attempts to develop new or improved scoring scales for a range of respiratory infection syndromes. There have also been a limited number of articles on how to manage patients with respiratory infection, including describing the efficacy of prevention by vaccination.

Overall, there has been a discernible emphasis on transferring advances in clinical science to actual clinical practice, with several papers using molecular methodologies or measuring levels of cytokines or other potential biomarkers to improve diagnostic accuracy in patients with lung infection. There have also been manuscripts linking specific pathogen genotypes to infection phenotype, an area that is likely to be increasingly important in explaining some of the variations in severity between patients with respiratory infection.

However, many questions remain on the optimum strategies for the management and prevention of pneumonia, bronchiectasis and tuberculosis, and there remains a strong need for further clinical research in order to make substantial improvements in the management of patients with lung infection.

Rapid molecular detection of tuberculosis and rifampicin drug resistance: retrospective analysis of a national UK molecular service over the last decade

Fast and reliable detection of Mycobacterium tuberculosis complex (MTBC) and drug resistance is crucial in establishing effective treatment and enforcing timely public health measures.

 Methods

The authors analysed the performance of a national UK molecular diagnostic service over a decade, based on the use of a line probe assay (Innolipa, LiPA) compared with conventional liquid and solid cultures with rapid molecular identification and culture-based drug resistance testing.

 Findings

Data were available for 7836 consecutive patient samples using LiPA and the reference microbiological technique (conventional liquid and solid cultures with rapid molecular identification and culture-based drug resistance testing). For all sputum specimens (n=3382) the sensitivity, specificity, positive predictive value, negative predictive value and accuracy for MTBC detection were 93.4%, 85.6%, 92.7%, 86.9% and 90.7%; the equivalent values for smear-positive sputum specimens (n=2606) were 94.7%, 80.9%, 93.9%, 83.3% and 91.3%. The sensitivity, specificity, positive predictive value, negative predictive value and accuracy for detection of rifampicin resistance in all sputum samples (n=1667) were 92.1%, 99.3%, 89.4%, 99.5% and 98.9%, respectively; the equivalent values for smear-positive sputum specimens (n=1477) were 93.3%, 99.3%, 87.5%, 99.6% and 99%. Between January 2006 and December 2008, LiPA saved 25.3 and 32.2 days for TB diagnosis and rifampicin resistance of smear-positive samples, respectively.

 Interpretation

A molecular diagnostic service, using a non-automated line probe assay approach, provides a rapid and reliable national service for diagnosing MTBC and rifampicin resistance.

Novel strategies for the management of right ventricular failure with pulmonary hypertension

The authors report a case where four novel strategies were successfully used in the management of advanced right ventricular failure with severe pulmonary hypertension and complex adult congenital heart disease.

These included combination and optimisation of three advanced therapies for pulmonary hypertension, therapeutic abdominal paracentesis, correction of underlying metabolic/endocrine disturbance and a new inotropic agent.

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