African Journal of Thoracic and Critical Care Medicine最新文献

Background: 'Forgotten' goitre (FG) is a mediastinal portion of the thyroid found after total thyroidectomy. It is extremely rare.

Objectives: To report on 5 cases and review the literature.

Methods: We retrospectively reviewed all patients with retrosternal goitre at Mohammed V Military Teaching Hospital, Rabat, Morocco, from 1 January 2010 to 31 December 2020 and identified 5 patients who underwent surgery for forgotten mediastinal goitre during this period. Data on patient characteristics, time of the first thyroidectomy, imaging (chest radiograph, chest computed tomography (CT) scan and magnetic resonance imaging), surgical approach, pathological findings and postoperative complications were collected.

Results: Five patients (3 female and 2 male) with a mean age of 46.2 years (range 32 - 56 years) with FG had surgery. Two patients were asymptomatic and 3 patients had dyspnoea, 2 of whom also had dysphonia and 1 signs of hyperparathyroidism. No patient had a history of thyroid cancer. The average time between the first thyroidectomy and re-operation was 4.3 years. The diameter of the masses on CT scan was 7 - 12 cm. All the patients underwent sternotomy. Postoperative transitory left recurrent laryngeal nerve palsy occurred in 1 case. There were no postoperative deaths. Pathological examination of the mediastinal goitre confirmed multi-heteronodular thyroid hyperplasia in all cases.

Conclusion: FG is an extremely rare condition, which can be prevented with thorough preoperative imaging.

Study synopsis: What the study adds. 'Forgotten' goitre is a mediastinal portion of the thyroid found after total thyroidectomy. It is extremely rare. We report on 5 cases.Implications of the findings. Thorough preoperative imaging of retrosternal goitre can prevent the occurrence of forgotten goitre and its associated morbidities. Sternotomy is usually required for reoperation, highlighting the importance of complete initial thyroidectomy.

We describe a rare case of perinatally acquired extensively drug-resistant tuberculosis in an infant. The infant was successfully treated with an individualised all-oral multidrug regimen containing delamanid, a drug rarely described in the treatment of perinatal tuberculosis. What the study adds. This brief report offers insight into a clinical case of perinatally acquired extensively drug-resistant tuberculosis (XDR-TB), and outlines the individualised treatment plan that led to a successful treatment outcome. Implications of the findings. The report highlights the need for evidence-based guidance on XDR-TB in this paediatric population, as well as further research on preventive strategies for mitigating mother-to-child transmission of TB.

Background: Inhalational exposures in the operating theatre, such as waste anaesthetic gases, surgical smoke, airborne particles, microbiological contaminants and cleaning agents, may compromise lung function.

Objectives: To evaluate pulmonary function test (PFT) values of operating theatre staff who work in resource-constrained settings.

Methods: This comparative cross-sectional study included 184 participants (exposed and matched unexposed cohorts). Data were acquired via a structured questionnaire, and the standard procedure was used to calculate each participant's forced vital capacity (FVC), forced expiratory volume in 1 second (FEV₁), FEV₁/FVC ratio and peak expiratory flow rate (PEFR). Mann-Whitney U-tests, Kruskal-Wallis tests, Spearman analysis and multiple linear regression analysis were used to investigate the statistical relationships between variables. A p-value <0.05 was considered significant.

Results: The study cohort comprised 38 surgeons, 28 anaesthetists, 14 scrub nurses and 12 assistants, with a median age of 34 years. The median age for the matched unexposed cohort was 33 years. The healthcare staff had significantly lower FEV₁ , FVC and PEFR values and FEV₁ /FVC ratios (p<0.05) than the unexposed cohort. These values decreased significantly as staff experience/exposure time increased (p=0.001). Furthermore, the scrub nurses and assistants had significantly lower PFT values than the other healthcare groups (p=0.001).

Conclusion: The study showed that PFT values were considerably lower among operating theatre healthcare staff than in a matched unexposed group, with measures decreasing as staff experience/duration of exposure rose.

Study synopsis: What the study adds. Since occupational lung disease places significant pressure on the healthcare system, this study evaluated the spirometric lung function of healthcare staff who worked in an environment without proper respiratory safeguards.Implications of the findings. The hospital environment may trigger respiratory problems, particularly for healthcare staff who work in operating theatres, restricting their economic productivity. It is therefore vital to establish, execute and maintain high-quality procedures that guarantee workplace health and safety, especially in settings with limited resources.

Background: Both open and closed intensive care unit (ICU) models are used in South Africa (SA). The literature is unclear with regard to which model is superior. The COVID-19 pandemic led to a critical care resource crisis that necessitated expansion of critical care capacity, often beyond the resources required to meet the structure of a closed ICU in the institutions using that model.

Objectives: This retrospective study aimed to compare the outcomes of non-COVID patients in a closed ICU setting and a temporary open unit that ran parallel to it during the pandemic, in order to assess this type of resource expansion as a viable option.

Methods: Data from the Intensive Care Electronic Record System in the Greys Hospital ICU in Pietermaritzburg, SA, were analysed for patients aged ≥12 years admitted to either the open or the closed ICU between April and August 2020. Data missing from the database were completed by referring to the medical records office. The primary outcome assessed was mortality, while secondary outcomes included adverse events and hospital length of stay.

Results: There was no significant mortality difference between the ICU components (16.9% in the open-model group v. 15.1% in the closed model group; p=0.769). The incidence of adverse events also did not differ (45.5% in the open model v. 38.9% in the closed model; p=0.357).

Conclusion: Patients requiring ICU admission have complex conditions or have undergone extensive surgery, necessitating specialised treatment and careful monitoring. In the event of an acute surge event, expanding ICU capacity by adding an open-model component in a setting that traditionally runs closed models may be an effective strategy to assist in the management of critically ill patients without significantly affecting outcomes.

Study synopsis: What the study adds. This retrospective study compared outcomes of non-COVID patients in a closed intensive care unit (ICU) v. a temporary open unit during the pandemic. The efficacy of open v. closed ICU models remains uncertain in the South African context. The study offers insights into the effectiveness of open and closed ICU models, particularly in the context of crises during which institutions may face a critical care resource shortage.Implications of the findings. The study suggests that incorporating open ICU units during crises can manage patient surges effectively without compromising outcomes. It contributes to the existing literature by providing practical implications for resource management, clinical practice and future research, ensuring quality patient care while optimising critical care capacity.

Background: Pulmonary hypertension (PH) after tuberculosis is increasingly recognised as important in high-burden tuberculosis settings. However, the ability of computed tomography (CT) imaging to accurately detect PH remains unclear.

Objectives: To evaluate the performance of standard CT measurements in detecting PH in patients with post-tuberculosis lung disease (PTLD), and to determine the potential role of CT imaging as a screening tool in this population.

Methods: A retrospective study of patients with PTLD was conducted from January 2019 to September 2021. Adult patients with both a CT chest scan and an echocardiogram performed within 9 months of each other were enrolled. A diagnosis of PH by echocardiography was made if the right ventricular systolic pressure (RVSP) was ≥36 mmHg or the peak tricuspid regurgitant jet velocity (TRVmax) >2.8 m/s. Radiological criteria for PH included a pulmonary artery/ascending aorta (PA/AA) diameter ratio >1, pulmonary artery diameter (PAD) ≥29 mm (males) or ≥27 mm (females), and right ventricle/left ventricle (RV/LV) diameter ratio ≥1.28. Spirometry was also performed.

Results: Of 173 patients with PTLD, 52 met the inclusion criteria. Significant correlations were found between the CT-measured PA/AA ratio and RVSP (p=0.0083) and TRVmax (p=0.0582), but not between the CT-measured RV/LV ratio and RVSP (p=0.1729) or TRVmax (p=0.0749). PAD was also significantly correlated with RVSP (p=0.0011) and TRVmax (p=0.0023). The PA/AA ratio identified patients with PH on echocardiography with ~100% sensitivity, 65% specificity and a positive predictive value of 39.1%, indicating a high potential for false-positive diagnosis. The forced vital capacity was 13.7% lower in patients with PH than in those without (p=0.044); however, the forced expiratory volume in 1 second was not statistically different.

Conclusion: A low PA/AA ratio can be used to rule out the diagnosis of PH in PTLD, but a high PA/AA ratio requires further investigation for PH.

Study synopsis: What the study adds. This study investigated the use of computed tomography (CT) chest imaging to detect pulmonary hypertension (PH) in patients with post-tuberculosis lung disease (PTLD). It revealed significant correlations between the CT-measured pulmonary artery/ascending aorta (PA/AA) diameter ratio and pulmonary artery diameter (PAD), and echocardiographic measures of PH. Notably, a low PA/AA ratio effectively rules out PH, while a high ratio warrants further investigation.Implications of the findings. These findings suggest that CT imaging, particularly PA/AA ratio measurements, could serve as a valuable initial screening tool for ruling out PH in patients with PTLD, particularly in settings with limited access to echocardiography. However, a high PA/AA in PTLD requires confirmation of PH by other means, owing to

Background: Transbronchial biopsy (TBB) with a cryoprobe, also known as transbronchial lung cryobiopsy (TBLC), has become a well established modality for sampling lung parenchyma. TBLC is performed under general anaesthesia in the majority of centres, utilising rigid or flexible bronchoscopy. In resource-constrained settings, however, most diagnostic bronchoscopies, including TBB, are performed under conscious sedation with flexible bronchoscopy without the presence of a specialist anaesthetist.

Objectives: Given the paucity of evidence on TBLC performed under conscious sedation for interstitial lung diseases (ILD), specifically in a resource-constrained setting, we aimed to describe its utility in a pilot study.

Methods: We prospectively enrolled the first 20 patients who underwent TBLC for ILD at a large tertiary hospital in South Africa. All TBLCs were performed under conscious sedation using a cryoprobe. Patients were actively monitored for complications. The final diagnosis and decision regarding need for a surgical biopsy were made at a multidisciplinary meeting that included at least two specialist pulmonologists with an interest in ILD, a thoracic radiologist, and an anatomical pathologist with an interest in ILD.

Results: Three patients experienced complications. Two (10%) developed a pneumothorax (neither required any intervention). Bleeding that required 10 minutes of tamponade with the endobronchial blocker was observed in one case. This patient experienced no haemodynamic or respiratory compromise and was discharged the same day. There were no complications arising from the use of conscious sedation. A definitive diagnosis was made in 17/20 (85%) of the patients.

Conclusion: TBLC performed at an experienced bronchoscopy centre using a cryoprobe under conscious sedation with a dedicated sedationist was safe and well tolerated. Furthermore, it had a high diagnostic yield, and surgical lung biopsy was avoided in 85% of the patients.

Study synopsis: What the study adds. There is a paucity of evidence for the use of transbronchial lung cryobiopsy (TBLC) for the diagnosis of interstitial lung diseases (ILD) in resource-constrained settings, especially when performed under conscious sedation. In this pilot study, TBLC performed under conscious sedation was safe and well tolerated, and had a high diagnostic yield.Implications of the findings. TBLC under conscious sedation can safely be rolled out in resource-constrained settings as a first-line diagnostic procedure when lung tissue needs to be obtained in patients with ILD, as its yield is comparable to TBLC under general anaesthesia. It potentially avoids surgical lung biopsy in >80% of cases, together with the need for general anaesthesia.