Objectives: To develop a clinical prediction rule (CPR) for the diagnosis of pleural tuberculosis (PT) in patients with pleural exudates in Peru. Methods: Clinical and laboratory information was collected from patients with exudative pleural effusion attending two reference hospitals in Lima, Peru. Predictive findings associated with PT in a multiple logistic regression model were used to develop the CPR. A definite diagnosis of PT was based on a composite reference standard including bacteriological and/or histological analysis of pleural fluid and pleural biopsy specimens. Results: A total of 238 patients were included in the analysis, of whom 176 had PT. Age, sex, previous contact with a TB patient, presence of lymphadenopathy, and pleural adenosine deaminase (ADA) levels were found to be independently associated with PT. These predictive findings were used to construct a CPR, for which the area under the receiver operating characteristics curve (AUC) was 0.92. The single best cut-off point was a score of ≥60 points, which had a sensitivity of 88%, specificity of 92%, a positive likelihood ratio of 10.9, and a negative likelihood ratio of 0.13. Conclusions: The CPR is accurate for the diagnosis of PT and could be useful for treatment initiation while avoiding pleural biopsy. A prospective evaluation is needed before its implementation in different settings.

Thoracic injuries caused by blunt trauma are commonly encountered emergencies in veterinary medicine. However, no literature exists comparing radiography to computed tomography (CT) in blunt thoracic trauma caused by motor vehicle accidents in canine patients. The aim of this prospective case series was to estimate the sensitivity (Se) and specificity (Sp) of thoracic radiography relative to CT for detecting lung contusions, pneumothorax, pleural effusion and rib fractures. The study further aimed to establish a severity scoring system for radiography and CT and to compare the findings between the two modalities. The hypothesis was that radiography would be less sensitive than CT at detecting these injuries and that radiography would underestimate the severity of lung contusions compared to CT. Fifty-nine patients met the inclusion criteria. Radiography underestimated the presence of lung contusions (Se = 69%, 95% Confidence interval (CI)) and overestimated the severity of the contusions relative to CT. There was also high interobserver variability in evaluating lung contusion severity (coefficient of variation = 91%). Both the three-view thoracic and horizontal beam radiography had poor sensitivities for the detection of pneumothorax (Se = 19% and 63% respectively) and pleural effusions (Se = 43% and 71% respectively). Similarly, the sensitivity (56%) of three-view thoracic radiographs for the detection of rib fractures was poor relative to CT. To conclude, three-view thoracic radiography had low sensitivity for pathology related to blunt thoracic trauma caused by motor vehicle accidents and CT could be considered as an additional diagnostic imaging modality in these patients. / Dissertation (MMedVet (Diagnostic Imaging))--University of Pretoria, 2019. / Companion Animal Clinical Studies / MMedVet (Diagnostic Imaging) / Unrestricted

A prospective study was undertaken to assess the diagnostic value of various rapid diagnostic tests for tuberculosis in pleural fluid, and to assess the sensitivity and speed of a radiometric mycobacterial culture system (BACTEC, Johnson Laboratories). Patients presenting to the Department of Medicine at Groote Schuur Hospital with pleural effusions for diagnostic pleural aspiration and biopsy over a 6 month period were entered into the study. Because the incidence of tuberculous effusions was observed to be high in this population (65% of 94 patients), patients from the Department of Radiotherapy with proven malignant disease and the development of new pleural effusions requiring diagnostic or therapeutic aspiration were included in the study in order to increase the number of control patients without tuberculosis. The 111 patients (17 of whom were recruited from the Department of Radiotherapy) were divided into 4 diagnostic categories: tuberculosis - 62 patients, malignant - 28 patients, miscellaneous conditions - 10 patients, and undiagnosed - 11 patients (3 of whom probably had tuberculosis). There were 59 male patients. The racial distribution was 11 whites, 51 of mixed race, and 49 blacks. Exudative pleural effusions were present in 109 patients. Closed pleural biopsies with the Abrams needle were performed on 100 patients using a modified version of the standard technique whereby larger specimens were obtained by stripping pleura off the chest wall. Seven pleural biopsies were reported as inadequate by the pathologist and the diagnostic yield of the procedure was 63%. Tuberculosis was confirmed histologically or by culture in 62 patients. The age distribution of these patients was bimodal, with most cases occuring in the third decade. The presentation was usually acute, with 60% of patients being symptomatic for less than 4 weeks. Granulomata were found on initial pleural biopsy in 52 cases (84%). Pleural biopsy culture was positive in 44 cases (71%). The radiometric culture system tested (12B BACTEC) yielded the same number (14) of positive cultures as conventional mycobacterial culture media in pleural fluid, but was almost twice as fast. Bedside inoculation of pleural fluid into 13A BACTEC bottles more than doubled the yield in the 24 patients tested (11 positive cultures compared with 4 each for conventional and 12B BACTEC media, p=0.046). The rapid diagnostic tests assessed on pleural fluid were adenosine deaminase (ADA), an antigen (BCG) capture enzymelinked immunosorbent assay (ELISA), and a specific DNA probe after amplification with the polymerase chain reaction. ADA was found to have a sensitivity of 0.77 and a specificity of 0.83 in the 109 patients tested, and values were significantly higher in tuberculosis patients compared with the other three diagnostic categories (p< 0.001 ). The ELISA test was performed on 103 patients and showed a sensitivity of only 0.26 and a specificity of 0.72. The DNA probe was performed on 43 patients, and had a sensitivity of 0.93 with a specificity of 0.43. Contamination of samples or latent tuberculous infection may have been responsible for the poor specificity of the DNA probe.

In this MMed thesis I have reviewed retrospectively the pericardial aspirations performed between 1 July 1987 and 12th October 1989 at Groote Schuur Hospital, Cape Town. Documenting the reasons for aspiration, the complications of pericardiocentesis, and how cytologic, bacteriologic and biochemical examination of the aspirate influenced the clinicians' management of the 52 patients reviewed. The relatively low mortality of less than 2% is noted, in a procedure carried out for the relief of cardiac tamponade in 57% of the patients. A significant relationship between an ADA level higher than 51 international units per litre and a positive culture of mycobacterium tuberculosis from pericardial aspiration is demonstrated. The relatively low successful culture of mycobacterium tuberculosis (32% of the 29 patients clinically assessed as having tuberculous pericarditis) is noted, and recommendations to improve the yield from culture are made.

京都大学 / 0048 / 新制・課程博士 / 博士(医学) / 甲第19572号 / 医博第4079号 / 新制||医||1013(附属図書館) / 32608 / 京都大学大学院医学研究科医学専攻 / (主査)教授 萩原 正敏, 教授 小西 靖彦, 教授 齊藤 博英 / 学位規則第4条第1項該当 / Doctor of Medical Science / Kyoto University / DFAM

Impingement is the most commonly used method of cooling in the hot stages of gas turbines. This is often combined with film cooling to further increase the cooling performance. The mainstream flow where in the coolant films discharge often has large stream wise pressure variations. All existing studies on coupled film and impingement cooling concentrated on the effect of the film depletion on the impingement heat transfer. This study investigates the impact of impingement on film cooling, where the jets impinging on a flat plate are depleted through arrays of film cooling holes in the presence of pressure gradient in the main gas path. The main characteristic of the test setup is that there is an impingement wall on the backside of the film effusion wall. The fluid used for both impingement flow and main flow is air. The impingement flow is heated as opposed to the usual practice of heating mainflow, and the array of film holes are configured under the impingement jet hole arrays such that there is no direct impingement on the film holes. The static pressure variations and Mach number (0.01 to 0.3) in the mainstream underneath the flat plate are controlled by inserts with varying flow area. The detailed temperature distribution on the film-covered surface is measured using the Temperature Sensitive Paint (TSP) technique, and film cooling effectiveness is calculated from the measurements. Results are presented for averaged impingement jet Reynolds numbers of 5000 and 8000. The effect of impingement on film effectiveness is studied by comparing the results from the two cases: one where film flow is directly supplied from a plenum and the other where the post- impingement flow is depleted through film effusion holes. The results are presented for cylindrical film cooling holes which are inclined at angles of 20 deg and 30 deg with respect to the target plate surface. The variation of the effectiveness of the film hole arrays along the mainstream are studied in detail. It is observed that the impingement through jet effects the pressure distribution on the target plate with film holes, which in turn affects the blowing rates of each row. The change in the blowing ratios because of a different pressure distribution on the impingement side of the target plate causes the effectiveness to change. From the results it is observed that the farther rows of impingement are affected by the pressure distribution underneath the film holes and have more flow through the film cooling rows, this increases the inlet flow of the films which increase the blowing ratios and in turn decreases the effectiveness of the film cooling holes. The pressure distribution and the change of effectiveness are studied in detail.

Effectiveness of impedance audiometry in diagnosing serous otitis media in children was examined in this study. The impedance test battery was performed on seventy-six ears of pre-myringotomy children (Mean age: 4.6 years). The status of the middle ear was assessed by the operating physician during surgery, and impedance results were correlated with the operative findings. Middle ear effusion was the variable that most influenced impedance results. Acoustic reflex threshold and tympanometry were the most sensitive tests in predicting effusion. Multiple correlations between these tests and the presence of significant effusion indicated that both measures together are diagnostically more sensitive than either test alone. Also, reflex measurement at one test frequency is as accurate a predictor of effusion as reflex measurement at all frequencies.

Introdução: A pleurodese com talco é o método mais popular para controle sintomático do derrame pleural maligno recidivante. A administração intrapleural do talco pode ser por videotoracoscopia ou dreno de tórax e qual o melhor método é uma questão controversa. Ainda que a expansão pulmonar seja um dos principais critérios de sucesso do procedimento, suas características pós-pleurodese ainda são pouco estudadas. Objetivo: Avaliar a expansão pulmonar após dois diferentes métodos de pleurodese com talco (dreno de tórax ou videotoracoscopia) em pacientes com derrame pleural maligno recidivante, considerando a evolução radiológica, diferença entre os métodos e correlação com desfecho clínico. O objetivo secundário foi comparar ambos os métodos quanto a: efetividade clínica, segurança, qualidade de vida e sobrevivência. Método: Estudo prospectivo randomizado que incluiu 60 pacientes (45 Mulheres, 15 Homens, idade média: 55,2 anos) com derrame pleural maligno recidivante entre janeiro de 2005 e janeiro de 2008. Os pacientes foram alocados em dois grupos: videotoracoscopia com insuflação de talco (VT) ou instilação de talco por dreno de tórax (DT). A expansão pulmonar imediata e a evolução da expansão pulmonar foram avaliadas através de tomografias de tórax obtidas nos primeiros 7 dias, 1, 3 e 6 meses após a pleurodese, as quais foram analisadas por dois observadores independentes. Efetividade clínica (considerada como ausência de necessidade de novos procedimentos pleurais durante o seguimento), complicações, tempo de drenagem e de internação hospitalar e qualidade de vida (questionários gerais e específicos) foram também analisados. A análise estatística foi realizada através dos testes de Qui-quadrado e Fisher para as variáveis categóricas e Mann-Whitney para variáveis contínuas não paramétricas. A sobrevivência foi analisada através do método de Kaplan- Meier e o teste de log-Rank para foi usado para identificar fatores que interferissem na sobrevida. Os resultados dos questionários de qualidade de vida foram avaliados através de ANOVA de duplo-fator. Resultados: Não houve diferença significativa entre os grupos nas variáveis clínicas préoperatórias. A expansão imediata total (>90%) foi observada em 27 (45%) pacientes e foi mais freqüente no grupo VT (60 vs. 30%, p=0.027). Durante o seguimento, 71% dos pacientes estudados tiveram melhora ou ao menos mantiveram a expansão pulmonar observada na 1ª tomografia, fato que ocorreu de forma semelhante entre os grupos (p=0,58). Novos procedimentos pleurais foram necessários em 9(15%) pacientes (5 recidivas no grupo VT e 4 no grupo DT, p=0.999). Não foram encontradas diferenças entre os grupos quanto a: complicações, tempo e de internação. A análise dos questionários de qualidade de vida revelou resultados semelhantes para ambos os grupos. A expansão pulmonar imediata não se correlacionou com recidiva radiológica, recidiva clínica ou complicações (p= 0.60, 0.15 e 0.20, respectivamente). A sobrevida após ambos os procedimentos foi semelhante, porém a ocorrência de recidivas foi um fator relacionado a sobrevida mais curta (p=0,02). Conclusão: Expansão pulmonar imediata parcial foi freqüente, particularmente no grupo DT. Contudo, manutenção do quadro radiológico e até melhora radiológica ocorreram na maioria dos casos. Não foi encontrada correlação entre expansão pulmonar imediata e desfecho clínico neste estudo. / Introduction: Talc pleurodesis is the most popular method to control recurrent malignant pleural effusion symptoms. Two methods may be used to deliver talc into the pleural space: videothoracoscopy or talc slurry through a chest tube ; which is the best method is still controversial. Although lung expansion is the most accepted pleurodesis outcome variable, its features are poorly studied. Objective: To analyze and compare radiological lung expansion after talc pleurodesis performed either by videothoracoscopy or chest tube and correlate it with clinical outcome. Secondary endpoints evaluated were: clinical efficacy, safety, quality of life and survival. Methods: Prospective randomized study that included 60 patients (45 Female, 15 Male, mean age: 55,2 years) with recurrent malignant pleural effusion, between January, 2005 and January, 2008. They were enrolled into two groups: videothoracoscopic talc poudrage (VT) and talc slurry through a chest tube (TS). Lung expansion was evaluated through chest CT scans obtained in the first 7 days and 1, 3 and 6 months after pleurodesis. All examinations were revised by two independent observers. Clinical efficacy (considered as lack of new procedures during follow up), complications, drainage duration, hospital stay and quality of life (general and specific questionnaires) were also analyzed. Categorical variables were compared with the Chi-Square test or Fisher´s exact test for small samples. Mann-Whitney test was used to compare continuous non parametric variables. Survival curves were calculated according to the Kaplan-Meier method and Log-rank test was used to identify factors that could interfere with survival. Double factor ANOVA was used to compare quality of life questionnaires results. Results: No significant difference in pre-procedure clinical variables was observed between groups. Postoperative lung expansion was total (>90%) in 27 (45%) patients and was more frequent in VT group (60% vs. 30%, p=0.027). During follow-up 71% of the patients showed unaltered or improved lung expansion and lung expansion evolution was similar in both groups (p=0.58). Nine (15%) patients needed new pleural procedures (5 recurrences in VT group and 4 in DT group, p=0.999). No statistical difference was found between groups regarding complications, drainage time and hospital stay. Quality of life questionnaires were evaluated but no difference between study arms was observed. There was no correlation between initial lung expansion and clinical recurrence, radiological recurrence or complications (p = 0.60, 0.15 and 0.20, respectively). No difference in survival between study arms was observed, but a shorter survival was observed in patients that developed clinical recurrence (p=0.02). Conclusion: Immediate partial lung expansion was a frequent finding and was more frequent in TS group. However, maintenance of the radiological image and even radiological improvement occurred in most cases. No correlation between immediate lung expansion and clinical outcome was found in this study

Introdução: O derrame pleural, reduzindo a capacidade funcional pulmonar, torna os pacientes incapacitados para o desenvolvimento de suas atividades habituais. A retirada do líquido pleural através da toracocentese pode reverter este quadro, porém seu impacto especialmente na capacidade ao exercício não foi totalmente estabelecido. Objetivos: Avaliar o impacto da toracocentese de alívio na capacidade funcional ao exercício, no comportamento da função pulmonar e na força dos músculos respiratórios 48 horas pós toracocentese. Casuística e Método: Foram incluídos no estudo 25 pacientes com derrame pleural unilateral, documentado por radiografia de tórax. O teste de caminhada de seis minutos (TC6M), a escala modificada de dispnéia de Borg, as variáveis espirométricas: Capacidade Vital Forçada (CVF), Volume Expiratório Forçado no Primeiro Segundo (VEF1) e as medidas de Pressão Inspiratória Máxima (Pimax) e Pressão Expiratória Máxima (Pemax) foram analisados antes e 48 horas após a retirada de volumes superiores a 600 mL. Resultados: Foram removidos 1564 + 695 mL de líquido pleural. Os valores da distância percorrida, da CVF, do VEF1, da Pimax e da Pemax aumentaram (p < 0,001) enquanto o escore de dispnéia diminuiu (p < 0,001) após o procedimento. Observaram-se correlações estatísticas (p < 0.001) entre a distância percorrida e a CVF (r = 0.725) e VEF1 (r = 0.661) avaliadas 48 horas pós toracocentese e entre a variação da distância percorrida e a variação porcentual da CVF (r = 0,450) e do VEF1 (r = 0,472), corrigidos pelo volume de líquido retirado (p < 0,05). Conclusão: Embora ocorra melhora da função pulmonar após a toracocentese, os benefícios observados são mais evidentes em situações de esforço, o que possibilita melhor readaptação dos pacientes às suas atividades rotineiras. / Introduction: Pleural effusion reducing pulmonary functional capacity hinders patients in carrying out their habitual activities. Pleural fluid removal by thoracentesis reverts the clinical situation but its impact especially on exercise capacity has not yet been determined. Objectives: To evaluate the impact of thoracentesis in functional exercise capacity on pulmonary function and on muscle strength 48 hours after thoracentesis. Methods: Twenty five patients with unilateral pleural effusion documented by chest X-ray were included. The 6 minute walk test (TC6M), Borg\'s modified dyspnea scale, spirometric variables: CVF (forced vital capacity), VEF1 (forced expiratory volume in the first second), Maximum Inspiratory Pressure (Pimax) and Maximum Expiratory Pressure (Pemax) were analyzed before and 48 hours after the removal of volumes greater than 600 mL. Results: The mean of pleural effusion removed was 1564 + 695 mL. After the procedure values of walked distance, CVF, VEF1, Pimax and Pemax covered increased (p < 0.001) while dyspnea decreased (p < 0.001). Statistical correlations (p < 0.001) between the walked distance and FVC (r = 0.725) and VEF1 (r = 0.661) were established noted measured 48 hours post thoracentesis and between the variation of the distance walked and the percentage of variation of CVF (r = 0.450) and VEF1 (r = 0.472), corrected by the volume of fluid removed (p < 0.05). Conclusions: Despite an improvement in lung function after thoracentesis, the benefits noted are more evident in effort situations of exertion, allowing a better readaptation of patients to their routine activities.

OBJECTIVES: Bacterial infections in the normally sterile environment of the middle ear cavity usually trigger host immune response, whereby the innate immune system plays a dominant role as the host’s first line of defense. In this study we evaluated the expression levels of Toll-like receptors (TLRs) -2, -4, -5, -9, and nucleotidebinding oligomerization domain-containing proteins (NODs) -1 and -2, all of which are related to bacterial infection in pediatric patients with otitis media with effusion (OME). METHODS: The study sample consisted of 46 pediatric patients with OME, all of whom had ventilation tubes inserted. The expression levels of TLR-2, -4, -5, -9, NOD-1 and -2 mRNA in middle ear effusion were assessed by polymerase chain reaction. RESULTS: All effusion fluid samples collected from patients with OME showed expression of TLR-2, -4, -5, -9, NOD-1, and -2 mRNA. However, we found no correlations among expression levels of pattern recognition receptors (PRRs) in relation to characteristics of exudates, presence of bacteria, or frequencies of ventilation tube insertion (p>0.05). CONCLUSION: Our findings suggest that exudates of OME patients show PRR expressions that are related to the innate immune response regardless of the characteristics of effusion fluid, presence of bacteria in exudates, or frequency of ventilation tube insertion.