Functional Adhesion of Pectin Biopolymers to the Lung Visceral Pleura

Pleural injuries and the associated “air leak” are the most common complications after pulmonary surgery. Air leaks are the primary reason for prolonged chest tube use and increased hospital length of stay. Pectin, a plant-derived heteropolysaccharide, has been shown to be an air-tight sealant of pulmonary air leaks. Here, we investigate the morphologic and mechanical properties of pectin adhesion to the visceral pleural surface of the lung. After the application of high-methoxyl citrus pectin films to the murine lung, we used scanning electron microscopy to demonstrate intimate binding to the lung surface. To quantitatively assess pectin adhesion to the pleural surface, we used a custom adhesion test with force, distance, and time recordings. These assays demonstrated that pectin–glycocalyceal tensile adhesive strength was greater than nanocellulose fiber films or pressure-sensitive adhesives (p < 0.001). Simultaneous videomicroscopy recordings demonstrated that pectin–glycocalyceal adhesion was also stronger than the submesothelial connective tissue as avulsed surface remnants were visualized on the separated pectin films. Finally, pleural abrasion and hyaluronidase enzyme digestion confirmed that pectin binding was dependent on the pleural glycocalyx (p < 0.001). The results indicate that high methoxyl citrus pectin is a promising sealant for the treatment of pleural lung injuries.

Lung Ultrasound in Pediatrics and Neonatology: An Update

The potential role of ultrasound for the diagnosis of pulmonary diseases is a recent field of research, because, traditionally, lungs have been considered unsuitable for ultrasonography for the high presence of air and thoracic cage that prevent a clear evaluation of the organ. The peculiar anatomy of the pediatric chest favors the use of lung ultrasound (LUS) for the diagnosis of respiratory conditions through the interpretation of artefacts generated at the pleural surface, correlating them to disease-specific patterns. Recent studies demonstrate that LUS can be a valid alternative to chest X-rays for the diagnosis of pulmonary diseases, especially in children to avoid excessive exposure to ionizing radiations. This review focuses on the description of normal and abnormal findings during LUS of the most common pediatric pathologies. Current literature demonstrates usefulness of LUS that may become a fundamental tool for the whole spectrum of lung pathologies to guide both diagnostic and therapeutic decisions.

Medical adhesive vs hookwire for computed tomography-guided preoperative localization and risk factors of major complications

Objective: To compare the efficacy of medical adhesive and hookwire as CT-guided non-palpable pulmonary nodule (NPN) localization methods before video-assisted thoracoscopic surgery (VATS) resection, and determine the risk factors for common complications during localization. Methods: This was a single-center non-randomized retrospective study. 102 consecutive patients with 109 NPNs were divided into Group A (medical adhesive, 66 patients, 72 nodules) and Group B (hookwire, 36 patients, 37 nodules) before VATS. Patient- and nodule-based characteristics were compared. Logistic regression was performed to identify the risk factors for complications. Results: Localization was successfully performed in all the NPNs. For Group A, the rate of pneumothorax immediately after localization was lower (p = 0.049) and the localization-to-surgery interval was longer (p = 0.011) than Group B. There was no significant difference in rates of hemorrhage after needle withdrawal between the two groups (p = 0.198). Hookwire ( vs medical adhesive) (β = 1.12, p = 0.018), total insertion depth (β = −0.41, p = 0.013), pleura-needle angle (β = −0.04, p = 0.025) and grade of hemorrhage after needle withdrawal (β = −0.96, p = 0.030) were independently associated with pneumothorax, while age (β = −0.94, p = 0.018), tumor size (β = 0.29, p = 0.007) and its distance from the pleural surface (β = 0.14, p = 0.004) were associated with higher grade hemorrhage after needle withdrawal. Conclusion: Compared with hookwire, localization with medical adhesive excelled in lower risk of pneumothorax, a more flexible localization-to-surgery interval, and had similar rates of hemorrhage after needle withdrawal. Hookwire is an independent risk factor of pneumothorax immediately after localization. Advances in knowledge: This study added new clinical evidence to the efficacy of medical adhesive in pre-operative CT-guided NPN localization.

Intrapleural Foreign Body: Case Report

The detection of foreign bodies in the pleural cavity is rare and mostly consequent to iatrogenic or traumatic events. The migration of an inhaled foreign body from the airways to the pleural space through a bronchopleural fistula is an exceptional event. We report a case of a pleural empyema consequent to an inhaled wooden skewer. CT scan and bronchoscopy were unable to identify the foreign body, due to its migration in the peripheral airways. The thin and pointed foreign body perforated the visceral pleural surface emerging in the pleural cavity.

Strongyloidiasis in a Puppy in Northeastern Brazil

Background: Strongyloides stercoralis is a nematode that causes intestinal infection in vertebrate hosts, especially in humans and dogs. The species S. stercoralis is responsible for chronic and asymptomatic infections in adult dogs or serious infections in puppies and immunosuppressed animals. In Brazil, natural infection in dogs was demonstrated by coproparasitological and serological methods, however, there are no reports that address the clinicopathological characteristics of the infection in the canine species. Thus, this paper aims to describe the epidemiological, clinical and pathological aspects of S. stercoralis infection in a puppy in Northeastern Brazil.Case: A puppy female Chihuahua was referred to the Animal Pathology Laboratory of the Veterinary Hospital of the Federal University of Campina Grande for necropsy with a historic of severe respiratory symptoms and gastrointestinal changes that included sanguineous diarrhea and vomiting that evolved to death in 5 days. Grossly, there was a moderate amount of slightly reddish fluid in the thoracic cavity. The lungs remained expanded with a smooth, shiny, and diffusely reddish pleural surface interspersed with multifocal and blackened coalescent areas. Upon cutting, a moderate amount of slightly yellow foamy liquid flowed from the airways and trachea. In the duodenum, the mucosa was diffusely reddened. Histologically, there were multifocal to coalescent areas of moderate interalveolar accumulation of fibrin, edema and hemorrhage in the lung surrounded by an inflammatory infiltrate composed of foamy macrophages associated with numerous parasitic structures in longitudinal and transverse sections in the alveolar lumen and pleural surface. In the duodenum, we observed flattening with diffuse and moderate fusion of the villi and multifocal areas of mucosal erosion. The crypts were moderately dilated, covered by attenuated epithelium, with numerous longitudinal and transversal sections of adult nematode parasites, larvae and eggs associated with inflammatory lymphplasmocytic infiltrate in the lamina propria. The morphological characteristics were compatible with the nematode S. stercoralis.Discussion: The diagnosis of strongyloidiasis was performed by means of microscopic lesions associated with parasitic structures morphologically compatible with the nematode S. stercoralis. This species is responsible for parasitism especially in humans, dogs, and cats. Parasites are the only ones that have a life cycle that involve free living form and parasitic. In this case, it was not possible to determine the primary portal of entry for the infection, but most infections commonly occur through the penetration of the larvae into the skin or mucous membranes, where they migrate via the haematogenous to the lung, then they are swallowed up to the intestine. Occasionally, there is autoinfection by larvae that enter the intestinal mucosa or perianal region and the contamination of neonates and puppies through the ingestion of milk. The clinical signs evidenced in this case, revealed the committed respiratory and gastrointestinal, possibly may be related to the migration of the larvae in the lungs and the destruction of the intestinal epithelium caused by the high number of parasites, respectively. It is concluded that strongyloidiasis is an uncommon infectious disease in puppies in Brazil, capable of causing severe respiratory and gastrointestinal changes that result in the death of animals with a high parasitic load and should be included in the differential diagnosis of diseases that affect the respiratory system and gastrointestinal tract of dogs.Keywords: dog disease, parasitic infection, nematode, Strongyloides stercoralis.

The Rise of Lung Ultrasound in the Era of COVID-19

The current global pandemic caused by the novel coronavirus severe acute respiratory syndrome coronavirus 2 (SARS-COV-2) presents a huge challenge for physicians. Rapid diagnosis, triage and clinical management of these patients is a challenge for physicians but may be aided using lung ultrasound. Lung ultrasound has been in use for over 10 years mainly by critical care practitioners and emergency physicians with variable uptake, but it has gained popularity during the Coronavirus disease-2019 (COVID-19) pandemic as a diagnostic tool and can be easily learned compared to the other ultrasound techniques. Image interpretation is based on identifying artefacts generated by the pleural surface. This technique is non-invasive and can be performed rapidly at the patient’s bedside. It has higher accuracy in diagnosis than auscultation and Chest X-ray (CXR) combined. In this article the authors describe the interpretation of lung ultrasound images, particularly in patients with COVID-19 and discuss indications for this technique. Physicians are recommended to gain familiarity with this technique and use of online resources for guidance.

Preoperative computed tomography-guided localization of lung nodules with needle placement: a series of cases

ABSTRACT Objective: to report the preoperative localization of pulmonary nodules with the placement of a guidewire oriented by Computed Tomography. Methods: the nodules were marked using a needle in the shape of a hook or another in the shape of a Q, guided by tomography. The choice of the location for the marking was the shortest distance from the chest wall to the nodule. The marking procedure was performed under local anesthesia and a tomographic control was obtained immediately at the end. Patients were referred to the operating room. Surgical resection occurred less than two hours after the needle placement. Results: between February 2017 and October 2019, 22 patients aged 43 to 82 years (mean 62.1) were included. The nodules had diameters that varied from 4 to 30 mm and the distance between the nodules and the pleural surface varied from 2 to 43 mm. The location and resection of the nodules were successfully performed in all cases. The guidewire was displaced in five cases. Five patients presented pneumothorax, with the space between the visceral and parietal pleura varying from 2 to 19 mm. In nine patients, an intraparenchymal hematoma of 6 to 35 mm in length was observed without signs, symptoms, or hemodynamic and ventilatory repercussions. The histopathological study was conclusive in all patients. Conclusions: the localization of pulmonary nodules through guidewires proved to be safe, reliable, and feasible in this series of cases. There was no need for surgical intervention to treat complications.

WFUMB position paper on reverberation artefacts in lung ultrasound: B-lines or comet-tails?

The analysis of vertical reverberation artefacts is an essential component of the differential diagnosis in pulmonary ultra-sound. Traditionally, they are often, but not exclusively, called B-line artefacts (BLA) and/or comet tail artefacts (CTA), but this view is misleading. In this position paper we clarify the terminology and relation of the two lung reverberation artefacts BLA and CTA to spe-cific clinical scenarios. BLA are defined by a normal pleura line and are a typical hallmark of cardiogenic pulmonary edema after exclusion of certain pathologies including pneumonia or lung contusion, whereas CTAs show an irregular pleura line representing a variety of parenchymal lung diseases. The dual approach using low frequency transducers to determine BLA and high frequency transducer to determine the pleural surface is recommended.