Pleural Effusion

Pleural effusion, sometimes referred to as “water on the lungs,” is the build-up of excess fluid between the layers of the pleura outside the lungs. The pleura are thin membranes that line the lungs and the inside of the chest cavity and act to lubricate and facilitate breathing. Normally, a small amount of fluid is present in the pleura.

Symptoms

Some patients with pleural effusion have no symptoms, with the condition discovered on a chest X-ray that is performed for another reason. The patient may have unrelated symptoms due to the disease or condition that has caused the effusion. Symptoms of pleural effusion include:

• Chest pain
• Dry, non-productive cough
• Dyspnea (shortness of breath, or difficult, labored breathing)
• Orthopnea (the inability to breathe easily unless the person is sitting up straight or standing erect)

Causes

The most common causes of transudative (watery fluid) pleural effusions include:

• Heart Failure
• Pulmonary Embolism
• Cirrhosis
• Post open heart surgery

Exudative (protein-rich fluid) pleural effusions are most commonly caused by:

• Pneumonia including Tuberculosis
• Cancer
• Pulmonary Embolism
• Kidney Disease
• Inflammatory disease

Other less common causes of pleural effusion include:

• Autoimmune disease
• Bleeding (due to chest trauma)
• Chylothorax (due to trauma)
• Rare chest and abdominal infections
• Asbestosis pleural effusion (due to exposure to asbestos)
• Meig’s syndrome (due to a benign ovarian tumor)
• Ovarian hyperstimulation syndrome

Certain medications, abdominal surgery and radiation therapy may also cause it. It may occur with several types of cancer including lung cancer, breast cancer and lymphoma. In some cases, the fluid itself may be malignant (cancerous), or may be a direct result of chemotherapy.

Diagnosis

The tests most commonly used to diagnose and evaluate include:

• Chest X-ray 
• Computed Tomography (CT) of the chest
• Ultrasonography of the chest
• Thoracentesis (a needle is inserted between the ribs to remove a biopsy, or sample of fluid)
• Pleural fluid analysis (an examination of the fluid removed from the pleura space)

When it has remained undiagnosed despite previous, less-invasive tests, thoracoscopy may be performed. Thoracoscopy is a minimally invasive technique, also known as video-assisted thoracoscopic surgery, or VATS, performed under general anesthesia that allows for a visual evaluation of the pleura). Often, treatment of the effusion is combined with diagnosis in these cases.

Treatment

• Treatment is based on the underlying condition and whether the effusion is causing severe respiratory symptoms, such as shortness of breath or difficulty breathing.
• Diuretics and other heart failure medications are used to treat pleural effusion caused by congestive heart failure or other medical causes. A malignant effusion may also require treatment with chemotherapy, radiation therapy or a medication infusion within the chest.
• A pleural effusion that is causing respiratory symptoms may be drained using therapeutic thoracentesis or through a chest tube (called tube thoracostomy).
• For patients who that are uncontrollable or recur due to a malignancy despite drainage, a sclerosing agent (a type of drug that deliberately induces scarring) occasionally may be instilled into the pleural cavity through a tube thoracostomy to create a fibrosis (excessive fibrous tissue) of the pleura (pleural sclerosis).
• Pleural sclerosis performed with sclerosing agents (such as talc, doxycycline, and tetracycline) is 50 percent successful in preventing the recurrence of pleural effusions.

Surgery

If cannot be managed through drainage or pleural sclerosis may require surgical treatment.

The two types of surgery include:

Video-assisted thoracoscopic surgery (VATS)

A minimally-invasive approach that is completed through 1 to 3 small (approximately ½ -inch) incisions in the chest. Also known as thoracoscopic surgery, this procedure is effective in managing pleural effusions that are difficult to drain or recur due to malignancy. Sterile talc or an antibiotic may be inserted at the time of surgery to prevent the recurrence of fluid build-up.

Thoracotomy (Also referred to as traditional, “open” thoracic surgery)

A thoracotomy is performed through a 6- to 8-inch incision in the chest and is recommended for pleural effusions when infection is present. A thoracotomy is performed to remove all of the fibrous tissue and aids in evacuating the infection from the pleural space. Patients will require chest tubes for 2 days to 2 weeks after surgery to continue draining fluid.

Surgeon will carefully evaluate you to determine the safest treatment option and will discuss the possible risks and benefits of each treatment option.

What is Ascites?

Ascites is a condition in which fluid collects in spaces within your abdomen. If severe, ascites may be painful. The problem may keep you from moving around comfortably. Ascites can set the stage for an infection in your abdomen. Fluid may also move into your chest and surround your lungs. This makes it hard to breathe.

Indications for Ascitic Fluid Tap (Abdominal Paracentesis)

• To aid diagnosis of the cause of ascites or in the diagnosis or exclusion of SBP
  • A diagnostic paracentesis should be performed in all patients with new onset grade 2 or 3 ascites, and in all patients hospitalized for worsening of ascites or any complication of cirrhosis

Samples in paracentesis

• Microbiology
  • Microscopy, culture & sensitivities (be explicit if yeast or mycobacterium suspected)
  • Culture in blood culture bottles inoculated at the bedside
• Hematology
  • Automated WCC count (send EDTA sample)
• Biochemistry
  • Albumin, Protein, LDH, Glucose
  • Remember to send a serum albumin, LDH and glucose at the same time (or at least from the same day).
  • Special tests: Fluid amylase,  Triglycerides, Bilirubin
• Cytology
  • Sent the largest sample
• Samples can also be sent for immunology (RF, ANA) and TB culture if clinically indicated

Contraindications to ascitic tap (paracentesis)

• Overlying infection
  • Chose another site
• Cautions – but not contraindications
  • Coagulopathy (INR>2.0)
    • Attempt to correct INR to <1.5 if possible.
  • Platelets<50
    • Thrombocytopenia and coagulopathy is often present in liver disease and though it is a caution, it not a contraindication to paracentesis or drainage
    • The incidence of clinically significant bleeding is low; routine FFP or platelets is not indicated
  • Pregnancy
  • Organomegaly
  • Obstruction/ileus
  • Distended bladder
  • Abdominal adhesions

What is Pontine Hemorrhage?

Pontine hemorrhages are a common form of intracerebral hemorrhage, and usually are a result of poorly controlled long-standing hypertension, although also have other causes. When due to chronic hypertension, the stigmata of chronic hypertensive encephalopathy are often present. It carries a very poor prognosis.

The pons is the largest component of the brain stem. When blood flow to the pons becomes interrupted, it causes a pontine stroke or pons stroke. When the disruption is caused by a blood clot in particular, it’s referred to as a pontine infarction or pontine infarct.

Epidemiology

Primary pontine hemorrhage accounts for ~7.5% (range 5-10%) of hemorrhagic strokes and has an incidence of ~3 per 100,000 people.

Cause of Pontine Stroke

Pontine strokes can be classified as either ischemic or hemorrhagic.

An ischemic stroke occurs when an artery in the brain becomes blocked by a blood clot, while a hemorrhagic stroke occurs when an artery in the brain bursts. Pontine strokes make up approximately 7% of all ischemic strokes (pontine infarct) and 10% of hemorrhagic strokes.

Hypertension and diabetes are two of the most common risk factors for all ischemic strokes and especially lacunar infarcts, a type of ischemic stroke that occurs in the deep areas of the brain such as the pons.

Other common causes of pontine stroke include diseases that affect the arteries such as small artery disease, large artery atherosclerosis (when the arteries become thickened with plaque), and cardiogenic emboli (when a blood clot travels from the heart to the brain).

Clinical Presentation of Pontine Hemorrhage

Patients present with sudden and precipitous neurological deficits. Depending on the speed at which the hematoma enlarges and the exact location, presentation may include:

• Decreased level of consciousness (most common)
• Long tract signs including quadriparesis
• Cranial nerve palsies
• Seizures
• Cheyne-Stokes respiration
• Pin-Point Pupil
• Dysarthria
• Dysphagia
• Locked-in syndrome: Involves paralysis of all four limbs (tetraplegia) as well as the face. The eyes are still able move. The survivor retains full cognitive function, aware of their environment but unable to interact with it except with eye movement — as long as the other areas of the pons that control eye movement were unaffected.
• Pure sensory deficits

Pathology

As is the case with penetrating arteries into the basal ganglia, the penetrating arteries from the basilar artery extending into the pons are subject to lipo-hyalinosis as a result of poorly-controlled hypertension. This renders the vessel wall prone to rupture. The larger paramedian perforators are more commonly the culprit vessels.

Radiographic features of Pontine Hemorrhage

CT

CT of the brain is usually the first, and often the only, investigation obtained upon presentation. Features typical of an acute intraparenchymal hemorrhage are noted, usually located centrally within the pons (on account of the larger paramedian perforators usually being the site of bleeding).

The hematoma more frequently extends in a rostro-caudal direction along the traversing long tracts rather than laterally into the middle cerebellar peduncle. Usually the hematoma does not extend beyond the pontomedullary junction inferiorly and the inferior midbrain superiorly. These hematomas frequently rupture into the 4th ventricle.

MRI

In patients who have small volume bleeds and who are thought to possibly have an underlying lesion, MRI may be of use (e.g. identification of a vascular malformation).

Treatment and Prognosis

Patient with this hemorrhages have a poor prognosis, with large bleeds being almost universally fatal. Open surgical evacuation of the clot is usually not performed, although stereotactic clot aspiration has been advocated by some.

In smaller hemorrhages, medical management and treatment of hydrocephalus with extraventricular drains may be life-saving, however, often with significant residual neurological deficits.

Overall mortality ranges between 30% and 90%, with the overall volume of the bleed and initial GCS being related to outcome.

Rehabilitation for Pontine Stroke Survivors

Rehabilitation can take many forms to address the unique secondary effects caused by a pontine stroke. Therapists will help you create a custom rehabilitation plan that addresses your unique goals to improve movement and/or sensation.

One major goal of rehabilitation is to spark neuroplasticity to help rewire the brain and recover as much function as possible. Neuroplasticity is activated through massed practice as the brain gets better at the activities and skills that we repeatedly practice.

Here are some of types of therapy that are commonly used to treat the effects of a pontine stroke:

Physical Therapy

During physical therapy, your therapist will guide you through rehabilitation exercises that help improve mobility in the affected muscles. Survivors with severe motor impairments can start slow with passive range of motion exercises to help prevent complications such as contractures or pressure sores. Passive movement also helps spark neuroplasticity and rewire the brain. Over time, they may be able to progress to more active exercises and even strengthening.

Occupational Therapy

Your occupational therapist specializes in maximizing independence with the activities of daily living. Your OT will provide you with both functional exercises and any necessary compensation techniques to help you complete your daily tasks. They can also offer recommendations for home modifications to help prevent falls, discuss safety concerns and precautions following sensation loss, and provide resources for getting back to work or back to drive again.

Speech Therapy

Speech therapists are able to address difficulties with speaking, swallowing, and general communication skills. They may use a variety of exercises to improve the strength and coordination of the muscles surrounding your mouth and face. They can also suggest methods of communication other than speaking, called augmentative and alternative communication (AAC). For example, if you have locked-in syndrome, they may recommend using technology designed to track your eye movements to communicate.

Home Therapy

A strong home exercise program after stroke can make a noticeable difference during recovery. Whether you have mild, moderate, or severe effects that you wish to recover, your therapist can provide suitable exercises for you to practice at home. Home therapy is essential to keep the brain constantly stimulated and maximize neuroplasticity.

Sensory Retraining

Sometimes a pontine stroke can cause changes in sensation such as numbness, tingling, or difficulty sensing temperature. For these sensory issues, sensory retraining exercises might be able to help. It involves safely exposing your skin to various textures and temperatures to stimulate the brain.

Recovery from Pontine Stroke

Overall, a pontine stroke can affect movement and/or sensation on one or both sides of the body. Although pontine infarcts are technically small in nature, they can create significant effects such as locked-in syndrome, especially when both sides of the pons were affected.

Fortunately, with a rigorous rehabilitation regimen, survivors can stimulate the brain and maximize their chances of recovery. Not all survivors will achieve a full recovery, but it’s a possibility for many. Approach your stroke recovery prognosis with curiosity to see how far you can go.

What is Urinary Bladder Cancer?

Urinary Bladder cancer is a common type of cancer that begins in the cells of the bladder. The bladder is a hollow muscular organ in your lower abdomen that stores urine.

Urinary bladder cancer most often begins in the cells (urothelial cells) that line the inside of your bladder. Urothelial cells are also found in your kidneys and the tubes (ureters) that connect the kidneys to the bladder. Urothelial cancer can happen in the kidneys and ureters, too, but it’s much more common in the bladder.

Most bladder cancers are diagnosed at an early stage, when the cancer is highly treatable. But even early-stage bladder cancers can come back after successful treatment. For this reason, people with bladder cancer typically need follow-up tests for years after treatment to look for bladder cancer that recurs.

What are Urinary bladder Cancer types?

There are three types of urinary bladder cancer. Each type is named for the cells that line the wall of your bladder where the cancer started. Bladder cancer types include:

• Transitional cell carcinoma: This cancer starts in transitional cells in the inner lining of your bladder wall. About 90% of all bladder cancers are transitional. In this cancer type, abnormal cells spread from the inner lining to other layers deep in your bladder or through your bladder wall into fatty tissues that surround your bladder. This bladder cancer type is also known as urothelial bladder cancer.
• Squamous cell carcinoma: Squamous cells are thin, flat cells that line the inside of your bladder. This bladder cancer accounts for about 5% of bladder cancers and typically develops in people who’ve had long bouts of bladder inflammation or irritation.
• Adenocarcinoma: Adenocarcinoma cancers are cancers in the glands that line your organs, including your bladder. This is a very rare type of bladder cancer, accounting for 1% to 2% of all bladder cancers.
• Small cell carcinoma of the bladder: This extremely rare type of bladder cancer affects about 1,000 people in the U.S.
• Sarcoma: Rarely, soft tissue sarcomas start in bladder muscle cells.

Healthcare providers may also categorize bladder cancer as being noninvasive, non-muscle-invasive or muscle-invasive.

• Noninvasive: This bladder cancer may be tumors in a small section of tissue or cancer that’s only on or near the surface of your bladder.
• Non-muscle-invasive: This refers to bladder cancer that’s moved deeper into your bladder but hasn’t spread to muscle.
• Muscle-invasive: This bladder cancer has grown into bladder wall muscle and may have spread into the fatty layers or tissues on organs outside of your bladder.

Risk Factors for Urinary Bladder Cancer

• Cigarette smoke: Smoking cigarettes more than doubles your risk of developing bladder cancer. Smoking pipes and cigars and being exposed to second-hand smoke may also increase your risk.
• Radiation exposure: Radiation therapy to treat cancer may increase your risk of developing bladder cancer.
• Chemotherapy: Certain chemotherapy drugs may increase your risk.
• Exposure to certain chemicals: Studies show that people who work with certain chemicals used in dyes, rubber, leather, paint, some textiles and hairdressing supplies may have an increased risk.
• Frequent bladder infections: People who have frequent bladder infections, bladder stones or other urinary tract infections may be at an increased risk of squamous cell carcinoma.
• Chronic catheter use: People who have a chronic need for a catheter in their bladder may be at risk for squamous cell carcinoma.

Symptoms of Urinary Bladder Cancer

Bladder cancer signs and symptoms may include:

• Blood in urine (hematuria), which is painless and may cause urine to appear bright red or cola colored, though sometimes the urine appears normal and blood is detected on a lab test
• Frequent urination
• Painful urination
• Back pain

Diagnosis of Urinary Bladder Cancer

• Urinalysis: Providers use a variety of tests to analyze your pee. In this case, they may do urinalysis to rule out infection.
• Cytology: Providers examine cells under a microscope for signs of cancer.
• Cystoscopy: This is the primary test to identify and diagnose bladder cancer. For this test, providers use a pencil-sized lighted tube called a cystoscope to view the inside of your bladder and urethra. They may use a fluorescent dye and a special blue light that makes it easier to see cancer in your bladder. Providers may also take tissue samples while doing cystoscopies.

If urinalysis, cytology and cystoscopy results show you have bladder cancer, healthcare providers then do tests to learn more about the cancer, including:

• Transurethral Resection of Bladder Tumor (TURBT): Providers do this procedure to remove bladder tumors for additional tests. TURBT procedures may also be a treatment, removing bladder tumors before the tumors can invade your bladder’s muscle wall. This test is an outpatient procedure done under spinal or general anesthesia.
• Magnetic Resonance Imaging (MRI): This imaging test uses a magnet, radio waves and a computer to take detailed images of your bladder.
• Computed Tomography (CT) Scan: Providers may do this test to see if cancer has spread outside of your bladder.
• Chest X-ray: This test lets providers check for signs bladder cancer has spread to your lungs.
• Bone scan: Like a chest X-ray, bone scans check for signs bladder cancer has spread to your bones.
• Biopsies to look for cancer spread.

How do I take care of myself?

About half of all people with bladder cancer have early-stage cancer that’s relatively easy to treat. But bladder cancer often comes back (recurs). People who’ve had bladder cancer will need regular checkups after treatment. Being vigilant about follow-up care is one thing you can do to take care of yourself. Here are some other suggestions from the Bladder Cancer Advocacy Network include:

• Follow a heart-healthy diet: Plan menus that include skinless poultry and fish, low-fat dairy products, nuts and legumes, and a variety of fruits and vegetables.
• Focus on high-fiber foods: Bladder cancer treatment may cause digestive issues and a fiber-rich diet may help.
• Get some exercise: Gentle exercise may help manage stress.
• Connect with others: Bladder cancer often comes back. It’s not easy to have a rare disease that’s likely to return. Connecting with people who understand what you’re going through may help.

A note from Bhavishya Clinic+

If you have bladder cancer, it may help to know about half of all people with the condition receive treatment when their tumors are limited to the inner layer of their bladder wall. For them, surgery to remove tumors means they’re cancer-free. But bladder cancer often comes back (recurs). If you’re worried about recurring cancer, talk to your healthcare provider. They’re your best resource for information on risk factors that increase the chance you’ll have another bout of bladder cancer. They’ll help you stay vigilant about symptoms that may be signs of recurring bladder cancer and be there for you if you need more bladder cancer treatment.