ID: 58: ACUPUNCTURE THERAPY, AN UNDERREPORTED CAUSE OF PNEUMOTHORAX

Introduction

Acupuncture is usually portrayed as a risk-free therapy; but is it? We report a case of a tension pneumothorax following acupuncture therapy.

Case Presentation

A 70 year-old-man was receiving acupuncture therapy for right-sided post-herpetic neuralgia involving the 4th–7th intercostal nerves. Shortly after, he started complaining of severe dyspnea and pleuritic chest pain and was transferred to the emergency department. His SpO2 was 77% on room air, respiratory rate 38/min, heart rate 129/min and blood pressure 154/82 mm Hg. Absence of breath sounds was noted on the right side. Chest X-ray (CXR) revealed a right-sided pneumothorax with mediastinal shift (figure 1). A 14F chest tube was placed and a follow-up CXR showed resolution of the pneumothorax. On hospital day#2, the air leak resolved and the chest tube was clamped, but the patient developed subcutaneous emphysema requiring unclamping of the chest tube and attaching it to suction (–40 cm H2O). On day#4, the chest tube was removed. Serial CXRs were done showing stable subcutaneous emphysema and absence of pneumothorax. He was discharged home on day#7 only to be readmitted 48h later with recurrent pneumothorax requiring placement of another 14F chest tube. Due to persistent air leak on suction, a chest CT was done showing small anterior right-sided pneumothorax and right-sided subpleural bullae (figure 2). Thoracic surgery was consulted and a Video-assisted thoracoscopic excision of ruptured bullae with talc pleurodesis was performed. He was discharged home on hospital day#13. At one month follow-up, he remained asymptomatic.

Discussion

Acupuncture is one of the most popular of all alternative therapies, and is a relatively safe procedure. Although rare; pneumothorax is the most reported serious complication. In a prospective observational study in Germany, the incidence of acupuncture-related pneumothorax was 1/100000 patients (1). Unfortunately, this study included various acupuncture treatments and not only the ones where needling of the thorax occurred.

High quality studies are absent and most data come from case reports. In a review of the Chinese literature, 30 cases were reported between 1980 and 2013(2). In the English literature, 26 cases were reported between 1965 and 1999(3), and 13 cases between 2000 and 2011, with only 3 cases in the USA(4).

Most reported cases have in common the lack of an informed consent. We are reporting this case to increase the awareness toward recognizing pneumothorax as a potential complication of acupuncture, and reinforce the need of an informed consent where benefits and risks of acupuncture therapy are discussed.

Abstract ID: 58 Figure 1

A Longitudinal Study of Idiopathic Exudative Lymphocytic Pleural Effusion in Older People

OBJECTIVES

To assess the long-term prognosis of older patients with idiopathic exudative lymphocytic pleural effusion.

DESIGN

Prospective observational study.

SETTING

A university-affiliated tertiary care center.

PARTICIPANTS

Forty-seven consecutive patients (aged 74.9+/-5.4) with idiopathic exudative lymphocytic pleural effusion were enrolled over a 42-month period.

MEASUREMENTS

Baseline sociodemographic information, clinical data, and Charlson Comorbidity Index score were obtained. After an exhaustive examination, clinical evaluation and periodic chest radiographs were taken until one of the endpoints was met: complete resolution of the pleural effusion, death from all causes, or the end of the study period.

RESULTS

The mean follow-up period was 16.3+/-17.0 months. During the course of the study, complete resolution of the pleural effusion occurred in 17% of the patients, whereas it remained stable in 45%, and progressed in 38%. In seven cases, the cause of the effusion was established after an average of 84 days, and in another two, the diagnosis was made postmortem. Malignancy was documented in eight of the nine cases. Although the burden of comorbidities and cardiac function at baseline were similar in the three categories, the 3-year survival rate was 63%, 5%, and 0%, respectively. None of the patients developed active tuberculosis, although 15% had positive tuberculin test.

CONCLUSION

By categorizing the presence of idiopathic effusion into resolving, persistent, or progressive, this study may provide a more practical approach to the long-term prognosis of older patients with idiopathic exudative lymphocytic effusion who refuse or are considered too frail to undergo an invasive procedure.

Increase in intranuclear nuclear factor kappaB and decrease in inhibitor kappaB in mononuclear cells after a mixed meal: evidence for a proinflammatory effect

BACKGROUND

In view of the stimulatory effect of glucose on reactive oxygen species (ROS) generation, we investigated the possibility that a mixed meal stimulates ROS generation and possibly induces concomitant proinflammatory changes.

OBJECTIVE

The objective was to determine whether the intake of a 900-kcal mixed meal induces an increase in ROS generation by leukocytes and an inflammatory response at the cellular level.

DESIGN

Nine normal-weight subjects were given a 900-kcal mixed meal, and 8 normal-weight subjects were given 300 mL water after an overnight fast. Blood samples were collected at 0, 1, 2, and 3 h. ROS generation by mononuclear cells and polymorphonuclear leukocytes and the expression of p47(phox) subunit were measured. Intranuclear nuclear factor kappaB (NF-kappaB) binding and the expression of inhibitor kappaBalpha (IkappaBalpha), IkappaB kinase alpha (IKKalpha), and IkappaB kinase beta (IKKbeta) were measured. Plasma concentrations of C-reactive protein (CRP) and soluble intercellular adhesion molecule were also measured.

RESULTS

ROS generation by mononuclear cells and polymorphonuclear leukocytes and p47(phox) expression increased significantly. The expression of IKKalpha and IKKbeta and DNA-binding activity of NF-kappaB increased significantly, whereas IkappaBalpha expression decreased. Plasma CRP concentrations increased. The intake of 300 mL water did not induce a change in any of the above indexes.

CONCLUSIONS

These data show that the intake of a mixed meal results in significant inflammatory changes characterized by a decrease in IkappaBalpha and an increase in NF-kappaB binding, plasma CRP, and the expression of IKKalpha, IKKbeta, and p47(phox) subunit. These proinflammatory changes are probably relevant to the state of chronic hypertension and obesity and to its association with atherosclerosis.

Earthquakes: health outcomes and implications in Lebanon

Earthquakes remain damaging to human life and property. Recent reports point out that there is 50% chance to have a damaging earthquake in the next 50 years in Lebanon. Major health outcomes of earthquakes include physical injuries, cardiovascular effects and psychological reactions. Physical injuries are correlated with entrapment, higher number of floors in buildings and behavior at time of impact. Cardiovascular effects of earthquakes are either immediate or delayed. Immediate cardiovascular effects are exemplified by increased coronary death while delayed effects are reflected by the increase in coronary risk factors such as serum triglycerides and heart rate. The severity of PTSD decreases as the distance from the epicenter of the earthquake increases. Preventive measures such as implementation of safety building codes, medical emergency readiness and public education should be carried out in areas threatened by earthquakes. Also special mental health programs should be executed following an earthquake.