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Background The additive benefit of inhaled corticosteroid when used with systemic corticosteroid in acute asthma is still unclear. The objective of this study was to assess the effect of high and repeated doses of inhaled budesonide when combined with the standard treatment of adult acute asthma. Methods It was a prospective double-blind randomized controlled study performed in the emergency department (ED) from May 1, 2010 to February 28, 2011 (ClinicalTrials.gov, NCT04016220). Fifty patients were included and were randomized to receive intravenous hydrocortisone hemisuccinate in association with nebulized budesonide (n = 23, budesonide group) or normal saline (n = 27, control group). Nebulization of budesonide or saline was done in combination with 5 mg of terbutaline every 20 min the first hour, then at 2 h (H2), and 3 h (H3). All patients received standard treatment. Efficacy and safety of inhaled budesonide were evaluated every 30 min for 180 min. Results A significant increase in peak expiratory flow (PEF) was observed in both treatment groups at evaluation times. The increase in PEF persisted significantly compared to the previous measurement in both groups. There was no significant difference in the PEF between the two groups at evaluation times. There was no significant difference between the two groups in the evolution in the respiratory rate and heart rate. There was also no statistically significant difference between the two groups in the rate of hospitalization, the discharge criteria before the end of the protocol. Conclusions Considering its limited power, our study suggests that the association of nebulized budesonide with hydrocortisone hemisuccinate has no additional effect over the use of hydrocortisone alone in adults’ acute asthma managed in the ED.

mediastinal cysts are rare lesions developed from mediastinal structures. They may be acquired like thoracic duct cysts or lymphangiomas or congenital like the bronchogenic cysts, enteric cysts or celomic cysts. These cysts are rare and may cause diagnostic challenges.To assess the major characteristics of these cysts based on a single institution experience.the authors performed a descriptive, retrospective study from January 2009 to March 2020 in a single institution. Cystic lesions taking birth from the mediastinum for which gross features, microscopic features were available were included.this study contained 52 mediastinal cysts that were completely resected and no patient presented complications after the surgical resection. The bronchogenic cysts were the most frequent and represented 57.69% of all lesions. Thymic cysts and pericardial cysts represented respectively 40.38% and 1.92% of the cases. The positive diagnosis was based on the microscopic exam. The final diagnosis was concordant with the radiologic findings in 15 cases reaching a rate of 28%.the diagnosis of mediastinal cysts is based on the microscopic analysis of the cystic wall. Pericardial cysts may be suspected based on their characteristic location in the cardiophrenic angle, thymic cyst may be evoked based on their location in the thymic region and bronchogenic cysts are mainly located in the middle mediastinum. Inspite of these most frequent locations, the cysts may be located in any part of the mediastinum and may be difficult to diagnose when the key diagnostic features are absent.

Vascular lesions in Von Recklinghausen’s disease also known as Neurofibromatosis type 1 (NF1), are rare but have a fatal and potentially life threatening complications such as spontaneous hemothorax. An emergent thoracotomy is indicated when there is an active bleeding associated unstable hemodynamic status. Despites surgery is laborious and unpredictable but it have a merit to stop hemorrhage. A conservative management with endovascular embolization or non-operative approach have also been reported in case of hemodynamic stability. We report two case report of spontaneous hemothorax in patient with Recklinghausen disease. A chest tube was immediately inserted for two patients. Due to continuous bleeding and hemodynamic instability (Patient 1), and the increase of pleural effusion volume (Patients 1 & 2), emergent surgery of thorax was done with favourable post-operative follow up.

Additional file 1: Additional Figure 1. Evolution of the respiratory rate. *p < 0.05 vs baseline in both groups. RR: respiratory rate. Additional Figure 2. Evolution of the dyspnea scale. *p < 0.05vs previous evaluation in both groups. Additional Figure 3. Evolution of the heart rate. * p < 0.05 vs baseline in the control. Additional Table 1. Baseline clinical characteristics in the most severe patients. Additional Table 2 Outcomes and side effects in the most severe patients.

IntroductionEctopic breast tissue is present in 2–6% of women. Ectopic breast cancer represents an uncommon disease accounting for about 0.3% of all breast neoplasms, limiting the available evidence. Thus, we aim to report long-term outcomes in five cases treated at our institution.Case seriesOur Tunisian patients’ median age was 48 years (33–60 years), and the median follow-up was 8 years (4–10 years). The ectopic breast tissue was located four times in the right axilla. The median tumor size was 25 mm (15–55 mm). Four of the patients underwent a wide local excision and axillary lymph node dissection. Three of those women had positive lymph nodes; thus, they received adjuvant chemotherapy, radiation therapy, and hormone therapy. The patient with a negative lymph node (case 5) had adjuvant radiation therapy and hormonal therapy. One of the patients (case 1) had a positive supraclavicular lymph node and received radiation therapy, chemotherapy, and hormonal therapy. The latter developed a locoregional relapse after 4 years and was treated with mastectomy and chemotherapy. One patient (case 4) had a distant metastasis after 2 years of follow-up and received chemotherapy. The three other patients were free of relapse during their follow-up period.ConclusionPrimary axillary breast carcinoma is a rare entity. Despite the paucity of literature, our findings and authors’ recommendations suggest that local excision can be performed safely with promising outcomes in this subset of patients.

Synovial sarcoma is a soft tissue sarcoma. Its occurrence as a primary mediastinal neoplasm is very rare. We report a case of mediastinal synovial sarcoma in a 14‐year‐old girl with exertive dyspnoea at presentation. On physical examination, there was a superior vena cava syndrome and café‐au‐lait spots. Chest X‐ray revealed a white left hemithorax with mediastinal deviation to the opposite side. Thoraco‐abdomino‐pelvic scanner showed a voluminous posterior cervico‐mediastinal tissue mass. Computed tomography (CT)‐guided biopsy of the mediastino‐pleural mass was performed. Histological examination reported fusocellular malignant mesenchymal proliferation. A complementary immunohistological study with a broad range of antibodies was performed with a high‐grade single‐phase spindle cell synovial sarcoma of the mediastinum. She presented a respiratory distress, did not respond to resuscitation, and died. Mediastinal synovial sarcoma is a rare tumour that is difficult to diagnose. Its slow progression and delay in diagnosis may lead to a fatal evolution., Synovial sarcoma is a soft tissue sarcoma. Its occurrence as a primary mediastinal neoplasm is very rare. We report a fatal case of mediastinal synovial sarcoma in a 14‐year‐old girl with exertive dyspnoea at presentation. We highlight the role of imaging, the means of diagnosis, and the importance of the speed of therapeutic management. Mediastinal synovial sarcoma is a rare tumour that is difficult to diagnose. Its slow progression and delay in diagnosis may lead to a fatal evolution.

Objectives:Primary cardiac tumors are rare and account for 0.001 to 0.03% of cardiac lesions. The authors aim to describe the clinical, the microscopic and the therapeutic characteristics of these tumors through a 13-year-experience in order to highlight the diagnostic challenges faced.Methods:We report 10 primary cardiac tumors diagnosed in the Departments of Pathology and Thoracic Surgery of the same hospital through a 13-year-period.Results:Our study was conducted on 7 women and 3 men. The mean age of the patients was 54.22 years (average, 12 to 79 years). Dyspnea represented the most frequent symptom. Physical examination was normal in all patients. Trans-thoracic ultra-sound examination was performed in all patients. Cardiac MRI allowed localizing the tumors in 2 patients. They were located into the left auricle (6 cases), the right auricle (1 case) and the pericardium (3 cases). The microscopic examination was concluded to myxoma (7 cases), haemangioma (2 cases) and hemangioendothelioma (1 case). Surgical resection was possible in 9 patients. It was impossible in the case of hemangioendothelioma because of the adherence. One death was recorded secondary to postoperative arrhythmia. The other patients presented no complications after a follow-up period ranging from 2 months to 5 years.Conclusion:Cardiac tumors are challenging in their diagnosis and management. A positive diagnosis is based on microscopic examination. Surgical treatment plays a key role and is possible in the majority of benign tumors. The prognosis of malignant tumors remains poor even if a complete surgical resection is possible.

The standard control parameters of cardiopulmonary bypass (CPB) currently used in Tunisia are replaced in Western countries by the concept of "goal-directed-perfusion" requiring oxygen delivery (DO2) minimum at 270ml / min / m2.In this study, we explored the association between the DO2 and the postoperative morbidity and mortality.This is a cross-sectional and retrospective observational study including a series of 50 patients operated on for myocardial revascularization under CPB.We noticed a significant correlation between starting DO2i and Creatinine clearance at day 0, Δcreate (day 1-day 0) and ventilation time. There was also a significant correlation between discharge DO2i and daytime urine output, ventilation time, hospital stay and in-hospital mortality. Through a univariable study, we compared the classic parameters of perfusion monitoring during CPB in addition to the starting DO2i with the different postoperative results. It was noted that the starting DO2i figures below the threshold of 270ml / min / m² were significantly correlated with the duration of administration of catecholamines postoperatively, with prolonged ventilation, with the variation in serum creatinine postoperatively and with in-hospital mortality.DO2 is a monitoring tool that has proven its advantages for monitoring under CPB.

Mediastinal paraganglioma presented as a large dumbbell tumor is a rare entity. We report a case of a 47 year old woman who suffered from spinal pain and sporadic lower limb paresis. The imaging studies showed a voluminous mass occupying the posterior mediastinum with right foraminal extension. For excellent results, a combined effort was necessary including thoracic and neurosurgeons teams. Complete resection was successfully performed without laminectomy. The operative course was uneventful.

Lung carcinoid tumours are rare neoplasms with a favourable prognosis. Bronchoplasty can be a conservative treatment for typical carcinoid tumours and can be applied for patients with limited respiratory function. We report the case of a 34‐year‐old woman, with a polypoid tumour located at the distal right main bronchus. Bronchial biopsy showed a typical carcinoid tumour. After resection of the tumour in the right main bronchus, bronchoplasty was performed by end‐to‐end anastomosis of the remaining right main bronchus, right upper lobar bronchus, and the upper bronchus intermedius. Bronchoscopy showed a good quality anastomosis with slightly reduced endoluminal calibre only. The post‐operative period was uneventful and the patient was discharged at the seventh day. One year later, no complications occurred and the patient is still being followed up regularly., In this article, we try to demonstrate the possibility of creating a "neo‐spur" without lobectomy to treat an intra‐bronchial typical carcinoid tumor.

Hamdi Boubaker,1,2 Mohamed Habib Grissa,1,2 Kaouther Beltaief,1,2 Zohra Dridi,3 Mohamed Fadhel Najjar,4 Wahid Bouida,1,2 Riadh Boukef,5 Soudani Marghli,6 Semir Nouira1,2 1Department of Emergency, Fattouma Bourguiba University Hospital, 2Research Laboratory (LR12SP18), University of Monastir, 3Department of Cardiology, 4Department of Biochemistry, Fattouma Bourguiba University Hospital, Monastir, 5Department of Emergency, Sahloul University Hospital, Sousse, 6Department of Emergency, Tahar Sfar University Hospital, Mahdia, Tunisia Background: The goal of this study was to determine the value of systolic time intervals and their change during Valsalva maneuver (VM) in the diagnosis of left ventricular dysfunction (LVD) in patients with acute exacerbation of chronic obstructive pulmonary disease (AECOPD).Methods: We included 166 patients admitted to the emergency department for AECOPD. Measurement of systolic time intervals included electromechanical activation time (EMAT), left ventricular ejection time (LVET), and EMAT/LVET ratio. These were performed at baseline and during the first strain phase of the VM using a computerized phonoelectrocardiographic method. The diagnosis of LVD was determined on the basis of clinical examination, echocardiography, and brain natriuretic peptide. The values of systolic time intervals were compared between patients with and without LVD; their diagnostic performance was assessed using the area under receiver operating characteristic (ROC) curve.Results: Patients with LVD (n=95) had a significantly higher EMAT and lower LVET and EMAT/LVET ratio compared to patients without LVD (n=71); the area under ROC curve was 0.79, 0.88, and 0.90, respectively, for EMAT, LVET, and EMAT/LVET ratio. All baseline systolic time intervals changed significantly during VM in patients without LVD but they did not change in patients with LVD. The area under ROC curve increased to 0.84 and 0.93,­respectively, for EMAT and EMAT/LVET ratio but did not change for LVET.Conclusion: Simple and noninvasive measurements of systolic time intervals combined with VM could be helpful to detect or rule out LVD in patients admitted to the emergency room for COPD excacerbation. The EMAT/LVET ratio seems to have the best diagnostic value. Keywords: chronic obstructive pulmonary disease, exacerbation, systolic time intervals, Valsalva maneuver&nbsp

Background: The objective study was to evaluate the use and the effectiveness of hyperbaric oxygen therapy as an adjuvant therapy in 6 cases of descending necrotizing mediastinitis.Methods: This is a retrospective descriptive study, performed between 2010 and 2019. Hyperbaric oxygen therapy was indicated in difficult clinical management cases despite surgery and antibiotic therapy.Results: Six patients had oxygen therapy sessions in addition to antibiotic treatment and surgery. There was marked clinical and radiological improvement in 5 cases. Only one patient died in a septic shock.Conclusions: Hyperbaric oxygen therapy, as adjuvant therapy to surgery and antibiotic treatment, can increase survival and provide good clinical results.