Ultrasound guidance reduces pneumothorax rate and improves safety of thoracentesis in malignant pleural effusion: report on 445 consecutive patients with advanced cancer.

Routine use of ultrasound guidance in femoral arterial access for peripheral vascular intervention decreases groin hematoma rates

Effect of the implementation of NICE guidelines for ultrasound guidance on the complication rates associated with central venous catheter placement in patients presenting for routine surgery in a tertiary referral centre

Background: Preoperative chemotherapy in breast cancer (bc) provides unique possibilities to evaluate effects of therapy by studying response and changes in the tumor during the course of treatment. A pathologic complete response (pCR) correlates positively with long term prognosis in high-proliferating bc. In triple negative bc (TNBC) the prognosis was still relatively serious in cases with pCR in one large meta-analysis (Cortazar Lancet 2014). Methods: 150 cases were included in this multicenter study, and treated with six cycles of epirubicin and docetaxel, adding bevacizumab from cycle 3, before surgery. Core needle biopsies were collected at free hand or with ultrasound (US) guidance and snap frozen at base-line and after cycle 2, tissue was also collected at surgery. Subtyping was performed using immunohistochemistry (IHC) of ER, Ki67 and HER2 according to modified St Gallen criteria; and using bead array gene expression profiling (GEX) according to PAM50. Results: Biopsies were successfully retrieved from 145/150 pts at baseline, 138 after cycle 2 and 139 at surgery. The mRNA yield was adequate for GEX from 123/145 (85%) at baseline, 82/138 (59%) at cycle 2 and 71/139 (51%) at surgery, the decrease being a result of tumor shrinkage during treatment. Initial PAM50 subtypes were as follows: luminal A (LA) 20%, luminal B (LB) 45%, HER2 5 %, basal like (BL) 22% and normal like (NL) 8%. PAM50 at baseline differed compared to IHC subtypes. Among IHC defined LA-like cases 15/33 (45%) were classified as LB by PAM50. Similarly, among IHC LB-like 22/57 (39%) were classified as non-LB (6 basal, 8 LA, 3 HER2 and 5 NL), while among IHC TNBC 7/28 (25%) were classified as non-BL subtypes (1 LA, 3 HER2 and 3 NL). Of the pts with a baseline GEX analysis, 17 (14%) achieved a pCR. The observed pCR rates among PAM50 subtypes were: LA 8%, LB 5%, HER2 17%, BL 53% and NL 20%. For non-pCR cases, 39/52 (75%) of the tumors changed PAM50 subtype between baseline and surgery. The majority changed to the NL subtype. 33% of the LB tumors changed to the LA subtype. Currently, after 2.2 years of follow-up, 16 pts are deceased due to bc. Among BL cases, 6/9 pts with a pCR at surgery remain alive; while 3/9 have died from bc. Exploratory analyses using functional gene modules (Desmedt Clin Cancer Res 2008) suggest that patients with BL tumors who have died have higher scores for PLAU/invasion and lower scores for STAT1/immune response compared with those who are still alive. Tumor size at baseline did not obviously correlate with outcome. Conclusion: We show that biological material can be retrieved from a substantial fraction of cases treated within a multicenter study of preoperative chemotherapy. The success rate may be ameliorated by routine use of US guidance. The distribution of subtypes differs between modified IHC St Gallen criteria and PAM50, especially within the luminal subtypes. The pCR rate is highest among cases with a BL tumor at baseline. Shift of the gene signature between different subtypes during the course of treatment is frequent. In this set of relatively large tumors, the prognosis among BL bc appears to be adverse in spite of a pCR. Citation Format: Niklas Loman, Ida Johansson, Judith Bjöhle, Jan Frisell, Tobias Lekberg, Lisa Rydén, Anna von Wachenfeldt, Jonas Bergh, Thomas Hatschek, Ingrid Hedenfalk. Preliminary translational results from PROMIX, a phase II trial of preoperative chemotherapy with the addition of bevacizumab in large operable and locally advanced HER2-negative breast cancer [abstract]. In: Proceedings of the Thirty-Seventh Annual CTRC-AACR San Antonio Breast Cancer Symposium: 2014 Dec 9-13; San Antonio, TX. Philadelphia (PA): AACR; Cancer Res 2015;75(9 Suppl):Abstract nr P2-05-02.

Who Should Be Performing Liver Biopsies?

Comparison of Frequency of Vascular Complications With Ultrasound-Guided Versus Fluroscopic Roadmap-Guided Femoral Arterial Access in Patients Who Underwent Transcatheter Aortic Valve Implantation

Measuring success: A comparison of ultrasound and landmark guidance for knee arthrocentesis in a cadaver model

Accumulating evidence shows that ultrasound (US) guidance improves effectiveness and safety of central venous catheter (CVC) placement. Several international guidelines therefore recommend the use of US for placement of CVCs. However, surveys show that the landmark-based technique is still widely used, while the percentage of physicians using US is increasing less than expected. The goal of this study was to investigate current practice for central venous catheterization in anaesthesiology and intensive care in the Netherlands, identify barriers for further implementation of US guidance and to evaluate whether personality traits are associated with the choice of technique. We conducted a web-based national survey, distributed among members of the Dutch societies of anaesthesiology (NVA) and intensive care (NVIC). The survey contained questions regarding physician and hospital characteristics, frequency of US use and reasons for use or non-use, as well as the NEO-FFI-3, a validated, translated questionnaire to characterize personality traits according to the ‘Big Five’ concept. Response rate was 22% (506/2291), of which 400 had also the personality questionnaire complete. Ultrasound guidance was used always or almost always in 68%; barriers for US use were working in a non-academic non-teaching hospital, providing cardiac anaesthesia and more years of physician experience. Reasons for not using US were perceived lack of benefit, increased procedure time, lack of US equipment and fear of loss of landmark technique skills. 13% of respondents had never experienced a complication during CVC placement, and 67% knew of a complication occurring the past year at their department. Ultrasound was thought not to be able to prevent the complication in half of these cases. Of the personality traits, only neuroticism and extraversion showed a minor positive association with US guidance. A majority of anaesthesiologists and intensivists uses US guidance for CVC placement, but a significant proportion of physicians still prefers the landmark technique. Most arguments from respondents against US guidance can be challenged. Personality traits most likely do not play a major role in the acceptance of US guidance for central venous catheterization. A potential intervention to increase US use could be formalizing local hospital policies mandating compliance with US guidance. Future research can perhaps focus on cognitive biases that currently limit more widespread use of US guidance.

The purpose of this study was to determine whether junior residents had higher rates of first cannulation and overall success at central venous catheter insertions with the use of ultrasound (US) guidance compared to the landmark technique. We conducted a secondary analysis of data from a prospective randomized controlled study of junior residents from January 2007 through September 2008, which assessed the impact of simulation training on central venous catheter insertion success rates. Blinded independent raters observed in-hospital central venous catheter insertions using a procedural checklist. Success at first cannulation and successful insertion were the primary outcomes. Secondary outcomes included rates of technical errors and mechanical complications. Independent raters observed 480 central venous catheter insertions by 115 residents. Successful first cannulation occurred in 27% of landmark compared to 49% of dynamic US-guided (P < .01), and 50% of static US-guided (P = .01) cannulations. Insertion success occurred for 55% of landmark compared to 80% of dynamic US-guided (P < .01) and 80% of static US-guided (P < .01) cannulations. Dynamic US guidance was associated with increased odds of first cannulation success compared to the landmark technique (odds ratio [OR], 2.24; 95% confidence interval [CI], 1.37-3.67) and successful insertion (OR, 3.80; 95% CI, 2.34-6.19). Static US guidance was associated with increased odds of first cannulation success compared to the landmark technique (OR, 2.59; 95% CI, 1.25-5.39) and successful insertion (OR, 3.48; 95% CI, 1.54-7.87). The results were independent of central venous catheter insertion training, patient comorbidities, and resident specialties. There was no difference related to mechanical complications between the procedures. Dynamic and static US guidance during central venous catheter insertion was associated with improved in-hospital first cannulation rates and overall success rates of insertions by junior residents.

Implantable venous access ports are essential for patients requiring chronic venous access. Ultrasound guided catheter placement has been recognized as a valuable adjunct for reducing complications during placement of access ports in the radiology and critical care medicine literature. We reviewed the medical records of patients undergoing insertion of implantable venous access ports from June 2006 through June 2009. All procedures were performed using ultrasound guidance with the internal jugular vein as the access site. There were 500 implantable venous access ports placed and included for review. There were no post-procedure pneumothoraces or hemothoraces. Carotid puncture was documented in 4 (0.8%)cases. Routine use of ultrasound guidance during placement of implantable venous access ports has eliminated the complications of pneumothorax and hemothorax during placement of internal jugular venous access ports on our vascular surgery service. Elimination of these complications and decreased use of chest x-rays should also provide increased cost savings for this procedure.

Routine Use of Ultrasound Guidance in Femoral Arterial Access for Peripheral Vascular Intervention Decreases Groin Hematoma Rates in High-Volume Surgeons

Regional anesthesia for the peripheral nerve or plexus has been widely used in the management of acute or chronic pain. To deliver a smaller volume to the targeted nerve without injury to it or its surrounding structures can be critical in the practice of regional anesthesia [1]. Therefore, the identification of the target nerve is important to provide better efficacy and safety in regional anesthesia. To increase the success rate of target nerve blocks, an electrical nerve stimulation device is popularly used. However, in spite of the use of a nerve stimulator, it is sometimes difficult to identify the exact position of the tip of the needle [2]. Since 1978, ultrasound has been widely used in several kinds of regional anesthetic practices. Recently, the improvements in ultrasound technology allow you to place the tip of the needle near the targeted nerve and monitor the spread of the local anesthetics precisely. In addition, ultrasound guidance enables the physician to replace the needle in the case of mal-distribution of the local anesthetic in real time. Therefore, ultrasound-guided technique has been considered the gold standard for performing regional anesthesia or peripheral nerve blocks [3]. The interscalene brachial plexus (IBP) block is very useful for upper extremity surgery. But IBP at the C6 level often fails to affect the ulnar nerve in up to 50% of blocks [4]. Kim et al. [2] injected 55 ml of local anesthetic via low approach IBP below the C6 level using a nerve stimulator for upper extremity surgery. A low approach IBP provided more caudad spread of local anesthesia in the brachial plexus, resulting in a better efficacy in blocking the ulnar nerve than the conventional IBP approach at the C 6 level (46% vs 81%; P < 0.0001). However, it may be associated with several concerns. The vertebral artery enters deep into the transverse process at the level of C6 or C7. Therefore, a nerve stimulant guided low approach IBP below the C6 level increases the risk of vertebral artery puncture, which may result in catastrophic outcomes. The nerves from C5 and C6 innervate the upper arm or forearm. When muscular twitching in the forearm is observed, it is difficult to identify whether the motor response originates from the C5 or C6 nerve. And thus, it is difficult to identify the exact position of the tip of the needle from the nerve stimulation. In this issue, Park et al. [5] reported the effect of ultrasound guided low approach IBP for upper limb surgery. They used 40 ml of local anesthetics for IBP, which provided adequate anesthesia without any significant complications in all 20 patients. Ultrasound provides direct visualization of the best site for the injection and helps avoid incidental puncture of blood vessels and damage to nerves. In addition, the volume of local anesthetic needed can be reduced by monitoring the spread of local anesthetics. Thus, continuously observing the distribution of local anesthetic and replacing the needle when mal-distribution of the injectate occurs improves the efficacy and safety of regional anesthesia or peripheral nerve block under ultrasound guidance. Substantially, the use of ultrasound can decrease the performance time of regional anesthesia, which may promote the routine use of ultrasound guidance in regional anesthesia. Therefore, it is justified to enable physicians to acquire the knowledge and techniques to use ultrasound guidance in regional anesthesia and in performing peripheral nerve blocks.

Ultrasound-guided versus palpation-guided radial artery catheterization in adult population: A systematic review and meta-analysis of randomized controlled trials

We describe our experience of combining the use of ultrasound (US) guidance with contrast enhancement and peripheral nerve stimulation for the insertion of infraclavicular brachial plexus catheters. Thirty patients scheduled to have upper limb surgery under regional block were studied. Under US guidance and peripheral nerve stimulation assistance, continuous peripheral nerve block needle and stimulating catheter were placed in the infraclavicular area. Needle and catheter tip location was confirmed with agitated 5% dextrose and seen under colour Doppler with US before injecting local anaesthetic (LA). Patients were evaluated in terms of onset times and efficacy of block. Post-operatively, on block recession a catheter was stimulated and visualization of spread of LA during injection through the catheter was done. Secondary block (subsequent to re-injection of LA) was assessed. Patients were followed-up for a week. Mean time to onset of block was 19.7 (+/- 4.9) min. There were no incomplete blocks and all components of the plexus were blocked completely. Post-operatively, in 95.7% of patients, the spread of hand-agitated LA via the catheter could be seen by color Doppler with ultrasonography. All patients had excellent post-operative analgesia and high degree of satisfaction. There were no complications. Contrast enhancement with US guidance during infraclavicular brachial plexus block enables direct visualization of needle and catheter tip location. Our early experience suggests that this leads to successful initial and subsequent post-operative block. Further controlled studies are needed to compare this technique with more prevalent and conventional techniques of catheter insertion.

Evidence-Based Medicine

This section reviews papers published in Respirology in 2014 regarding prevention, novel diagnostic techniques, translational research and treatments for lung cancer. Other important developments in this field are also addressed. Cannabis is the most commonly used illicit substance worldwide.1 Although cannabis is known to contain harmful and carcinogenic substances, little is understood with regard to its effects on respiratory health, such as the potential for chronic obstructive pulmonary disease (COPD) and lung cancer. Gates et al.2 reported the results of an excellent review regarding cannabis smoking and respiratory health. Based on the previous literature, chronic cannabis use is associated with an increased prevalence of symptoms of chronic bronchitis.3 In contrast, the relationship between cannabis and lung cancer is contentious, although some papers have suggested a positive association. What about electronic cigarettes (e-cigarettes)? Are they safe or potentially harmful? E-cigarettes or electronic nicotine delivery system (ENDS) devices deliver a vaporized liquid to the lungs that usually contains nicotine and other chemicals. While some studies have shown that individuals who do not intend to quit smoking may reduce their intake of combustible cigarettes by smoking e-cigarettes, other studies have failed to show the superiority of this approach over the use of nicotine replacement medicine in individuals trying to quit smoking.4 Therefore, the potential benefits of ENDS are not well proven. In contrast, the inhalation of vapor from e-cigarette cartridges has been shown to enhance inflammatory changes in mouse airways, and the short-term use of e-cigarettes has been shown to adversely affect the lung function. Therefore, e-cigarettes are considered to be potentially harmful. Lam D et al.4 mentioned, in an editorial published in Respirology, that the Asian Pacific Society of Respirology (APSR) fully supports the joint statement by the Forum of International Respiratory Societies (FIRS) on the use of e-cigarettes, that electronic nicotine delivery devices should be restricted or banned until more information about their safety is available. The incidence of adenocarcinoma (Ad) has increased, while that of squamous cell carcinoma (Sq) and small cell lung carcinoma (SCLC) has decreased in Europe, North America and Japan.5 However, few studies have assessed the incidence and histological type of lung cancer in China. Kong et al.6 reported the findings of a population-based study of the incidence of lung cancer in Tianjin, the third largest city in China, during the period of 1981–2005. According to their report, the most common histological type is Sq in males and Ad in females. However, during the 25-year study period, the age-adjusted incidence of Sq declined sharply, while that of Ad continued to increase among younger groups. The authors concluded that tailored strategies for prevention and control should be developed to meet the needs of various populations. In Respirology, Alcada et al.7 evaluated the features of mediastinal lymphadenopathy on computed tomography (CT) and the clinical data of 217 human immunodeficiency virus (HIV) patients in the era of combination antiretroviral therapy. Among these patients, 52 were identified to have mediastinal lymphadenopathy, and 17 (33%) were diagnosed with pulmonary malignancy, including lung cancer. Larger lymph nodes were associated with increased odds of malignancy (OR 2.89; 95% confidence interval 1.24–6.1) according to a multivariate analysis. The reason for the high association between lung malignancy and HIV was discussed; however, the mechanisms remain unknown. The authors emphasized the need for a histological diagnosis in patients exhibiting swollen mediastinal lymph nodes. Although the National Lung Cancer Screening Trial (NLST) demonstrated that the application of low-dose computed tomography (LDCT) is useful for reducing lung cancer-related mortality,8 whether the detection of subcentimeter non-calcified nodules without changes in size over a 2-year follow-up period are indicative of malignancy or should be further followed up remains unknown. Shin et al.9 performed a retrospective study to answer this question. The authors investigated 635 subjects who received follow-up for LDCT for an initial 2-year screening period with three additional years thereafter in whom non-calcified subcentimeter nodules were evaluated. A total of 1107 subcentimeter nodules (1037 solid, 70 ground-glass opacity nodules) were detected. All solid subcentimeter nodules exhibiting stability for the initial 2-year period on screening LDCT were considered benign, as none of these lesions showed growth in the subsequent period. In contrast, subcentimeter GGNs have a greater potential for growth than solid nodules and require further follow-up with CT for more than 2 years, as some of them could be malignant. As a result of the increasing rate of detection of lung cancer nodules during lung cancer screening using CT, the development of a non-invasive diagnostic method for reducing the risks associated with biopsies is warranted. Confocal laser endoscopy (CLE) allows for real-time non-invasive histological imaging, and a probe-based CLE (pCLE) method has been developed in which the probe can be passed into the distal airway via the working channel of the bronchoscope, thus obtaining an optical biopsy sample. Meanwhile, Sorokina et al.10 performed an ex vivo study to evaluate the correlations between light microscopic findings and pCLE imaging findings of primary lung cancer. The authors examined 18 lobectomy samples from 18 different patients and found that pCLE can be used to identify lung carcinoma in ex vivo samples. Certain light microscopic features of lung carcinoma may be visualized on pCLE. These results suggest that pCLE is a non-invasive diagnostic method for making the histological diagnosis of nodules detected on CT scans. The volume doubling time (VDT) can be calculated using serial CT scans and may be applied to evaluate indeterminate pulmonary nodules detected at lung cancer screening. A retrospective study of VDT in surgically resected non-small cell lung cancer patients was recently reported by Mackintosh et al.11 The authors investigated 109 eligible scans in 46 patients with lung cancer (36 Ad, six Sq, two large cell and two carcinoids) and demonstrated that the non-small cell lung carcinoma (NSCLC) growth rate appears to be highly variable and related to both the histological subtype and smoking history, but not the presence of symptoms at diagnosis. Relatively slow-growing Ad lesions frequently metastasize. Araz et al.12 examined the correlations between the Ki-67, p53, transforming growth factor (TGF)-b and lysyl oxidase (LOX) values and the metastatic stage in various types of lung cancers. Consequently, high levels of cellular LOX and TGF-b were found to be related to an increased incidence of distant metastasis in Ad patients. LOX and TGF-b may therefore be useful markers of metastatic disease in patients with Ad. Furthermore, Ming et al.13 evaluated the diagnostic utility of the vascular endothelial growth factor (VEGF) messenger ribonucleic acid (mRNA) and specificity protein-1 (SP-1) mRNA expression levels in cells obtained via bronchial brushing in 93 patients with lung cancer and 51 benign pulmonary lesions as a control. In the cancer group, the VEGF mRNA levels were significantly correlated with the SP-1 mRNA levels (P < 0.01) and showed the highest diagnostic rate, with a sensitivity of 89.2% and accuracy of 90.3%. These values were significantly better than those for cytology (P < 0.01). The authors concluded that the detection of VEGF mRNA and SP-1 mRNA in bronchial brushing cells may be useful for identifying early-stage lung cancer. Ost et al. and Yasufuku et al. both published excellent reviews with regard to multi-modality systematic approaches to mediastinal lymph node staging and the role of the bronchoscopist in identifying molecular profiles in cases of non-small cell lung cancer, respectively14, 15 Accurate and efficient lymph node staging is essential for selecting the treatment modality, and determining the molecular profile of the tumour is necessary for choosing appropriate molecular target drugs and prolonging the patient's survival. Qvale et al.16 showed that paraneoplastic Hu and collapsing response mediator protein 5 antibodies, which were originally thought to be specific markers for paraneoplastic syndrome, are found only in smokers without cancer or neurological disease using sera obtained from 552 smokers (379 smokers with and 173 without COPD) and 300 healthy controls. Preoperative physiological assessments are important for accurate patient selection and to provide appropriate treatment. Although the Eastern Cooperative Oncology Group (ECOG) performance status (PS) is usually used in clinical practice, its accuracy is not satisfactory. Therefore, Roman et al.17 compared the peak oxygen consumption (VO2 peak) with the ECOG PS in order to evaluate the clinical utility of the VO2 peak in operable patients with non-small cell lung cancer. The authors employed 392 NSCLC patients. PS scoring systems do not provide sensitive measurements of the functional status. Therefore, the authors concluded that the VO2 peak may be useful in the clinical management of oncology patients. Patients with advanced adenoid cystic carcinoma (ACC) of the central airway often develop fibrotic airway stenosis following radiotherapy. Eom et al.18 revealed the clinical utility of bronchoscopic intervention, including silicone airway stenting, in such patients. Forty-seven patients with ACC who received radiotherapy were analysed. Twenty-three per cent of the patients suffered from fibrotic airway stenosis after radiotherapy and underwent bronchoscopic intervention. The authors demonstrated this intervention to be safe and useful for treating airway stenosis after radiotherapy in patients with ACC. The intrapleural delivery of a commercially available compound made up of proteins produced by Staphylococcus aureus is used clinically to induce pleurodesis. Lansley et al.19 reported the findings of a proof-of-principle study showing the efficacy of inhibiting mesothelioma growth with a compound consisting of Staphylococcus aureus bioproducts. The authors demonstrated that in addition to its pleurodesing effect, this bacterial compound has anti-tumoural activities against pleural malignancies and concluded that its anti-tumoural activity against mesothelioma warrants clinical validation.20 Finally, a very attractive treatment strategy, stem cell therapy, was recently introduced in an editorial published in Respirology.21 It has been reported that cellular therapy using stem cells may constitute a major component of future therapies. Pleural procedures such as thoracentesis and chest drain insertion are commonly performed worldwide. Complications, including iatrogenic pneumothorax, bleeding and re-expansion pulmonary oedema, may occur although probably at a lower rate than previously thought. In a 3.5-year audit of 529 bedside procedures using safety checklists, and ultrasound-guidance in 86% of the cases, the complication rate was only 3% and was similar whether being performed by either pulmonologist or non-pulmonologist operators.22 The presence of COPD independently increased the risk of complications by nearly sevenfold. In another large series of 9320 ultrasound-guided thoracenteses, the overall complication rate (0.98%) and pneumothorax rate (0.61%) was also lower than many published studies.23 Specifically, the incidence of re-expansion pulmonary oedema was extremely low (0.01%). Recently, an intriguing preliminary observation of cough-related changes in pleural pressure during therapeutic thoracentesis in three patients showed that elevation of pleural pressure not only coincided with coughing episodes but persisted shortly thereafter.24 Thus, the authors hypothesized that cough might have a beneficial effect preventing the excessive drop in pleural pressure. Determination of epidermal growth factor receptor (EGFR) and Kirsten rat sarcoma viral oncogen homologue (KRAS) mutational status, as well as anaplastic lymphoma kinase rearrangement, has become an essential part of the evaluation of lung cancer patients because of its prognostic and therapeutic implications. Obtaining tissue samples for this purpose is often difficult, whereas analysing pleural fluid is easy and less invasive. In a study of 57 patients with malignant pleural effusions (84% with lung cancer), detection of KRAS mutations by peptide nucleic acid clamping was higher in pleural fluid samples (14%) and their cellular blocks (16.7%) than in matched tumour tissues (5%) and serum (3.6%) specimens, thus reinforcing the suitability of the former for mutation analyses.25 An excellent review addressed the current controversies and trends in the management of malignant pleural effusions.26 The main goal when dealing with this condition should be to relieve patient's symptoms with the least invasive and cost-effective strategies, while reducing hospitalization time. Therapeutic thoracentesis, due to its temporary benefits, is indicated in patients with: (i) very short expected survival (e.g. ≤4 weeks) or poor performance status; (ii) potential multifactorial causes of breathlessness in order to establish the relative contribution of the effusion to this symptom; and (iii) tumours in which a favourable short-term response to targeted therapies or chemotherapy is expected (eg. small cell lung cancer, lung cancer with EGFR mutations, lymphoma). Even though the risk of re-expansion pulmonary oedema is extremely low, recommended fluid removal is generally limited to 1.5 L unless pleural pressure is monitored during the procedure. Pleurodesis and placement of an indwelling pleural catheter (IPC) are the common definitive procedures to control symptomatic malignant effusions, but the preferred choice is controversial.26 The ideal timing for pleurodesis, that is, whether it should be performed routinely at the diagnosis of malignant pleurisy or deferred until symptomatic recurrence occurs, has not been established. Talc poudrage pleurodesis through thoracoscopy has not demonstrated superiority over chest tube talc slurry.26 If talc is selected as the sclerosant agent, large particle size preparations are recommended to avoid the development of an acute respiratory distress syndrome. Finally, IPC allows the ambulatory drainage of malignant effusions with similar symptomatic benefits as pleurodesis. It is indicated either as a primary approach or when pleurodesis fails (up to 30%) or is unsuitable (trapped lung). The procedure has few minor complications (eg. catheter blockage, cellulitis, symptomatic loculation) and spontaneous pleurodesis ensues in almost half the patients at an average time of 2 months, a situation in which IPC is definitely removed.26 Future treatment strategies for malignant pleural effusions should encompass advances in translational and experimental medicine. For example, one study evaluated the anti-tumoural effects of a S. aureus bio-product which has been used as a pleurodesing agent.19 This commercially available compound killed mesothelial cells in vitro and retarded tumour growth in a murine model of mesothelioma. A review described the role of interventional pulmonology in the management of bacterial infections of the pleural space.27 All patients with community-acquired parapneumonic effusions or empyema should receive empirical antibiotics covering Gram-positive cocci and anaerobes, but usually not atypical bacterial pathogens such as Legionella or Mycoplasma. The optimal duration of antibiotic therapy is unknown, although a period of 4 to 6 weeks is not uncommon.27 Nutritional supplementation is advised if poor nutrition is a concern. A decision on whether to drain non-purulent effusions is challenging and generally based on radiological (large effusions) and pleural fluid biochemical (low pH or glucose) or microbiological (positive Gram stains or cultures) data. As there are no randomized controlled studies offering guidance, it may be wise to follow the recommendation of Dr Light in initially performing a therapeutic rather than a diagnostic thoracentesis.28 The rationale is that if no fluid re-accumulates, no additional therapy will be necessary. Alternatively, when indicators for pleural drainage exist, small-bore chest drains placed under ultrasound guidance are the procedure of choice.27 The rightful place for intrapleural fibrinolytics remains a matter of intense debate. Meta-analyses of randomized controlled trials that have included the negative First Multicenter Intrapleural Sepsis Trial 1 (MIST1) and second MIST2 studies still conclude that urokinase or alteplase might be potentially effective for reducing the need for surgery.29 According to MIST2 study, the administration of alteplase and DNase intrapleurally should be considered whenever patients, particularly those who are not good surgical candidates, fail to respond to thoracostomy drainage. Surgical (i.e. video-assisted thoracoscopic surgery or open thoracotomy) rather than medical thoracoscopy is favoured when sepsis is uncontrolled despite the previously instituted therapies or when lung entrapment develops as a complication of the pleural infection. A systematic review reported the clinical characteristics and treatment of patients with yellow-nail syndrome (YNS).30 It is probably an acquired disease affecting lymphatic drainage, which is diagnosed when at least two of the following three characteristics are met: yellow nails, lymphoedema and chronic respiratory symptoms including pleural effusions in 40–50% of the cases. The authors compiled 150 YNS patients with pleural effusions.30 The median age was 60 years, without gender predominance. All patients had lymphoedema, yet 14% did not exhibit yellow nails. Pleural effusions were bilateral in two thirds, had a serous appearance in 75% of the cases and milky in 20%, and met exudative criteria with lymphocytic predominance in 95%. On pleural biopsy, findings were either unspecific or consistent with chronic pleuritis. For symptomatic persistent effusions, pleurodesis or decortication/pleurectomy is effective in most cases. Acute respiratory infection is a major cause of morbidity and mortality among children, especially in developing countries. In a study by Wu et al.31 in Hubei, China, indirect immunofluorescence assays for immunoglobulin M antibodies were positive in 7046 (67.5%) of 10 435 serum specimens collected from hospitalized children presenting with acute respiratory infection symptoms against at least one of the following nine pathogenic viruses and atypical bacteria: Mycoplasma virus respiratory virus Legionella and had the highest detection rate followed by virus and respiratory virus for hospitalization and diagnostic criteria for study might have to the high detection As many as specimens were positive for at least two an of the in current and of the profile with their specific and age may still to the clinical management of children hospitalized for acute respiratory infection. et al. the potential role of acute a common disease of in the of Acute in has been associated with an increased risk of the primary However, it remains whether acute to the subsequent development of or it the clinical in to between various and viral is to be by in different of these may important prognostic and to prevention treatment. In a by et al. studies with a total of patients, the positive negative and diagnostic odds of the receptor on for diagnosis of lower respiratory infection were and The overall diagnostic was similar for community-acquired and in but not was significantly by the method in analysis. for were in studies using different on either serum or fluid as the is a clinical studies are to the diagnostic utility of in different clinical Mycoplasma be diagnosed through clinical symptoms and in children and with community-acquired et al. reported findings on CT of the chest in of cases of infection with cough or more and a chest observation the sensitivity of chest in or due to An chest should not be to in children or presenting with acute respiratory A clinical risk using of 4 for for 2 for chronic and 1 for has previously been found to well at patients regarding their risk for S. aureus or in patients via the with bacterial et al. another risk for by potentially pathogens using of for 5 for 2 for and for the presence of other risk for The risk the in pathogens in the with among patients hospitalized with bacterial and in a subsequent with among similar patients. An optimal between sensitivity and specificity was at a low of A of or hospitalization may thus the for appropriate antibiotic against in the empirical treatment of bacterial The of from bacterial not to a clinically infection. In the study by et among patients with from respiratory specimens, was diagnosed by treatment or fluid in patients whereas with was diagnosed in another Patients with were independently associated with a of of more than radiological findings other than and a of or In a study by et of patients diagnosed of had of symptoms as by a time interval of over from to The time from to diagnosis was independently associated with previous and antibiotic therapy, and less While it was associated with a higher rate of there was less need for and no effect on has been shown to be a useful addition to the diagnostic for community-acquired A higher mortality was in as compared to but in a previous In a study by et al. patients for the performed the of showed a sensitivity of results were independently associated with a higher risk of treatment and thus prognostic of a positive in in presence of of to and duration of antibiotic treatment for acute respiratory infections has been shown to reduce antibiotic consumption without on treatment or mortality different clinical In a study by et serum was found to be an of mortality among to a with cough for 2 or more weeks in serum and could be into a prognostic model to patients with different mortality risks from variable to a model may be useful in identifying patients at high risk of from lower respiratory infections in low and HIV infection is In a study by et previous use of in patients hospitalized for was independently associated with a inflammatory response as by lower tumour factor but there was no on association persisted in a of patients with A previous study demonstrated a different inflammatory with a lower in among patients with COPD as compared to those but such was not and COPD therefore to inflammatory response in with potential on disease clinical treatment has also been associated with a lower incidence of parapneumonic effusion in patients with different chronic respiratory The clinical of pulmonary is often to In an study by et al. a total of pulmonary patients in the size of decreased in and increased in another on serial chest CT during a median follow-up duration of 1 was associated with higher more and was associated with size of and of prognostic markers are in patients with and infection. et al. a retrospective of 52 with and pulmonary nodules and on at were found to be of chemotherapy was more to to as compared with patients with but there was no in survival. The has to be with as it is often to selection especially in to who to and when to in an et al. an using and to the role of an in the of a of on the and survival of in was found to be of to either or of with and the of thus to a role of the in the et al. evaluated the performance of microscopic observation in 173 samples collected from patients to have its time as compared to the the clinical utility of the was still