Cause Of Effusion Research Articles

Role of thoracoscopy in diagnosis of tubercular pleural effusion in low ADA setting- A prospective, observational study

BackgroundTubercular Pleural effusion (TBPE) is one of most common extrapulmonary tuberculosis. It can be difficult to diagnose due to low sensitivity of pleural fluid smear, culture and CBNAAT. Diagnosis of TBPE is then dependent on the level of pleural fluid Adenosine Deaminase (ADA). Thoracoscopic pleural biopsy gives definite diagnosis specially in Low Pleural fluid ADA setting. Aims and objectiveThis study was planned to find out the prevalence of tubercular etiology in patients of exudative pleural effusion with low ADA (ADA <40 IU/L). Material and methodsA Prospective, observational study was carried out in a tertiary teaching institute in north India. Total 142 patients of pleural effusion with low ADA were enrolled. All patients underwent rigid thoracoscopy for confirmation of their diagnosis. ResultsOut of 142 patients, male were 78 (55%) and female were 64 (45%). Mean age of patients were 57.4 years. Tuberculosis was diagnosed as a cause of effusion in 22 (15.5%) out of 142 patients. Majority of TBPE patients had pleural thickening as thoracoscopic finding. Mean ADA level in TBPE was 27.36 ± 11.6 as compared to 18.55 ± 9.02 in non tubercular pleural effusion patients and this difference was significant statistically (P- 0.002). ConclusionThe diagnosis of patients having exudative, low ADA pleural effusion can be very easily confirmed by thoracoscopy guided pleural biopsy which has a very high diagnostic yield.

The laboratory investigation of pleural fluids: An update based on the available evidence.

Selecting appropriate laboratory tests based on available evidence is central to improve clinical effectiveness and impacting on patient outcome. Although long studied, there is no mutual agreement upon pleural fluid (PF) management in the laboratory context. Given the experienced confusion about the real contribution of laboratory investigations to guide clinical interpretation, in this update, we tried to identify useful tests for the PF analysis, aiming to unravel critical points and to define a common line in requesting modalities and practical management. We performed a careful literature review and a deepened study on available guidelines to finalize an evidence-based test selection, intended for clinicians' use to streamline PF management. The following tests depicted the basic PF profile routinely needed: (1) abbreviated Light's criteria (PF/serum total protein ratio and PF/serum lactate dehydrogenase ratio) and (2) cell count with differential analysis of haematological cells. This profile fulfils the primary goal to determine the PF nature and discriminate between exudative and transudative effusions. In specific circumstances, clinicians may consider additional tests as follows: the albumin serum to PF gradient, which reduces exudate misclassification rate by Light's criteria in patients with cardiac failure assuming diuretics; PF triglycerides, in differentiating chylothorax from pseudochylothorax; PF glucose, for identification of parapneumonic effusions and other causes of effusion, such as rheumatoid arthritis and malignancy; PF pH, in suspected infectious pleuritis and to give indications for pleural drainage; and PF adenosine deaminase, for a rapid detection of tuberculous effusion.

Massive Pleural Effusion Suggesting a Malignant Effusion

Background: Massive pleural effusion is one of the way of presentations of malignant effusion, it is unlikely to be seen in other causes of effusions, thorough workup and follow up is necessary, in this case series most of the cases was confirmed to be of malignant etiology. Objectives: The main objective from this study is to detect the cause behind massive pleural effusion and for early detection of a malignant etiology. Methods: Case series study involving 11 inpatient cases of massive effusion that had been evaluated sequentially with pleural fluid cytology then if negative pleural biopsy with either medical pleuroscopy or video assisted thoracoscopy (VATS). Results: Six of eleven cases were discovered to have malignant effusion, two cases were tuberculous pleuritis (TB pleuritis), one case were complicated parapneumonic effusion; the other 2 cases there were no specific diagnoses. Conclusions: Most of the cases of massive pleural effusion were discovered to be malignant effusion.

Comparison of clinical manifestation among Australian Indigenous and non-indigenous patients presenting with pleural effusion.

There is sparse evidence in the literature in relation to the nature and causes of pleural effusion among Australian Indigenous population. To investigate the clinical and demographic characteristics of adult indigenous patients presenting with pleural effusion in the Northern Territory of Australia. In this retrospective study, indigenous and non-indigenous adults diagnosed to have pleural effusion over a 2-year study period were included for comparative analysis. Of the 314 patients, 205 (65%) were non-indigenous and 52% were male. In comparison with non-indigenous patients, the indigenous patients were younger (50 years (interquartile range (IQR) 39-60) vs 63 years (IQR 52-72); P < 0.001), female (61% vs 41%; P = 0.001), had a higher prevalence of renal and cardiovascular disease and tended to have exudative effusion (93% vs 76%; P = 0.032). Infections were judged to be the most common cause of effusion in both groups, more so among the indigenous cohort. Effusion secondary to renal disease was higher (13% vs 1%; P < 0.001) among Australian Indigenous patients, but in contrast, malignant effusions were higher (13% vs 4%; P = 0.004) among non-indigenous patients. Length of hospital stay was longer for indigenous patients (P = 0.001), and a greater proportion received renal dialysis (13% vs 1%; P < 0.001). Intensive care unit admission rates were higher with infective aetiology of pleural effusion (82% vs 53% indigenous and 44% vs 39% non-indigenous respectively). Re-presentations to hospital were higher among indigenous patients (46% vs 33%; P = 0.046) and were associated with renal and cardiac disease and malignancy in non-indigenous patients. There are significant differences in the way pleural effusion manifests among Australian Indigenous patients. Understanding these differences might facilitate approaches to management and to implementation of strategies to reduce morbidity and mortality in this population.

Managing malignant pleural effusions: A single center’s experience

Occurring among the most common findings in cases of metastatic disease, malignant pleural effusion (MPE) is identified in up to 15% of patients with cancer. This research was undertaken to provide an overview of advances in the treatment of MPE in recent years. A total of 186 patients with MPE were evaluated retrospectively after having consulted or been hospitalized in our hospital between March 2019 and December 2021. The evaluated data included gender, age, cause of effusion, treatment method, length of hospital stay, and complications. Lung cancer was in first place, affecting 64 of the patients treated for MPE. In this cohort, 142 patients had received a cytological diagnosis. These patients underwent pleurodesis with talc after tube thoracostomy. A definitive diagnosis could not be determined from the cytological samples of 44 patients. VATS was performed diagnostically and then pleurodesis was performed with postoperative talc. The complication rate was 13%. The mortality rate was 5%. Recurrence was observed in 37 patients during the 2-month follow-up period after the procedure. The optimal treatment of MPE remains uncertain, and treatment decisions require the cooperation of many medical departments. Nowadays, less invasive approaches are preferred in managing cases of pleural effusion. This treatment approach protects patients from the risks of more invasive interventions and reduces treatment costs.

Comparison of effusion cell block and biopsy immunohistochemistry in mesothelial hyperplasia, mesothelioma, and carcinoma in dogs.

Determining the cause of effusions is challenging and might require a biopsy. Whether cell blocks from effusions are representative of biopsies requires investigation. A previously developed immunohistochemical panel aids in the differentiation of hyperplastic and neoplastic mesothelium in canine biopsies but has not been investigated in effusions. The study aimed to assess cell blocks as an alternative to biopsies and determine whether immunohistochemistry helps distinguish hyperplastic mesothelium, mesothelioma, and carcinoma. Effusions and biopsies were collected from five dogs with mesothelial hyperplasia (group MH), six with mesothelioma (group M), and five with carcinoma (group C). Immunohistochemistry (IHC) for cytokeratin, vimentin, Wilm's tumor protein 1 (WT1), desmin, glucose transporter 1 (GLUT1), and insulin-like growth factor II mRNA-binding protein 3 (IMP3) was performed. Sections were scored for staining intensity and the percentage of positively stained cells. In paired cell blocks and biopsies, vimentin and WT1 staining were positively correlated for intensity and the percentage of positive cells, although not all paired results were identical. The intensity of IMP3 staining in cell blocks was higher in group M than in group C (P=0.012), and WT1 staining was higher in group MH than in group C (P=0.020). For biopsies, the intensity of WT1 staining was higher in group MH than in group C (P=0.031). In group C, WT1 was negative in all cell blocks and biopsies, and desmin was negative in four of five cases. IHC results for the cell blocks and biopsies were comparable for potentially useful markers, such as WT1, which helped discriminate between groups. IHC provided additional information, although results were not always definitive. Further studies on a larger population are required.

A study to assess the cholesterol levels in pleural fluid and its role in differentiate between exudative and transudate pleural effusion

The pathophysiology of the transudate pleural effusion occurs when the systemic factors are involved in the formation and absorption of plural effusion, where the source of pleural fluid is originating from Lung, Peritoneal or Pleural Cavity. The origin of exudative pleural fluid effusion is when capillaries or the pleural surfaces where the fluid originates gets altered. Hence when we the pleural fluid is found to be transudate further diagnostic evaluation is not required and treat the systemic disease affecting it and if the fluid is exudate we need to investigate further to find out the cause of effusion. To assess the role of pleural fluid cholesterol in differentiating exudative and transudative pleural effusion. : The present cross sectional study was conducted by the Department of Chest and Respiratory Medicine at Chamarajanagara Institute of Medical Sciences from March 2019 to December 2019. A total of 100 cases of clinically confirmed cases of pleural effusion cases were selected for the purpose of the study. Based on the Light’s Criteria the Pleural Fluid was analyzed and 94% of them were classified as exudates and 6% of them to be transudates and Pleural fluid cholesterol of more than 45mg/dl 74% of them were exudates and 26% of them were transudates. In the present study based on final diagnosis out of 74 subjects who were classified as exudates, 72 subjects were classified as exudates and misclassified 2 cases as transudate. Lights Criteria diagnosed only 4 cases as transudate pleural fluid among the 26 cases of transudate pleural fluid based on final diagnosis Light‘s criteria is the most accepted criteria for differentiating between exudates and transudate in pleural effusion. By the Present study we could conclude that the estimation of Pleural Cholesterol Level has good sensitivity, Positive Predictive Value than lights criteria in diagnosing exudative and transudate Pleural Fluid.

Percutaneous Ultrasound-guided Pigtail Catheter for Pleural Effusions: Efficacy and Safety.

ObjectivesSmall-bore pigtail catheters are now being used more frequently for draining pleural effusions. This study aimed to measure the efficacy, safety, and tolerability of these devices in different clinical conditions.MethodsWe retrospectively collected data from 141 patients with pleural effusions of various etiologies who underwent ultrasound-guided pigtail catheter insertion at Sultan Qaboos University Hospital, Muscat, Oman.ResultsThe majority 109 (77.3%) of patients had exudates. The mean age was 50.0±18.6 years in patients with exudates and 67.3±15.5 in patients with transudates (p < 0.001). There was no significant difference (p = 0.232) in the median drainage duration between exudates (6.0 days) and transudates (4.5 days). The incidence of pain requiring regular analgesics, pneumothorax, and blockage were 36.2% (n = 51), 2.8% (n = 4), and 0.7% (n = 1), respectively. The overall success rate of pleural effusion drainage was 90.1%. Among the 109 cases of exudative pleural effusion, 89.0% were successful compared to a 93.8% success rate among patients with transudative effusion (p = 0.737). Short-term success rates were high in all causes of effusions: lung cancer (100%), metastasis (90.0%), pleural infections (83.3%), cardiac failure (94.7%), renal disease (85.7%), and liver disease (100%).ConclusionsUltrasound-guided pigtail catheter insertion is an effective, comfortable, and safe method of draining pleural fluid. It should be considered as the first intervention if drainage of a pleural effusion is clinically indicated.

Cytologic analysis of body fluids with an emphasis on malignant effusions

Introduction: Fluid cytology, a relatively non invasive technique, throws light on both malignant and non malignant causes of effusions. It especially contributes in cancer research and staging of various tumors. Materials and Methods: This was a retrospective study done over a period of two years from January 2014 to December 2015 in the department of Pathology, Kamineni Academy of Medical Sciences and Research Centre, Hyderabad. The body fluids included in the study were pleural, peritoneal, pericardial and synovial fluids. All other fluids were excluded. The relevant clinical data was noted. Gross, cell count and cytomorphological examinations of fluid were done. Results: Out of 302 cases, pleural fluids, 148 (49.0%) cases, were most common, followed by peritoneal fluid, 125 (41.39%) cases and least common was pericardial fluid, 8 (2.64%) cases. The maximum numbers of cases was in 5th decade. The age range was 3 years to 84 years. Female preponderance was observed with M: F ratio of 1: 1.17. Lymphocyte rich exudates were most common in pleural effusion. In peritoneal and pericardial effusions, transudates were more and suppurative inflammation was predominant in synovial fluid analysis. Over all, malignant effusions constituted 18.54% of effusions. Metastatic adenocarcinoma was the commonest malignancy detected in all body cavity effusions. Conclusions: Fluid cytology is relatively painless, simple, cost effective, rapid technique that yields quick and reliable results. Some cases may present major interpretative challenges to the pathologist. Ancillary studies such as cell count, biochemical, microbiologic evaluation, cell block and immunohistochemistry (IHC) study help in accurate identification of diagnosis. Keywords: Body fluids, Malignant effusions, Transudates.

Prospective evaluation of pericardial catheter placement versus needle pericardiocentesis in the management of canine pericardial effusion.

To compare the safety and efficacy of pericardial catheter placement with needle pericardiocentesis in dogs with pericardial effusion (PE) DESIGN: Prospective, randomized clinical trial. University teaching hospital. Thirty client-owned dogs requiring pericardiocentesis between January 2017 and August 2019. Dogs were randomized to undergo PE drainage via indwelling pericardial catheter placement (catheter group) followed by elective drainage every 4-6hours or needle pericardiocentesis (needle group) repeated as necessary. Fifteen dogs were allocated to the catheter group and 15 to the needle group. Data collected included signalment, cause of effusion, occurrence of arrhythmias pre-, during, and post-pericardiocentesis, procedural length, and details of repeated drainages. There was no significant difference between mean procedural times for pericardial catheter placement (17.7 min [±11.8]) and needle pericardiocentesis (12.1 min [±8.6]) (P= 0.192) or the rate of new arrhythmias in the catheter (36%) and needle (64%) groups (P= 0.24). Pericardial catheters were kept in situ for a median of 21hours (range, 14-85). Three of 15 (20%) dogs in the needle group required repeated pericardiocentesis within 24hours of initial pericardiocentesis. Pericardial catheters enabled repeated large volume PE drainage in 4 cases (median, 10.6mL/kg; range, 8-5-10.6). Pericardial catheters appear to offer a safe alternative to needle pericardiocentesis. Minimal sedation is required for placement, and they can be placed quickly. Their indwelling nature and use was not associated with a higher rate of arrhythmia compared to that of needle pericardiocentesis alone, and may be beneficial in the event that clinically significant PE recurs.

BILOTHORAX: A RARE OCCURRENCE AFTER LAPAROSCOPIC GASTRIC SLEEVE RESECTION

SESSION TITLE: Medical Student/Resident Disorders of the Pleura Posters SESSION TYPE: Med Student/Res Case Rep Postr PRESENTED ON: October 18-21, 2020 INTRODUCTION: Bilothorax is the presence of bile in the pleural space and represents a rare cause of pleural effusion of extra vascular origin (PEEVO). Most reported cases are primarily right sided and due to pleurobiliary fistula resulting from biliary tract injury, direct spread of infection from the liver, or trauma to the hepatobiliary tree or diaphragm. We present a unique case of a large left-sided bilothorax occurring one month after laparoscopic gastric sleeve resection complicated by splenic hematoma and hemoperitoneum without evidence of pleurobiliary fistula. CASE PRESENTATION: A 52-year-old woman presented with dyspnea and left sided abdominal pain 1 month after laparoscopic sleeve gastrectomy complicated by hemoperitoneum and splenic hematoma. Computed tomographic (CT) imaging was obtained and revealed a moderate, complex left-sided pleural effusion without associated ascites and decrease in splenic hematoma. A thoracentesis was performed which evacuated 800 milliliters of brownish-green pleural fluid. Bacterial and fungal cultures were negative. The pleural fluid was exudative by Light’s Criteria (Table 1) and fluid bilirubin was 2.6 mg/dL, compared to a serum total bilirubin level of 0.9 mg/dL, confirming a diagnosis of bilothorax. Given the persistence of complex effusion following thoracentesis, a 14 french pigtail catheter was inserted with significant improvement in the residual effusion. Dedicated assessment of the CT imaging revealed no evidence of abnormal connection between the pleural space and biliary tree. Therefore, the bilothorax was likely due to breakdown of the splenic hematoma with resorption into the pleural space. This theory was supported by no additional reaccumulation over the next three days. The patient was discharged and remains without pleural effusion. DISCUSSION: Bilothorax is primarily seen as a complication of invasive biliary procedures and typically presents as biliary peritonitis with associated right-sided pleural effusion. We describe a case of left-sided bilothorax presenting with dyspnea and no signs of biliary peritonitis or pleurobiliary fistula one month after a laparoscopic gastric sleeve resection complicated by splenic hematoma. We posit that breakdown and subsequent resorption of the hematoma across the diaphragm into the pleural space was the primary cause of effusion. To our knowledge, this is the first case to describe such a mechanism in the formation of a bilothorax. CONCLUSIONS: A high index of clinical suspicion is necessary for diagnosis of this PEEVO due to resorption of splenic hematoma across the diaphragm. Delay in diagnosis of bilothorax can result in serious pleural complications such as the development of complex fibrinous septations and empyema. Our patient did well with drainage alone and required no further surgical intervention. Reference #1: Jenkinson MRJ, Campbell W, Taylor MA. Bilothorax as a rare sign of intra-abdominal bile leak in a patient without peritonitis. Ann R Coll Surg Engl. 2013;95(7):e12–e13. doi:10.1308/003588413X13629960047678 DISCLOSURES: No relevant relationships by Ankur Aneja, source=Web Response No relevant relationships by Matt Schimmel, source=Web Response No relevant relationships by Keriann Van Nostrand, source=Web Response

VANISHING PLEURAL EFFUSION: DRESSLER-LIKE SYNDROME IN PATIENT WITH FOREIGN BODY REACTION

SESSION TITLE: Fellows Disorders of the Pleura Posters SESSION TYPE: Fellow Case Report Posters PRESENTED ON: October 18-21, 2020 INTRODUCTION: We describe a patient who developed bilateral right greater than left pleural effusions after surgical alteration of her prior silicone breast implants. She had near-complete resolution of her effusion with a course of non-steroidal anti-inflammatory drugs (NSAIDs). CASE PRESENTATION: We describe a 42 y/o lady, former 5.5 pack-year smoker, triple-negative breast cancer in remission, status-post bilateral mastectomy and silicone breast implantation. She since had bilateral breast reconstruction, involving superior gluteal artery perforator (SGAP) flap. She developed dyspnea and pleuritic pain within 2 weeks of her SGAP procedure, and presented to our center. She had stable vitals on admission, and did not require supplemental oxygen; however, her dyspnea and pleuritic pain were affecting her daily activities. Chest X-ray revealed a moderate right and a small left pleural effusion, confirmed on PE protocol CT scan, which was negative for PE. She was initially treated with diuretics which failed to improve her symptoms or pleural effusion size. Right thoracentesis was then performed, yielding 800 mL of serous yellow fluid. Fluid studies were consistent with an exudative effusion, with negative cytology and no bacterial or fungal growth, pH 7.48, LDH 200, glucose 88, total protein 4.1. Immediate post-procedure chest x-ray showed significant improvement in right effusion, and dyspnea was alleviated. Within 24 hours, the effusion on the right re-accumulated to a size equivalent to prior to thoracentesis. She was once again dyspneic. Suspecting an underlying inflammatory process, the patient was started on ibuprofen 600 mg QID. Within 2 days, patient felt symptomatic improvement. Outpatient follow-up chest X-ray 10 days after NSAID initiation was revealing of near-complete resolution of right effusion and symptoms. NSAID taper was then initiated. Repeat chest-XR 1 month after first dose of NSAID’s showed total resolution of pleural effusions. DISCUSSION: Foreign body reaction (FBR), or an inflammatory response to non-native entities such as breast implants, has been described as a cause of systemic release of inflammatory factors [1]. One report describes the development of pleural effusion 6 weeks after silicone breast implants [2]. We postulate the SGAP flap procedure resulted in manipulation of her prior silicone implants, resulting in an FBR. Neither IV diuretics nor therapeutic thoracentesis resulted in lasting resolution of her effusion, making fluid overload less likely. Pleural fluid studies were negative for cancer cells. The marked improvement with NSAIDs suggests an underlying systemic inflammatory response, not unlike Dressler’s Syndrome. CONCLUSIONS: Clinicians should be aware of pleural effusions that are secondary to a foreign body reaction, and consideration of a course of non-steroidal anti-inflammatory drugs should be considered if other causes of effusion have been ruled out. Reference #1: Tralhão, António et al. “The return of a disappearing entity: Dressler's syndrome after transvenous pacemaker implantation.” BMJ case reports vol. 2014 bcr2013203401. 20 Mar. 2014, doi:10.1136/bcr-2013-203401 Reference #2: Silicone Breast Implants: A Rare Cause of Pleural Effusion Shaik, Imam et al. CHEST, Volume 148, Issue 4, 444A DISCLOSURES: no disclosure on file for Alexander Geyer; No relevant relationships by Saamia Hossain, source=Web Response

Diagnostic Accuracy of Transthoracic Ultrasound Guided Biopsy Versus Medical Thoracoscopic Pleural Biopsies in Unexplained Exudative Pleural Effusions in El-Minia University Hospital (Single Center Experience)

Background: Transthoracic ultrasound (TUS) has been established to be important in chest diseases including pleural diseases. Interventional pulmonology showed rapid growth and flex–rigid thoracoscopy development, which brought medical thoracoscopy to the forefront. Objective: To compare the diagnostic accuracy, advantages and complications of TUS pleural biopsies versus medical thoracoscopic pleural biopsies in patients with idiopathic and exudative pleural effusion (PE) in El-Minia University Hospital. Patients and methods: Seventy patients with idiopathic and exudative PE were divided randomly into two groups; group I included 45 patients underwent sonar guided pleural biopsy and group II involved 25 patients underwent thoracoscopic pleural biopsy. Results: TUS-guided biopsy was diagnostic in 40 of 45 (88.8%) compared to 24 of 25 cases (96%) were diagnosed by thoracoscopy. Forty-two patients had malignant cause of effusion; 23 patients (51%) in TUS group and 19 (76%) patients in thoracoscopy group. Twenty-two patients had nonmalignant pleural effusion; 17 in group I and 5 in group II. The diagnosis was unclear in 6 patients, 5 of them in group I. Thoracoscopic group displayed greater percentages of post-procedural complications especially pain in site of puncture. Conclusion: TUS examination has close sensitivity and specificity to medical thoracoscopy and allows better assessment of effusion with fewer complications.

The utility of flow cytometry in the diagnostic work up of malignant effusions due to nonhematopoietic neoplasms.

Malignant pleural effusion and peritoneal carcinomatosis are frequent causes of effusion. Cytological evaluation (PAP-stained slides followed by immunocytochemistry, IHC, if applicable) is currently the gold standard for the diagnosis of malignant effusions, but its sensitivity varies between 40 and 80%, being a time-consuming technique. Although flow cytometry (FC) is not routinely used in the diagnosis or follow-up of nonhematopoietic neoplasms, it has the advantage of being rapidly applicable to fresh samples, potentially decreasing the time for the diagnosis. The main objective of this study was to assess the utility of FC as a confirmatory tool in the diagnosis of neoplastic effusions, based on the expression of EpCAM antibody in tumor cells versus the cytological evaluation. In this work 1,535 serous fluids were collected, of which 101 (68 pleural, 33 ascites) were selected through a screening algorithm and sent to the FC and cytological evaluation. Seventy-three of these samples (46 pleural, 27 ascites) were considered malignant as determined by clinical, cytological and radiological criteria. According to our data, 75% (55/73) of these samples were positive by Cytology/IHC and 74% (54/73) by FC. We noticed that, although the sensitivity, specificity, and area under the curve were similar, the turn-around time was shorter when using FC. Moreover, these results clearly improved by combining both techniques. We conclude that FC provides information about malignant effusions faster than immunohistochemical staining, and we believe that performing both techniques in parallel would improve diagnostic performance.

Diagnostic Yield of Medical Thoracoscopy in Undiagnosed Exudative Pleural Effusion- A Tertiary Centre Experience from Aligarh Muslim University, Uttar Pradesh, India

Introduction: Pleural effusions are one of the most common entities encountered by pulmonologists worldwide which have a very long list of causes. Initial workup of these patients begins with a chest X-ray and percutaneous or Ultrasound (USG) guided thoracocentesis followed by biochemical and cytological evaluation of the fluid to ascertain the cause of effusion. A 20 to 25% of cases remain undiagnosed even after thoracocentesis and closed pleural biopsy. Medical Thoracoscopy is emerging as a safe diagnostic procedure in these patients. Aim: To detect the diagnostic yield of medical thoracoscopy in cases of undiagnosed exudative lymphocytic pleural effusion and to study the complications associated with it. Materials and Methods: This was a prospective observational study, carried out in the Department of Pulmonary Medicine, JN Medical College and hospital, Aligarh Muslim University (AMU), Aligarh, Uttar Pradesh, India, from August 2016 to August 2018. Undiagnosed exudative pleural effusion was defined as pleural effusion with Adenosine Deaminase (ADA) levels less than 70 IU/L and negative pleural fluid cytology for malignancy. Thoracoscopic examination of the pleural space using flexi-rigid thoracoscopy was done and biopsy was taken from suspected areas and the tissue obtained, was send for histopathological examination. The results were presented as mean±SD (Standard Deviation) or percentage. Differences in categorical data were compared using the chi-square test or the Fisher-exact test. A p-value of &lt;0.05 was considered statistically significant. Results: Fifty patients underwent thoracoscopy for undiagnosed pleural effusion. Most common gross thoracoscopy finding was nodules which was seen in 23 patients. Malignancy was the most common histopathological finding, seen in 22 patients. Minor complications were seen in five patients. A final diagnosis could be made in 41 patients; the diagnostic yield was 82%. Conclusion: Medical thoracoscopy should be performed in all patients in which radiological and pleural fluid examinations could not lead to a definitive diagnosis as it has high sensitivity and a very low rate of complications.

Analysis of endothelial dysfunction in the context of pleural effusions of various origins using skin thermometry

To analyze the mechanisms and severity of endothelial dysfunction in patients with pleural effusion of various origins using skin thermometry. We studied microcirculation in 135 patients with pleural effusions of various origins. Local skin thermometry and computer wavelet analysis were performed in 3-5 days after thoracoscopy with pleural biopsy using Microtest-100WF device with a temperature measuring resolution of 0.001°C. We estimated endothelial, myogenic and neurogenic indices using spectral analysis of skin temperature fluctuations in a range 0.0095-2 Hz. The control group comprised 40 healthy participants aged 23-36 years. Three groups of patients were distinguished depending on the cause of effusion: malignant pleural effusions (n=65, 48.1%); inflammatory pleural effusions (para-pneumonic, post-traumatic, pancreatogenic, tuberculous) (n=58, 43%); transudates (hepatogenic, cardiogenic, and nephrogenic) (n=12, 8.9%). There were no significant differences in vascular tone in response to local heating of the second finger of the hand up to 40°C. Measurements were carried out within 10 min in all groups. Patients with diabetes mellitus and cardiovascular diseases (n=48, 35.6%) had significant decrease of thermal vasodilation index in endothelial range up to 2.93±1.77, in the control group - up to 4.21±2.40 (p=0.041). Endothelial dysfunction is a universal non-specific aspect in pathogenesis of various diseases. This process is essential in pleural effusion. Local thermometry and computer wavelet analysis revealed no significant differences between patients with malignant, inflammatory and transudative pleural effusions. Pleural effusions in the context of cardiovascular pathology and/or diabetes mellitus occur due to impaired vasodilatation mechanisms in endothelial range.

Canine cavitary effusion: a retrospective study of 304 cases in Brazil

ABSTRACT The objective of this study was to determine the frequency of different categories of specific and general classification in canine cavitary effusions (CE), as well as their association with the underlying etiologies. The laboratorial and clinical data from 304 cases of canine CE were retrospectively assessed. In 32.9% (100 cases), at least one of the specific classification categories was established, with a subtotal predominance of neoplasia (42%), bacterial serositis (24%) and hemorrhage (16%). Neoplasia was confirmed by effusion cytology in 57.5% of the cases with histopathological confirmation. From the cases in which the specific classification was not obtained, 35.8% were classified as modified transudate, 30.4% as pure transudate, 21.1% % as exudate and 12.7% was not included in any general category. The most common causes of effusion among these cases were hypoproteinemia and/or hipoalbuminemia (HPHA) (25.8%), hepatopathy (22.5%), cardiac insufficiency (15.5%) and cytologically undetected cases of neoplasia (12.4%). In conclusion, HPHA, hepatopathy and neoplasia represents important etiologies for canine CE development. Classification of effusions, solely based on [TP] and TNCC, might be an inaccurate diagnostic tool of effusions. New laboratorial classification methods for canine CE should be researched.

Non-specific pleuritis: pathological patterns in benign pleuritis

A pleural biopsy without granulomatous inflammation or tumour cells is interpreted as 'non-specific pleuritis' (NSP), a diagnosis without any specificity, often frustrating for physicians. However, varying histological features are found in NSPs with unknown significance. The aim of this study was to describe the detailed microscopic features of NSP and correlate them with the underlying aetiology. One hundred patients diagnosed with NSP after pleural biopsy were retrospectively evaluated. A benign cause of pleural effusion was attributed. Histological features evaluated were inflammation, fibrosis, vascular proliferation, haemorrhage, fibrin, oedema and mesothelial hyperplasia. A semi-quantitative scoring was applied. Bacterial-caused and autoimmune disease-associated NSPs showed a higher score followed by viral and drug-induced conditions, while pneumothorax and cardiac-induced NSPs showed a lower score (p<0.0001). The degree of fibrosis was higher in bacterial NSP, and the type of fibrosis was cellular in this group (p=0.006). Vascular proliferation differed between groups (p<0.0001), and was higher in bacterial NSP. Histological findings differ significantly between the varying aetiologies of NSP, and this may be used to suggest the cause of the effusion.

ХИРУРГИЯ ЭКССУДАТИВНЫХ ПЕРИКАРДИТОВ

In the article are presented modern approaches to diagnostics, etiological search and methods of surgical correction of pericardial effusion (PE) of different etiology. PE being the most common disease of the pericardium, often has a secondary nature. The overview of modern literature data is presented about terminology and classification of PE, the possibility of etiological search for the cause of effusion in the pericardial cavity, the main diagnostic methods, as well as the main tasks and methods of pericardial surgical interventions and its indications. Based on the analysis of literary sources, we can conclude that the consensus on the clinical and nosological structure, effectiveness and necessity of using various tests and interventions, clinical progression, epidemiology, prognosis and the reasons for the unsatisfactory results of treated PE is actually absent. Our analysis indicates the absence of a systematic and differential approach to choice of treatment tactics.

Sonographic Indicators for Treatment Choice and Follow-Up in Patients with Pleural Effusion.

Aim The aim of this study was to evaluate the role of thoracic sonography in treatment of pleural effusions and to identify sonographic indicators for surgical intervention. Materials and Methods This study included 378 patients with pleural effusions. US characteristics of effusions as the echo structure and pleural thickening were analyzed. Regarding the US finding, the diagnostic or therapeutic procedure was performed. Results The study included 267 male and 111 female patients, an average of 56.7 years. Infection was the most frequent cause of effusion. Two hundred sixty-nine patients had loculated and 109 free pleural effusion. Most frequent echo structure of loculated effusion was complex septate, whereas free effusion was mostly anechoic. Successful obtaining of the pleural fluid without real-time guidance was in 88% and under real-time guidance in 99% patients (p < 0.012). There was no significant difference in success rate between free and loculated effusion and regarding the echo structure (p=0.710 and 0.126, respectively). Complete fluid removal after serial thoracentesis or drainage was achieved in 86% patients. Forty-five patients with significantly thicker pleural peel and impairment of the diaphragmatic function than remaining of the group (p < 0.001) underwent surgery. Open thoracotomy and decortication was more frequently performed in patients with completely fixed diaphragm and complex, dominantly septated effusions. There is no significant difference in US parameters comparing to patients underwent VATS, but the number of VATS is too small for valid conclusion. Conclusion Thoracic sonography is a very useful tool in the evaluation of clinical course and treatment options in patients with pleural effusions of a different origin.