Diagnosis Of Pleural Effusion Research Articles

A Comparative Study of Conventional Cytology and Cellblock Method in Diagnosis of Pleural Effusion and their Correlation with Clinicopathological and Radiological Diagnosis

AbstractBackground: Cytological Smear (CS) is extremely useful in patients with pleural effusions especially when malignancy is suspected. Cellblock (CB) technique is another method for examination of pleural fluid. In this study we aimed to compare the diagnostic yields of CS and CB technique and the combi-nation of both, regardless of the etiology of Pleural Effusion (PE), and to compare their results with clinicopathological and radiological results.Aim of Study: This study aims to compare the diagnostic yields of CS and CB techniques and their combination in diagnosis of PF regardless of its etiology.Material and Methods: 140 cases of PE samples were obtained, CS and CB were done, results were compared with each other and correlated with the clinicopathological and radiology results when available.Results: Agreement between results of CS and CB was 87.86% (p=0.0001). There was an agreement between CS at one side and either radiological findings or biopsy at the other side; 88.89% and 88.1% respectively (p=0.0001 for each). There was an agreement also between CB results and either radiological findings or biopsy; 94.87% and 95.24% respec-tively (p=0.0001 for each).Conclusions: Our study showed that the CB method yielded better results in diagnosis of malignancy in PE. Therefore, this technique could be considered as a useful adjuvant in evaluating PE fluid cytology and final cytodiag-nosis, along with the routine CS method.

Correlation of hematological parameters with right-sided pleural effusion in pediatric dengue cases – A cross-sectional study

Background: Capillary leak in dengue presents as ascites, pleural effusion (PE), and pericardial effusion. Objectives: The objectives of the study were to correlate the hematological parameters with radiological findings in cases with right-sided PE. Materials and Methods: This was a cross-sectional study conducted at the tertiary care teaching hospital. A total of 138 cases were included in the study. Investigations included complete hemogram on the day of admission, day of diagnosis of PE and at discharge. Radiological investigations included chest X-ray, ultra-sonogram of abdomen, and chest which were correlated with hematocrit and platelet count. Results: Out of 138 cases, 71 (51%) had PE; out of which, 46 cases (64.78%) had bilateral effusions with right side more than left. About 21 (15.2%) cases had only right-sided PE. The mean platelet count and hematocrit were 67,640/?L and 31.8%, respectively, on the day of PE. Conclusion: In cases of dengue, right-sided PE is more common in cases with platelet count ranging between 20,000 and 50,000/?L.

Identification of Pleural Response Patterns: A Cluster Analysis

BackgroundPleural effusion occurs as a response of the pleura to aggressions. The pleura reacts differently according to the type of injury. However, pleural reactions have not yet been characterized. The objective of this study was to identify homogeneous clusters of patients based on the analytical characteristics of their pleural fluid and identify pleural response patterns. MethodsA prospective study was conducted of consecutive patients seen in our unit for pleural effusion. Principal component and cluster analyses were carried out to identify pleural response patterns based on a combination of pleural fluid biomarkers. ResultsA total of 1613 patients were grouped into six clusters, namely: cluster 1 (10.5% of the cohort, primarily composed of patients with malignant pleural effusions); cluster 2 (17.4%, pleural effusions with inflammatory biomarkers); cluster 3 (16.1%, primarily composed of patients with infectious pleural effusions); cluster 4 (2.5%, a subcluster of cluster 3, superinfectious effusions); cluster 5 (23.4%, paucicellular pleural effusions); and cluster 6 (30.1%, miscellaneous). Significant differences were observed across clusters in terms of the analytical characteristics of PF (p<0.001 for all), age (p<0.001), and gender (p=0.016). A direct relationship was found between the type of cluster and the etiology of pleural effusion. ConclusionPleural response is heterogeneous. The pleura may respond differently to the same etiology or similarly to different etiologies, which hinders diagnosis of pleural effusion.

Aetiological Diagnosis of Pleural Eusion: A cross sectional study

Pleural effusion is a common clinical problem with different possible causes. It can be due to local, systemic, infectious or non-infectious causes. Aetiological diagnosis is important for proper treatment. To evaluate the aetiological diagnosis of pleural effusion of hospitalized adult patients this cross-sectional, descriptive study conducted from April to September 2012 at Bangabandhu Sheikh Mujib Medical University (BSMMU). A total of 100 cases were selected by purposive sampling. Data were collected using a structured questionnaire. Complete history was taken either from patient or accompanying attendants. Clinical examination was done and relevant investigations report were collected. Data were analyzed using statistical package for the social sciences (SPSS). The mean age of the patient was 41.2 SD± 7.4 years with a male to female ratio of 3:1. Over half (52%) of the patients were poor, 34% were middle class and 14% were rich. Over two-third (67%) of the patients were smoker and the remaining 33% were non smoker. Out of 100 patients with pleural effusion, 52 had tuberculosis and 16 patients had malignancy. Among the malignant cases 14 were found to have bronchial carcinoma and 2, had lymphoma. The remaining 32 patient had other causes of pleural effusion which included nephrotic syndrome 14, congestive cardiac failure 5, cirrhosis of liver 4, rheumatoid arthritis 3, amoebic liver abscess 2, and undiagnosed 4. Tuberculosis is the predominant cause of pleural effusion in our country and the second leading cause is malignancy.&#x0D; Bangladesh Med J. 2018 May; 47 (2): 29-34

BLINDED BY THE LIGHT: A CASE OF MALIGNANT PLEURAL EFFUSION WITH TRANSUDATIVE PROPERTIES

SESSION TITLE: Tuesday Medical Student/Resident Case Report Posters SESSION TYPE: Med Student/Res Case Rep Postr PRESENTED ON: 10/22/2019 01:00 PM - 02:00 PM INTRODUCTION: Light’s criteria is routinely used to help aid in the diagnosis and treatment of pleural effusions by categorizing them into transudates or exudates. Pleural effusions due to malignancy and infection are classically exudative, while effusions from heart failure, cirrhosis, and renal failure are examples of usual transudates (1). When exceptions to this pattern do occur, it is most often that a transudate is misclassified as an exudate (1). Presented is a case where a transudative effusion was later discovered to be malignant due to likely concurrent hepatic hydrothorax. CASE PRESENTATION: A 59 year-old male with a history of alcoholic cirrhosis presented with respiratory distress and right upper quadrant pain was found to have complete opacification of the left hemithorax on chest X-ray. Upon admission, the pulmonary service was consulted where bedside evaluation confirmed a large right pleural effusion anechoic by ultrasound. Diagnostic thoracentesis was consistent with a transudative effusion with pleural protein 1.1, serum protein 5.6, pleural lactate dehydrogenase 76, and serum lactate dehydrogenase 269. Hepatic hydrothorax was considered to be the likely etiology given presence of ascites and a history of cirrhosis. Medical cytology however later revealed atypical neoplastic cells. Abdominal imaging revealed a large mass in the right hepatic lobe. IR-guided biopsy revealed metastatic adenocarcinoma with a primary cholangiocarcinoma. Prior to oncologolical evaluation for chemotherapeutic options, the patient decompensated with worsening encephalopathy and respiratory distress from re-accumulation of pleural fluid and abdominal ascites. Given overall grave prognosis, goals of care discussions were held and comfort care was initiated with the patient passing comfortably shortly thereafter. DISCUSSION: Light’s criteria are routinely used to help aid in the diagnosis and treatment of pleural effusions by categorizing them into transudates or exudates. Certain etiologies of pleural effusions are classically transudative, while others are exudative (1). When pleural studies do not meet Light’s criteria for an exudative effusion, physicians will tend to consider that malignancy and infection are ruled out (2, 3). This can lead to a missed or incorrect diagnosis since malignant effusions have been described in the literature to be transudative in as much 10.6% (4) of cases. We describe a case where pleural studies did not meet criteria for an exudative effusion, so a malignant etiology was initially considered to be unlikely. However, medical cytology later showed malignant cells, leading to further work-up revealing the primary underlying cholangiocarcinoma. CONCLUSIONS: When an effusion is transudative, one cannot assume that malignancy is ruled out, otherwise a deadly diagnosis may be missed. Reference #1: Light RW. “The Light criteria. The beginning and why they are useful 40 years later.” Clinical Chest Medicine 2013; 34(1): 21-6. Reference #2: McGrath EE, Anderson PB. “Diagnosis of pleural effusion: a systematic approach.” American Journal of Critical Care 2011; 20(2): 119-27. Reference #3: Thomas R, Cheah HM, Creaney J, Turlach BA, Lee YCG. “Longitudinal measurement of pleural fluid biochemistry and cytokines in malignant pleural effusions.” Chest 2016; 149(6): 1494-500. DISCLOSURES: no disclosure on file for Alfredo Astua; No relevant relationships by Dawn Maldonado, source=Web Response No relevant relationships by Michael Megally, source=Web Response

ES19.02 Best Endoscopic Tools for the Best Results

Undiagnosed pleural effusion is an increasingly common clinical problem and represents significant burden of disease both to patients and healthcare resources. With the increase in annual incidence of both primary and secondary pleural malignancies, better diagnostics and treatment options are very much needed. Medical thoracoscopy, also known as local anaesthetic thoracoscopy [2], is a procedure where a rigid or semi-rigid scope is inserted into the pleural cavity via a port for direct visualisation of the pleura and biopsy of abnormal areas, besides completion of talc poudrage, where appropriate. It is usually performed under conscious sedation and local anaesthesia. This procedure avoids risks of general anaesthesia and single lung ventilation, required for video-assisted thoracoscopic surgery (VATS) and therefore can be performed in patients who are unfit for anaesthesia/surgery. The procedure of thoracoscopy is performed in a controlled environment such as in an operating theatre setting, endoscopy suite or treatment room with adequate staffing. Diagnostic advantage A significant number of cases of pleural effusion are undiagnosed after a single diagnostic pleural aspiration and the diagnostic yield of pleural fluid cytology is only approximately 60% [3]. A second aspiration only modestly increases diagnostic yield by 15% and a third sample is non-contributory [3]. A blind pleural biopsy (also known as closed pleural biopsy) increases the diagnostic yield above pleural fluid cytology by only 7-27% [3]. In mesothelioma however, the diagnostic yield of pleural fluid cytology is even lower, at around 32% [4]. A blind pleural biopsy only increases sensitivity to around 50% [5]. Medical thoracoscopy is substantially superior in diagnostic power compared to pleural fluid cytology and blind pleural biopsy. As it allows direct visual assessment of the pleura and subsequent biopsy of the abnormal areas, it maximises diagnostic yield to >90% in malignant pleural diseases [5,6]. Rigid thoracoscopy generates similar diagnostic yield compared to semirigid thoracoscopy in exudative pleural effusions but larger biopsy samples can be obtained during rigid thoracoscopy [5,6]. The sensitivity of medical thoracoscopy in malignant mesothelioma appears to be equally good and the efficacy of rigid medical thoracoscopy in regards to diagnosis in pleural malignancy is as high as VATS [2]. With the increasing need to secure an accurate diagnosis and plan optimal treatment in possible pleural malignancy, medical thoracoscopy offers a high diagnostic yield earlier in the patient journey. Therefore, this is the preferred procedure where the option exists and helps to reduce the need for repeated diagnostic procedures and reduces the time taken to establish diagnosis and commence appropriate treatment. Medical thoracoscopy as a therapeutic procedure Another advantage of medical thoracoscopy is that it is a diagnostic and therapeutic procedure in the same setting. Complete drainage of pleural fluid can be achieved during the procedure and talc poudrage can also be performed during medical thoracoscopy. It is a highly effective method of pleurodesis with an efficacy of 84% at 1 month, which is at least equivalent to talc slurry via a seldinger chest drain, with possibly increased efficacy in the subgroup of patients who have breast or lung carcinoma and without trapped lung [2]. Medical thoracoscopy is also effective in the management of TB pleurisy and empyema. Septations and adhesions in complex infected effusions can be divided during thoracoscopy which can facilitate accurate chest tube placement and drainage. Advanced Thoracoscopy Techniques Narrow Band Imaging- using Semirigid Thoracoscope Autofluorescence Rigid Thoracoscopy Biopsy- with Insulated Tip Diathermy Knife Cryobiopsy- using Semirigid Thoracoscope Rigid Thoracoscope Semi-rigid Thoracoscope Diacon AH, Van de Wal BW, Wyser C, et al. Diagnostic tools in tuberculous pleurisy: a direct comparative study. Eur Respir J 2003;22:589e91. Rahman NM, Ali NJ, Brown G, Chapman SJ, O’Davies RJ, Downer NJ, Gleeson FV, Howes TQ, Treasure T, SinghS and Phillips GD Local anaesthetics thoracoscopy: British Thoracic Society pleural disease guideline 2010. Thorax 2010;65(Suppl 2):ii54-ii60 Mohan A, Chandra S, Agarwal D, Naik S and Munavvar M. Utility of semirigid thoracoscopy in the diagnosis of pleural effusions: a systematic review. Journal of Bronchology and Interventional Pulmonology 17 (3), 195-201 Munavvar M, Khan MAI, Edwards J, Waqaruddin Z and Mills J. The autoclavable semirigid thoracoscope: the way forward in pleural disease? Eur Respir J 2007; 29: 571-574 Dhooria S, Singh N, Agarwal AN, Gupta D and Agarwal R. A randomized trial comparing the diagnostic yield of rigid and semirigid thoracoscopy in undiagnosed pleural effusion. Respir Care 2014:59 (5), 756-764 Rozman A, Camlek L, Marc-Malovrh M, Triller N, Kern I. Rigid versus semi-rigid thoracoscopy for diagnosis of pleural disease: a randomized pilot study. Respirology, 2013 May;18(4):704-10. Loddenkemper R, Lee P, Noppen M, Mathur PN. Medical thoracoscopy/pleuroscopy: step by step. Breathe. 2011;8(2):156-67. Rigid Thoracoscopy, Semi-rigid Thoracoscopy, Advanced Techniques

URINOTHORAX SECONDARY TO UNILATERAL URINOMA CAUSED BY URETERAL STRICTURE

SESSION TITLE: Global Case Report Posters SESSION TYPE: Global Case Reports PRESENTED ON: 10/23/2019 09:45 AM - 10:45 AM INTRODUCTION: Urinothorax is a rare and atypical cause of pleural effusion and it usually involves patient with obstructive uropathy, iatrogenic genitourinary procedure complications or abdominal trauma. CASE PRESENTATION: A 67-year-old male with PMHx of colon cancer s/p right hemicolectomy with entero-colonic anastomosis presented with right flank pain radiating to umbilical/pelvic region for 5 days. He was hemodynamically stable. His P/E showed decrease air entry with decreased percussion in the right mid lung and tenderness in the right flank area. His CXR which was significant for right pleural effusion and CT abdomen showed severe right kidney perinephric fluid, stranding with dilation of the pelvicalyceal system and focal rupture of the superior right renal pelvis and proximal-mid ureter stricture without any present of renal or ureteral calculus. This large perinephric collection is consistent with Urinoma. Patient underwent thoracocentesis yellow color fluid was removed. The analysis showed pH of 7.34, glucose 102, WBC 27 (Lymph: 87), RBC 26, LDH of 53 and protein of 2. Serum chemistry showed protein of 8.1 and LDH of 108.The pleural fluid was transudative which is suggestive of urinothorax. The patient successfully received a right ureteral stent, relieving his obstruction, and was subsequently discharged home. Follow up CXR and CT abdomen after discharge showed resolved pleural effusion and patent ureteral stent. DISCUSSION: In our patient, the cause of the pleural effusion is due to unilateral obstructive uropathy leading to rupture pelvis and accumulation of urine in the retroperitoneal space (Urinoma) that leaked into the pleural space. The most plausible theory that would explain our case is that the urinoma drained into the pleural space via the communication between the retroperitoneal and pleural lymphatic systems due to increased retroperitoneal or intraperitoneal pressure. Urinothorax is mostly a transudative process where the pleural fluid is typically a yellow color with very low total urine protein, pH <7.4 and low cell count as well which correlated with the finding of the pleural fluid analysis in our patient. The diagnosis of urinothorax and its underlying cause can be identified with an ultrasound or CT scan of the abdomen. The management of the urinothorax may require a thoracentesis for diagnostic and symptomatic relief purposes. In our case, the underlying cause was ureteral stricture most likely risen from the complication of his right hemicolectomy. The ureteral stricture was relieved with a ureteral stent resulting in the rapid resolution of the urinothorax. CONCLUSIONS: Unilateral urinothorax is rare entity caused due to genitourinary obstruction, surgical complications and abdominal trauma, which can be resolved once the underlying cause is treated. We highlight this case to show that “zebras” should always remain in the differential diagnosis of pleural effusion. Reference #1: Casallas A, Castañeda-Cardona C, Roselli D. Urinothorax: case report and systematic review of the literature. Urol Ann 2016;8:91-4. 10.4103/0974-7796.164851 Reference #2: Toubes ME, Lama A, Ferreiro L, et al. Urinothorax: a systematic review. Journal of Thoracic Disease. 2017;9(5):1209-1218. https://doi.org/10.21037/jtd.2017.04.22 Reference #3: Garcia-Pachon E, Padilla-Navas I. Urinothorax: case report and review of the literature with emphasis on biochemical diagnosis. Respiration. 2004;71(5):533-36. DISCLOSURES: No relevant relationships by Waheed Abdul, source=Web Response

Protocolo diagnóstico y terapéutico del derrame pleural

For the future management of each specific case, the clinical context of the diagnosis of pleural effusion in emergency department is essential. In most cases, thoracentesis is the mainly exploratory maneuver, allowing fluid extraction and improving symptomatology when necessary. On suspicion of complicated parapneumonic effusion or hemothorax, thoracentesis should be performed urgently.

Diagnostic Accuracy of CYFRA21-1 in the Differential Diagnosis of Pleural Effusions.

Approximately 20% of pleural effusions are associated with cancer; about 50% require invasive procedures to perform diagnosis. Determination of the concentration of soluble cytokeratin 19-fragments (CYFRA21-1) may help identify patients with malignant effusions. However, pathologies other than cancer can increase its concentration. The identification of these possible false positives with routine tests CRP, ADA, % polymorphonuclear cells (PN) may improve diagnostic accuracy. This study aimed to determine the diagnostic accuracy of CYFRA21-1 in the detection of malignant pleural effusions and the possible false positives. Analysis of CYFRA21-1, adenosine deaminase (ADA), C-reactive protein (CRP), and the percentage of polymorphonuclear leukocytes (PN%) in the fluid from 643 consecutive undiagnosed pleural effusions was performed. CYFRA21-1 showed 38.7% sensitivity and 97.3% specificity at 175 ng/ml cut-off. Effusions not suspicious of a false-positive showed 39.0% sensitivity and 98.2% specificity, while effusions suspicious of false positive showed lower sensitivity (36.4%) and specificity (95.0%). The diagnostic accuracy of CYFRA21-1 in pleural effusions can be improved by classification according to the possibility of false positives.

Efficacy of ultrasonography in diagnosis of pleural effusion

Background: Pleural effusion is due to excessive accumulation of pleural fluid in the pleural space that exceeds the physiological amount. Pleura effusion imaging technique will play important role in diagnosis and subsequent management of the disease. Ultra sound (US) is a non radiation technique and it can be used in immediate application at the point of care. Methods: A Prospective study. Study, containing 60 pleural effusion cases. Demographic data was collected followed by history regarding current health status, history of medication, alcoholism and Active smoking. In all the subjects, chest radiography posteroanterior data was obtained. Conventional CT of the chest was performed and ultrasound scan was recorded for each participant. Results: In the present study encysted effusions, pleural thicknees, pleural mass and consolidation are less diagnosed by chest x-ray compared with ultrasound. The number of pleural effusions, encysted effusions, pleural thicknees, pleural mass and consolidation are equally diagnosed by ultrasound and computed tomography. The number of unilateral and bilateral are equally diagnosed by ultrasound and computed tomography. Conclusion: Present study finding suggested that ultrasound is an easy accessible method for detection of pleural effusion and it is very helpful in detection of encysted effusions, pleural thickness, pleural mass and pleural nodules. Ultrasound will not only helpful in diagnosis of pleural effusion it will also useful in the management of pleural effusions.

Ultrasound elastography: a novel tool for the differential diagnosis of pleural effusion.

Traditional thoracic ultrasound (TUS) is often the initial tool used to help diagnose malignant pleural effusion (MPE). Ultrasound elastography, a relatively new technique, has been used to differentiate malignant disease from benign disease by evaluating tissue "stiffness". However, no studies evaluating the efficacy of ultrasound elastography for diagnosing MPE are available. We assessed the value of ultrasound elsatography for diagnosing MPE prospectively. All 244 enrolled patients were divided into a development set and a validation set in chronological order. The cut-off elasticity index was established using a receiver operating characteristic curve constructed from the continuous data of the patients in the development set. The diagnostic performance of ultrasound elastography was compared with that of TUS in the validation set. In the development set, the mean elasticity index (47.25 kPa) was the optimal cut-off. In the validation set, pleural ultrasound elastography had a sensitivity of 83.64%, a specificity of 90.67%, a positive predictive value of 86.79%, a negative predictive value of 88.31%, a positive likelihood ratio of 8.96 and a negative likelihood ratio of 0.18 for diagnosing MPE. The sensitivity of ultrasound elastography was significantly higher (p=0.006) than that of TUS (60%). Pleural ultrasound elastography is a better technique than TUS for differentiating MPE from benign pleural disease.

Potential Diagnostic and Prognostic Role of Microenvironment in Malignant Pleural Mesothelioma

IntroductionA comprehensive analysis of the immune cell infiltrate collected from pleural fluid and from biopsy specimens of malignant pleural mesothelioma (MPM) may contribute to understanding the immune-evasion mechanisms related to tumor progression, aiding in differential diagnosis and potential prognostic stratification. Until now such approach has not routinely been verified. MethodsWe enrolled 275 patients with an initial clinical diagnosis of pleural effusion. Specimens of pleural fluids and pleural biopsy samples used for the pathologic diagnosis and the immune phenotype analyses were blindly investigated by multiparametric flow cytometry. The results were analyzed using the Kruskal-Wallis test. The Kaplan-Meier and log-rank tests were used to correlate immune phenotype data with patients’ outcome. ResultsThe cutoffs of intratumor T-regulatory (>1.1%) cells, M2-macrophages (>36%), granulocytic and monocytic myeloid-derived suppressor cells (MDSC; >5.1% and 4.2%, respectively), CD4 molecule–positive (CD4+) programmed death 1–positive (PD-1+) (>5.2%) and CD8+PD-1+ (6.4%) cells, CD4+ lymphocyte activating 3–positive (LAG-3+) (>2.8% ) and CD8+LAG-3+ (>2.8%) cells, CD4+ T cell immunoglobulin and mucin domain 3–positive (TIM-3+) (>2.5%), and CD8+TIM-3+ (>2.6%) cells discriminated MPM from pleuritis with 100% sensitivity and 89% specificity. The presence of intratumor MDSC contributed to the anergy of tumor-infiltrating lymphocytes. The immune phenotype of pleural fluid cells had no prognostic significance. By contrast, the intratumor T-regulatory and MDSC levels significantly correlated with progression-free and overall survival, the PD-1+/LAG-3+/TIM-3+ CD4+ tumor-infiltrating lymphocytes correlated with overall survival. ConclusionsA clear immune signature of pleural fluids and tissues of MPM patients may contribute to better predict patients’ outcome.

Primary fetal pleural effusion: Characteristics, outcomes, and the role of intervention.

We aimed to present the natural history and outcomes of fetal primary pleural effusions (PPE). Fetuses with prenatal diagnosis of PPE delivered between January 2011 and June 2018 were included. Fetal PPE were separated into groups: resolved, stable, or progressive. Progressive PPE was diagnosed, using fetal echocardiography, by the new onset of fetal hydrops or impaired cardiac function. Data were reported as median [range] and n (%). Among 189 fetuses with antenatal diagnosis of pleural effusion, 30 had a PPE. A total of 26.7% (n=8), 26.7% (n=8), and 40.0% (n=12) were classified as resolved, stable, and progressive, respectively; two were lost to follow-up. In 14 cases (50%), there were bilateral pleural effusions. Of the 12 cases in the progressive group, four (33.3%) had amnioreduction, six (50.0%) had thoracentesis, and eight (66.7%) had shunt placement performed. There were two fetal deaths, both in the progressive group, one of which received amnioreduction and the other underwent both thoracentesis and shunt placement prior to demise. In more than half of fetuses with prenatal PPE, the effusion remained stable or spontaneously resolved, and the perinatal outcomes were generally favorable. This information will be useful in optimizing the counseling and care of these patients.

Pleural Cryobiopsy versus Flexible Forceps Biopsy in Subjects with Undiagnosed Exudative Pleural Effusions Undergoing Semirigid Thoracoscopy: A Crossover Randomized Trial (COFFEE Trial)

Background: There is no randomized study comparing pleural cryobiopsy (CB) and flexible forceps biopsy (FFB) in subjects undergoing medical thoracoscopy for the diagnosis of pleural effusions. Objective: In this crossover study, we compared the diagnostic yield of CB versus FFB in subjects undergoing semirigid thoracoscopy. Methods: Subjects undergoing semirigid thoracoscopy for undiagnosed pleural effusions were subjected to both CB and FFB, with the order of performing the biopsy randomized in a 1:1 ratio. The primary outcome was the diagnostic yield obtained with CB versus FFB. The secondary outcomes included the biopsy size, depth, histologic interpretability, artefacts, the difficulty of performing biopsy on an operator-rated visual analog scale, the severity of bleeding observed at the time of the biopsy, and the duration of the procedure. Results: Of the 201 subjects screened, 50 (mean age 52.4 years; 18 women) were included. The diagnostic yield of CB (78.0%) was not different from FFB (76.0%, p = 1.00). CB yielded a larger specimen than FFB (median size 7.0 vs. 4.0 mm; p < 0.001), and a greater depth of specimens (up to the pleural fat or deeper, CB vs. FFB 65.2 vs. 40.8%; p = 0.02). The CB procedure was quicker than FFB (median duration 10 vs. 15 min; p < 0.001). There were no significant differences in the difficulty of performing the biopsy, the severity of bleeding, histologic interpretability, or artefacts in the specimens between the CB and FFB groups. Conclusion: The diagnostic yield of pleural CB was comparable to FFB during semirigid thoracoscopy.

Nilai Diagnostik Adenosine Deaminase (ADA) Cairan Pleura pada Penderita Efusi Pleura Tuberkulosi

Background: Tuberculosis pleural effusion is the most common extrapulmonary TB after lymphadenitis TB. Limited diagnostic methods make TB pleural effusion hard to diagnose. Adenosine deaminase ADA is an enzyme in purin catabolism process which catalyze adenosine into inosine and deoksiadenosine into deoksiinosin. This process is important in lymphoid cell differentiation. ADA is elevated in TB pleural effusion. Method: This study was a cross sectional analytic observational. Statistic analysis was using two independent samples T test. ROC curve was used to determine cut off value of ADA. Kappa test was used to determined the level of agreement of ADA cut off value. Results: Forty eight samples were included in this study, 18 samples with TB pleural effusion and 30 samples with non TB pleural effusion. There was significant difference between pleural fluid ADA in TB and non TB. Positivity of AFB sputum and MTB culture did not show any significant differences. Cut off ADA value for TB pleural effusion diagnosis was 39,19 with sensitivity 88,9% and spesificity 90%. Conclusion: Examination of ADA level in pleural fluid is a usefull tool to diagnose TB pleural effusion.

EXPERIENCE IN MEDICAL THORACOSCOPY: A FOUR-YEAR RETROSPECTIVE STUDY

PURPOSE: To document our experience in rigid medical thoracoscopy in diagnosis of pleural effusion of undetermined origin in a four year retrospective study regarding its safety, complications and diagnostic yield. METHODS: Data of 134 patients who underwent medical thoracoscopy in Alexandria Main University Hospital, Chest department for diagnosing pleural effusion of undetermined origin were retrospectively reviewed to assess the diagnostic yield, safety and complications of rigid medical thoracoscopy, RESULTS: We reviewed records of 134 patients [62 males (46%) and 72 females (54%)]. Their mean age was 54±13.43 years. Combining histopathological and bacteriological examination results of thoracoscopic pleural biopsies, all patients were finally diagnosed except 13 patients (10%) that remained idiopathic, 97 patients (72%) were diagnosed as malignant pleural effusion (MPE)&24 (18%) patients were diagnosed as benign pleural effusion. Regarding patients with MPE, 10 patients were diagnosed as primary pleural mesothelioma. The frequency of primary tumor organ among the 87 patients with metastatic pleural disease, with no respect to patient gender, was; the lung being the most common primary organ (48%), the next three primary organ sites encountered in descending order were breast (20%), ovary and colon (5%). In 9 patients (10%) the primary site of the neoplasm was never determined. The commonest complication encountered was post-procedural pain (35 %), followed by subcutaneous emphysema (19%) CONCLUSIONS: Medical thoracoscopy showed very high diagnostic yeild. Overall, the procedure was safe even in elderly patients. No procedure related mortality was reported CLINICAL IMPLICATIONS: Medical thoracoscopy, in our experience, is safe & well-tolerated even in elderly patients with high diagnostic yield.

Detection of carcinoembryonic antigen levels in pleural effusion and serum and their ratio for differential diagnosis of pleural effusion resulting from tuberculosis and lung cancer

To study the clinical value of detecting carcinoembryonic antigen levels in pleural effusion (PCEA) and serum (SCEA) and their ratio (P/S) in the differential diagnosis of pleural effusions resulting from tuberculosis and lung cancer. This retrospectively study was conducted among 82 patients with pleural effusion caused by pulmonary tuberculous (TB; control group) and 120 patients with pleural effusion resulting from lung cancer in our hospital between April, 2016 and March, 2018. PCEA, SCEA and P/S were compared between the two groups and among the subgroups of lung cancer patients with squamous cell carcinoma (SqCa), adenocarcinoma (ACA), small cell carcinoma (SCLC). The receiveroperating characteristic curve (ROC) analysis was used to confirm the optimal critical value to evaluate the diagnostic efficiency of different combinations of PCEA, SCEA and P/S. PCEA, SCEA and P/S were significantly higher in the overall cancer patients and in all the 3 subgroups of cancer patients than in the patients with TB (P &lt; 0.05). The areas under the ROC curve of PCEA, SCEA and P/S were 0.925, 0.866 and 0.796, respectively; PCEA had the highest diagnostic value, whose diagnostic sensitivity, specificity, accurate rate, and diagnostic threshold were 83.33%, 96.34, 88.61%, and 3.26 ng/ml, respectively; SCEA had the lowest diagnostic performance; the diagnostic performance of P/S was between that of SCEA and PCEA, but its combination with SCEA greatly improved the diagnostic performance and reduced the rates of misdiagnosis and missed diagnosis. Parallel tests showed that the 3 indexes combined had significantly higher diagnostic sensitivity than each or any two of the single indexes (P &lt; 0.05), but the diagnostic specificity did not differ significantly. The area under the ROC curve of combined detections of the 3 indexes was 0.941 for diagnosis of lung cancer-related pleural effusion, higher than those of any other combinations of the indexes. The combined detection of PCEA, SCEA and P/S has a high sensitivity for diagnosis of lung cancer-related pleural effusion and provides important information for rapid and accurate diagnosis of suspected cases.

Experience in medical thoracoscopy: a 4-year retrospective study

ObjectiveThe aim was to document our experience in rigid medical thoracoscopy in the diagnosis of pleural effusion of undetermined origin in a 4-year retrospective study regarding its safety, complications, and diagnostic yield.Patients and methodsData of 134 patients who underwent medical thoracoscopy in Alexandria Main University Hospital, Chest Department, for diagnosing pleural effusion of undetermined origin were reviewed to assess the diagnostic yield, safety, and complications of rigid medical thoracoscopy.ResultsWe reviewed records of 134 patients [62 (46%) males and 72 (54%) females]. Their mean age was 54±13.43 years. On combining histopathological and bacteriological examination results of thoracoscopic pleural biopsies, all patients were finally diagnosed, except for 13 (10%) patients who remained idiopathic; 97 (72%) patients were diagnosed as having malignant pleural effusion and 24 (18%) patients were diagnosed as having benign pleural effusion. The commonest complication encountered was postprocedural pain (35%), followed by subcutaneous emphysema (19%). Overall, the procedure was safe even in elderly patients. No procedure-related mortality was reported.ConclusionMedical thoracoscopy, in our experience, is a safe and well-tolerated procedure even in elderly patients with high diagnostic yield.

Application of Unit-Level Cost Transparency, Education, Enhanced Audit, and Feedback of Anonymized Peer Ranking to Promote Judicious Use of 25% Albumin in Critical Care Units.

Objective: Hyperoncotic 25% albumin is widely used for fluid resuscitation in intensive care units. However, this practice remains controversial. By 2012 in our intensive care unit, annual 25% albumin expenditures had steadily increased to exceed $1 million. This prompted efforts to promote more judicious use. Design: Prospective time series cohort analysis using statistical process control charts. Setting: Seventy-six-bed quaternary level cardiovascular surgical intensive care unit (CVICU), organized into 6 adjacent units. Patients: Adult cardiac, thoracic, and vascular surgery patients admitted postoperatively to the CVICU during the study period. Interventions: Over 12 months starting March 2013, we sequentially implemented unit-level 25% albumin cost transparency, provider education, and individualized audit and feedback of anonymized peer ranking of albumin prescriptions. Measurements and Main Results: C control charts were used for analysis of monthly unit-level direct albumin costs for 20 months. Balance measures including red cell transfusions, number of diagnoses of pleural effusions, and length of stay were also tracked. Monthly average albumin expenditures had decreased 61% by December 2014, and there was no evidence of adverse changes in any of the balance measures. These reductions have been sustained. Conclusion: Sequential implementation of multimodal strategies can alter clinician practices to achieve substantial unit-level reduction in 25% albumin utilization without harm to patients.

Differentiating transudative and exudative pleural effusion by pleural fluid cholesterol

Background: Pleural effusion is one of the common condition encountered in day to day practise. Pleural effusions represent a very common diagnostic task to the physician. A correct diagnosis of the underlying disease is essential to rational management. Today there are a number of laboratory tests available to differentiate exudates and transudates which are considered cost effective to the patients, so this study was designed for the measurement of pleural fluid cholesterol to differentiate transudative and exudative pleural effusions (sensitivity-97.8%, specificity-100%) with the advantage that a contemporary blood sample is not required, thereby lowering cost of diagnostic procedure. Objectives: To study the diagnostic value of Pleural fluid Cholesterol in differentiating transudative and exudative pleural effusions. Methodology: This cross sectional descriptive study was conducted on patients of pleural effusion (n=60)age &gt;18 years patients with definitive clinical diagnosis and evidenced by radiological diagnosis of pleural effusion were taken as inclusion criteria. Results: The results showed majority of the patients were males (63.3%) and females (36.7%). According to lights criteria 46 patients were exudates and 14 patients were transudates and according to Pleural fluid Cholesterol criteria 45 patients were exudates and 15 patients were transudates with sensitivity of 97.8% and specificity of 100% and accuracy of 98.3%. Conclusion: The pleural fluid cholesterol criteria were found to be the most efficient criteria. Since this parameter involves the measurement of only pleural fluid values of cholesterol, it has following advantages-Economically it reduces number of biochemical tests and Simpler as there is no need to take simultaneous blood sample at the time of thoracocentesis.