Infectious Pleural Effusions Research Articles

A novel interleukin 36 gamma for diagnosing and differentiating malignant from infectious pleural effusion

Background Pleural effusions can be caused by various diseases, making their diagnosis challenging. Light’s criteria are often used to distinguish transudative and exudative effusions. Exudative effusions have a more complex etiology, including parapneumonic, tuberculous, and malignant effusion. Objectives The main objective of this study was to evaluate the effectiveness and sensitivity of Interleukin 36 gamma (IL-36γ) as a diagnostic marker for differentiating between malignant and infectious pleural effusions. Methods The study involved 100 patients with pleural effusion. Patients were categorized into five groups based on their final diagnosis. An ELISA technique was used to quantitatively measure the levels of pleural fluid IL-36γ. Results The results showed that pleural IL-36γ levels were higher in tuberculous pleural effusion compared with malignant, transudative, and uncomplicated pleural effusion. In contrast, pleural IL-36γ levels were higher in complicated pleural effusion compared with tuberculous, malignant, transudative, and uncomplicated pleural effusion. Conclusion Based on the study’s findings, it was concluded that pleural IL-36γ is a novel biomarker that can be used to diagnose and differentiate malignant pleural effusion from infectious pleural effusion.

Inoculation of pleural fluid in blood culture bottles could be a routine practice in pleural infection

Background Worldwide, pleural infections are becoming more common. Overuse of empirical antibiotics has been linked to longer hospital stays and higher death rates, causing the emergence of antibiotic-resistant pathogens. So, proper care requires the identification of the pathogenic bacteria using pleural fluid culture. In addition to normal culture, pleural fluid inoculation in blood culture bottles enhances the proportion of patients with detectable infections in less time. Aim To assess whether inoculating pleural fluid into a blood culture bottle will increase the yield of isolated pathogens compared to routine culture techniques in evaluating pleural infection. Also, to compare the time of pathogen detection when comparing the detection by blood culture bottle versus the routine microbiological culture technique. Recognize the distribution of isolated bacteria from our center and their susceptibility profile to different antibiotics and predict the most effective empirical antibiotics. Patients and methods Cross-sectional analytical prospective study conducted at the Department of Pulmonology and Clinical Pathology in Cairo University Hospitals. It included 70 patients with infected pleural effusion. Under ultrasound supervision, pleural fluid was extracted and transported to the laboratory for routine microbiological culture. At the same time, an automated blood culture bottle was inoculated with 5–10 ml to be incubated. All the detected pathogens were identified and tested for antimicrobial susceptibility according to CLSI. Results The mean age of our patients was 47.1 ± 15.6 years. Empyema was documented in 16 (22.9%) of our patients, whereas 54 (77.1%) had exudative pleural effusion. Positive aerobic infection in blood culture bottle was seen in 37 patients, compared to 21 patients in direct pleural culture. A statistically significant difference was found between the culture positive rate in aerobic blood culture bottles and direct pleural culture (P=0.001). Conclusion Blood culture bottle inoculation of infected pleural fluid increases the sensitivity of microbial yield in a shorter time than standard culture.

Transcriptomic Profiling of Pleural Effusions: Differences in Malignant and Infectious Fluids.

Background and Objectives: Different cellular and molecular processes are involved in the production of malignant and infectious pleural effusions. However, the underlying mechanisms responsible for these differences or their consequences remain incompletely understood. The objective of this study was to identify differences in gene expression in pleural exudates of malignant and infectious aetiology and establish the possible different biological processes involved in both situations. Materials and Methods: RNA transcriptomic analysis was performed on 46 pleural fluid samples obtained during diagnostic thoracocenteses from 46 patients. There were 35 exudates (19 malignant and 16 infectious effusions) and 11 transudates that were used as a reference control group. Differential gene expression analysis for both exudative groups was identified. An enrichment score using the Human Kegg Orthology database was used for establishing the biological processes associated with malignant and infectious pleural effusions. Results: When comparing malignant exudates with infectious effusions, 27 differentially expressed genes with statistical significance were identified. Network analysis showed ten different biological processes for malignant and for infectious pleural effusions. In malignant fluids, processes related to protein synthesis and processing predominate. In infectious exudates, biological processes in connection with ATP production prevail. Conclusions: This study demonstrates differentially expressed genes in malignant and infectious pleural effusions, which could have important implications in the search for diagnostic or prognostic biomarkers. In addition, for the first time, biological processes involved in these two causes of pleural exudates have been described.

Evaluation of lung adverse events with nivolumab using the spontaneous reporting system in Japan

This study was conducted to examine times to onset, incidence rates, and outcomes of nivolumab-induced lung adverse events (AEs), using the Japanese Adverse Drug Event Report database. We analysed data for the period between April 2004 and March 2021. Data on lung AEs were extracted, and relative risks of AEs were estimated using the reporting odds ratio. We analysed 5,273,115 reports and found 18,721 reports of nivolumab-related AEs, including 3084 lung AEs. Signals were detected for nine lung AEs: interstitial lung disease; pneumonitis; lung disorder; organising pneumonia; pleural effusion; pneumonia aspiration; pneumonia bacterial; radiation pneumonitis; and infectious pleural effusion. Among these, interstitial lung disease was the most frequently reported (68.7%) and included some fatal cases. A histogram of median times to onset showed AEs occurring from 34 to 79 days after the first dose, but some cases occurred even more than one year after starting administration. In conclusion, we focused on lung AEs caused by nivolumab as post-marketing AEs. Some cases could potentially involve serious outcomes, particularly in interstitial lung disease. Patients should be monitored for signs of the development of these AEs not only at the start of administration, but also over an extended time.

A novel biomarker for pleural effusion diagnosis: Interleukin‐36γ in pleural fluid

Numerous studies have described the critical importance of interleukin (IL) -36γ in host defense against lung infections, but it is unknown whether it plays a role in infectious pleural effusion (IPE). This study aimed to examine the levels of IL-36γ in pleural effusions of different etiologies and evaluate the diagnostic accuracy of IL-36γ in the differential diagnosis of IPE. A total of 112 individuals was enrolled in this research. IL-36γ levels in pleural fluids of all 112 patients were measured by enzyme-linked immunosorbent assay (ELISA). We also characterized these markers' diagnostic values across various groups. Patients with tuberculous pleural effusion (TPE) and parapneumonic effusion (PPE) had exhibited markedly higher IL-36γ levels in their pleural fluid than the malignant pleural effusion (MPE) and transudative effusion patients. Furthermore, the IL-36γ concentrations in TPE patients were evidently higher than in uncomplicated parapneumonic effusion (UPPE) patients but significantly lower than in complicated parapneumonic effusion (CPPE)/empyema patients. Pleural fluid IL-36γ is a useful marker to differentiate TPE from UPPE, at a cut-off value for 657.5pg/ml (area under the curve=0.904, p < 0.0001) with 70.0% sensitivity and 95.7% specificity. The elevated IL-36γ in pleural effusion may be used as a novel biomarker for infectious pleural effusion diagnosis, particularly in patients with CPPE/empyema, and is a potentially promising biomarker to differentiate between TPE and UPPE.

Intrapleural Instillation of Sodium Bicarbonate versus Urokinase in Management of Complicated Pleural Effusion: A Comparative Cohort Study.

The main target is evacuation; however, with evidence about the value of intrapleural instillation of different fibrinolytic agents still under evaluation, our aim was comparing the effectiveness and safety of intrapleural instillation of sodium bicarbonate (NaHCO3) in comparison with urokinase in patients with infected pleural effusion. Our prospective cohort study included 40 patients with complicated empyema; the diagnosis was based on analysis of aspirated fluid in association with radiological and bacteriological culture. The patients were subjected to instillation of two different fibrinolytic agents; the first one was NaHCO3, the second was urokinase. The commonest underlying chest infection that was visualized by CT was pneumonia 70%. Nearly half of cases had community-acquired infection (45%), and more than half of them (55%) had anaerobic infection, and only five cases had TB pleural effusion based on ADA-positive, tuberculin skin test in addition to Abram's needles closed biopsy. The rate of repeated therapeutic thoracentesis success in each group was 85%; 80% in NaHCO3 group, and 90% in urokinase group, both of them was significantly equal, P=0.37. Moreover, the frequency of complications in all patients was less than 13%, hence hemothorax and iatrogenic pneumothorax was 12.5%, and only 10% of cases were admitted in ICU after the maneuver, with insignificant difference in between the groups. However, looking at the smaller rate of RTT failure of NaHCO3 or urokinase, the logistic regression model showed that RTT-NaHCO3 was insignificantly related to failure in both unadjusted and adjusted models, P=0.37 and 0.32, respectively, and only smoking habits increase the likelihood of failure 9-fold (OR=8.9, P=0.04) with respect to age, sex, and treatment methods. The efficacy of repeated therapeutic thoracentesis (RTT) with intrapleural instillation of NaHCO3 was effective and safe, the same as urokinase, with consideration that NaHCO3 was much more available and affordable than urokinase.

The molecular analysis of antibiotic resistance and identification of the aerobic bacteria isolated from pleural fluids obtained from patients.

Pleural effusion is a common clinical condition due to various etiological causes. Infectious pleural effusion can be seen in 20-40% of patients. In this study, follow-up of patients admitted to our hospital and diagnosed with pleural effusion are reported. It was aimed to investigate the prevalence of bacteria isolated from patients with pleural effusion and their antibiotic resistance profiles. The pleural fluids obtained from the patients during surgical operations were analyzed microbiologically. Conventional culture, Vitek 2, 16S rRNA, and single Polymerase Chain Reaction (sPCR) were used for microbiological analysis. Twenty-two (12.2%) bacteria were isolated from 180 patients. The most prominent of them were 16 (8.8%) Klebsiella pneumoniae strains. As for the antibiotic sensitivity, gram-negative bacteria showed the highest sensitivity to colistin, while Gram-positive bacteria showed sensitivity to different antibiotics. In 16S rRNA PCR, 22 samples were found to be positive. In the analysis of antibiotic resistance genes, the OXA-48 gene was determined as the highest. In our region, it is essential to perform a microbiological analysis of the sample in patients with pleural effusion. It was thought that revealing both the phenotype and genotype of the antibiotic resistance of the patients was important in terms of treatment. In hospital surveillance, it was considered important to reveal and record the resistance gene profiles of the patients.

Chest CT Findings in Patients with HIV Presenting to the Emergency Department: A Single Institute Experience

The aim of this study was to analyze chest CT imaging findings and relevant clinical factors in patients with HIV presenting to the emergency department (ED). A retrospective review was performed to identify patients with HIV who received chest CT imaging evaluation in the acute ED setting. Analyzed patients included adults with a known diagnosis of HIV who presented to the ED at a single tertiary care center between 2004 and 2020 and received chest CT imaging. Chest CT findings were assessed by 2 radiologist readers, and relevant clinical data were gathered. Statistical analysis was performed to determine if imaging and clinical factors demonstrate significant associations with CD4 count, viral load, and antiretroviral therapy status. A total of 113 patients with HIV were identified who presented to the ED and underwent chest CT imaging evaluation (mean age 47 ± 11 years). Frequently detected chest CT findings included infectious pneumonia (24%), malignancy (11%), pleural effusion (17%), pericardial effusion (13%), and pulmonary embolism (4%). CD4 count, viral load, and active retroviral therapy demonstrated statistically significant associations with a number of key imaging and clinical factors, including presence of pneumonia, malignancy, average length of hospital admission, and survival. Patients with HIV present with a wide range of imaging findings when presenting in the acute ED setting. CD4 count, viral load, and active retroviral therapy status demonstrate statistically significant associations with multiple key imaging findings and clinical factors. Chest CT plays an integral role in the clinical management of this unique patient population.

Elevated Nitrite/Nitrate Ratio as a Potential Biomarker for the Differential Diagnosis of Pleural Effusions.

Pleural effusions (PEs) are common in clinical practice and can be due to many different underlying diseases such as cancer, congestive heart failure, or pneumonia. An accurate differential diagnostic categorization is essential, as the treatment and prognosis of PEs largely depend on its cause. In this study, we tested the hypothesis that nitrite and nitrate concentrations in PEs are associated with the inflammation and infection conditions. We therefore measured the nitrite and nitrate levels in 143 PE samples using a sensitive liquid chromatography-tandem mass spectrometry method and investigated their diagnostic potential in differentiating PEs. The results showed that nitrite concentrations and nitrite/nitrate ratios were higher in exudates than in transudates (NO2−: 2.12 vs. 1.49 μM; NO2−/NO3−: 23.3 vs. 14.0). Both the nitrite concentrations and the nitrite/nitrate ratios were positively correlated with the three Light’s criteria. Moreover, the receiver operating characteristic curve analysis revealed that the nitrite/nitrate ratio with an area under the curve of 0.71 could be a potential diagnostic biomarker in separating infectious PEs (IPEs) from other types of PEs. Taken together, the nitrite/nitrate ratio not only reflected the statuses of inflammation, but also the nitrate reduction by pathogenic bacteria infection in the pleural cavity. The nitrite/nitrate ratio could be a better biomarker in the differential diagnosis of PEs than the nitrite concentration alone.

Subcapsular hepatic hematoma as a complication of severe preeclampsia: a case report

BackgroundSubcapsular hepatic hematoma is a rare and life-threatening complication of pregnancy. It is most commonly associated with severe preeclampsia and hemolytic anemia, elevated liver enzymes, and low platelets syndrome. Patients with subcapsular hepatic hematoma typically present with epigastric, right upper quadrant or shoulder pain, nausea and vomiting, and/or shortness of breath. Here we describe a patient with a classic pain presentation, a large unruptured hematoma, and an unusual postpartum course.CaseA 40-year-old gravida 1 para 0 Caucasian woman presented at 39 + 6 weeks gestational age with a 3-day history of new onset pain in an otherwise uncomplicated pregnancy. She described the pain along her right torso as severe, shooting, and sharp, but at times pleuritic in nature. She was found to have new onset preeclampsia and hemolytic anemia, elevated liver enzymes, and low platelets syndrome. Induction of labor was initiated and eventually she delivered by cesarean section. Her pain persisted in the postpartum period and abdominal computed tomography scan revealed a 16 cm subcapsular hepatic hematoma. Despite the hematoma being thin walled, conservative management was recommended by the general surgeon. She then re-presented on postpartum day 15 with tachypnea, dyspnea, and pleuritic chest pain. Secondary to the subcapsular hepatic hematoma, she then developed an infected and loculated, large pleural effusion. This required video-assisted thoracoscopic surgery before her eventual discharge home on postpartum day 21.ConclusionsThere should be high clinical suspicion of subcapsular hepatic hematoma in patients with persistent pain in the right upper quadrant of the abdomen. Urgent imaging to investigate for subcapsular hepatic hematoma is then indicated. Cesarean delivery without labor and treatment for severe preeclampsia should be undertaken if subcapsular hepatic hematoma is found. Conservative management and serial imaging are reasonable for the follow-up of a large, unruptured hematoma. Hepatic artery embolization should also be considered. Subcapsular hepatic hematoma may be complicated by infected pleural effusions and require video-assisted thoracoscopic surgery.

Nicotinamide phosphoribosyltransferase as a biomarker for the diagnosis of infectious pleural effusions

Nicotinamide phosphoribosyltransferase (NAMPT) has been reported to be involved in infectious diseases, but it is unknown whether it plays a role in infectious pleural effusions (IPEs). We observed the levels of NAMPT in pleural effusions of different etiologies and investigated the clinical value of NAMPT in the differential diagnosis of infectious pleural effusions. A total of 111 patients with pleural effusion were enrolled in the study, including 25 parapneumonic effusions (PPEs) (17 uncomplicated PPEs, 3 complicated PPEs, and 5 empyemas), 30 tuberculous pleural effusions (TPEs), 36 malignant pleural effusions (MPEs), and 20 transudative effusions. Pleural fluid NAMPT levels were highest in the patients with empyemas [575.4 (457.7, 649.3) ng/ml], followed by those with complicated PPEs [113.5 (103.5, 155.29) ng/ml], uncomplicated PPEs [24.9 (20.2, 46.7) ng/ml] and TPEs [88 (19.4, 182.6) ng/ml], and lower in patients with MPEs [11.5 (6.5, 18.4) ng/ml] and transudative effusions [4.3 (2.6, 5.1) ng/ml]. Pleural fluid NAMPT levels were significantly higher in PPEs (P < 0.001) or TPEs (P < 0.001) than in MPEs. Moreover, Pleural fluid NAMPT levels were positively correlated with the neutrophil percentage and lactate dehydrogenase (LDH) levels and inversely correlated with glucose levels in both PPEs and TPEs, indicating that NAMPT was implicated in the neutrophil-associated inflammatory response in infectious pleural effusion. Further, multivariate logistic regression analysis showed pleural fluid NAMPT was a significant predictor distinguishing PPEs from MPEs [odds ratio (OR) 1.180, 95% confidence interval (CI) 1.052–1.324, P = 0.005]. Receiver-operating characteristic (ROC) analysis demonstrated that NAMPT was a promising diagnostic factor for the diagnosis of infectious effusions, with the areas under the curve for pleural fluid NAMPT distinguishing PPEs from MPEs, TPEs from MPEs, and IPEs (PPEs and TPEs) from NIPEs were 0.92, 0.85, and 0.88, respectively. In conclusion, pleural fluid NAMPT could be used as a biomarker for the diagnosis of infectious pleural effusions.

Analysis of the concise etiology of pleural effusion in 3707 pediatric patients in a single clinical center

Purpose: To summarize the concise etiology of pleural effusion in 3707 patients over a period of 13 years at the Children’s Hospital of Chongqing Medical University. Methods: A total of 3707 patients with pleural effusion were included from January 2007 to December 2019 at our hospital. According to etiology, pleural effusion was divided into infectious pleural effusion and noninfectious pleural effusion. The infection factors were further subdivided as being caused by tuberculous, paragonimiasis, parapneumonic factors (including multiple bacterias, multiple viruses, mycoplasma, chlamydia, chlamydia, fungus and fever, blood routine examination shows increased white blood cells and neutrophils). The noninfectious factors were further subdivided into neoplastic, trauma, other causes. They were also divided into the infants and young children group (3 y and below), the preschool group (3–6 y) and the school-age group (above 6 y) depending on age. Results: Among the 3707 children, there were 2925 (78.9%) patients with infectious pleural effusions, and 782 (21.1%) patients with noninfectious pleural effusions. The incidence of infectious pleural effusions caused by parapneumonic factors decreased significantly with increasing age; however, parapneumonic factors remained the primary etiology of infectious pleural effusion in each group. The incidence of infectious pleural effusions caused by tuberculosis and paragonimiasis increased significantly with increasing of age. Tumor was the primary cause of noninfectious pleural effusion. The incidence of noninfectious pleural effusion caused by tumor and other causes increased significantly with increasing age. The incidence of noninfectious pleural effusion caused by trauma in the preschool group was significantly greater than that of the infants and young children group and school-age group. The number of noninfectious pleural effusion caused by other causes in the school-age group were significantly greater than those of in the infants and young children group and preschool group. Conclusion: In our center, pediatric pleural effusion was primarily caused by infections. parapneumonic factors were the primary causes of infectious pleural effusions. The proportion of noninfective pleural effusions in the etiology of pleural effusion in children was small; however, some were difficult to treat, requiring long-term treatment and possibly poor prognosis. Therefore, multidisciplinary treatment should be combined.

Pleural cytokines MIF and MIP-3\u03b1 as novel biomarkers for complicated parapneumonic effusions and empyema

Patients with complicated parapneumonic effusion (CPPE)/empyema have high morbidity and mortality, particularly when adequate management is delayed. We aimed to investigate novel dysregulated cytokines that can be used as biomarkers for infectious pleural effusions, especially for CPPE/empyema. Expression of 40 cytokines in parapneumonic effusions (PPE) was screened in the discovery phase, involving 63 patients, using a multiplex immunobead-based assay. Six cytokines were subsequently validated by enzyme-linked immunosorbent assays (ELISAs). We then used ELISA to further evaluate the diagnostic values and cutoff values of these cytokines as potential biomarkers in an expanded group that included 200 patients with uncomplicated parapneumonic effusion (UPPE), CPPE, empyema, transudates, other exudates, and malignant pleural effusion (MPE). The pleural levels of four cytokines (MIF, MIP-3α, IL-1β, ENA-78) were highest and significantly increased in CPPE/empyema compared with those in other etiologies. According to receiver operating characteristic curve analysis, the four cytokines (MIF, MIP-3α, IL-1β, and ENA-78) had areas under the curve (AUCs) greater than 0.710 for discriminating parapneumonic pleural effusion from noninfectious pleural effusions. In a comparison of nonpurulent CPPE with UPPE, logistic regression analysis revealed that pleural fluid MIF ≥ 12 ng/ml and MIP-3α ≥ 4.3 ng/ml had the best diagnostic value; MIF also displayed the highest odds ratio of 663 for nonpurulent CPPE, with 97.5% specificity, 94.44% sensitivity, and an AUC of 0.950. In conclusion, our results show that elevated MIF and MIP-3α may be used as novel biomarkers for PPE diagnosis, particularly in patients with CPPE/empyema; the findings indicate that dysregulated cytokine expression may provide clues about the pathogenesis of pleural infection.

Detection of Klebsiella pneumoniae cfDNA in pleural fluid and its clinical value

Klebsiella pneumoniae (KP) is an important opportunistic pathogen that can easily cause pneumonia and pleural effusion when body resistance is reduced. However, the positive rate of KP detected from clinical pleural effusion by traditional methods, including bacterial culture, is meager. Therefore, new detection methods are urgently needed to improve the positive detection rate of KP and other bacteria in pleural effusion. Simulated pleural fluid of KP infection was first set up. Then circulating cell-free DNA (cfDNA) was extracted from cultured hydrothorax and detected by fluorescence polymerase chain reaction (PCR) to verify KP cfDNA in the pleural fluid. The specificity, sensitivity, and repeatability of this method are verified by detecting the cfDNAs in pleural effusion, samples of malignant pleural effusion, tuberculous pleural effusion, and other common microbial infections. Finally, this method was compared with three traditional methods, pleural effusion, precipitation DNA, sputum culture, and pleural effusion culture to explore the clinical diagnostic value of this method. KP cfDNA was positive by fluorescence PCR from the simulated KP infected pleural effusion, which confirmed KP cfDNA in pleural effusion. KP cfDNA was positive by fluorescence PCR from the pleural effusion of KP infected patients, while with the same detection method, KP cfDNA in clinical carcinomatous hydrothorax, tuberculosis hydrothorax, and other standard microbial infection samples was negative, which confirmed the method had high specificity, high sensitivity, and reproducibility. Compared with the three traditional methods, this method has a higher positive rate. Compared with the gold standard, sputum bacterial culture, the sensitivity, specificity, positive predictive value, and negative predictive value of this method were 91.67%, 95.45%, 91.7%, and 95.5%, respectively. The detection of cfDNA by fluorescence PCR is possible. Moreover, the positive rate of this method in clinical pleural effusions is high.

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.

Early morbidities following paediatric cardiac surgery: a mixed-methods study

BackgroundOver 5000 paediatric cardiac surgeries are performed in the UK each year and early survival has improved to &gt; 98%.ObjectivesWe aimed to identify the surgical morbidities that present the greatest burden for patients and health services and to develop and pilot routine monitoring and feedback.Design and settingOur multidisciplinary mixed-methods study took place over 52 months across five UK paediatric cardiac surgery centres.ParticipantsThe participants were children aged &lt; 17 years.MethodsWe reviewed existing literature, ran three focus groups and undertook a family online discussion forum moderated by the Children’s Heart Federation. A multidisciplinary group, with patient and carer involvement, then ranked and selected nine key morbidities informed by clinical views on definitions and feasibility of routine monitoring. We validated a new, nurse-administered early warning tool for assessing preoperative and postoperative child development, called the brief developmental assessment, by testing this among 1200 children. We measured morbidity incidence in 3090 consecutive surgical admissions over 21 months and explored risk factors for morbidity. We measured the impact of morbidities on quality of life, clinical burden and costs to the NHS and families over 6 months in 666 children, 340 (51%) of whom had at least one morbidity. We developed and piloted methods suitable for routine monitoring of morbidity by centres and co-developed new patient information about morbidities with parents and user groups.ResultsFamilies and clinicians prioritised overlapping but also different morbidities, leading to a final list of acute neurological event, unplanned reoperation, feeding problems, renal replacement therapy, major adverse events, extracorporeal life support, necrotising enterocolitis, surgical infection and prolonged pleural effusion. The brief developmental assessment was valid in children aged between 4 months and 5 years, but not in the youngest babies or 5- to 17-year-olds. A total of 2415 (78.2%) procedures had no measured morbidity. There was a higher risk of morbidity in neonates, complex congenital heart disease, increased preoperative severity of illness and with prolonged bypass. Patients with any morbidity had a 6-month survival of 81.5% compared with 99.1% with no morbidity. Patients with any morbidity scored 5.2 points lower on their total quality of life score at 6 weeks, but this difference had narrowed by 6 months. Morbidity led to fewer days at home by 6 months and higher costs. Extracorporeal life support patients had the lowest days at home (median: 43 days out of 183 days) and highest costs (£71,051 higher than no morbidity).LimitationsMonitoring of morbidity is more complex than mortality, and hence this requires resources and clinician buy-in.ConclusionsEvaluation of postoperative morbidity provides important information over and above 30-day survival and should become the focus of audit and quality improvement.Future workNational audit of morbidities has been initiated. Further research is needed to understand the implications of feeding problems and renal failure and to evaluate the brief developmental assessment.FundingThis project was funded by the NIHR Health Services and Delivery Research programme and will be published in full inHealth Services and Delivery Research; Vol. 8, No. 30. See the NIHR Journals Library website for further project information.

Su1016 SINGLE-VERSUS MULTIPLE-DOSE ANTIMICROBIAL PROPHYLAXIS IN PERORAL ENDOSCOPIC MYOTOMY: A RANDOMIZED CONTROLLED STUDY

Peroral endoscopic myotomy (POEM) is a safe and efficacious treatment for achalasia.Prophylactic antibiotics are routinely prescribed for a variable duration to prevent infectious complications after POEM. However, infections are rare after POEM procedure. In this study, we aim to compare single dose versus multiple doses antibiotic regimens to prevent infectious complications after POEM. The study was a prospective, randomized, single blinded, non-inferiority trial conducted at a single tertiary care center. The patients were randomized into single dose and multiple doses antibiotic groups. In the single dose group, patients received one dose of antibiotic (third generation cephalosporin) within 30-minutes of the POEM procedure. In the multiple doses group, patients received the same antibiotic for a total of three days. Systematic, objective evaluation of sepsis was done in both the groups using blood culture, erythrocyte sedimentation rate (ESR), c-reactive protein (CRP) and procalcitonin. All the patients were followed for one month for any clinical signs of sepsis. A total of 94-patients (mean age 40.33±14.69 years; 47 males) were randomized into single (n=48) and multiple (n=46) antibiotic doses arms. The baseline demographic characteristics were similar in both the groups. All the POEM procedures were performed by posterior route. Inflammatory markers including ESR and CRP were significantly elevated after POEM as compared to baseline values in both the arms. There was no significant difference in the mean post-POEM ESR and CRP levels in both the arms i.e. single vs multiple (ESR 20.96±12.48 vs 21.44±11.54, p=0.847) (CRP 1.940±2.37 vs 1.22±0.68, p=0.69; p=0.051). Post-POEM serum procalcitonin was similar in both the arms (0.220±0.267 vs 0.437±0.866; p=0.101). There were no cases with positive blood cultures in either of the arms. There were no cases of prolonged fever or immediate infectious complications requiring prolonged hospitalization in both the arms. There were three re-hospitalizations for infectious complications within first month of POEM procedure (infected pleural effusion in two and mucosal barrier failure in one). Infectious complications are uncommon after POEM procedure. Single dose of antibiotic is non-inferior to multiple dose antibiotic prophylaxis during POEM procedure. (Clinical trial registration number NCT03784365)Outcome of single dose vs multiple doses antibiotic prophylaxis during per-oral endoscopic myotomyView Large Image Figure ViewerDownload Hi-res image Download (PPT)

Pilot Study of the Difference C-TBNA with EBUS-TBNA in Mediastinal Bronchial-Derived Cysts

Objective: To investigate the difference value of conventional transbronchial needle aspiration (C-TBNA) and endobronchial ultrasound-guided transbronchial needle aspiration (EBUS-TBNA) in mediastinal bronchogenic cysts. Method: A retrospective analysis of clinical data and follow-up data of 27 patients using conventional TBNA and EBUS-TBNA techniques diagnosed as mediastinal bronchogenic cysts from May 2008 to December 2016 in the First Affiliated Hospital of Soochow University was done. Results: In 8 years, there were 13 cases of C-TBNA and 14 cases of EBUS-TBNA-diagnosed mediastinal bronchogenic cysts. C-TBNA extracted clear liquid and its volume was 8.9 ± 1.5 ml. The 14 patients examined by EBUS had a homogenous anechoic signal. Clear liquid was extracted, and its volume was 29.1 ± 7.5 ml. The cyst liquid extracted with EBUS-TBNA was significantly more than that extracted with CTBNA (P &lt; 0.05). During follow-up, 1 patient had cyst rupture after being punctured by C-TBNA, secondary pulmonary infection and right pleural effusion, followed by surgical treatment. The recurrence rate for C-TBNA was 100.00% (13/13), and that for EBUS-TBNA was 14.29% (2/14) (P &lt; 0.05). Conclusion: The C-TBNA and EBUS-TBNA technologies have high diagnostic value for the mediastinal bronchogenic cysts. Both C-TBNA and EBUS-TBNA technologies have the risk of secondary infection and recurrence of cysts.

Massive choleperitoneum three months after mini-gastric bypass for morbid obesity: what every emergency surgeon should be prepared to face. A case report.

Background: Surgery for morbid obesity has spread worldwide, to the point that more than half a million people are operated on each year. As a result, significant numbers of people are living with a new anatomical condition. A mini-gastric bypass is a relatively new bariatric procedure that has gained popularity because of its simplicity and efficacy. Leak rate after this procedure is relatively low (on the order of 1.6%), but marginal ulcer of gastrojejunal anastomosis, if undetected, may lead to leak development. No cases of delayed massive choleperitoneum caused by an almost complete disruption of gastrojejunal anastomosis after mini-gastric bypass have yet been described. Case presentation: We describe here the case of a 51-year-old woman who presented at the emergency department three months after a mini-gastric bypass with acute abdomen caused by massive choleperitoneum due to an almost complete disruption of gastrojejunal anastomosis. The patient underwent an emergency conversion to a Roux-en-Y laparoscopic gastric bypass with associated re-gastrectomy. The postoperative period was characterized by fever due to an infected left pleural effusion, which required treatment with chest tube placement. The patient was discharged three weeks after the operation, in good condition. Six-month follow-up was regular. Conclusions: If suspected, the possibility of marginal ulcer should be investigated as soon as possible. When possible, every obese patient who has complications should be referred to a bariatric surgery department, but each emergency surgeon must be aware of these conditions to be able to treat them optimally.

Heparan sulfate chains contribute to the anticoagulant milieu in malignant pleural effusion

BackgroundWhile malignant pleural effusion (MPE) is a common and significant cause of morbidity in patients with cancer, current treatment options are limited. Human heparanase, involved in angiogenesis and metastasis, cleaves...