Parapneumonic Effusion Research Articles

Evaluation of Adenosine Deaminase as a Diagnostic Marker in Tuberculous Pleural Effusion

Abstract: Tuberculous pleural effusion (TPE) is a common medical condition more frequently encountered in poor countries. It is the second most common form of extra-pulmonary tuberculosis. The diagnosis of TPE is problematic because the clinical features are non-specific, and most laboratory tests are not diagnostic. An accurate diagnosis requires the detection of TB bacilli in the pleural fluid or tissue sample from the pleura, which is not an easy task due to the scarcity of bacilli in the pleural fluid and the need for invasive maneuvers to get pleural tissue for histopathological, bacteriological or molecular confirmation for the TB bacilli. : Different markers in pleural fluid have been evaluated to aid in diagnosing TPE. Among those biomarkers, Adenosine deaminase (ADA) was the most studied marker. It is an enzyme predominantly produced by T-lymphocytes and catalyzes the conversion of adenosine to inosine and deoxyadenosine. It is a hallmark of active cellular immunity. A high level of ADA can be found in exudative effusion of different etiologies such as parapneumonic, tuberculous and malignant effusions. : Although there is still a debate over the diagnostic accuracy of ADA as a marker for TPE, many studies recommend its use. A correct diagnosis is crucial for the start of treatment for TPE. Therefore, it is crucial to assess the diagnostic value of adenosine deaminase in diagnosing tuberculous pleural effusion. The ADA optimal cutoff value is still under investigation.

Acute phase reactants in non-COVID-19 community-acquired pneumonia

BackgroundAcute phase reactants (APR) are markers of inflammation that could be applied for the assessment of community-acquired pneumonia (CAP) severity in association with various pneumonia severity scores. So, the aim of the study was to assess levels of APR such as total leucocytic count (TLC), platelets, neutrophils, neutrophils-to-lymphocyte ratio (NLR), CRP, D-dimer, ferritin, and ESR in patients with CAP and to correlate between their values and disease severity.MethodologyThe study included 51 patients diagnosed as non-COVID-19 (CAP). Patients were classified into two groups group A (pneumonia only) and group B (pneumonia complicated with empyema/complicated para-pneumonic effusion). All patients underwent clinical evaluation, CURB65, radiological assessment, and blood sampling to measure APR.ResultsThe mean age of patients was 47 ± 17 years. The main symptoms were productive cough (90.2%) and Fever (92.2%).TLC, platelets, neutrophils, CRP, D-dimer, ferritin, and ESR were elevated than normal values. Significant positive correlations were found between the duration of fever and CRP, D-dimer, and ferritin with p values = 0.024, 0.012, and 0.034 respectively. Significant positive correlations were found between CURB65 and both CRP and ferritin with p values = 0.007 and 0.020. A significant increase in platelet count and ESR values was found in group B than in group A.ConclusionAPR are important markers that can be used in the assessment of CAP in collaboration with clinical evaluation and severity scores. CRP, D-dimer, and ferritin were positively correlated with CURB65, while ESR and platelets could be considered predictors of the development of complications.Trial registrationRetrospectively registered, registration number NCT05926089, date of registration is 06/29/2023.

Pleural penetration of amoxicillin and metronidazole during pleural infection: An ambispective cohort study

The pharmacokinetics of antibiotics in pleural fluid during pleural infections has been poorly described. This study aimed to explore amoxicillin and metronidazole diffusion into the pleural space. This was an ambispective, single-centre study that included patients with complicated parapneumonic effusion or pleural empyema managed with repeated therapeutic thoracentesis as first-line treatment between 2014 and 2022. Pleural steady-state or trough concentrations of amoxicillin and metronidazole were measured, with a lower limit of quantification of 5 mg/L. Seventy paired blood and pleural samples were analysed from 40 patients. The median (interquartile range) patient age was 55 years (45-67 years) and 88% were male. The median patient weight was 65.8 kg (57.3-82 kg) and median plasma albumin concentration was 29.7 g/L (23.7-33.9 g/L). Median creatinine clearance was 106 mL/min (95-117 mL/min). Median amoxicillin pleural concentrations in patients treated with oral, bolus and continuous intravenous administrations (6 g/day) were, respectively, 5.2 (<5-6.4), 9.4 (8-13.1) and 10.8 (7.1-13.1) mg/L. Pleural concentrations were <5 mg/L in 5/11 samples (45%) with oral treatment and 6/59 (10%) with intravenous treatment. Median metronidazole pleural concentrations were 18.4 (15.7-22.8) mg/L, with all patients being treated orally (1.5 g/day). Oral metronidazole (1.5 g/day) and intravenous amoxicillin (6 g/day) achieved therapeutic targets in pleural fluid in most cases, but oral amoxicillin did not.

Effects of Concurrent Dosing on the Efficacy of Tissue Plasminogen Activator and Deoxyribonuclease in the Treatment of Pleural Infection.

The goal of this study was to evaluate how the administration of concurrent tissue plasminogen activator (tPA) and deoxyribonuclease (DNase) therapy with variable dosing for complicated parapneumonic effusions and empyema affects patient outcomes in an inner-city community hospital. This retrospective analysis was performed at an inner-city hospital located in Raleigh, North Carolina. A list of all patients treated with tPA and DNase between July 1, 2015, and December 31, 2017, was generated and screened. Data were collected through a review of past medical records, including demographics, past medical history, and details about their hospital course. A total of 38 patients were found to have been treated with concurrent tPA and DNase for complicated parapneumonic effusion or empyema. Twenty (52.6%) patients received the full six doses of combined concurrent tPA/DNase. Of the 18 (47.4%) patients who did not receive the full six doses, 11 did not require the full six doses for effusion resolution, and seven had to discontinue therapy due to tube blockage or pain. Only seven (18.4%) patients had complications related to tPA/DNase administration, most commonly pain. Nineteen (50%) patients had complete radiological clearance of effusion, with 13 (34.2%) having partial clearance, and six (15.8%) having no change or worsening of their effusion. Eight (21.1%) patients needed further surgical management of their effusion. The current most common dosing pattern for combined tPA and DNase therapy of twice daily for three days may not be optimal for all patients. The dosing regimen should be individualized depending on clinical response.Concurrent dosing is safe.

A multicenter study on the epidemiology of complicated parapneumonic effusion in the era of currently available pneumococcal conjugate vaccines

BackgroundParapneumonic effusion (PPE) is a common complication of pneumonia. Streptococcus pneumoniae is the most common cause of bacterial pneumonia. A reduction in pneumonia hospitalizations has been observed since the introduction of the 7-valent pneumococcal conjugate vaccine (PCV7). Despite this apparent benefit, an increase in the incidence of PPE was recorded in some countries following PCV7 implementation. As the 13-valent pneumococcal conjugate vaccine (PCV13) was expected to provide a wider protection against PPE, the aim of the present study was to evaluate the impact of PCV13 introduction on the epidemiology of complicated parapneumonic effusion (c-PPE) among children in the Athens greater area. MethodsAll cases of community-acquired pneumonia (CAP) with PPE requiring chest tube insertion (complicated PPE, c-PPE) hospitalized in the 3 public Children’s hospitals in Athens between 01/01/2004 and 31/12/2019 were included in the study. ResultsA total of 426 cases of c-PPE associated with pneumonia were recorded of which 198 were admitted during 2004–2010 (period A, prePCV13/PCV −7 introduction period) and 228 during 2011–2018 (period B, post - PCV13 period). A definite bacterial etiology was established in 44.4 % of all cases and of those 25.4 % were caused by S. pneumoniae. An increasing trend in c-PPE incidence was observed during period A; although, a significant decrease on c-PPE annual rates was observed during the period B (p = 0.011), a remarkable increase in serotype 3 cases was recorded. ConclusionA decreasing time trend in c-PPE cases among children was shown after the introduction of PCV13 in our area. However, serotype 3 is nowadays a common cause of PPE. Hence, continuous surveillance is imperative in order to follow c-PPE epidemiology over time.

Intrapleural streptokinase with pigtail catheter drainage versus medical thoracoscopy in complicated parapneumonic effusion

Abstract Context Parapneumonic effusion and empyema are commonly encountered by the pulmonologist. The decision regarding management is still challenging. Aim To compare outcomes of intrapleural streptokinase with pigtail catheter drainage versus medical thoracoscopy in complicated parapneumonic effusion. Methods and material Forty patients with complicated parapneumonic effusion were randomly allocated to one of two groups. Twenty patients underwent streptokinase intrapleural instillation via pigtail catheter. The other twenty patients underwent medical thoracoscopy. Results Intrapleural streptokinase instillation procedure was significantly shorter duration (12.80 ± 3.05 min) than medical thoracoscopy procedure (25.26 ± 4.66 min). However medical thoracoscopy showed a significant less days required to remove the drainage system (5.80 ± 1.70 days) versus intrapleural streptokinase instillation procedure (9.40 ± 3.91 days). Both groups had no significant complications. Lung expansion was achieved in 90% of patients treated with intrapleural streptokinase instillation and in 95% of patients treated with a medical thoracoscopy technique, with no statistically significant difference between the two groups. Conclusions Treatment of complicated parapneumonic effusions is undeniably interdisciplinary. Both intrapleural streptokinase with pigtail catheter drainage and medical thoracoscopy are safe and improve outcomes in complicated parapneumonic effusion. Medical thoracoscopy has an advantage of fewer days required for tube withdrawal. Pigtail insertion has an advantage of shorter procedure time compared to medical thoracoscopy

Retrospective review of empyema and parapneumonic effusions in hospitalized children in Ghana

Objectives: Empyema and parapneumonic effusions (PPEs) are common complications of community-acquired pneumonia in children. Both contribute to prolonged hospital stay, increased morbidity, and less frequent mortality. This study aimed to describe the demographics, immunization status, clinical profile, etiology, and outcomes in children admitted with empyema and PPE to the Komfo Anokye Teaching Hospital. Materials and Methods: This was a retrospective cross-sectional study that reviewed folders and electronic records of children admitted from January 2016 to December 2020. Information on demographic characteristics, immunization status, clinical profile, date of admission, and discharge or death were documented. Information was extracted using Microsoft Excel. Data was then analysed with Stata statistical software package version 16. Results: Records were available for 51 out of 65 children, the median age was 42 months interquartile range (IQR) (22.5–96) and 68.6% (n = 35) of the children were males. Three of the children 5.9% did not have a chest drain inserted. In all, 60.8% (n = 31) of the children had received all doses of the pneumococcal conjugate vaccine (PCV) up-to-date for age. Four children (7.8%) had oxygen saturation &lt;90%, whereas 43.9% (n = 18) had axillary temperature &gt;38°C. Blood cultures were done for 72.6% (n = 37) of patients, Staphylococcus aureus was isolated in 5 patients (13.5%, n = 5/37) and Streptococcus pneumoniae was isolated in 1 patient (2.7%, n = 1/37). While the rest, 83.8% (n = 31) had no bacterial growth. The pleural aspirate culture was done in 64.7% (n = 33) of the patients and 6 (18.1%) had S. aureus isolated. Common antibiotics administered were amoxicillin clavulanic acid in 33.3% (n = 17) of the patients, and ceftriaxone in 31.4% (n = 16) of the patients. Three (5.9%) children died. The median length of hospital stay was 9 days IQR (7–14). Conclusion: Empyema and PPE occurred more commonly in children older than 1 year, with a low mortality rate among the children. Most children with empyema were full immunised with PCV-13.

Diagnostic Accuracy of Lactate Dehydrogenase/Adenosine Deaminase Ratio in Differentiating Tuberculous and Parapneumonic Effusions: A Systematic Review.

Tuberculous pleural effusion (TPE) and parapneumonic effusion (PPE) are often difficult to differentiate owing to the overlapping clinical features. Observational studies demonstrate that the ratio of lactate dehydrogenase to adenosine deaminase (LDH/ADA) is lower in TPE compared to PPE, but integrated analysis is warranted. We conducted a systematic review to evaluate the diagnostic accuracy of the LDH/ADA ratio in differentiating TPE and PPE. We explored the PubMed and Scopus databases for studies evaluating the LDH/ADA ratio in differentiating TPE and PPE. From a yield of 110 studies, five were included for systematic review. The cutoff value for the LDH/ADA ratio in TPE ranged from &lt;14.2 to &lt;25. The studies demonstrated high heterogeneity, precluding meta-analysis. Quality Assessment of Diagnostic Accuracy Studies Tool 2 assessment revealed a high risk of bias in terms of patient selection and index test. LDH/ADA ratio is a potentially useful parameter to differentiate between TPE and PPE. Based on the limited data, we recommend an LDH/ADA ratio cutoff value of &lt;15 in differentiating TPE and PPE. However, more rigorous studies are needed to further validate this recommendation.

Analysis of clinical characteristics and risk factors of community-acquired pneumonia complicated by parapneumonic pleural effusion in elderly patients

BackgroundCommunity-acquired pneumonia (CAP) patients usually present with parapneumonic pleural effusion (PPE), which complicates the treatment of pneumonia. This study aims to investigate the clinical characteristics and risk factors of elderly CAP patients hospitalised with PPE.MethodsThe clinical data of 132 elderly patients with CAP were retrospectively analysed. A total of 54 patients with PPE (PPE group) and 78 patients without PPE (NPPE group) were included in this study. Clinical data, laboratory examinations, treatments and other relevant indicators were collected. Univariate analysis and multivariate logistic regression analysis will be used to explore the possible risk factors for PPE.ResultsThe proportion of PPE in elderly patients with CAP was 40.9%. PPE patients were significantly more likely to be older, have comorbid neurological diseases, experience chest tightness, and have a lasting fever (P < 0.05). In contrast to NPPE patients, the total number of lymphocytes, serum albumin and blood sodium levels in the PPE group were significantly lower (P < 0.05). The blood D-dimer, C-reactive protein and CURB-65 score of PPE patients were significantly higher (P < 0.05) than those of NPPE patients. Multivariate logistic regression identified chest tightness (OR = 3.964, 95% CI: 1.254–12.537, P = 0.019), long duration of fever (OR = 1.108, 95%CI: 1.009–1.217, P = 0.03), low serum albumin (OR = 0.876, 95%CI: 0.790– 0.971, P = 0.012) or low blood sodium (OR = 0.896, 95%CI: 0.828–0.969, P = 0.006) as independently associated with the development of parapneumonic pleural effusion in the elderly.ConclusionThis study has identified several clinical factors, such as chest tightness, long duration of fever, low serum albumin, and low blood sodium, as risk factors for the development of pleural effusion in elderly patients with CAP. Early identification and prompt management of these patients can prevent inappropriate treatment and reduce morbidity and mortality.

Utility of systemic immune-inflammation Index as a serum biomarker to differentiate between complicated and simple para-pneumonic effusion.

The systemic immune-inflammation index (SII) is a novel inflammatory biomarker. Simple and complicated para-pneumonic effusion (PPE) are two significant complications of pneumonia. We evaluated the efficacy of the systemic immune inflammation index (SII) to differentiate between the two. Records of all children up to 18 years of age admitted between April 2019 and September 2022 and diagnosed with Simple or complicated PPE were retrospectively evaluated. SII and other biomarkers were compared between both groups. ROC with the Youden index was used to estimate the discriminative value of SII. Fifty children were enrolled with a median (IQR) age of 81.5 (36.7, 133.5) months; 31 (62%) were male. Thirty-one (62%) had complicated PPE, and 19 (38%) had simple PPE. SII was significantly higher in complicated PPE (p=0.007). Good areas under the curve (AUCs) were found for CRP (0.771) and SII (0.736) to differentiate complicated from simple PPE. The best cut-off value for SII to differentiate complicated PPE from simple PPE was 1557×103µL, with a sensitivity of 82.4% and specificity of 57.6%. SII can be used as a screening tool to differentiate between complicated and simple PPE at the time of presentation.

The diagnostic value of interleukin-36 cytokines in pleural effusions of varying etiologies

BackgroundThe clinical management of pleural effusion (PE) poses challenges due to its diverse etiologies. The objective of this research was to investigate the concentrations of interleukin-36 (IL-36) cytokines in pleural fluid (PF) from different etiologies and assess their diagnostic efficacy in distinguishing the causes of PE. MethodsThis study enrolled 89 patients with confirmed PE, comprising 11 cases classified as transudate, 24 cases as malignant pleural effusion (MPE), 24 cases as tuberculous pleural effusion (TPE), and 30 cases as parapneumonic pleural effusion (PPE). The PPE group was further subdivided into 20 cases of uncomplicated parapneumonic effusion (UPPE) and 10 cases of complicated parapneumonic effusion (CPPE)/empyema. The concentrations of IL-36 cytokines in the PF of all 89 patients were quantified by the enzyme-linked immunosorbent assay (ELISA). ResultsIL-36α exhibited excellent diagnostic accuracy in TPE, achieving a sensitivity of 91.7 % and specificity of 83.1 %, along with a cut-off value of 435.3 pg/ml. IL-36Ra also demonstrated relatively favorable diagnostic performance in PPE, with a sensitivity of 80.0 % and specificity of 76.3 %, along with a cut-off value of 390.8 pg/ml. Multivariable logistic regression models were successfully developed for both TPE and PPE, confirming their diagnostic utility. Furthermore, the levels of IL-36Ra were notably elevated in CPPE/empyema in comparison to UPPE. Moreover, in PF, IL-36γ exhibited positive associations with both IL-36α and IL-36Ra. ConclusionIL-36α and IL-36Ra may serve as novel biomarkers for diagnosing TPE and PPE, respectively. The multivariate models established significantly enhance the diagnostic efficacy of both TPE and PPE. Furthermore, IL-36Ra can function as an indicator for assessing the extent of pleural inflammation. Additionally, the interaction among IL-36 cytokines in PF may contribute to their expression modulation.

Diagnostic Yield of 16S Ribosomal Ribonucleic Acid Gene-Based Targeted Metagenomic Sequencing for Evaluation of Pleural Space Infection: A Prospective Study

ObjectiveTo better understand the microbial profile of complicated parapneumonic effusions and empyema, and to evaluate whether antimicrobial selection would differ if guided by targeted metagenomic sequencing (tMGS) vs conventional cultures (CCs) alone. Patients and MethodsWe analyzed the pleural fluid of a cohort of 47 patients undergoing thoracentesis from January 1, 2017 to August 31, 2019, to characterize their microbial profile. All samples underwent 16S ribosomal ribonucleic acid gene polymerase chain reaction, followed by tMGS. ResultsPleural space infection was deemed clinically present in 20 of the 47 (43%) participants. Of those, n=7 (35%) had positive pleural fluid cultures and n=14 (70%) had positive tMGS results. The organisms identified by tMGS were concordant with CCs; however, tMGS detected additional bacterial species over CCs alone. Streptococcus and Staphylococcus species were the most common organisms identified, with Streptococcus intermedius/constellatus identified in 5 patients. Polymicrobial infections were found in 6 of the 20 patients, with anaerobes being the most common organisms identified in these cases. ConclusionStreptococci and staphylococci were the most common organisms identified in infected pleural fluid. Anaerobes were common in polymicrobial infections. When compared with CCs, tMGS had higher sensitivity than CCs. Targeted metagenomic sequencing identified additional organisms, not identified by CCs, with associated potential management implications.

The mTORC2/SGK1/NDRG1 Signaling Axis Is Critical for the Mesomesenchymal Transition of Pleural Mesothelial Cells and the Progression of Pleural Fibrosis.

Progressive lung scarring because of persistent pleural organization often results in pleural fibrosis (PF). This process affects patients with complicated parapneumonic pleural effusions, empyema, and other pleural diseases prone to loculation. In PF, pleural mesothelial cells undergo mesomesenchymal transition (MesoMT) to become profibrotic, characterized by increased expression of α-smooth muscle actin and matrix proteins, including collagen-1. In our previous study, we showed that blocking PI3K/Akt signaling inhibits MesoMT induction in human pleural mesothelial cells (HPMCs) (1). However, the downstream signaling pathways leading to MesoMT induction remain obscure. Here, we investigated the role of mTOR complexes (mTORC1/2) in MesoMT induction. Our studies show that activation of the downstream mediator mTORC1/2 complex is, likewise, a critical component of MesoMT. Specific targeting of mTORC1/2 complex using pharmacological inhibitors such as INK128 and AZD8055 significantly inhibited transforming growth factor β (TGF-β)-induced MesoMT markers in HPMCs. We further identified the mTORC2/Rictor complex as the principal contributor to MesoMT progression induced by TGF-β. Knockdown of Rictor, but not Raptor, attenuated TGF-β-induced MesoMT in these cells. In these studies, we further show that concomitant activation of the SGK1/NDRG1 signaling cascade is essential for inducing MesoMT. Targeting SGK1 and NDRG1 with siRNA and small molecular inhibitors attenuated TGF-β-induced MesoMT in HPMCs. Additionally, preclinical studies in our Streptococcus pneumoniae-mediated mouse model of PF showed that inhibition of mTORC1/2 with INK128 significantly attenuated the progression of PF in subacute and chronic injury. In conclusion, our studies demonstrate that mTORC2/Rictor-mediated activation of SGK1/NDRG1 is critical for MesoMT induction and that targeting this pathway could inhibit or even reverse the progression of MesoMT and PF.

Clinical Significance of Pleural Lactate Measurement in Critically Ill Patients with Parapneumonic Pleural Effusion.

Pleural fluid pH measurement is recommended for tube thoracostomy decisions in complicated parapneumonic pleural effusions. However, pleural fluid pH may be affected by blood pH in critically ill patients with common systemic acid-base disorders. We aimed to investigate the use of pleural fluid lactate to distinguish culture-positive parapneumonic effusions from other pleural effusions. This prospective observational study included 121 eligible patients (51 female and 70 male). All patients with pleural effusion who underwent thoracentesis were assessed. Pleural fluid lactate was measured by a blood gas analyzer. Of the 121 patients, 30 (24.8%) were transudate and 91 (75.2%) were exudate. Of the 91 patients with exudative pleural effusion, 61 were diagnosed as culture-negative parapneumonic, 13 as culture-positive parapneumonic, 9 as malignant, and 8 as other exudative effusion. There was a strong positive linear association between serum pH and pleural fluid pH (R = 0.77, P < .001). The post hoc tests for pleural fluid lactate revealed there was a significant difference between culture-positive parapneumonic versus culture-negative parapneumonic groups (P = .004), culture-positive parapneumonic versus transudative effusion groups (P < .001), culture-negative parapneumonic versus transudative effusion groups (P = .008) and lastly; malignant effusion versus transudative effusion groups (P = .001). Receiver operating characteristics curve analysis for culture-positive parapneumonic indicated a cutoff of 4.55 mmol/L for pleural fluid lactate to have a sensitivity of 76.9% and a specificity of 84.3% (positive predictive value: 37%, negative predictive value: 96.8%). A cutoff of 4.55 mmol/L of pleural fluid lactate can be used as a useful tool to distinguish culture-positive parapneumonic effusions from other effusions in critically ill patients.

Associations of physical activity and quality of life in parapneumonic effusion patients.

Little is known about activity behaviours and quality of life (QoL) of patients with parapneumonic pleural effusions (PPE) after hospital discharge. This study is a secondary analysis of a randomised trial (dexamethasone versus placebo) for hospitalised patients with PPE. We: 1) described the patients' activity behaviour patterns and QoL measured at discharge and at 30 days post-discharge; and 2) examined the association between activity behaviours and QoL scores. Activity behaviour (7-day accelerometry; Actigraph GT3X+) and QoL (Medical Outcomes Study Short-Form 36) were assessed. Repeated measures analysis of covariance controlling for baseline values and a series of linear regression models were undertaken. 36 out of 53 eligible participants completed accelerometry assessments. Despite modest increases in light physical activity (+7.5%) and some domains of QoL (>2 points) from discharge to 30 days post-discharge, patients had persistently high levels of sedentary behaviour (>65% of waking wear time) and poor QoL (≤50 out of 100 points) irrespective of treatment group (p=0.135-0.903). Increasing moderate-to-vigorous physical activity was associated with higher scores on most QoL domains (p=0.006-0.037). Linear regression indicates that a clinically important difference of 5 points in physical composite QoL score can be achieved by reallocating 16.1 min·day-1 of sedentary time to moderate-to-vigorous physical activity. Patients with PPE had low levels of physical activity and QoL at discharge and 30 days post-discharge irrespective of treatment. Moderate-to-vigorous physical activity participation was associated with higher QoL scores. Increasing moderate-to-vigorous physical activity following discharge from the hospital may be associated with improvements in QoL.

Current Management of Pediatric Parapneumonic Pleural Effusions and Pleural Empyema.

Current Management of Pediatric Parapneumonic Pleural Effusions and Pleural Empyema.

Could pleural fluid lactate level have an added diagnostic value in para pneumonic effusion?

Abstract Background Pleural effusion is the accumulation of fluid in the pleural space, can be classified into transudative and exudative effusion. A parapneumonic effusion is a pleural effusion that forms adjacent to pneumonia. Para pneumonic effusion can be sub-typed into uncomplicated and complicated effusion. The aim of our work was to identify accuracy of pleural fluid lactate level to discriminate transudative from exudative effusion and uncomplicated from complicated parapneumonic effusion. Methods Thoracocentesis was done with subsequent evaluation of pleural fluid PH, protein, LDH, glucose and lactate.Also, gram stain, microbiological cultures, cytological examination was performed. Medical thoracoscopy was done whenever indicated. Results Our study included 52 males and 38 females with mean age 57.14 ± 11.69 years. Transudative effusions were detected in 22 patients (24.4%). Parapneumonic effusions accounted for 39 cases (43.3%), of these 23 cases were uncomplicated and 16 cases were complicated. The median pleural fluid lactate level in exudative effusion was significantly higher than transudative effusion (P value&lt;0.001), in complicated parapneumonic effusion was significantly higher than uncomplicated parapneumonic effusion (P value&lt;0.001). Pleural fluid lactate cut-off value of 2.68 mmol/l or more yielded 97% sensitivity, 90.9% specificity for detection of exudative effusion (Auc 0.968). A cut of value of 6.22 mmol/l had 87.5% sensitivity, 91.3% specificity for detection of complicated parapneumonic effusion. (Auc 0.971). Conclusion The pleural fluid lactate level has a high accuracy to discriminate transudative from exudative pleural effusion and uncomplicated from complicated parapneumonic effusion.

Frequency and etiology of pericardial effusion among patients with dyspnea presenting at emergency department

Aim: To determine the frequency and etiology of pericardial effusion among patients with dyspnea presenting at emergency department. Material and Methods: This retrospective observational study was carried out at emergency Department Hayatabad Medical Complex Peshawar from September 2022 to March 2023 on 120 patients. Patients having age more than 18 years presenting with dyspnea. The frequency and etiology of pericardial effusion were determined. Results: Mean age observed was 45.23±7.52 years. Pericardial effusion in our study was 15%. The most leading etiology found was para-pneumonic effusion 33.3%, renal failure 27.7%, and malignancy 22.2% while other factors 16.6%. Conclusion: we conclude that the frequency of pericardial effusion among patients presenting with dyspnea was 15%, the most common etiological factors identified were para-pneumonic effusion, renal failure and malignancy.

Conservative and Surgical Modalities in the Management of Pediatric Parapneumonic Effusion and Empyema: A Living Systematic Review and Network Meta-Analysis

The optimal treatment for community-acquired childhood pneumonia complicated by empyema remains unclear. In children with parapneumonic effusion or empyema, do hospital length of stay and other key clinical outcomes differ according to the treatment modality used? A living systematic review of randomized controlled trials (RCTs) was conducted by searching the Cochrane Central Register of Controlled Trials, Embase, Latin American and Caribbean Health Sciences Literature, Ovid MEDLINE, and Web of Science Core Collection databases. Eligible RCTs included patients aged< 18 years and compared two of the following treatment modalities: antibiotics alone, chest tube insertion with or without fibrinolytics, video-assisted thoracoscopic surgery (VATS), and decortication via thoracotomy. A network meta-analysis was performed to evaluate treatment effects on hospital length of stay (LOS), the primary outcome. Eleven trials including a total of 590 patients were selected for the network meta-analysis. Compared with a chest tube alone, a chest tube with fibrinolytics, thoracotomy, and VATS were all associated with shorter LOS, with a mean difference of 5.05days (95%CI, 2.46-7.64), 6.33days (95%CI, 3.17-9.50), and 5.86days (95%CI, 3.38-8.35), respectively. No substantial differences in LOS were observed between the latter three interventions. None of the 11 RCTs compared antibiotics alone vsother types of treatment. Most trials reported peri-procedural complications and the need for reintervention, but the descriptions differed significantly between trials, preventing meta-analysis. In trials reporting health care-associated costs, fibrinolytics had cost advantages compared with VATS. Short- and long-term morbidity and mortality were very low, regardless of the treatment modality. The results of this network meta-analysis showed that a chest tube alone was associated with a longer LOS compared with other treatment modalities. The lower cost associated with a chest tube plus fibrinolytics warrants consideration when choosing between treatment options, given similar LOS and clinical outcomes compared with the other modalities.

CHARACTERISTICS OF COMMUNITY ACQUIRED PNEUMONIA AT A SINGLE CENTER IN CENTRAL SRI LANKA DURING COVID-19 PANDEMIC: A DESCRIPTIVE CROSS-SECTIONAL STUDY.

Introduction and Objective:Community acquired pneumonia (CAP) is associated with increased mortality and morbidity. The disease severity is multifactorial, co-morbid conditions and advanced age are the most important risk factors. At present, there is a sparsity in published data on CAP in Sri Lankan adults and adolescents. Aim of study to identify complications and outcome of CAP.Methods:A single center descriptive prospective study was carried out in Respiratory Unit 11 in National Hospital-Kandy, Sri Lanka, among diagnosed CAP patients during six months from 1st of September 2020 to 28th of February 2021. Data were analyzed by SPSS (Statistical Package for Social Sciences) 21 package. Results:105 cases were analyzed; of which 35.2% had complications. Parapenumonic effusion was the commonest complication, whilst pyothorax was the rarest complication. Nine patients (24%) had multiple complications. Prevalence of complications significantly correlated with CURB 65 score (pearson correlation coefficient 0.57, p value 0.001). 93.3% of patients survived with treatment, however 6.6% of them demised with male predominance and all had at least 2 preexisting diseases. Five deaths (71.4%) occurred in the intensive care unit. During follow up, 3.8% were diagnosed with bronchial malignancy, 5.7% pulmonary tuberculosis, 2.8% other chronic infections (melioidosis) and 1.9% chronic organizing pneumonia, respectively.Conclusion:CAP is a major health concern in central Sri Lanka during COVID-19 pandemic. Most CAP patients recovered completely. Mortality 6.6% with male predominance. Parapneumonic effusion was the commonest complication. Number of Complications had significant correlation with CURB 65 score