Thoracic Ultrasonography in Chronic Obstructive Pulmonary Disease: A and B Lines.

The Role of Clinical Characteristics, Thoracic Ultrasonography and Pleural Fluid Parameters in Differentiating Malignant from Benign Pleural Effusion.

Abstract Paragonimus is the only genus in the family Troglotrematidae. Dogs, cats and other mammals may become infected by consuming crabs or shrimp harbouring metacercariae. A 1.11‐year‐old cat was presented with chronic coughing episodes. Thoracic radiography and ultrasonography suggested diffuse pneumonia. Cytology from a pulmonary granuloma and faecal examination revealed numerous trematode eggs (50–100 µm) consistent with Paragonimus spp. Molecular analysis of faecal DNA confirmed 100% nucleotide identity with Paragonimus mexicanus metacercariae previously reported from freshwater crabs in Puntarenas, Costa Rica. Antiparasitic therapy combining praziquantel, pyrantel and mebendazole resolved clinical signs. This case highlights the importance of including paragonimiasis in the differential diagnosis of cats with chronic respiratory disease in Central America, where aquatic intermediate hosts and wild reservoirs are abundant, even in peri‐urban settings.

Background: Hemothorax represents a rare but serious complication after posterior correction surgery (PCS) for spinal deformities, occurring in roughly 0.1% of cases. When diagnosis is delayed or the condition is missed, the clinical consequences can be severe. In this retrospective review, we evaluated pediatric patients who developed hemothorax after PCS, aiming to describe the perioperative diagnostic difficulties and management experiences encountered. Methods: From 2016 to 2021, we retrospectively reviewed the records of 135 children who underwent posterior correction surgery for spinal deformity. Five of these patients were diagnosed with postoperative hemothorax and were included in the study. The variables assessed comprised demographic information, intraoperative imaging findings, the onset of hemodynamic deterioration, and the treatments applied. Results: The mean patient age at the time of surgery was 12.4 ± 2.9 years. Intraoperative posteroanterior chest radiographs were routinely obtained to confirm the placement of spinal instrumentation. A retrospective review of these films showed clear signs of hemothorax in four children and suspicious findings in one. None of the cases received intraoperative intervention for hemothorax. Because of subsequent hemodynamic instability, all five were transferred from the ward to the intensive care unit at different times after surgery. Chest tube drainage was required in three patients, thoracentesis in one, and surgical decortication in another. Conclusion: Early recognition of hemothorax plays a key role in preventing postoperative complications. For patients considered at higher risk, intraoperative bedside thoracic ultrasonography should be routinely employed. When this option is not accessible, performing a chest X-ray in the reverse Trendelenburg position before extubation may help reduce the likelihood of a missed diagnosis

Bovine respiratory disease (BRD) poses a significant health and economic challenge in cattle farming, particularly affecting young calves. Although previous SNP-based genome-wide association studies (GWAS) have identified candidate loci linked to BRD susceptibility, they only explain a fraction of the trait’s heritability. Using genotypes from a previous study that employed a selective genotyping approach, we analyzed Holstein calves classified as BRD-resistant or BRD-susceptible, based on thoracic ultrasonography and clinical scoring. In particular, structural variations, specifically copy number variants (CNVs) and runs of homozygosity (ROH), were investigated due to their emerging role as complementary genomic features that may be involved in disease resistance. A total of 2,666 CNVs were identified, and the CNV-GWAS revealed 10 significant CNV regions (CNVRs), encompassing or near 15 candidate genes. While the ROH analysis identified 8,226 segments, we further applied a fixed-window approach to compare ROH frequencies between groups, revealing 19 regions with significantly different ROH frequencies. Gene annotation of both CNVRs and differential ROH windows uncovered genes linked to immune response, lung development, and known BRD-associated pathways. Functional enrichment analyses using DAVID and Cytoscape-GeneMANIA indicated involvement of antiviral responses, GPCR signaling, calcium signaling, and estrogen receptor pathway in disease resistance. Notably, 37% of the genes identified in this study overlapped with those reported in previous BRD-related studies. This integrative genomic analysis highlights the relevance of structural variation in shaping BRD resistance and susceptibility in dairy calves. By integrating CNV mapping, ROH analysis, and functional annotation approaches, we identified novel and previously reported candidate genes potentially involved in innate immune processes. These findings support the implementation of precision breeding strategies aimed at improving disease resilience in cattle.

This report presents a case of esophageal and nodal metastasis in a primary pulmonary histiocytic sarcoma in a dog. Histiocytic sarcoma is a malignant neoplasm originating from histiocytic cells, characterized by its aggressive nature, high metastatic potential and high mortality rate. Pulmonary involvement occasionally results in pleural effusion and regional lymph node involvement, such as the tracheobronchial, sternal, and mediastinal lymph nodes. Thoracic radiography is the preferred complementary diagnostic test when respiratory disorders are suspected, as it can identify pulmonary masses and associated complications, such as pleural effusion. Similarly, ultrasonography can be used when pulmonary conditions are suspected, helping to differentiate lesions. A one-year-old, intact male mixed-breed dog weighing 18kg was referred for emergency clinical care due to severe inspiratory dyspnea. Thoracic radiography and ultrasonography revealed a large intrathoracic mass located in the mediastinum, displacing adjacent structures, along with associated pleural effusion. The primary diagnostic hypothesis was a neoplasm of cranial mediastinal origin. During the thoracocentesis procedure, the animal decompensated and died. Necropsy revealed a large, multilobulated tumor mass in the mediastinum, showing direct extension into the esophagus, as well as another nodule similar to the mediastinal mass in the left caudal lung lobe. Histopathological analysis supported the diagnosis of pulmonary histiocytic sarcoma with esophageal and nodal metastasis, confirmed through an immunohistochemical panel. The involvement of cranial mediastinal and tracheobronchial lymph nodes, as well as the presence of pleural effusion, are common features associated with HS. However, the occurrence of esophageal metastases is considered uncommon, highlighting the uniqueness of this case, as well as supporting the potential for its occurrence. Thoracic radiography and ultrasonography played a crucial role in the initial suspicion of neoplasia, emphasizing their importance in early diagnostic approaches.

Introduction: Pleural effusion classification guides management, but Light’s criteria require invasive sampling and laboratory infrastructure and may be prone to misclassifications. A rapid, bedside alternative is needed, particularly in resource-limited settings. Aim: This study aimed to develop and validate a novel, four-point sonographic scoring system, the TELL (pleural thickening (T), fluid echogenicity (E), loculations (L), and laterality (L)) score, for differentiating pleural effusions at the bedside.Materials and methods: This is a prospective observational study conducted at Saveetha Medical College Hospital, a tertiary care centre in South India from March 2021 to February 2022. Seventy-four adult patients with pleural effusions underwent thoracic ultrasonography, assessing four “TELL” parameters: pleural thickening (≥3 mm), fluid echogenicity, laterality (unilateral effusions), and presence of loculations. Each positive finding scored one point (range 0-4). Diagnostic performance was compared against Light’s criteria using diagnostic indices and receiver operator characteristic (ROC) curve analysis.Results: Among 74 participants (mean age 58.7±17.2 years; 59.5% male), 64 effusions (86.5%) were exudates, mainly tuberculosis and malignancy. Sonographic features were more common in exudates: pleural thickening (95.3%), echogenicity (98.4%), loculations (29.7%), and unilateral distribution (85.9%; all p < 0.01). At cut-off ≥2, the TELL score achieved 98.4% sensitivity, 40% specificity, negative predictive value (NPV) 80%, and area under the curve (AUC) 0.79 (95% confidence interval CI: 0.64-0.94)Conclusions: The TELL score is a rapid, non-invasive screening tool with high sensitivity and NPV, particularly useful when lab confirmation is delayed or unavailable. Multicentre validation and reliability studies in larger cohorts are needed.

A randomized clinical trial to examine hazelnut skin extract's effects on diarrhea and bronchopneumonia incidence, growth rate, antioxidant status, and fecal microbiota in neonatal dairy heifers.

Canine idiopathic pulmonary fibrosis (CIPF) is an interstitial lung disease reported in West Highland white terriers (WHWTs). B-mode ultrasonography (US) is used in human medicine as an adjunct tool for interstitial lung disease, including idiopathic pulmonary fibrosis. In veterinary medicine, thoracic US has been described as helpful for the diagnosis of various pulmonary diseases. The aim of this study was to describe the thoracic B-mode US findings in CIPF WHWTs, compared with those in control WHWTs. Twenty-seven WHWTs, including CIPF and control WHWTs, were prospectively enrolled. Standardised thoracic B-mode US was performed. The presence of an irregular pleural surface, ring-down artefact and peripheral nodules was assessed and scored for each location. An overall cumulative score was calculated by adding the individual scores of each location. WHWTs affected with CIPF had significantly higher overall scores compared to the control group. The ring-down artefact score was significantly higher in the CIPF group compared to the control group. No preferential location for the lesions was observed. A cut-off value of 15 ring-down artefacts for the entire thorax predicted CIPF in WHWTs with a sensitivity of 76.5% and a specificity of 80% (AUC 0.815). The present study describes B-mode US findings in CIPF WHWTs.

Ultrasonography of the bovine lung is a noninvasive technique allowing recognition of lower respiratory tract lesions and differentiation from disease limited to the upper respiratory tract. Techniques for scanning the thorax have evolved to facilitate examination of cohorts of calves quickly, while maintaining accuracy. Classification systems for the interpretation of images, their assignment as normal or abnormal, and grading of their severity are varied. Without a reporting consensus, comparison of short-and long-term outcomes attributable to ultrasonographic findings is challenging. Differences in operator agreement might complicate interpretation further. The objective of this review was to gather methods for screening calf lungs using thoracic ultrasonography and describe the heterogeneity in scanning techniques and methods of image interpretation, including available scoring methods.

Acromegaly is a rare disease characterized by elevated levels of growth hormone (GH) and insulin-like growth factor 1 (IGF-1), leading to changes in various organ systems. However, the effects of this disease on pulmonary function are often overlooked. Early detection of pleural thickness and pulmonary function changes could offer significant clinical value. This study aimed to assess the role of thoracic ultrasonography (TUS) and pulmonary function tests in evaluating functional lung changes in patients with acromegaly and to explore the potential of ultrasonographic pleural assessment in predicting pulmonary involvement. This prospective single-center study, conducted at Gazi University Hospital between April and September 2022, included 34 patients with acromegaly and 34 healthy controls. Total lung capacity, residual volume, and forced vital capacity were significantly higher in patients with acromegaly compared to the control group (p=0.004, p=0.004, and p=0.005, respectively), while maximal inspiratory pressure and maximal expiratory pressure (MEP) were significantly lower (p=0.001 and p<0.001, respectively). Additionally, pleural thickness was higher in the acromegaly group (p<0.001). In the acromegaly group, MEP was negatively correlated with GH (r=-0.398, p=0.033), and pleural thickness was positively correlated with IGF-1 upper limit of normal (r=0.349, p=0.047). In conclusion, our study suggests that TUS combined with pulmonary function tests may help detect subtle thoracic changes in patients with acromegaly. This is the first study to evaluate TUS in these patients, and further research is needed to validate our findings.

Bovine Respiratory Disease (BRD) is a leading cause of morbidity and mortality in young cattle upon feedlot arrival. The immune response plays a dual role in infection control and lung tissue damage, but few studies have assessed cytokine levels during natural BRD outbreaks. Advances in multiplexed assays now allow for broader cytokine and chemokine profiling in cattle. In this nested case-control study, 184 young bulls from nine French fattening farms were clinically assessed and underwent thoracic ultrasonography (TUS) weekly during the first month on feed. BRD cases (n = 98) and matched healthy controls (n = 86) were selected based on clinical signs. Fifteen cytokines and chemokines were quantified in plasma using a bovine-specific bead-based multiplex assay, on the day an animal was first detected as sick and in its matched control sampled on the same day. BRD-associated pathogens were assessed using qPCR on nasal swabs and paired serology. The link between cytokines and clinical, microbiological, and preconditioning (vaccination and preventive antibiotic treatment) variables was investigated using the Wilcoxon-Mann-Whitney test, mixed-effects linear regression models, and multivariate clustering. Cytokine and chemokine levels did not distinguish clinically sick from healthy animals. No specific cytokine profile was associated with infection by a given pathogen. However, IL-17A and IFN-γ concentrations were positively associated with treatment relapse and disease severity, suggesting that they may have prognostic potential. Cluster analysis revealed three subgroups with distinct cytokine patterns and health outcomes, in association with preconditioning variables, highlighting the critical role of these interventions in shaping the immune response during BRD outbreaks. This study is the first to report the measurement of such a wide range of cytokines during spontaneous BRD episodes in young bulls. While not diagnostic when considered individually, cytokine profiles may hold prognostic value and could be integrated into multimodal risk stratification tools, in combination with clinical, microbiological data, and TUS results, to improve BRD management in the field. Preconditioning practices, such as vaccination or preventive antibiotic administration, significantly influence early immune responses and should further be investigated to refine prevention strategies and individualize health monitoring protocols at feedlot entry.

To describe surgical treatment and outcome for horses with extensive perianal melanomas. Gray horses treated surgically for extensive perianal melanoma between July 1, 2020, and July 31, 2023, were eligible. Horses without the entire perianal skin covered with coalescing or ulcerating melanomas were excluded. 59 horses (30 mares, 27 geldings, and 2 stallions) met the inclusion criteria. Median age was 16 years (range, 7 to 28 years). Clinical signs included tenesmus (n = 53), weight loss (3), and hind limb lameness (1). Six horses presented with no complaints; in these horses, surgery was performed preventively. Time since melanoma first appeared was < 5 years (n = 21), 5 to 10 years (18), > 10 years (9), or unknown (11). Tails were affected in all horses. Melanoma occurred elsewhere for 58 horses. All horses underwent presurgical thoracic and abdominal ultrasonography. Horses underwent standing sedation combined with epidural anesthesia (n = 51) or general anesthesia (8). Surgery involved circumferential incisions at the junction between the skin and melanomas and mucocutaneous junction of the rectum, blunt and sharp dissection to remove the masses, and rectal reconstruction. Perirectal tumors were removed via separate vertical incisions. Tail amputation was performed for 13 horses. Follow-up data (median, 19 months; range, 6 to 48 months) were available for 50 horses; clinical signs improved for 44 (88%), recurrence was observed for 6 (12%), and complications occurred for 15 (30%). Results indicated that this surgical procedure is a viable treatment option for horses with extensive perianal melanoma.

ABSTRACTBackgroundThoracic ultrasonography (TUS) could improve antibiotic treatment selection in cattle with respiratory diseases.Hypothesis/ObjectivesEvaluate the association between respiratory pathogens and consolidations on TUS in feedlot cattle, at both individual and group levels.AnimalsA total of 221 bulls, aged 8.8 months and weighing 322.5 ± 160 kg, from nine farms.MethodsCross‐sectional study including all data from clinical examinations and TUS collected weekly during the first month on feed. Pathogens were assessed by seroconversion (all animals) and qPCR on nasal swabs (sick animals). At the individual level, the association between pathogen detection and TUS consolidation was investigated using univariate logistic regression, and the ability of consolidation size to differentiate bacterial from non‐bacterial pneumonia was assessed using receiver operating characteristic curves. Principal component analysis identified clusters at the group level based on pathogen detection and TUS results.ResultsAt the individual level, bulls infected with multiple pathogens (odds ratio [OR], 8.1; 95% confidence interval [CI], 2.21–29.8) or a single virus (OR, 5.49; 95% CI, 1.42–21.3) were more likely to have consolidations than those not infected. A total consolidation size > 14 cm2 in the scanned thoracic region differentiated bacterial from non‐bacterial pneumonia with a sensitivity of 47.8% (95% CI, 36.4–83.3) and specificity of 94.1% (95% CI, 60.0–100.0). These results were consistent at the group level; clustering based on bacterial versus non‐bacterial etiology correlated with the number and size of consolidations.Conclusions and Clinical ImportanceConsolidation size could help differentiate bacterial from non‐bacterial pneumonia, guiding treatment at both individual and group levels.

Abstract Bovine respiratory disease (BRD) is the leading cause of death in calves and can affect cattle at different ages. Dairy calves with BRD at weaning had decreased average daily gain (ADG) and decreased future milk production. However, the impacts of BRD on the lifetime growth performance of beef x dairy cattle, reared in similar systems, is unknown. The objective was to evaluate the impact of lung consolidation in calves (n=139 beef × Holstein) at weaning on feedlot growth performance and carcass characteristics. Calves were sourced from two dairies and raised in three cohorts. Calves with ≥ 1 cm2 in at least one lobe at 4 d post-weaning via thoracic ultrasonography (TUS) were deemed to have lung consolidation (TUS+). Calves were fed milk replacer (0.84 kg/d) with ad-lib access to calf starter and water until weaned, 57 ± 14 d. At 4 ± 2 d post-weaning, calves moved to a growing farm. At 329 d of age, cattle were moved to the feedlot (60 km) where they were fed a total mixed ration ad libitum. Calf ADG was calculated by periods: pre-weaning ((1 to 4 d of age – weaning wt)/d), post-weaning ((weaning wt – 329 d wt)/d), and feedlot ((329 d wt - final wt)/d). The targeted final weight for steers and heifers was 680 kg and 635 kg, respectively. Cattle were sent to slaughter in 5 loads. Mixed linear models assessed associations of TUS+ status with ADG (pre-weaning, post-weaning, and feedlot), dry matter intake (DMI), feedlot arrival body weight (ABW), final body weight (FBW), feed efficiency (GF), hot carcass weight (HCW), dressing percentage, ribeye area (REA), marbling score, 12th rib fat thickness (BF), and calculated yield grade. Models included source dairy, calf ranch, and gender as fixed effects and breed as a random effect. At weaning, 35 calves were diagnosed with BRD by TUS+. There were no differences (P&amp;gt;0.05) between calves diagnosed with BRD and calves defined as healthy calves for ADG, DMI, ABW, FBW, or feed efficiency. Similarly, there were no differences (P&amp;gt;0.05) in HCW, dressing percentage, REA, BF, and calculated yield among calves diagnosed with BRD at weaning and healthy calves. However, the marbling score was greater (P=0.02) in carcasses from healthy calves (492 ± 12) compared to carcasses from calves with BRD (448 ± 18). These data suggest lung consolidation at weaning in beef x dairy cattle did not have long-term effects on growth performance but compromised marbling.

ABSTRACTBackgroundThe depth of lung consolidation (≥ 1 and ≥ 3 cm) on thoracic ultrasonography (TUS) is increasingly used as a criterion for antimicrobial treatment. However, its association with bacterial infections remains unclear.ObjectivesTo investigate the associations of clinical and ultrasonographic findings, particularly consolidation depth, with opportunistic bacterial infections (OBI), viral infections, or Mycoplasma bovis (also known as Mycoplasmopsis bovis) infections. Different definitions of OBI were explored, based on various combinations of bacterial species, with or without a neutrophilic profile on cytology.AnimalsEighty‐six group‐housed calves with at least one clinical sign of respiratory disease from 19 herds experiencing a respiratory epidemic.MethodsCross‐sectional study. A physical examination, TUS, and non‐bronchoscopic bronchoalveolar lavage were performed. The definitions of OBI were based on semi‐quantitative culture results and cytology.ResultsCalves with consolidations of ≥ 0.5 cm had higher odds of having an OBI considering most definitions, on M. bovis isolation (odds ratio [OR] = 57.3; 95% confidence interval [CI] = 1.5–2300; p = 0.03) and isolation of a bacterial agent in general (OR = 15.5; 95% CI = 2.3–100; p = 0.01). Animals with consolidation ≥ 1 cm had higher odds of OBI considering all definitions, virus isolation (OR = 15.6; 95% CI = 1.0–240; p = 0.05) and isolation of a bacterial agent in general (OR = 6.9; 95% CI = 1.7–28; p = 0.01). Consolidation ≥ 3 cm, cough, and the California score were not significantly associated with OBI, M. bovis, or both.ConclusionIn herds experiencing a respiratory epidemic, consolidation depths ≥ 0.5 and ≥ 1 cm might indicate respiratory disease with a bacterial component.

Fluid overload in patients with end-stage kidney disease (ESKD) usually results in pleural effusions (PEs). While volume overload remains the primary etiology of PE, other possible causes must be ruled out. Thoracic ultrasonography (TUS) is a practical and efficient method for evaluating volume in patients undergoing hemodialysis (HD), although evidence regarding its usefulness in this context is limited. We aimed to investigate the relationship between pleuropulmonary TUS patterns and overload symptoms and their correlation with optimal HD, as measured by total urea clearance (Kt/V) and the urea reduction rate (URR). This prospective longitudinal observational study included patients with ESKD who underwent renal replacement therapy with HD. Point-of-care TUS was performed before and after HD sessions. The ultrasound parameters recorded included the presence, location, sonographic patterns and volume of PE. A total of 136 patients were included in the study. TUS abnormalities compatible with interstitial syndrome (B-lines) were identified in 56 (41%) patients. Forty-four patients (32%) had PE. The PE volume showed a statistically significant decrease after HD and normalized in 12% of the patients. No significant difference in the proportion of patients who achieved a URR > 65 or optimal Kt/V was observed between patients with abnormal (B-lines) and normal TUS results (P = .39). The presence of PE and B-lines was significantly associated with overload symptoms; however, these overload symptoms were not related to optimal HD, as measured by the Kt/V or URR. PE and B-lines demonstrated a stronger association with overload symptoms than Kt/V or URR in HD patients. No relationship was found between the TUS pleuropulmonary changes and HD efficacy.

The thoracic duct (TD) is the largest lymphatic vessel proximal to the venous system. It undergoes morphological changes in response to lymph flow from the periphery, with automatic contraction controlling the dynamics to propel lymph toward the venous system. Recent advancements in ultrasonography have facilitated non-invasive observations of the TD’s terminal, including its valve and wall motions. Observations of TD movements allow predictions of lymphatic flow dynamics. However, no studies have yet documented the changes in the TD under exercise-induced lymph flow enhancement in humans. Here, using 18-MHz high-frequency ultrasonography, we demonstrate for the first time that the TD diameter significantly expands under exercise load. This study analyzed 20 participants; the maximum TD diameters at rest and post-exercise were 2.69 ± 1.06 mm and 3.41 ± 1.32 mm, respectively (p = 0.00000056). While various methods exist for observing the TD, our approach—dynamically monitoring the TD diameter using sonography in real time and correlating it with lymphatic flow dynamics—offers a novel contribution.

BackgroundBacteremia is a potential systemic complication of bronchopneumonia (BP) in dairy calves, which increases the risk of sepsis and mortality. However, data on bacteremia in farm conditions is still limited. This study investigates the prevalence of bacteremia in calves with BP on farms, examining isolated pathogens and the associations between thoracic ultrasonography (TUS) and non-endoscopic bronchoalveolar lavage (nBAL) findings.ResultsThe study enclosed 13 dairy farms and included 211 eligible preweaned dairy calves, of which 88 were diagnosed with BP based on a highly sensitive threshold of ≥ 1 cm for lung consolidation detected by TUS. The affected calves underwent non-endoscopic bronchoalveolar lavage (nBAL) and blood culture procedures. Blood culture results showed a positivity rate of 6.8%, identifying Salmonella Dublin in five cases and Campylobacter fetus in one case. Twenty-four (27.2%) blood samples grew presumed bacterial contaminants, while 58 (65.9%) samples had no growth. In contrast, nBAL samples revealed a 75% positivity rate, with Pasteurella multocida and Mycoplasma bovis being the most frequently identified pathogens. No associations were observed between TUS-detected lung lesions and bacteremia. Notably, BP pathogens were not identified in blood cultures, except for one instance where Salmonella Dublin was detected in the nBAL and blood culture.ConclusionsThe study indicates a low prevalence of bacteremia in dairy calves with BP diagnosed through TUS, suggesting that recommending treatment or revisions in disease management related to potential bacteremia in these patients may not be warranted. The findings imply that lung lesions detected via TUS may occur independently of bacteremia, highlighting the value of TUS for early diagnosing and monitoring BP in field conditions.

Pleural procedures are fundamental skills for intensive care specialists. While competency in these procedures is not explicitly mandated within the Intensive Care Medicine (ICM) curriculum, achieving proficiency remains a vital goal for ICM trainees. Anecdotal evidence suggests that training in this area is often perceived as inadequate, with considerable variability in practice across intensive care units (ICUs). We conducted the first survey of ICM trainees in the UK to evaluate routine practices, formal training, accreditation, and perceived competence. The findings revealed significant gaps in training. Confidence levels in performing chest drain varied widely, and a notable deficiency in thoracic ultrasonography (US) training was identified. Additionally, it was observed that many ICUs frequently rely on non-ICM specialists to perform pleural procedures. These results underscore critical areas for improvement within ICM training. The authors advocate for enhanced education, structured training programmes, and increased support to address these deficiencies. This will ensure that trainees and future consultants are adequately equipped to perform pleural procedures with confidence and competence.