Pleural effusion

Use of continuous positive airway pressure in drainage of pleural effusion: Educational intervention for evidence-based practice

OBJECTIVE

To create an educational intervention for health professionals and test its effectiveness in implementing the use of CPAP in hospitalized patients with pleural effusion undergoing thoracic drainage.

METHODS

This implementation study was developed in 5 hospitals in Brazil and one in Belgium within four phases: (I) Situational diagnosis (professionals and patients' knowledge about CPAP usage for drained pleural effusion and checking medical records for the last 6 months); (II) Education and training of professionals; (III) New situational diagnosis (equal to phase I); (IV) Follow-up for two years.

RESULTS

65 professionals, 117 patients' medical records, and 64 patients were enrolled in this study. Initially, only 72% of medical records presented a description of interventions. CPAP usage was mentioned in only one patient with a chest tube. After phase III, the number of professionals who used CPAP for their patients with drained pleural effusion increased from 28.8% to 66.7%, p < 0.001. Similarly, the acceptability of this therapy for this clinical situation also increased among professionals from 6.4 ± 1.3 to 7.8 ± 1.4, p < 0.001. However, before the implementation, only one medical record described the use of CPAP in one patient with drained pleural effusion. After two years, the use of CPAP therapy by healthcare professionals for patients with drained thoracic drainage was sustained in 3 hospitals.

CONCLUSIONS

The educational intervention for the use of CPAP in patients with drained pleural effusion was effective for health professionals. Results were sustained after two years in three of the six hospitals.

Validation of a diagnostic flowchart for tuberculous pleurisy in pleural fluid with high levels of adenosine deaminase

INTRODUCTION

Adenosine deaminase (ADA) in pleural fluid is a useful marker for diagnosing tuberculous pleurisy. However, recent studies have reported a lower specificity of pleural fluid ADA levels. We previously developed a diagnostic flowchart for patients with pleural fluid ADA ≥40 U/L, incorporating variables such as pleural fluid lactate dehydrogenase <825 U/L, predominant pleural fluid neutrophils or cell degeneration, and a pleural fluid ADA/total protein ratio <14. This flowchart was effective in distinguishing between tuberculous pleurisy and other diseases. Here, we conducted a validation analysis of this flowchart.

MATERIALS AND METHODS

We retrospectively collected data from 458 patients with pleural fluid ADA concentrations ≥40 U/L across eight institutions from January 2019 to December 2023. The diagnostic accuracy rate, sensitivity, and specificity of the diagnostic flowchart were analysed and compared to those in the original study.

RESULTS

Eighty-seven patients were diagnosed with tuberculous pleurisy, and 371 patients were diagnosed with other diseases. The diagnostic accuracy, sensitivity, and specificity for diagnosing tuberculous pleurisy were 77.7%, 86.2%, and 75.7%, respectively. Compared with that in the original study, the rate of tuberculous pleurisy was lower (19.0% vs. 44.5%, p < 0.001), but the diagnostic accuracy rates were not significantly different (p = 0.253). On the basis of the findings from this validation study, we have revised the flowchart to enhance its utility.

CONCLUSION

The diagnostic flowchart exhibited high diagnostic accuracy in this validation study, comparable to that in the original study. This validation confirms the effectiveness of the flowchart, even in settings with a low incidence of tuberculosis.

Lung cancer cells detection by a photoelectrochemical MoS2 biosensing chip

This research aims to explore the potential application of this approach in the production of biosensor chips. The biosensor chip is utilized for the identification and examination of early-stage lung cancer cells. The findings of the optical microscope were corroborated by the field emission scanning electron microscopy, which provided further evidence that the growth of MoS2 is uniform and that there is minimal disruption in the electrode, hence minimizing the likelihood of an open circuit creation. Furthermore, the bilayer structure of the produced MoS2 has been validated through the utilization of Raman spectroscopy. A research investigation was undertaken to measure the photoelectric current generated by three various types of clinical samples containing lung cancer cells, specifically the CL1, NCI-H460, and NCI-H520 cell lines. The findings from the empirical analysis indicate that the coefficient of determination (R-Square) for the linear regression model was approximately 98%. Furthermore, the integration of a double-layer MoS2 film resulted in a significant improvement of 38% in the photocurrent, as observed in the device's performance.

mRNA markers associated with malignant pleural effusion

Malignant pleural effusions (MPE) commonly result from malignant tumors and represent advanced-stage cancers. Thus, in clinical practice, early recognition of MPE is valuable. However, the current diagnosis of MPE is based on pleural fluid cytology or histologic analysis of pleural biopsies with a low diagnostic rate. This research aimed to assess the diagnostic ability of eight previously identified Non-Small Cell Lung Cancer (NSCLC)-associated genes for MPE. In the study, eighty-two individuals with pleural effusion were recruited. There were thirty-three patients with MPE and forty-nine patients with benign transudate. mRNA was isolated from the pleural effusion and amplified by Quantitative real-time PCR. The logistic models were further applied to evaluate the diagnostic performance of those genes. Four significant MPE-associated genes were discovered in our study, including Dual-specificity phosphatase 6 (DUSP6), MDM2 proto-oncogene (MDM2), Ring finger protein 4 (RNF4), and WEE1 G2 Checkpoint Kinase (WEE1). Pleural effusion with higher expression levels of MDM2 and WEE1 and lower expression levels of RNF4 and DUSP6 had a higher possibility of being MPE. The four-gene model had an excellent performance distinguishing MPE and benign pleural effusion, especially for pathologically negative effusions. Therefore, the gene combination is a suitable candidate for MPE screening in patients with pleural effusion. We also identified three survival-associated genes, WEE1, Neurofibromin 1 (NF1), and DNA polymerase delta interacting protein 2 (POLDIP2), which could predict the overall survival of patients with MPE.

Pleural CEA, CA-15-3, CYFRA 21-1, CA-19-9, CA-125 discriminating malignant from benign pleural effusions: Diagnostic cancer biomarkers

INTRODUCTION

There is a need for a rapid, accurate, less-invasive approach to distinguishing malignant from benign pleural effusions. We investigated the diagnostic value of five pleural tumor markers in exudative pleural effusions.

METHODS

By immunochemiluminescence assay, we measured pleural concentrations of tumor markers. We used the receiver operating characteristic curve analysis to assess their diagnostic values.

RESULTS

A total of 281 patients were enrolled. All tumor markers were significantly higher in malignant pleural effusions than benign ones. The area under the curve of carcinoembryonic antigen (CEA), carbohydrate antigen (CA) 15-3, cytokeratin fragment 19 (CYFRA) 21-1, CA-19-9, and CA-125 were 0.81, 0.78, 0.75, 0.65, and 0.65, respectively. Combined markers of CEA + CA-15-3 and CEA + CA-15-3 + CYFRA 21-1 had a sensitivity of 87% and 94%, and specificity of 75% and 58%, respectively. We designed a diagnostic algorithm by combining pleural cytology with pleural tumor marker assay. CEA + CYFRA 21-1 + CA-19-9 + CA-15-3 was the best tumor markers panel detecting 96% of cytologically negative malignant pleural effusions, with a negative predictive value of 98%.

CONCLUSIONS

Although cytology is specific enough, it has less sensitivity in identifying malignant pleural fluids. As a result, the main gap is detecting malignant pleural effusions with negative cytology. CEA was the best single marker, followed by CA-15-3 and CYFRA 21-1. Through both cytology and suggested panels of tumor markers, malignant and benign pleural effusions could be truly diagnosed with an accuracy of about 98% without the need for more invasive procedures, except for the cohort with negative cytology and a positive tumor markers panel, which require more investigations.

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

BACKGROUND

There is sparse evidence in the literature in relation to the nature and causes of pleural effusion among Australian Indigenous population.

METHODS

In this retrospective study, Indigenous and non-Indigenous adults diagnosed to have pleural effusion over a two-year study period were included for comparative analysis.

RESULTS

Of the 314 patients, 205 (65%) were non-Indigenous and 52% were males. In comparison to non-Indigenous, the Indigenous patients were younger (50 years (IQR 39,60) vs 63 years (IQR 52,72), p<0.001), females (61% vs 41%, p=0.001), have higher prevalence of renal and cardiovascular disease and tend to have exudative effusion (93% vs 76%, p=0.032). Infections was judged to be the most common cause for effusion in both groups, more so among the Indigenous cohort. Effusion secondary to renal disease was higher (13% vs 1%, p<0.001) among Indigenous Australians, in contrast malignant effusions were higher (13% vs 4%, p=0.004) among non-Indigenous. Length of hospital stay was longer for Indigenous patients (p=0.001), and a greater proportion received renal dialysis (13% vs 1%, p<0.001). Intensive care unit (ICU) admissions rates were higher with infective etiology of pleural effusion (82% vs. 53% Indigenous & 44% vs. 39% non-Indigenous respectively). Re-presentations to hospital were higher among Indigenous patients (46% vs 33%, p=0.046) and were associated with renal and cardiac disease and malignancy in non-Indigenous.

CONCLUSION

There are significant differences in the way pleural effusion manifests among Australian Indigenous patients. Understanding these differences may facilitate approaches to the management and to implement strategies to reduce morbidity and mortality in this population. This article is protected by copyright. All rights reserved.

Cell-free DNA From Pleural Effusion Samples: Is It Right for Molecular Testing in Lung Adenocarcinoma?

Pathogenic molecular features gained specific significance in therapeutic decisions in lung carcinoma in the past decade. Initial and follow up genetic testing requres appropriate amounts and quality of tumor derived DNA, but tumor sampling, especially for disease monitoring is generally limited. Further to the peripheral blood (PB), samples from pleural fluid, accumulating in diverse lung processes might serve as an alternative source for cell-free DNA (cfDNA) for genetic profiling. In our study, cfDNA isolated from the pleural effusion and from the PB, and genomic DNA (gDNA) obtained from tissue/cellular samples were analyzed and compared from altogether 65 patients with pulmonary disease, including 36 lung adenocarcinomas. The quantity of effusion cfDNA yield appeared to be significantly higher compared to that from simultaneously collected PB plasma (23.2 vs. 4.8 ng/μl, p < 0.05). Gene mutations could be safely demonstrated from the effusion cfDNA fraction obtained from adenocarcinoma patients, 3/36 EGFR, 9/36 KRAS and 1/36 BRAF gene variants were detected. In this series, 9/13 samples showed an effusion+/plasma-mutational status, while only 1/13 samples presented with the opposite findings (effusion-/plasma+). gDNA analysis from sediment cell blocks from the identical effusion sample was surprisingly ineffective for lung adenocarcinoma profiling due to the low DNA yield. In conclusion, the cell free supernatant of pleural effusions appears to concentrate cancer derived cfDNA and seems to be particularly suitable for serial genotyping of pulmonary adenocarcinoma.

Three-Dimensional Printing of Hydroxyapatite Composites for Biomedical Application

Hydroxyapatite (HA) and HA-based nanocomposites have been recognized as ideal biomaterials in hard tissue engineering because of their compositional similarity to bioapatite. However, the traditional HA-based nanocomposites fabrication techniques still limit the utilization of HA in bone, cartilage, dental, applications, and other fields. In recent years, three-dimensional (3D) printing has been shown to provide a fast, precise, controllable, and scalable fabrication approach for the synthesis of HA-based scaffolds. This review therefore explores available 3D printing technologies for the preparation of porous HA-based nanocomposites. In the present review, different 3D printed HA-based scaffolds composited with natural polymers and/or synthetic polymers are discussed. Furthermore, the desired properties of HA-based composites via 3D printing such as porosity, mechanical properties, biodegradability, and antibacterial properties are extensively explored. Lastly, the applications and the next generation of HA-based nanocomposites for tissue engineering are discussed.

Diagnosis of pleural empyema/parapneumonic effusion by next-generation sequencing

BACKGROUND

Although a microbiological diagnosis of pleural infection is clinically important, it is often complicated by prior antibiotic treatment and/or difficulties with culturing some bacterial species. Therefore, we aimed to identify probable causative bacteria in pleural empyema/parapneumonic effusions by combining 16S ribosomal RNA (rRNA) gene amplification and next-generation sequencing (NGS).

METHODS

Pleural fluids were collected from 19 patients with infectious effusions and nine patients with non-infectious malignant effusions. We analysed DNA extracted from the pleural fluid supernatant by NGS using the Genome Search Toolkit and GenomeSync database, either directly or after PCR amplification of the 16S rRNA gene. Infectious and non-infectious effusions were distinguished by semi-quantitative PCR of the 16S rRNA gene.

RESULTS

Only 8 (42%) effusions were culture-positive, however, NGS of the 16S rRNA gene amplicon identified 14 anaerobes and 7 aerobes/facultative anaerobes in all patients, including Streptococcus sp. (n = 6), Fusobacterium sp. (n = 5), Porphyromonas sp. (n = 5), and Prevotella sp. (n = 4), accounting for >10% of the total genomes. The culture and NGS results were discordant for 3 out of 8 patients, all of whom had previously been treated with antibiotics. Total (2^ΔCT value in semi-quantitative PCR of the 16S rRNA gene) and specific (total bacterial load multiplied by the proportion of primary bacteria in NGS) bacterial loads could efficiently distinguish empyema/parapneumonic effusion from non-infectious effusion.

CONCLUSION

Combining NGS with semi-quantitative PCR can facilitate the diagnosis of pleural empyema/parapneumonic effusion and its causal bacteria.

Bevacizumab plus chemotherapy in nonsquamous non-small cell lung cancer patients with malignant pleural effusion uncontrolled by tube drainage or pleurodesis: A phase II study North East Japan Study group trial NEJ013B

Background

Pleurodesis is the standard of care for non‐small cell lung cancer (NSCLC) patients with symptomatic malignant pleural effusion (MPE). However, there is no standard management for MPE uncontrolled by pleurodesis. Most patients with unsuccessful MPE control are unable to receive effective chemotherapy. Vascular endothelial growth factor (VEGF) plays an important role in the pathogenesis of MPE. This multicenter, phase II study investigated the effects of bevacizumab plus chemotherapy in nonsquamous NSCLC patients with unsuccessful management of MPE.

Methods

Nonsquamous NSCLC patients with MPE following unsuccessful tube drainage or pleurodesis received bevacizumab (15 mg/kg) plus chemotherapy every three weeks. The primary endpoint was pleural effusion control rate (PECR), defined as the percentage of patients without reaccumulation of MPE at eight weeks. Secondary endpoints included pleural progression‐free survival (PPFS), safety, and quality of life (QoL).

Results

A total of 20 patients (median age: 69 years; 14 males; 20 adenocarcinomas; six epidermal growth factor receptor mutations) were enrolled in nine centers. The PECR was 80% and the primary end point was met. The PPFS and the overall survival (OS) were 16.6 months and 19.6 months, respectively. Patients with high levels of VEGF in the MPE had shorter PPFS (P = 0.010) and OS (P = 0.002). Toxicities of grade ≥ 3 included neutropenia (50%), thrombocytopenia (10%), proteinuria (10%), and hypertension (2%). The cognitive QoL score improved after treatment.

Conclusions

Bevacizumab plus chemotherapy is highly effective with acceptable toxicities in nonsquamous NSCLC patients with uncontrolled MPE, and should be considered as a standard therapy in this setting.

Key points

Significant findings of the study

Bevacizumab plus chemotherapy is highly effective with acceptable toxicities in nonsquamous NSCLC patients with uncontrolled MPE.

What this study adds

Bevacizumab plus chemotherapy should be considered as a standard treatment option for patients with uncontrolled MPE.

Clinical trial registration

UMIN000006868 was a phase II study of efficacy of bevacizumab plus chemotherapy for the management of malignant pleural effusion (MPE) in nonsquamous non‐small cell lung cancer patients with MPE unsuccessfully controlled by tube drainage or pleurodesis (North East Japan Study Group Trial NEJ‐013B) (http://umin.sc.jp/ctr/).

Features of Parapneumonic Effusions

Introduction: Parapneumonic effusions, as a complication of community-acquired pneumonia (CAP), usually have a good course, but they sometimes progress into complicated parapneumonic effusion (CPPE) and empyema, thus becoming a significant clinical problem.

Aim: To review clinical and radiological features, as well as diagnostic and therapeutic options in parapneumonic effusions.

Material and methods: The analysis included 94 patients with parapneumonic effusion hospitalized at the University Infectious Diseases Clinic in Skopje during a 4 year period. Out of 755 patients with CAP, 175 (23.18%), had parapneumonic effusion. Thoracentesis was performed in 94 (53.71%) patients, 50 patients were with uncomplicated parapneumonic effusions (UCPPE) and 44 with complicated parapneumonic effusions (CPPE).

Results: More patients (59.57%) were male; the average age was 53.82±17.5 years. The most common symptoms included: fever (91; 96.81%), cough (80; 85.11%), pleuritic chest pain (68; 72.34%), dyspnea (65; 69.15%). Alcoholism was the most common comorbidity registered in 12 (12.77%) patients. Macroscopically, effusion was yellow and clear in most cases (36; 38.29%). Localization of pleural effusion was often in the left costophrenic angle (53; 56.38%) and ultrasonographic non-septated complex. Between the two groups of effusions there was a significant difference between the ERS, WBC and CRP in serum and CRP in pleural fluid. Statistical difference existed in terms of days of hospitalization with a longer hospital stay for patients with CPPE (p <0.0001).

Conclusion: Patients with parapneumonic effusion have the symptoms of acute respiratory infection and frequent accompanying diseases. Future diagnostic and therapeutic treatment depends on pleural fluid features and imaging lung findings.

(F)utility of computed tomography of the chest in the presence of pleural effusion

BACKGROUND

Pleural effusion is common and can cause significant morbidity. The chest X-ray is often the initial radiological test, but additional tests may be required to reduce uncertainty and to provide additional diagnostic information. However, additional exposure and unnecessary costs should be prevented. The objective of the study was to assess the clinical benefit of an additional chest computed tomography (CT) scan over plain chest X-ray alone in the management of patients with pleural effusion.

METHODS

Retrospective analysis in 94 consecutive patients with pleural effusion who underwent chest X-ray and CT scan over an 18-month period in a single institution. All chest X-ray and CT scan reports were compared and correlated with clinical parameters in order to assess their utility in the clinical management. No blinding was applied.

RESULTS

In 75 chest CT scan reports (80 %), information provided by the radiologist did not change clinical management when compared to plain chest X-ray alone and did not provide any additional information over chest X-ray. Only 2/49 (4 %) of the native chest CT scan reports provided clinically relevant information as compared to 17/45 (38 %) contrast-enhanced chest CT scan reports (p<0.001).

CONCLUSIONS

In this retrospective cohort of patients with pleural effusion, an additional chest CT scan was not useful in the majority of patients. However, if a chest CT scan is required, then a contrast-enhanced study after pleural aspiration should be performed. Further prospective studies are required to confirm these findings.

Vascular endothelial growth factor and protein level in pleural effusion for differentiating malignant from benign pleural effusion

Pleural effusion is associated with multiple benign and malignant conditions. Currently no biomarkers differentiate malignant pleural effusion (MPE) and benign pleural effusion (BPE) sensitively and specifically. The present study identified a novel combination of biomarkers in pleural effusion for differentiating MPE from BPE by enrolling 75 patients, 34 with BPE and 41 with MPE. The levels of lactate dehydrogenase, glucose, protein, and total cell, neutrophil, monocyte and lymphocyte counts in the pleural effusion were measured. The concentrations of interleukin (IL)-1β, IL-4, IL-5, IL-6, IL-8, IL-10, IL-12, tumor necrosis factor-α, interferon γ, transforming growth factor-β1, colony stimulating factor 2, monocyte chemoattractant protein-1 and vascular endothelial growth factor (VEGF) were detected using cytometric bead arrays. Protein and VEGF levels differed significantly between patients with BPE and those with MPE. The optimal cutoff value of VEGF and protein was 214 pg/ml and 3.35 g/dl respectively, according to the receiver operating characteristic curve. A combination of VEGF >214 pg/ml and protein >3.35 g/dl in pleural effusion presented a sensitivity of 92.6% and an accuracy of 78.6% for MPE, but was not associated with a decreased survival rate. These results suggested that this novel combination strategy may provide useful biomarkers for predicting MPE and facilitating early diagnosis.

The Exploration of Peptide Biomarkers in Malignant Pleural Effusion of Lung Cancer Using Matrix-Assisted Laser Desorption/Ionization Time-of-Flight Mass Spectrometry

Background. Diagnoses of malignant pleural effusion (MPE) are a crucial problem in clinics. In our study, we compared the peptide profiles of MPE and tuberculosis pleural effusion (TPE) to investigate the value of matrix-assisted laser desorption/ionization time-of-flight mass spectrometry (MALDI-TOF-MS) in diagnosis of MPE. Material and Methods. The 46 MPE and 32 TPE were randomly assigned to training set and validation set. Peptides were isolated by weak cation exchange magnetic beads and peaks in the m/z range of 800–10000 Da were analyzed. Comparing the peptide profile between 30 MPE and 22 TPE samples in training set by ClinProTools software, we screened the specific biomarkers and established a MALDI-TOF-MS classification of MPE. Finally, the other 16 MPE and 10 TPE were included to verify the model. We additionally determined carcinoembryonic antigen (CEA) in MPE and TPE samples using electrochemiluminescent immunoassay method. Results. Five peptide peaks (917.37 Da, 4469.39 Da, 1466.5 Da, 4585.21 Da, and 3216.87 Da) were selected to separate MPE and TPE by MALDI-TOF-MS. The sensitivity, specificity, and accuracy of the classification were 93.75%, 100%, and 96.15%, respectively, after blinded test. The sensitivity of CEA was significantly lower than MALDI-TOF-MS classification (P = 0.035). Conclusions. The results indicate MALDI-TOF-MS is a potential method for diagnosing MPE.

The Role of Serum Coagulation Factors in the Differential Diagnosis of Patients with Pneumonia and Parapneumonic Effusion

The aim of this study was to identify the participations of the serum coagulations and fibrinolysis factors that contribute to the differential diagnosis of the patients with community-acquired pneumonia (CAP) without effusion, uncomplicated parapneumonic effusion (UCPPE) and complicated parapneumonic effusion (CPPE). The coagulations system is fundamental for the maintenance of homeostasis, and contributes to the inflammatory process responsible for CAP and the parapneumonic effusion. The factors of coagulations and fibrinolysis participate in the cellular proliferation and migration as in the synthesis of the inflammatory mediators. We evaluated the laboratory profile of coagulations and fibrinolysis in the serum of 148 patients with CAP without effusion, 50 with UCPPE and 44 with CPPE. We determined the test of the coagulation cascade which measures the time elapsed from the activation of the coagulation cascade at different points to the fibrin generation. As a consequence, there is an activation of the fibrinolytic system with the increased D-dimer levels measured in the plasma in the three groups. The patients were with mean age ± SD (53,82 ± 17,5) min - max 18-93 years. A significantly higher number of thrombocytes was in the group with CPPE with median 412 × 109/L (rank 323-513 × 109/L). The extended activation of the prothrombin time (aPTT) was significantly higher in the same group of patients with median of 32 sec. (rank 30-35 sec). The mean D-dimer plasma level was 3266,5 ± 1292,3 ng/ml in patients with CPPE, in CAP without effusion 1646,6 ± 1204 ng/ml and in UCPPE 1422,9 ± 970 ng/ml. The coagulations system and the fibrinolysis play important role in the development and pathophysiology of CAP and the parapneumonic effusions.

Efficacy of ultrasound-guided thoracentesis catheter drainage for pleural effusion

The factors influencing the efficacy of ultrasound-guided thoracentesis catheter drainage were investigated in the present study. A retrospective analysis of clinical data from 435 patients who presented with a pleural effusion was performed. Patients were divided into a control group and an intervention group. Thirty-seven patients in the control group were given standard care using pleural puncture to draw the excess fluid. The 398 patients in the intervention group were treated using ultrasound-guided thoracentesis catheter drainage. The rate of successful drainage of a pleural effusion was significantly higher (P<0.05), while the rate of complication was lower, in the ultrasound-guided thoracentesis cases compared to standard care treatment. In conclusion, ultrasound-guided thoracentesis catheter drainage is an efficient, safe and minimally invasive procedure to alleviate pleural effusion. The efficacy of the procedure is related to the separation of pleural effusion, drainage tube type and tube diameter.

Clinical, Laboratory and Radiographic Features of Patients with Pneumonia and Parapneumonic Effusions

BACKGROUND:

Parapneumonic effusions complicating pneumonia are associated with increased morbidity and mortality.

AIM:

To determine the role of the clinical, laboratory and radiographic features to the differential diagnosis of patients with community- acquired pneumonia (CAP) without effusion, uncomplicated parapneumonic effusion (UCPPE) and complicated parapneumonic effusion (CPPE).

MATERIAL AND METHODS:

We analysed 148 patients with CAP without effusion, 50 with UCPPE and 44 with CPPE. In three groups of patients, the majority was male patients (58.11%, 58%, 61.36%) consequently.

RESULTS:

The chronic heart failure was the most common comorbidity in a group with CAP (28; 18.92%) and UCPPE (7; 14%), alcoholism (12;12.77%) in a group with CPPE. Patients with CPPE had significantly longer fever compared to patients with CAP without effusion (p = 0.003). Pleuritic chest pain (86.36%) and dyspnea (88.64%) were the most common symptoms in CPPE, then to group with UCPPE (60%; 52%), and in CAP without effusion (25.68%; 47,97%). Diffuse pulmonary changes were detected more frequently in the group with CAP without effusion compared with the group with CPPE (64.86 % vs. 27.27 %), while the segment lung changes were more common in patients with CPPE (50% vs. 20.27%). Patients with CPPE were significant with higher erythrocytes sedimentation rate (ESR), white blood cells (WBC) and serum C- reactive protein (CRP) than it the other two groups (p = 0.00090, p = 0.01, p= 0.000065).

CONCLUSION:

Proper analysis of clinical, laboratory and radiographic features of patients with CAP and parapneumonic effusion can prevent mismanagement in these patients and will reduce morbidity and mortality.

Are the days of closed pleural biopsy over? Yes

In the modern management of pleural diseases, thoracoscopy has a clear advantage over closed pleural biopsy. By way of its high yield, both in malignant pleural disease and pleural Tuberculosis - the two commonest cause of undiagnosed pleural effusion, thoracoscopy has the added advantage of faster symptom relief and offering effective pleurodesis. This makes it an attractive diagnostic and therapeutic procedure of choice and features high in the algorithms of many international guidelines on the approach to pleural diseases.

Chemical Pleurodesis Using Mistletoe Extraction (ABNOVAviscum(®) Injection) for Malignant Pleural Effusion

PURPOSE

Malignant pleural effusion (MPE) is common in patients with advanced cancer. Chemical pleurodesis can be considered for MPE that do not respond to chemotherapy, radiotherapy, or therapeutic thoracentesis. However, it is not yet clear which agent is more effective and safer in chemical pleurodesis.

METHODS

This study was designed as a single arm, multicenter, and open-label phase III clinical trial to evaluate efficacy and safety of chemical pleurodesis using mistletoe extraction (ABNOVAviscum(®) Injection). References of other agents in chemical pleurodesis were investigated to compare efficacy and safety. Efficacy was evaluated by followed up chest X-ray and changes of clinical symptoms and Karnofsky performance scale. Safety was evaluated by serious adverse event (SAE) and changes of laboratory findings. A follow-up period was 4 weeks after last pleurodesis.

RESULTS

Of 62 patients, 49 (79.0%) had complete response, 11 (17.7%) had partial response, and two had no response. Mean response rate was significantly different in this study comparing with reference response rate which was 64% (p <0.0001). There were two SAEs, but all were recovered without sequelas.

CONCLUSION

The results of this study suggest that mistletoe extraction (ABNOVAviscum(®) Injection) could be an effective and safe agent of chemical pleurodesis in patients with MPE.

Clinical Investigation of Benign Asbestos Pleural Effusion

There is no detailed information about benign asbestos pleural effusion (BAPE). The aim of the study was to clarify the clinical features of BAPE. The criteria of enrolled patients were as follows: (1) history of asbestos exposure; (2) presence of pleural effusion determined by chest X-ray, CT, and thoracentesis; and (3) the absence of other causes of effusion. Clinical information was retrospectively analysed and the radiological images were reviewed. There were 110 BAPE patients between 1991 and 2012. All were males and the median age at diagnosis was 74 years. The median duration of asbestos exposure and period of latency for disease onset of BAPE were 31 and 48 years, respectively. Mean values of hyaluronic acid, adenosine deaminase, and carcinoembryonic antigen in the pleural fluid were 39,840 ng/mL, 23.9 IU/L, and 1.8 ng/mL, respectively. Pleural plaques were detected in 98 cases (89.1%). Asbestosis was present in 6 (5.5%) cases, rounded atelectasis was detected in 41 (37.3%) cases, and diffuse pleural thickening (DPT) was detected in 30 (27.3%) cases. One case developed lung cancer (LC) before and after BAPE. None of the cases developed malignant pleural mesothelioma (MPM) during the follow-up.

Diagnostic utility of LUNX mRNA and VEGF mRNA in pleural fluid for differentiating benign from malignant origin

OBJECTIVE

The purpose of this study was to evaluate the diagnostic utility of lung-specific X protein (LUNX) mRNA and vascular endothelial growth factor mRNA in differentiating pleural effusion of different origin.

METHODS

A total of 136 patients with pleural effusion (46 cases of malignant pleural effusion caused by lung cancer, 30 cases of malignant pleural effusion caused by other cancers and 60 cases of benign pleural effusion) were enrolled in this study. Levels of LUNX mRNA and vascular endothelial growth factor mRNA in pleural fluid were detected by real-time quantitative polymerase chain reaction. Pleural fluid carcinoembryonic antigen and Cyfra21-1 were also measured simultaneously.

RESULTS

The LUNX mRNA level was significantly higher in malignant pleural effusion caused by lung cancer than in malignant pleural effusion caused by other cancers and in benign pleural effusion. In malignant pleural effusion caused by cancers of different origin, the vascular endothelial growth factor mRNA level was significantly higher than in benign pleural effusion. For the diagnosis of malignant pleural effusion caused by lung cancer, LUNX mRNA exhibited higher sensitivity (80%), when compared with vascular endothelial growth factor mRNA (65%), carcinoembryonic antigen (67%) and Cyfra21-1 (61%), with the same specificity (95%). The combination of LUNX mRNA and cytology achieved a sensitivity of 85%. The combined use of LUNX mRNA and vascular endothelial growth factor mRNA and cytology raised the sensitivity to 89%, with 95% specificity. In initial cytology-negative pleural effusion from lung cancer, LUNX mRNA achieved the highest positive result (65%) among the four markers.

CONCLUSIONS

The detection of LUNX mRNA and vascular endothelial growth factor mRNA in pleural fluid may be a complementary tool for the diagnosis of malignant pleural effusion. In particular, pleural fluid LUNX mRNA provided a valuable adjunct in distinguishing malignant pleural effusion caused by lung cancer from benign pleural effusion.

The preliminary exploration of 64-slice volume computed tomography in the accurate measurement of pleural effusion

BACKGROUND

Using computed tomography (CT) to rapidly and accurately quantify pleural effusion volume benefits medical and scientific research. However, the precise volume of pleural effusions still involves many challenges and currently does not have a recognized accurate measuring.

PURPOSE

To explore the feasibility of using 64-slice CT volume-rendering technology to accurately measure pleural fluid volume and to then analyze the correlation between the volume of the free pleural effusion and the different diameters of the pleural effusion.

MATERIAL AND METHODS

The 64-slice CT volume-rendering technique was used to measure and analyze three parts. First, the fluid volume of a self-made thoracic model was measured and compared with the actual injected volume. Second, the pleural effusion volume was measured before and after pleural fluid drainage in 25 patients, and the volume reduction was compared with the actual volume of the liquid extract. Finally, the free pleural effusion volume was measured in 26 patients to analyze the correlation between it and the diameter of the effusion, which was then used to calculate the regression equation.

RESULTS

After using the 64-slice CT volume-rendering technique to measure the fluid volume of the self-made thoracic model, the results were compared with the actual injection volume. No significant differences were found, P = 0.836. For the 25 patients with drained pleural effusions, the comparison of the reduction volume with the actual volume of the liquid extract revealed no significant differences, P = 0.989. The following linear regression equation was used to compare the pleural effusion volume (V) (measured by the CT volume-rendering technique) with the pleural effusion greatest depth (d): V = 158.16 × d - 116.01 (r = 0.91, P = 0.000). The following linear regression was used to compare the volume with the product of the pleural effusion diameters (l × h × d): V = 0.56 × (l × h × d) + 39.44 (r = 0.92, P = 0.000).

CONCLUSION

The 64-slice CT volume-rendering technique can accurately measure the volume in pleural effusion patients, and a linear regression equation can be used to estimate the volume of the free pleural effusion.

Proteomic analysis of pleural effusion from lung adenocarcinoma patients by shotgun strategy

PURPOSE

To construct a protein catalogue of malignant pleural effusion from lung adenocarcinoma patients and to screen the potential candidates of biomarkers for diagnostic value in human lung adenocarcinoma.

METHOD

Five malignant pleural effusion samples of lung adenocarcinoma patients were collected from January 2009 to September. A composite sample was analyzed using shotgun strategy. Pleural effusion samples were separated by means of SDS-PAGE. Proteomic analysis was performed by 1D-LC-MS/MS, and then the proteins were identified using SEQUEST software and protein database search.

RESULTS

Among 230 unique proteins, 123 proteins were identified with higher confidence levels (at least two unique peptide sequences matched). Most of these proteins have been reported in plasma. However, there are 7 proteins, including JUP protein, suprabasin, annexin A2, transforming growth factor-beta-induced protein ig-h3 (βig-h3), V-set and immunoglobulin domain-containing protein 4 precursor, ifapsoriasin 2 and actin, cytoplasmic 1 have not been reported in serum.

CONCLUSIONS

Seven proteins may represent potential candidates of biomarkers. Annexin A2 is of special interest since it may play a role in the regulation of intercellular adhesion and cell proliferation.

Superiority and clinical significance of Lunx mRNA in the diagnosis of malignant pleural effusion caused by pulmonary carcinoma

Background

Pulmonary carcinoma is the main cause of malignant pleural effusions (MPEs). However, there is no satisfactory marker for diagnosing MPEs caused by pulmonary carcinoma. The purpose of this study is to assess the clinical significance of Lunx mRNA detection in diagnosing MPEs caused by pulmonary carcinoma.

Methods

A total of 209 patients with pleural effusions were recruited. The patients were diagnosed by cast-off cells, bronchoscopy, and pleural biopsy. The levels of Lunx mRNA in the pleural effusions were determined by real-time PCR. The levels of PH, LDH, glucose, albumin, and CEA were also determined. Patients who accepted chemotherapy underwent Lunx mRNA detection before and after the first chemotherapy session. The patients were divided into four groups according the effect of chemotherapy: complete remission (CR), partial remission (PR), no change (NC), and progressive disease (PD). The patients were also divided into two groups according the change in direction of Lunx mRNA expression after chemotherapy: increased group and decreased group. The patients were followed up to determine survival.

Results

Lunx mRNA was positive in 89 of 106 patients with pleural effusions caused by pulmonary carcinoma. The specificity and sensitivity were 95.9% and 84.9%. The area under the ROC curve was 0.922. Lunx mRNA detection was better than detection using cast-off cells and CEA. All of the Lunx-positive patients with MPEs were diagnosed with pulmonary carcinoma, and all extrapulmonary carcinoma patients were Lunx-negative. The positive predictive value of Lunx mRNA for the source of tumor cells was 100%. Lunx mRNA expression decreased after the first session of chemotherapy in the CR and PR groups, increased in the PD group, there was no change in the NC group. Further analysis indicated the change in direction of Lunx mRNA expression was associated with the overall survival of patients. The patients in the increased group had longer overall survival times than those in the decreased group.

Conclusion

Lunx mRNA is a specific tumor gene that is highly expressed in MPEs caused by pulmonary carcinoma. The changes in Lunx mRNA levels after chemotherapy can predict the prognosis of patients with MPEs caused by pulmonary carcinoma.

Automatic segmentation and measurement of pleural effusions on CT

Pleural effusion is an important biomarker for the diagnosis of many diseases. We develop an automated method to evaluate pleural effusion on CT scans, the measurement of which is prohibitively time consuming when performed manually. The method is based on parietal and visceral pleura extraction, active contour models, region growing, Bezier surface fitting, and deformable surface modeling. Twelve CT scans with three manual segmentations were used to validate the automatic segmentation method. The method was then applied on 91 additional scans for visual assessment. The segmentation method yielded a correlation coefficient of 0.97 and a Dice coefficient of 0.72±0.13 when compared to a professional manual segmentation. The visual assessment estimated 83% cases with negligible or small segmentation errors, 14% with medium errors, and 3% with large errors.

Pleural fluid cell-free DNA integrity index to identify cytologically negative malignant pleural effusions including mesotheliomas

Background

The diagnosis of malignant pleural effusions (MPE) is often clinically challenging, especially if the cytology is negative for malignancy. DNA integrity index has been reported to be a marker of malignancy. The aim of this study was to evaluate the utility of pleural fluid DNA integrity index in the diagnosis of MPE.

Methods

We studied 75 pleural fluid and matched serum samples from consecutive subjects. Pleural fluid and serum ALU DNA repeats [115bp, 247bp and 247bp/115bp ratio (DNA integrity index)] were assessed by real-time quantitative PCR. Pleural fluid and serum mesothelin levels were quantified using ELISA.

Results

Based on clinico-pathological evaluation, 52 subjects had MPE (including 16 mesotheliomas) and 23 had benign effusions. Pleural fluid DNA integrity index was higher in MPE compared with benign effusions (1.2 vs. 0.8; p<0.001). Cytology had a sensitivity of 55% in diagnosing MPE. If cytology and pleural fluid DNA integrity index were considered together, they exhibited 81% sensitivity and 87% specificity in distinguishing benign and malignant effusions. In cytology-negative pleural effusions (35 MPE and 28 benign effusions), elevated pleural fluid DNA integrity index had an 81% positive predictive value in detecting MPEs. In the detection of mesothelioma, at a specificity of 90%, pleural fluid DNA integrity index had similar sensitivity to pleural fluid and serum mesothelin (75% each respectively).

Conclusion

Pleural fluid DNA integrity index is a promising diagnostic biomarker for identification of MPEs, including mesothelioma. This biomarker may be particularly useful in cases of MPE where pleural aspirate cytology is negative, and could guide the decision to undertake more invasive definitive testing. A prospective validation study is being undertaken to validate our findings and test the clinical utility of this biomarker for altering clinical practice.

Mesothelial cells activate the plasma kallikrein-kinin system during pleural inflammation

Pleural inflammation underlies the formation of most exudative pleural effusions and the plasma kallikrein-kinin system (KKS) is known to contribute. Mesothelial cells are the predominant cell type in the pleural cavity, but their potential role in plasma KKS activation and BK production has not been studied. Bradykinin concentrations were higher in pleural fluids than the corresponding serum samples in patients with a variety of diseases. Bradykinin concentrations did not correlate with disease diagnosis, but were elevated in exudative effusions. It was demonstrated, using a range of primary and transformed mesothelial and mesothelioma cell lines, that cells assembled high molecular weight kininogen and plasma prekallikrein to liberate bradykinin, a process inhibited by novobiocin, a heat shock protein 90 (HSP90) inhibitor, cysteine, bradykinin and protamine sulphate. Of the common plasma prekallikrein activators, mesothelial cells expressed HSP90, but not prolylcarboxypeptidase or Factor XII. Calcium mobilisation was induced in some mesothelium-derived cell lines by bradykinin. Des-Arg9-bradykinin was inactive, indicating that mesothelial cells are responsive to bradykinin, mediated via the bradykinin receptor subtype 2. In summary, pleural mesothelial cells support the assembly and activation of the plasma KKS by a mechanism dependent on HSP90, and may contribute to KKS-mediated inflammation in pleural disease.

Diagnostic molecular biomarkers for malignant pleural effusions

Malignant pleural effusions (MPEs) are a common and important cause of cancer-related mortality and morbidity. Prompt diagnosis using minimally invasive tests is important because the median survival after diagnosis is only 4–9 months. Pleural fluid cytology is pivotal to current MPE diagnostic algorithms but has limited sensitivity (30–60%). Consequently, many patients need to undergo invasive diagnostic tests such as thoracoscopic pleural biopsy. Recent genomic, transcriptomic, methylation and proteomic studies on cells within pleural effusions have identified novel molecular diagnostic biomarkers that demonstrate potential in complementing cytology in the diagnosis of MPEs. Several challenges will need to be addressed prior to the incorporation of these molecular tests into routine clinical diagnosis, including validation of molecular diagnostic markers in well-designed prospective, comparative and cost–effectiveness studies. Ultimately, minimally invasive diagnostic tests that can be performed quickly will enable clinicians to provide the most effective therapies for patients with MPEs in a timely fashion.

Diagnosis of pleural effusion: a systematic approach

In most diseases related to pleural effusion, the fluid analysis yields important diagnostic information, and in certain cases, fluid analysis alone is enough for diagnosis. The many important characteristics of pleural fluid are described, as are other complementary investigations that can assist with the diagnosis of common and rare pleural effusions. For a systematic review of pleural effusion, a literature search for articles on the practical investigation and diagnosis of pleural effusion was done. Articles included guidelines, expert opinion, experimental and nonexperimental studies, literature reviews, and systematic reviews published from May 2003 through June 2009. The search yielded 1 guideline, 2 meta-analyses, 9 literature reviews, 1 randomized control trial, and 9 clinical studies. On the basis of class IIa or class I evidence from these articles, a step by step approach is recommended for investigating a pleural effusion, beginning with assessment of the medical history, clinical examination, radiology, pleural fluid evaluation, and finally, if no diagnosis is forthcoming, a pleural biopsy under image guidance or thoracoscopy.

COMPUTER AIDED EVALUATION OF PLEURAL EFFUSION USING CHEST CT IMAGES

A pleural effusion is a condition where there is a buildup of abnormal fluid within the pleural space. This paper presents an automated method to evaluate the severity of pleural effusion using regular chest CT images. First the lungs are segmented using region growing, mathematical morphology and anatomical knowledge. Then the visceral and parietal layers of the pleura are extracted based on anatomical landmarks, curve fitting and active contour models. Finally, the pleural space is segmented and the pleural effusion is quantified. Our method was tested on 15 chest CT studies. The automated segmentation is validated against manual tracing and radiologist's qualitative grading. The Pearson correlation between computer evaluation and radiologist's grading is 0.956 (P=10(-7)). The Dice coefficient between the automated and manual segmentation is 0.74±0.07, which is comparable to the variation between two different manual tracings.

Assessment and management of patients with pleural effusion

Pleural effusions are a common medical condition with a significant source of morbidity, and there are wide variations in management. Over the past 5 years there has been rapid advancement in the knowledge and treatment of pleural diseases and effusions. This article provides an overview of the anatomy and physiology of the pleural space and pleural membranes, and an update on assessment and management of patients with pleural effusions in line with new developments and related national guidelines.

Expression and regulation of epithelial Na+ channels by nucleotides in pleural mesothelial cells

Pleural effusions are commonly clinical disorders, resulting from the imbalance between pleural fluid turnover and reabsorption. The mechanisms underlying pleural fluid clearance across the mesothelium remain to be elucidated. We hypothesized that epithelial Na(+) channel (ENaC) is expressed and forms the molecular basis of the amiloride-sensitive resistance in human mesothelial cells. Our RT-PCR results showed that three ENaC subunits, namely, alpha, beta, gamma, and two delta ENaC subunits, are expressed in human primary pleural mesothelial cells, a human mesothelioma cell line (M9K), and mouse pleural tissue. In addition, Western blotting and immunofluorescence microscopy studies revealed that alpha, beta, gamma, and delta ENaC subunits are expressed in primary human mesothelial cells and M9K cells at the protein level. An amiloride-inhibitable short-circuit current was detected in M9K monolayers and mouse pleural tissues when mounted in Ussing chambers. Whole-cell patch clamp recordings showed an ENaC-like channel with an amiloride concentration producing 50% inhibition of 12 microM in M9K cells. This cation channel has a high affinity for extracellular Na+ ions (K(m): 53 mM). The ion selectivity of this channel to cations follows the same order as ENaC: Li+ > Na+ > K+. The unitary Li(+) conductance was 15 pS in on-cell patches. Four ENaC subunits form a functional Na+ channel when coinjected into Xenopus oocytes. Furthermore, we found that both forskolin and cGMP increased the short-circuit currents in mouse pleural tissues. Taken together, our data demonstrate that the ENaC channels are biochemically and functionally expressed in human pleural mesothelial cells, and can be up-regulated by cyclic AMP and cyclic GMP.

Electrolyte and Fluid Transport in Mesothelial Cells

Mesothelial cells are specialized epithelial cells, which line the pleural, pericardial, and peritoneal cavities. Accumulating evidence suggests that the monolayer of mesothelial cells is permeable to electrolyte and fluid, and thereby govern both fluid secretion and re-absorption in the serosal cavities. Disorders in these salt and fluid transport systems may be fundamental in the pathogenesis of pleural effusion, pericardial effusion, and ascites. In this review, we discuss the location, physiological function, and regulation of active transport (Na(+)-K(+)-ATPase) systems, cation and anion channels (Na(+), K(+), Cl(-), and Ca(2+) channels), antiport (exchangers) systems, and symport (co-transporters) systems, and water channels (aquaporins). These secretive and absorptive pathways across mesothelial monolayer cells for electrolytes and fluid may provide pivotal therapeutical targets for novel clinical intervention in edematous diseases of serous cavities.

[Transthoracic ultrasonography in diagnosis and treatment of acute pleural empyema]

The aim of this study was to estimate validity of transthoracic ultrasonography in diagnosis and evaluation of the results of initial surgical therapy of acute pleural empyema. The study included 49 patients with II stage acute pleural empyema. Initial surgical tretament was indicated according to CT and transthoracic ultrasonography findings. Evaluation of initial therapy results has been made by transthoracic ultrasonography (TUS). Clinical significance of standard x-ray, CT and TUS in different stages of diagnostic and therapeutic procedure has been analyzed. Chest drainage was initial treatment in 10 (20.4%) patients, thoracentesis in 39 (79.6%). Complete cure with this two methods was achieved in 22 (44.9%) patients. In 27 (55.1%) patients initial treatment failed. TUS was sufficient for adequate estimate of initial treatment results in 41 (83.6%). Additional CT was indicated in 8 (16.3%) patients. Transthoracic ultrasonography has impotrant role in choice of initial surgical therapy of acute pleural empyema. If initial estimate of therapy results is made by TUS, CT is rarely necessary.

Bacteriology of complicated parapneumonic effusions

PURPOSE OF REVIEW

The bacteriology of complicated parapneumonic effusions has changed in recent decades, but the causative organisms often remain obscure in up to 40% of cases. Recently, new molecular methods have become available which might help clinical management and improve our understanding of this condition. In this review, we will consider the current bacteriological spectrum of pleural infection and look at some of the new molecular methods.

RECENT FINDINGS

Hospital-acquired pleural infection exhibits a different bacteriology than pleural infection originating in the community. It carries a significantly higher mortality and requires different antibiotics at presentation. Streptococcal and anaerobic infections have low associated mortalities whereas staphylococcal, enterobacterial and mixed aerobic infections carry a worse prognosis. The yield of causative organisms can be significantly increased by the use of bacterial nucleic acid amplification and this may have a role in routine clinical practice in the near future.

SUMMARY

The bacteriology of pleural infection has changed markedly in recent years. Mortality is highest with hospital-acquired pleural infection and infections caused by staphylococci, Enterobacteriacae and mixed aerobes. New molecular microbiological methods substantially increase bacterial yield in pleural fluid.

[Parapneumonic effusion and empyema]

The infectious effusion, one of the most frequent causes of pleural effusions in the clinical practice, is a sign of complication of the pneumonic disease. The early recognition of the parapneumonic effusion is crucial to determine the best treatment form and reduce the risk of morbidity and mortality. The evolution in the diagnostic methods and the contribution of several studies published in the literature allowed to establish evidence-based guidelines that are used to guide the treatment of the parapneumonic pleural effusion and empyema.

Minimal access thoracic surgery in the pediatric population

Thoracoscopy was initially described for use in children to obtain pulmonary biopsy samples in the immunocompromised patient. With refinements in technique, development of better instrumentation, and advances in pediatric anesthesia, there are now many diagnostic and therapeutic indications for the use of thoracoscopy in children. One of the most common indications includes pleural debridement for empyema. Many centers consider this the optimal approach for biopsy of mediastinal lesions and excision of bronchogenic or duplication cysts. The technique is useful for pleural disorders, such as spontaneous pneumothorax and chylothorax. Thoracoscopy has been used to achieve exposure for spinal diskectomy in children with thoracic scoliosis, and newer techniques are being developed in performing anatomic lobectomies, repair of esophageal atesias, and closure of diaphragmatic hernias. The role of the robot in pediatric thoracoscopy is still in the early stages of definition.

Clinical presentation and management of empyema, lung abscess and pleural effusion

PURPOSE OF REVIEW

Pleural effusions, lung abscess and empyema remain a commonly encountered clinical problem and a significant source of morbidity. The aim of this review is to summarize recent developments with emphasis on controlled trials.

RECENT FINDINGS

There is wide variation in the management of infectious pleural effusions, partly because of the relative lack of randomized controlled trials. The recent MRC/BTS UK controlled trial of interapleural streptokinase for pleural infection assessed the efficacy of intrapleural streptokinase compared with placebo in complicated parapneumonic effusions. The study showed no difference in the primary end point, mortality, or in the need for surgery or length of the hospital stay among patients with pleural infection. The first large report published for over a decade has suggested that the bacteriological characteristics of lung abscess have changed.

SUMMARY

The major recent development in the management of pleural infections is the finding that we should dampen the ardor for the routine use of fibrinolytic agents in all patients with pleural infections. We strongly recommend the necessity for additional, well-designed trials to help determine optimal care for these seriously ill patients.

Recent Publications on Medications and Pharmacy

Hospital Pharmacy presents this new feature to keep pharmacists abreast of new publications in the medical/pharmacy literature. Articles of interest will be abstracted monthly regarding a broad scope of topics. Suggestions or comments may be addressed to Joyce Generali, Director of Drug Information at Kansas University Medical Center, 3901 Rainbow Blvd, Kansas City, KS 66160 or jgeneral@kumc.edu .