Significance of congestive heart failure as a cause of pleural effusion: Pilot data from a large multidisciplinary teaching hospital

Clinical characteristics and prognostic factors of non-malignant pleural effusions in hospitalised patients: a retrospective cohort study

OBJECTIVE

Non-malignant pleural effusions (NMPE) are common in hospitalised patients. Data on NMPE inpatients are scarce and the factors influencing the prognosis are unknown.

DESIGN

This was a retrospective cohort study.

SETTING AND PARTICIPANTS

We conducted a retrospective cohort of inpatients (n=86 645) admitted to the Chinese PLA General Hospital from 2018 to 2021, based on electronic medical records. The observations of 4934 subjects with effusions confirmed by chest radiological tests (CT or X-ray) without a diagnosis of malignancy were followed during admission. Logistic regression was used to analyse organ damage and other factors associated with in-hospital death. Patients were clustered according to their laboratory indicators, and the association between the clustering results and outcomes was studied.

OUTCOME

The outcome of this study was in-hospital mortality.

RESULTS

Among 4934 patients, heart failure + pneumonia + renal dysfunction was the most common (15.12%) among 100 different diagnostic groups. 318 (6.4%) patients died during hospitalisation. Lung (OR 3.70, 95% CI 2.42 to 5.89), kidney (OR 2.88, 95% CI 2.14 to 3.90) and heart (1.80, 95% CI 1.29 to 2.55) damage were associated with in-hospital mortality. Hierarchical clustering of laboratory indicators (estimated glomerular filtration rate, white blood cell count, platelet count, haemoglobin, N-terminal pro-B-type natriuretic peptide, serum albumin) demonstrated the ability to discriminate patients at high risk of in-hospital death.

CONCLUSION

Comorbidities and multiorgan failure are the prominent characteristics of NMPE patients, which increase the risk of in-hospital mortality, and comprehensive intervention for specific comorbidity patterns is suggested.

ACR Appropriateness Criteria® Workup of Pleural Effusion or Pleural Disease

Pleural effusions are categorized as transudative or exudative, with transudative effusions usually reflecting the sequala of a systemic etiology and exudative effusions usually resulting from a process localized to the pleura. Common causes of transudative pleural effusions include congestive heart failure, cirrhosis, and renal failure, whereas exudative effusions are typically due to infection, malignancy, or autoimmune disorders. This document summarizes appropriateness guidelines for imaging in four common clinical scenarios in patients with known or suspected pleural effusion or pleural disease. The American College of Radiology Appropriateness Criteria are evidence-based guidelines for specific clinical conditions that are reviewed annually by a multidisciplinary expert panel. The guideline development and revision process support the systematic analysis of the medical literature from peer reviewed journals. Established methodology principles such as Grading of Recommendations Assessment, Development, and Evaluation or GRADE are adapted to evaluate the evidence. The RAND/UCLA Appropriateness Method User Manual provides the methodology to determine the appropriateness of imaging and treatment procedures for specific clinical scenarios. In those instances where peer reviewed literature is lacking or equivocal, experts may be the primary evidentiary source available to formulate a recommendation.

Diagnosing Lung Abnormalities Related to Heart Failure in Chest Radiogram, Lung Ultrasound and Thoracic Computed Tomography

Heart failure (HF) is a multidisciplinary disease affecting almost 1-2% of the adult population worldwide. Symptoms most frequently reported by patients suffering from HF include dyspnoea, cough or exercise intolerance, which is equally often observed in many pulmonary diseases. The spectrum of lung changes related to HF is wide. The knowledge of different types of these abnormalities is essential to distinguish patients with HF from patients with lung diseases or both disorders and thus avoid unnecessary diagnostics or therapies. In this review, we aimed to summarise recent research concerning the spectrum of lung abnormalities related to HF in three frequently used lung imaging techniques: chest X-ray (CXR), lung ultrasound (LUS) and chest computed tomography (CT). We discussed the most prevalent abnormalities in the above-mentioned investigations in the context of consecutive pathophysiological stages identified in HF: (i) redistribution, (ii) interstitial oedema, and (iii) alveolar oedema. Finally, we compared the utility of these imaging tools in the clinical setting. In conclusion, we consider LUS the most useful and promising imaging technique due to its high sensitivity, repeatability and accessibility. However, the value of CXR and chest CT is their potential for establishing a differential diagnosis.

Lung Cancer: Spectral and Numerical Differentiation among Benign and Malignant Pleural Effusions Based on the Surface-Enhanced Raman Spectroscopy

We present here that the surface-enhanced Raman spectroscopy (SERS) technique in conjunction with the partial least squares analysis is as a potential tool for the differentiation of pleural effusion in the course of the cancerous disease and a tool for faster diagnosis of lung cancer. Pleural effusion occurs mainly in cancer patients due to the spread of the tumor, usually caused by lung cancer. Furthermore, it can also be initiated by non-neoplastic diseases, such as chronic inflammatory infection (the most common reason for histopathological examination of the exudate). The correlation between pleural effusion induced by tumor and non-cancerous diseases were found using surface-enhanced Raman spectroscopy combined with principal component regression (PCR) and partial least squares (PLS) multivariate analysis method. The PCR predicts 96% variance for the division of neoplastic and non-neoplastic samples in 13 principal components while PLS 95% in only 10 factors. Similarly, when analyzing the SERS data to differentiate the type of tumor (squamous cell vs. adenocarcinoma), PLS gives more satisfactory results. This is evidenced by the calculated values of the root mean square errors of calibration and prediction but also the coefficients of calibration determination and prediction (R2C = 0.9570 and R2C = 0.7968), which are more robust and rugged compared to those calculated for PCR. In addition, the relationship between cancerous and non-cancerous samples in the dependence on the gender of the studied patients is presented.

Effectiveness and Safety of Real-Time Transthoracic Ultrasound-Guided Thoracentesis

Purpose: The purpose of the present study was to specifically evaluate the effectiveness and safety of real-time ultrasound-guided thoracentesis in a case series of pleural effusion. Patients and methods: An observational prospective study was conducted. From February 2018 to December 2019, a total of 361 consecutive real-time transthoracic ultrasound (TUS)-guided thoracentesis were performed in the Unit of Diagnostic and Interventional Ultrasound of the Research Hospital “Fondazione Casa Sollievo della Sofferenza” of San Giovanni Rotondo, Foggia, Italy. The primary indication for thoracentesis was therapeutic in all the cases (i.e., evacuation of persistent small/moderate pleural effusions to avoid super-infection; drainage of symptomatic moderate/massive effusions). For completeness, further diagnostic investigations (including chemical, microbiological, and cytological analysis) were conducted. All the procedures were performed by two internists with more than 30 years of experience in interventional ultrasound using a multifrequency convex probe (3–8 MHz). For pleural effusions with a depth of 2–3 cm measured at the level of the costo-phrenic sinus was employed a dedicated holed convex-array probe (5 MHz). Results: In all the cases, the attempts at thoracentesis were successful, allowing the achievement of the therapeutic purpose of the procedure (i.e., the complete drying of the pleural space or the withdrawal of fluid till a “safe” quantity [a mean of 1.5 L, max 2 L] producing relief from symptoms) regardless of the initial extent of the pleural effusion. There were only 3 cases of pneumothorax, for a prevalence rate of complications in this population of 0.83%. No statistical difference was recorded in the rate of pneumothorax according to the initial amount of pleural fluid in the effusion (p = 0.12). All the pleural effusions classified as transudates showed an anechoic TUS appearance. Only the exudative effusions showed a complex nonseptated or a hyperechoic TUS appearance. However, an anechoic TUS pattern was not unequivocally associated with transudates. Some chronic transudates have been classified as exudates by Light’s criteria, showing also a complex nonseptated TUS appearance. The cytological examination of the drained fluid allowed the detection of neoplastic cells in 15.89% cases. On the other hand, the microbiological examination of effusions yielded negative results in all the cases. Conclusions: Real-time TUS-guided thoracentesis is a therapeutically effective and safe procedure, despite the diagnostic yield of the cytological or microbiological examinations on the collected liquid being very low. Future blinded randomized studies are required to definitely clarify the actual benefit of the real-time TUS-guided procedure over percussion-guided and other ultrasound-based procedures.