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The Lancet. Respiratory Medicine Jun 2024Most patients with pleural mesothelioma (PM) present with symptomatic pleural effusion. In some patients, PM is only detectable on the pleural surfaces, providing a... (Review)
Review
Most patients with pleural mesothelioma (PM) present with symptomatic pleural effusion. In some patients, PM is only detectable on the pleural surfaces, providing a strong rationale for intrapleural anticancer therapy. In modern prospective studies involving expert radiological staging and specialist multidisciplinary teams, the population incidence of stage I PM (an approximate surrogate of pleura-only PM) is higher than in historical retrospective series. In this Viewpoint, we advocate for the expansion of intrapleural trials to serve these patients, given the paucity of data supporting licensed systemic therapies in this setting and the uncertainties involved in surgical therapy. We begin by reviewing the unique anatomical and physiological features of the PM-bearing pleural space, before critically appraising the evidence for systemic therapies in stage I PM and previous intrapleural PM trials. We conclude with a summary of key challenges and potential solutions, including optimal trial designs, repurposing of indwelling pleural catheters, and new technologies.
Topics: Humans; Pleural Neoplasms; Mesothelioma; Pleura; Mesothelioma, Malignant; Antineoplastic Agents; Pleural Effusion, Malignant
PubMed: 38740045
DOI: 10.1016/S2213-2600(24)00111-5 -
Annals of the American Thoracic Society Sep 2023The diagnostic yield of traditional ultrasound-guided pleural biopsy remains unsatisfactory, particularly when the pleural thickness is ⩽5 mm and/or no pleural...
The diagnostic yield of traditional ultrasound-guided pleural biopsy remains unsatisfactory, particularly when the pleural thickness is ⩽5 mm and/or no pleural nodules are detected. Pleural ultrasound elastography (UE) has a better diagnostic yield than traditional ultrasound for malignant pleural effusion (MPE). However, studies on UE-guided pleural biopsies are lacking. To evaluate the feasibility and safety of UE-guided pleural biopsy. In this multicenter prospective single-arm trial, patients with pleural effusion whose pleural thickness was ⩽5 mm with no pleural nodules were enrolled between July 2019 and August 2021. The diagnostic yield of UE-guided pleural biopsy for pleural effusion and its sensitivity for detecting MPE were evaluated. Ninety-eight patients (mean age, 62.4 ± 13.2 yr; 65 men) were prospectively enrolled. The diagnostic yield of UE-guided pleural biopsy for making any diagnosis was 92.9% (91/98), and its sensitivity for MPE was 88.7% (55/62). In addition, its sensitivity for pleural tuberculosis was 69.6% (16/23). The rate of postoperative chest pain was acceptable, and there was no pneumothorax. UE-guided pleural biopsy is a novel technique for diagnosing MPE with good diagnostic yield and sensitivity. Clinical trial registered with https://www.chictr.org.cn (ChiCTR2000033572).
Topics: Male; Humans; Middle Aged; Aged; Prospective Studies; Elasticity Imaging Techniques; Ultrasonics; Pleural Effusion; Pleural Effusion, Malignant; Image-Guided Biopsy; Diagnostic Tests, Routine
PubMed: 37098021
DOI: 10.1513/AnnalsATS.202212-1047OC -
Geriatrics (Basel, Switzerland) Aug 2023Frailty is a syndrome characterised by increased vulnerability to negative outcomes. Interstitial lung disease (ILD), asthma, and pleural disease are leading causes of... (Review)
Review
BACKGROUND
Frailty is a syndrome characterised by increased vulnerability to negative outcomes. Interstitial lung disease (ILD), asthma, and pleural disease are leading causes of morbidity and mortality. We aimed to investigate the prevalence and impact of frailty in adult patients with these diseases.
METHODS
We conducted a systematic review and meta-analysis, searching PubMed, Web of Science, The Cochrane Library, and EMBASE for studies reporting on frailty in ILD, asthma, and pleural disease. MeSH terms including interstitial lung disease, Idiopathic Pulmonary Fibrosis, Non-specific Interstitial Pneumonia, Chronic Hypersensitivity Pneumonitis, systemic sclerosis-associated ILD, connective tissue disease-associated ILD, and frailty were used as key words. The primary outcome was prevalence of frailty. Where enough contextually homogeneous studies were included, a pooled random-effects meta-analysis was performed with mortality and hospitalisation as the outcomes.
RESULTS
The review found three studies relating to frailty in asthma. No studies relating to pleural disease and frailty were identified. The median prevalence in asthma was 9.5% (IQR, 7.8-11.3). Six relevant studies incorporating 1471 ILD patients (age 68.3 ± SD2.38; 50% male) were identified, which were either cohort or cross-sectional design rated either good or fair. The median prevalence of frailty was 48% (IQR, 25-50). There was a positive association between frail ILD patients and increased risk of long-term mortality (pooled OR, 2.33 95%CI 1.31-4.15, 9%). One study reported a hospitalization rate of HR = 1.97(1.32-3.06) within 6 months in frail ILD patients.
CONCLUSIONS
Frailty is very common and associated with increased mortality in patients with ILD. There are still minimal data regarding the prevalence of frailty and its influence on the risk in this population.
PubMed: 37623275
DOI: 10.3390/geriatrics8040082 -
Chest Nov 2023The optimal treatment for community-acquired childhood pneumonia complicated by empyema remains unclear.
BACKGROUND
The optimal treatment for community-acquired childhood pneumonia complicated by empyema remains unclear.
RESEARCH QUESTION
In children with parapneumonic effusion or empyema, do hospital length of stay and other key clinical outcomes differ according to the treatment modality used?
STUDY DESIGN AND METHODS
A living systematic review of randomized controlled trials (RCTs) was conducted by searching the Cochrane Central Register of Controlled Trials, Embase, Latin American and Caribbean Health Sciences Literature, Ovid MEDLINE, and Web of Science Core Collection databases. Eligible RCTs included patients aged < 18 years and compared two of the following treatment modalities: antibiotics alone, chest tube insertion with or without fibrinolytics, video-assisted thoracoscopic surgery (VATS), and decortication via thoracotomy. A network meta-analysis was performed to evaluate treatment effects on hospital length of stay (LOS), the primary outcome.
RESULTS
Eleven trials including a total of 590 patients were selected for the network meta-analysis. Compared with a chest tube alone, a chest tube with fibrinolytics, thoracotomy, and VATS were all associated with shorter LOS, with a mean difference of 5.05 days (95% CI, 2.46-7.64), 6.33 days (95% CI, 3.17-9.50), and 5.86 days (95% CI, 3.38-8.35), respectively. No substantial differences in LOS were observed between the latter three interventions. None of the 11 RCTs compared antibiotics alone vs other types of treatment. Most trials reported peri-procedural complications and the need for reintervention, but the descriptions differed significantly between trials, preventing meta-analysis. In trials reporting health care-associated costs, fibrinolytics had cost advantages compared with VATS. Short- and long-term morbidity and mortality were very low, regardless of the treatment modality.
INTERPRETATION
The results of this network meta-analysis showed that a chest tube alone was associated with a longer LOS compared with other treatment modalities. The lower cost associated with a chest tube plus fibrinolytics warrants consideration when choosing between treatment options, given similar LOS and clinical outcomes compared with the other modalities.
Topics: Child; Humans; Anti-Bacterial Agents; Chest Tubes; Community-Acquired Infections; Drainage; Empyema, Pleural; Network Meta-Analysis; Pleural Effusion; Pneumonia; Thoracic Surgery, Video-Assisted
PubMed: 37463660
DOI: 10.1016/j.chest.2023.06.010 -
Medicine Dec 2023Fungal pleural infections are infrequent and insidious, for which there are neither large clinical studies nor targeted guidelines to provide standardized treatment... (Review)
Review
Fungal pleural infections are infrequent and insidious, for which there are neither large clinical studies nor targeted guidelines to provide standardized treatment options. We reported 4 cases of fungal pleural infection and reviewed the cases of fungal pleural infections in previous studies to provide a basis for the diagnosis and treatment of fungal pleural infections. There were 2 females and 2 males with a mean age of 58.5 years in our data. The average time from onset to diagnosis was 30.25 days. Risk factors most frequently included pulmonary diseases (n = 4) and malignancy (n = 1). Two patients underwent pleural biopsy through a thoracoscope, and no pathogens were detected. Pleural fluid culture was positive in 2 out of 3 cases. The diagnoses were "possible" (n = 1), "probable" (n = 1), and "proven" (n = 2). All patients received systemic antifungal therapy, and 3 received combined thoracic drainage. The outcomes were cured (n = 1), improved (n = 2) and lost to follow-up (n = 1). We reviewed 12 cases of fungal pleural infection in previous studies. The diagnosis was confirmed via culture in 7 cases and via biopsy in 8 cases. The pathogen was Aspergillus in 7 cases. After a combination of systemic antifungal (n = 12) and local treatment (n = 11), 10 patients improved and 2 patients died. Diagnosis of fungal pleural infection should incorporate risk factors, clinical presentation and fungal evidence, with pleural fluid culture being an important and feasible mean of confirming the diagnosis; and treatment should be based on systemic antifungal therapy supplemented by topical therapy.
Topics: Male; Female; Humans; Middle Aged; Antifungal Agents; Mycoses; Pleura; Prognosis; Communicable Diseases; Pleural Diseases
PubMed: 38050212
DOI: 10.1097/MD.0000000000036411 -
The Journal of Pediatrics Oct 2023To evaluate the association between consolidation on chest radiograph and typical bacterial etiology of childhood community acquired pneumonia (CAP) in the Etiology of...
OBJECTIVE
To evaluate the association between consolidation on chest radiograph and typical bacterial etiology of childhood community acquired pneumonia (CAP) in the Etiology of Pneumonia in the Community study.
STUDY DESIGN
Hospitalized children <18 years of age with CAP enrolled in the Etiology of Pneumonia in the Community study at 3 children's hospitals between January 2010 and June 2012 were included. Testing of blood and respiratory specimens used multiple modalities to identify typical and atypical bacterial, or viral infection. Study radiologists classified chest radiographs (consolidation, other infiltrates [interstitial and/or alveolar], pleural effusion) using modified World Health Organization pneumonia criteria. Infiltrate patterns were compared according to etiology of CAP.
RESULTS
Among 2212 children, there were 1302 (59%) with consolidation with or without other infiltrates, 910 (41%) with other infiltrates, and 296 (13%) with pleural effusion. In 1795 children, at least 1 pathogen was detected. Among these patients, consolidation (74%) was the most frequently observed pattern (74% in typical bacterial CAP, 58% in atypical bacterial CAP, and 54% in viral CAP). Positive and negative predictive values of consolidation for typical bacterial CAP were 12% (95% CI 10%-15%) and 96% (95% CI 95%-97%) respectively. In a multivariable model, typical bacterial CAP was associated with pleural effusion (OR 7.3, 95% CI 4.7-11.2) and white blood cell ≥15 000/mL (OR 3.2, 95% CI 2.2-4.9), and absence of wheeze (OR 0.5, 95% CI 0.3-0.8) or viral detection (OR 0.2, 95% CI 0.1-0.4).
CONCLUSIONS
Consolidation predicted typical bacterial CAP poorly, but its absence made typical bacterial CAP unlikely. Pleural effusion was the best predictor of typical bacterial infection, but too uncommon to aid etiology prediction.
Topics: Humans; Child; Pneumonia; Radiography; Pleural Effusion; Causality; Community-Acquired Infections; Radiology
PubMed: 36736585
DOI: 10.1016/j.jpeds.2023.01.010 -
Arthritis Research & Therapy Jan 2024To early recognise and improve the prognosis of children systemic lupus erythematosus (cSLE)-associated pancreatitis by summarising and analysing clinical features and...
OBJECTIVE
To early recognise and improve the prognosis of children systemic lupus erythematosus (cSLE)-associated pancreatitis by summarising and analysing clinical features and prognosis data from 12 cases.
METHODS
Retrospective analysis of clinical data from 12 cases of cSLE-associated pancreatitis diagnosed and treated from January 2016 to December 2021 at hospitals such as Children's Hospital of Capital Institute of Paediatrics.
RESULTS
The median SLEDAI-2K score for disease activity was 18.00 (range 12.25-21.00) in the case group and 10.00 (range 7.00-18.00) in the control group, with a statistically significant difference (P < 0.05) between the two groups. The case group had a higher proportion of abdominal pain, vomiting, abdominal distension, pleural effusion, Raynaud's phenomenon (RP), splenic infarction, and concurrent macrophage activation syndrome (MAS) than the control group, with a statistically significant difference (P < 0.05). Serum ferritin (SF), alanine transaminase (ALT), aspartate transaminase (AST), lactate dehydrogenase (LDH), amylase, and increased 24-h urine protein levels were statistically different between the two groups (P < 0.05); platelet counts (PLT) reduction was also statistically different (P < 0.05). The case group had a higher proportion of methylprednisolone pulse therapy, cyclophosphamide pulse therapy during remission induction, and therapeutic plasma exchange than the control group, with a statistically significant difference (P < 0.05) between the two.
CONCLUSION
CSLE-associated pancreatitis has a high fatality rate. The presence of RP, splenic infarction, pleural effusion, and MAS warrants attention from clinicians regarding the possibility of pancreatitis. Once pancreatitis is detected, the primary disease needs active treatment for better prognosis.
Topics: Humans; Child; Retrospective Studies; Splenic Infarction; Lupus Erythematosus, Systemic; Pancreatitis; Pleural Effusion
PubMed: 38233944
DOI: 10.1186/s13075-024-03265-1 -
Journal of Surgical Oncology Sep 2023Pleural metastasis has extremely poor prognosis. Resection of pleural implants with infusion of intrathoracic hyperthermic chemotherapy may offer a survival advantage in... (Review)
Review
OBJECTIVES
Pleural metastasis has extremely poor prognosis. Resection of pleural implants with infusion of intrathoracic hyperthermic chemotherapy may offer a survival advantage in selected patients. We evaluated the safety and efficacy of hyperthermic intrathoracic extracorporeal chemotherapy (HITEC) in patients who underwent pleurectomy/decortication (P/D) for secondary malignant pleural disease (SPD).
METHODS
A total of 101 patients were evaluated over 72 months, with 35 patients electing to proceed with P/D and 60 minutes of HITEC with cisplatin at 42°C. Inclusion criteria were adults 18-79 years with unilateral pleural dissemination. Exclusion criteria were patients without control of primary site, extrathoracic metastatic disease, significant comorbidities, and a history of adverse reaction to cisplatin.
RESULTS
Median age was 56 years (36-73); 60% were women. SPD was thymoma in 13, breast cancer in 9, lung cancer in 6, colon cancer in 2, renal cell in 2, and esophageal, anal, and thymic cancers in one each. There was no operative mortality. Postoperative complications occurred in 18 patients (51%). No patient developed renal failure. Median follow-up was 24 months (4-60). The overall survival rate was 61%; 17 patients (49%) developed recurrent disease at a median of 12 months (6-36). There were no recurrences after 36 months Eleven patients (31%) died of metastatic disease at a median of 17 months (7-25).
CONCLUSIONS
Surgical cytoreduction of SPD followed by HITEC with cisplatin was well tolerated. No patient developed cisplatin-related toxicities. Long-term follow-up is warranted to determine survival advantage and refinement of inclusion criteria.
Topics: Adult; Humans; Female; Middle Aged; Male; Cisplatin; Combined Modality Therapy; Pleural Neoplasms; Mesothelioma; Thymus Neoplasms; Pleural Diseases; Hyperthermia, Induced
PubMed: 37409778
DOI: 10.1002/jso.27389 -
Journal of Bronchology & Interventional... Oct 2023Thoracoscopic pleural biopsy is the gold standard for diagnosing tubercular pleural effusion (TPE). Various thoracoscopic appearances like sago grain nodules, caseous...
BACKGROUND
Thoracoscopic pleural biopsy is the gold standard for diagnosing tubercular pleural effusion (TPE). Various thoracoscopic appearances like sago grain nodules, caseous necrosis, and adhesions have been described in TPE. However, none of these have high specificity for diagnosing TPE. In this study we evaluate a novel finding on thoracoscopy, the " Pleural Pustule."
METHODS
This is a retrospective analysis of patients who underwent thoracoscopy for undiagnosed pleural effusion. Visual inspection of the pleura was performed to identify abnormalities. Biopsies were obtained from those areas and sent for histopathology, acid fast bacillus (AFB) smear, culture, and Xpert MTB/Rif assay. Pleural pustule was defined as a pus filled nodule on the pleural surface.
RESULTS
Of the 259 patients included, 92 were diagnosed with TPE. Pleural pustule(s) were identified in 16 patients with TPE. Presence of pleural pustule had a sensitivity, specificity, positive predictive value, and negative predictive value of 17.4%, 100%, 100% and 68.7%, respectively, for diagnosing TPE. Histopathology of pleural pustule demonstrated necrotizing granulomas in all. In patients with pleural pustule, a microbiological diagnosis of tuberculosis was achieved in 93.7% patients (AFB smear, Xpert MTB/Rif assay, and MTB culture positive in 31.3%, 93.7%, and 43.7% cases, respectively). There is a strong association between pleural pustule and positive Xpert MTB/Rif assay ( P =0.002) and microbiologic confirmation of diagnosis ( P =0.017).
CONCLUSION
The presence of pleural pustule on thoracoscopy has a high positive predictive value for TPE. In tuberculosis-endemic countries, this can be considered suggestive for TPE. When identified, a biopsy from the pleural pustule should be performed as it will likely yield a positive microbiologic diagnosis.
Topics: Humans; Tuberculosis, Pleural; Pleura; Retrospective Studies; Sensitivity and Specificity; Pleural Effusion; Mycobacterium tuberculosis
PubMed: 35968962
DOI: 10.1097/LBR.0000000000000887 -
Revista Espanola de Anestesiologia Y... May 2024
Topics: Humans; Hernia; Lung Diseases; Male; Pleural Diseases; Herniorrhaphy; Tomography, X-Ray Computed; Thoracic Injuries
PubMed: 38423463
DOI: 10.1016/j.redare.2024.02.017