Eosinophilic pleural effusion due to lung cancer has a better prognosis than non-eosinophilic malignant pleural effusion.

OBJECTIVE: Tumor-related eosinophilia may have extended survival benefits for some cancer patients. However, there has been no report on the prognosis difference between eosinophilic pleural effusion (EPE) and non-EPE in lung cancer patients. Our study aimed to investigate the prognosis difference between EPE and non-EPE due to lung cancer. PATIENTS AND METHODS: We retrospectively reviewed patients diagnosed with lung cancer who presented with malignant pleural effusion (MPE) between May 2007 and September 2020 at the National Hospital Organization Kochi Hospital. EPE is defined as pleural fluid with a nucleated cell count containing 10% or more eosinophils. RESULTS: A total of 152 patients were included: 89 were male (59%). The median age was 74.4 years (range 37-101), and all patients were pathologically shown to have MPE. Most patients (140; 92%) had an Eastern Cooperative Oncology Group (ECOG) Performance Status (PS) of 0/1. Twenty patients had EPE. The median overall survival (OS) of all 152 lung cancer patients with MPE was 298 days. The median OS of the patients with EPE was 766 days, and the median OS of the patients with non-EPE was 252 days. Kaplan-Meier univariate analysis showed that lung cancer patients with EPE had a significantly better prognosis than patients with non-EPE (P < 0.05). Cox proportional regression analysis showed that EPE, ECOG PS, sex, and the neutrophil-to-lymphocyte ratio in the serum (sNLR) may be independent prognostic factors affecting survival in patients with MPE. CONCLUSION: Lung cancer patients with EPE have a better prognosis than those with non-EPE.

Molecular Epidemiology and Clinical Features Analysis of Respiratory Adenovirus Infections Reveals Correlations between Genotype, Inflammatory Biomarkers, and Disease Severity.

BACKGROUND: Human adenoviruses (HAdVs) are commonly causing respiratory disease. We molecularly genotyped HAdV circulating in Chinese hospitalized children with respiratory infections and summarized the clinical profiles and common inflammatory biomarkers, so as to better determine their associations with disease severity. METHOD: Children with respiratory single HAdV infection cases that occurred from December 2017 to March 2019 were enrolled for a cross-sectional study. Clinical/laboratory features based on the genotypes of respiratory HAdV infection were reviewed for comparative analysis. RESULTS: A total of 84 patients were enrolled, and HAdV types were identified from 82 patients. Species B (HAdV-7, 44%; HAdV-3, 43%, and HAdV-14, 5%) was the most common, followed by C (HAdV-2, 4% and HAdV-1, 1%) and E (HAdV-4, 1%). Severe HAdV infection and HAdV-7 infection groups were associated with significantly longer duration of fever and hospitalized days, higher morbidity of tachypnea/dyspnea, more pleural effusion, more respiratory rales, more frequently required mechanical ventilation, and significantly higher fatality rate. The elevated procalcitonin (PCT) and C-reactive protein (CRP) levels were significantly associated with severe HAdV infection. CONCLUSIONS: HAdV-7 and HAdV-3 were the most common types among children with respiratory adenovirus infection; vaccines against these two genotypes are in urgent need. PCT and CRP are significantly associated with the severity of HAdV infection.

Intrapleural Fibrinolytic Therapy versus Early Medical Thoracoscopy for Treatment of Pleural Infection. Randomized Controlled Clinical Trial.

Rationale: Pleural infection is frequently encountered in clinical practice and is associated with high morbidity and mortality. Limited evidence exists regarding the optimal treatment. Although both early medical thoracoscopy (MT) and tube thoracostomy with intrapleural instillation of tissue plasminogen activator and human recombinant deoxyribonuclease are acceptable treatments for patients with complicated pleural infection, there is a lack of comparative data for these modes of management.Objectives: The aim of this study was to compare the safety and efficacy of early MT versus intrapleural fibrinolytic therapy (IPFT) in selected patients with multiloculated pleural infection and empyema.Methods: This was a prospective multicenter, randomized controlled trial involving patients who underwent MT or IPFT for pleural infection. The primary outcome was the length of hospital stay after either intervention. Secondary outcomes included the total length of hospital stay, treatment failure, 30-day mortality, and adverse events.Results: Thirty-two patients with pleural infection were included in the study. The median length of stay after an intervention was 4 days in the IPFT arm and 2 days in the MT arm (P = 0.026). The total length of hospital stay was 6 days in the IPFT arm and 3.5 days in MT arm (P = 0.12). There was no difference in treatment failure, mortality, or adverse events between the treatment groups, and no serious complications related to either intervention were recorded.Conclusions: When used early in the course of a complicated parapneumonic effusion or empyema, MT is safe and might shorten hospital stays for selected patients as compared with IPFT therapy. A multicenter trial with a larger sample size is needed to confirm these findings.Clinical trial registered with ClinicalTrials.gov (NCT02973139).

Prognostic Value of Hematological Inflammatory Markers in Patients with Pleural Effusion Due to Heart Failure.

BACKGROUND: Pleural effusions due to heart failure are associated with a high 1-year mortality. Several hematological parameters have been shown to provide prognostic information in patients with cardiovascular diseases. The objective was to assess whether hematological markers can also provide prognostic information in patients with pleural effusion caused by heart failure. METHODS: This was a retrospective study of patients with pleural effusion due to heart failure who underwent a diagnostic thoracentesis. The hematological parameters evaluated were as follows: neutrophils, lymphocytes, neutrophil-to-lymphocyte ratio, platelet count, platelet-to-lymphocyte ratio, mean platelet volume (MPV), and MPV-to-platelet ratio. Patients were divided into two groups: those who died within 1 year and survivors of more than 1 year. Differences and possible correlations were analyzed with non-parametric tests. Diagnostic values were estimated. Survival analysis was performed using the Kaplan-Meier method. Cox regression analysis was performed to identify independent variables. RESULTS: Twenty five of 55 (45%) patients died within 1-year from thoracentesis. Patients who died in this period were older, aged 83 years (73 - 87, median and interquartile range, IQR) vs. 74 (65 - 82); with lower platelet count: 181 x 103 (140 - 258 x 103) vs. 241 x 103 (198 - 324 x 103); and higher MPV/platelet: 48.1 (34.9 - 75.6) vs. 35.6 (27.1 - 42.9). In the regression analysis only the MPV/platelet had statistical significance (p = 0.002). MPV/platelet > 50 had a specificity of 87% for 1-year mortality, and a ratio > 30 had a sensitivity of 84%. CONCLUSIONS: Simple hematological parameters such as platelet count and MPV/platelet, may provide useful prognostic information for predicting 1-year mortality in patients with pleural effusion due to heart failure.

Impacto clínico de una unidad de patología pleural en un hospital de tercer nivel / Clinical Impact of a Pleural Unit in a Tertiary Level Hospital

INTRODUCCIÓN: La enfermedad pleural conlleva un gran número de ingresos y elevadas estancias hospitalarias. Con el fin de mejorar esto, se creó en nuestro hospital una unidad de patología pleural (UPP). Nuestro objetivo es analizar el impacto clínico de dicha unidad. MATERIAL Y MÉTODOS: Estudio prospectivo en el que incluimos a los pacientes ingresados en la UPP del Hospital Universitario Central de Asturias por neumotórax espontáneo primario (NEP), secundario (NES), derrame pleural paraneumónico complicado (DPPC) y derrame pleural maligno (DPM), entre enero de 2015 y diciembre de 2018. Analizamos parámetros descriptivos, estancias medias, reingresos al mes, necesidad de cirugía y, en los DPPC, también la mortalidad hospitalaria. Los datos se compararon con los de los pacientes ingresados por la misma enfermedad en neumología durante los 2 años previos (2013-2014). Describimos además todos los procedimientos realizados en la UPP, tanto ambulatorios como en pacientes ingresados. RESULTADOS: Se incluyeron 741 pacientes. Objetivamos una disminución progresiva de los ingresos totales por enfermedad pleural y de la estancia media (días) en dichas afecciones, excepto en el DPM: NEP de 6,2 a 4,2 (p = 0,004), NES de 13,2 a 8,6 (p = 0,005), DPM de 10,3 a 12,3 (p = 0,05) y DPPC de 18,3 a 11,3 (p = 0,001). Existió una reducción de los reingresos al mes y de la mortalidad hospitalaria por DPPC en el periodo de la UPP (14,9% al 5,5%) (p = 0,021). CONCLUSIONES: La creación de una UPP podría disminuir el número de ingresos innecesarios, favoreciendo una reducción de las estancias medias y, en los DPPC, también la mortalidad hospitalaria

INTRODUCTION: Pleural disease involves a large number of admissions and long hospital stays. In order to improve this situation, a Pleural Unit (PU) was created in our hospital. Our aim was to analyze the clinical impact of this unit. MATERIAL AND METHODS: In this prospective study, we included patients admitted to the PU of the Hospital Universitario Central de Asturias for primary spontaneous pneumothorax (PSP), secondary spontaneous pneumothorax (SSP), complicated parapneumonic pleural effusion (CPPE), and malignant pleural effusion (MPE) between January 2015 and December 2018. We analyzed descriptive parameters, mean length of stay, readmissions at 1 month, need for surgery, and in the CPPE group, in-hospital mortality. The data were compared with those of patients admitted to the respiratory medicine department for the same diseases during the previous two years (2013-2014). We also describe all procedures performed in the PU, in both inpatients and outpatients. RESULTS: A total of 741 patients were included, We observed a progressive decrease in total admissions for pleural diseases and mean length of stay (days) (with the exception of MPE), as follows: PSP: from 6.2 to 4.2 (P = .004); SSP: 13.2 to 8.6 (P = .005), MPE: 10.3 to 12.3 (P = .05); and CPPE: 18.3 to 11.3 (P = .001) There was a reduction in hospital readmissions at 1 month and in in-hospital mortality due to CPPE in the PU period (14.9% to 5.5%) (P = .021). CONCLUSIONS: The creation of a PU could decrease the number of unnecessary admissions, and reduce mean lengths of stay and, in the case of CPPE, in-hospital mortality

Multiplex bacterial polymerase chain reaction in a cohort of patients with pleural effusion.

BACKGROUND: The identification of the pathogens in pleural effusion has mainly relied on conventional bacterial culture or single species polymerase chain reaction (PCR), both with relatively low sensitivity. We investigated the efficacy of a commercially available multiplex bacterial PCR assay developed for pneumonia to identify the pathogens involved in pleural infection, particularly empyema. METHODS: A prospective, monocentric, observational study including 194 patients with pleural effusion. Patients were evaluated based on imaging, laboratory values, pleura ultrasound and results of thoracentesis including conventional microbiology studies during hospitalisation. Multiplex bacterial PCR (Curetis Unyvero p55) was performed in batch and had no influence on therapeutic decisions. RESULTS: Overall, there were 51/197 cases with transudate and 146/197 with exudate. In 42% (n = 90/214) there was a clinical suspicion of parapneumonic effusion and the final clinical diagnosis of empyema was made in 29% (n = 61/214) of all cases. The most common microorganisms identified in the cases diagnosed with empyema were anaerobes [31] followed by gram-positive cocci [10] and gram-negative rods [4]. The multiplex PCR assay identified more of the pathogens on the panel than the conventional methods (23.3% (7/30) vs. 6.7% (2/30), p = 0.008). CONCLUSION: The multiplex PCR-based assay had a higher sensitivity and specificity than conventional microbiology when only the pathogens on the pneumonia panel were taken into account. A dedicated pleural empyema multiplex PCR panel including anaerobes would be needed to cover most common pathogens involved in pleural infection.

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

BACKGROUND: Epidemiological data on the causes of pleural effusion (PE) are scarce. Data on the local prevalence of various causes of PE may play a crucial role in the management strategy of patients with PE. The aim of the study was to investigate the causes of PE and to assess 30-day mortality rate in unselected adult patients treated in a large, multidisciplinary hospital. METHODS: Retrospective analysis of medical records, including chest radiographs, of 2835 consecutive patients admitted to the hospital was performed. Radiograhic signs of PE were found in 195 of 1936 patients in whom chest radigraphs were available. These patients formed the study group. RESULTS: The leading causes of PE were as follows: congestive heart failure (CHF; 37.4%), pneumonia (19.5%), malignancy (15.4%), liver cirrhosis (4.2%) and pulmonary embolism. The cause of PE in 6.7% patients was not established. There was a significant predominance of small volume PE as compared to a moderate or large volume PEs (153, 28 and 14 patients, respectively). Almost 80% of patients with CHF presented with small volume PE, while almost 50% of patients with malignant PE demonstrated moderate or large volume PE. Thirty-day mortality rate ranged from 0% for tuberculous pleurisy to 40% for malignant PE (MPE). CONCLUSIONS: Pleural effusion was found in 10.1% of patients treated in a large multidisciplinary hospital. CHF was the leading cause of PE. Although 30-day mortality in patients with CHF was rela-tively high, it was lower than that in parapneumonic PE and MPE.

Pleural Effusion Outcomes in Intensive Care: Analysis of a Large Clinical Database.

BACKGROUND: Pleural effusions are common in critically ill patients. However, the management of pleural fluid on relevant clinical outcomes is poorly studied. We evaluated the impact of pleural effusion in the intensive care unit (ICU). METHODS: A large observational ICU database Multiparameter Intelligent Monitoring in Intensive Care III was utilized. Analyses used matched patients with the same admission diagnosis, age, gender, and disease severity. RESULTS: Of 50 765, 3897 (7.7%) of critically ill adult patients had pleural effusions. Compared to patients without effusion, patients with effusion had higher in-hospital (38.7% vs 31.3%, P < .0001), 1-month (43.1% vs 36.1%, P < .0001), 6-month (63.6% vs 55.7%, P < .0001), and 1-year mortality (73.8% vs 66.1%, P < .0001), as well as increased length of hospital stay (17.6 vs 12.7 days, P < .0001), ICU stay (7.3 vs 5.1 days, P < .0001), need for mechanical ventilation (63.1% vs 55.7%, P < .0001), and duration of mechanical ventilation (8.7 vs 6.3 days, P < .0001). A total of 1503 patients (38.6%) underwent pleural fluid drainage. Patients in the drainage group had higher in-hospital (43.9% vs 35.4%, P = .0002), 1-month (47.7% vs 39.7%, P = .0005), 6-month (67.1% vs 61.8%, P = .0161), and 1-year mortality (77.1% vs 72.1%, P = .0147), as well as increased lengths of hospital stay (22.1 vs 16.0 days, P < .0001), ICU stay (9.2d vs 6.4 days, P < .0001), and duration of mechanical ventilation (11.7 vs 7.1 days, P < .0001). CONCLUSIONS: The presence of a pleural effusion was associated with increased mortality in critically ill patients regardless of disease severity. Drainage of pleural effusion was associated with worse outcomes in a large, heterogeneous cohort of ICU patients.

Prognostic value of chest radiographs in patients with acute heart failure: the Radiology in Acute Heart Failure (RAD-ICA) study. / Estudio RAD-ICA: valor pronóstico de la radiografía de tórax obtenida en urgencias en pacientes con insuficiencia cardiaca aguda.

OBJECTIVES: To determine whether chest radiographs can contribute to prognosis in patients with acute heart failure (AHF). MATERIAL AND METHODS: Consecutive patients with AHF were enrolled by the participating emergency departments. Radiographic variables assessed were the presence or absence of evidence of cardiomegaly and pleural effusion and the pulmonary parenchymal pattern observed (vascular redistribution, interstitial edema, and/or alveolar edema). We gathered variables for the AHF episode and the patient's baseline state. Outcomes were in-hospital and 1-year mortality; hospital stay longer than 7 days, and a composite of events within 30 days of discharge (revisit, rehospitalization, and/or death). Crude and adjusted hazard ratios were calculated for the 3 categories of radiographic variables. The variables were also studied in combination. RESULTS: A total of 2703 patients with a mean (SD) age of 81 (19) years were enrolled; 54.5% were women. Cardiomegaly was observed in 1711 cases (76.8%) and pleural effusion in 992 (36.7%). A pulmonary parenchymal pattern was observed in all cases, as follows: vascular redistribution in 1672 (61.9%), interstitial edema in 629 (23.3%) and alveolar edema in 402 (14.9%). The adjusted hazard ratios showed that cardiomegaly lacked prognostic value. However, the presence of pleural effusion was associated with a 23% (95% CI, 2%-49%) higher rate of the 30- day composite outcome; in-hospital mortality was 89% (30%-177%) higher in the presence of alveolar edema, and 1-year mortality was 38% (14%-67%) higher in association with vascular redistribution. The results for the variables in combination were consistent with the results for individual variables. CONCLUSION: A diagnostic chest radiograph can also contribute to the prediction of adverse events. Pleural effusion is associated with a higher rate of events after discharge, and alveolar edema is associated with higher mortality.

OBJETIVO: Investigar si la radiografía de tórax en pacientes con insuficiencia cardiaca aguda (ICA) puede contribuir a establecer el pronóstico. METODO: Se incluyeron pacientes consecutivos diagnosticados de ICA en urgencias. Se valoró: cardiomegalia radiológica (CR), derrame pleural (DP) y el patrón parenquimatoso pulmonar (PPP: redistribución vascular, edema intersticial, edema alveolar). Se recogieron variables del estado basal del paciente y del episodio. Las variables de resultado evaluadas fueron mortalidad intrahospitalaria y al año, ingreso prolongado (> 7 días) y evento combinado (reconsulta, rehospitalización o muerte) a 30 días postalta, para las cuales se calcularon las hazard ratio crudas y ajustadas para las tres variables radiológicas y su combinación entre ellas. RESULTADOS: Se incluyeron 2.703 pacientes con una edad media de 81 (DE 19) años; el 54,5% eran mujeres. Se observó CR en 1.711 casos (76,8%), DP en 992 (36,7%) y todos los pacientes mostraron PPP (redistribución vascular el 61,9%, edema intersticial el 23,3% y edema alveolar el 14,9%). El análisis ajustado mostró que la CR no tuvo valor pronóstico; el DP incrementó un 23% (IC 95% 2-49%) los eventos combinados a los 30 días postalta; y el PPP edema alveolar aumentó un 89% (30-177%) la mortalidad intrahospitalaria y un 38% (14-67%) la mortalidad al año respecto al PPP redistribución vascular (referencia). El estudio de la combinación de estos tres hallazgos radiológicos mostró resultados similares y congruentes con los hallazgos del estudio individualizado. CONCLUSIONES: La radiografía de tórax, además de ayudar a establecer el diagnóstico de ICA, puede contribuir a estimar el pronóstico de eventos adversos. Así, el DP se asocia a un incremento de eventos adversos postalta y el PPP edema alveolar a una mayor mortalidad.

What's the Score? Do Pleural Effusion Clinical Scoring Systems Help in Management of Disease?

Pleural effusion is a common condition, affecting over 3,000 people per million population every year. More than 50 causes of pleural effusions are known, including pleural infection and malignant pleural disease. These conditions place a large burden on healthcare systems with one-fourth of patients with pleural infection having a length of hospital stay of more than 1 month. Malignant pleural effusion represents advanced malignant disease with a correspondingly high mortality. Prognostic models using clinical information in combination with blood or pleural fluid biomarkers predicting survival and other outcome measures are therefore a priority in improving clinical care, and potentially outcomes. Identifying patients with poor prognosis may help avoid discomfort and unnecessary interventions at the end of their lives, while, on the other hand, individuals with scores predicting a particularly good prognosis might be selected for more aggressive early treatment. Such scores must be based on data representing routine practice in a general hospital and variables chosen based on their clinical availability at clinical decision points (i.e., before treatment is instituted), making the findings widely applicable.

Efficacy and safety of transjugular intrahepatic portosystemic shunt in difficult-to-manage hydrothorax in cirrhosis.

BACKGROUND: Pleural effusions (PE) complicate cirrhosis in ~5% of patients. Identification of cause and related complications is imperative. Unlike refractory ascites, large-scale studies on interventions for refractory PE are limited. METHODS: Consecutive hospitalized cirrhotics having PE were retrospectively analysed. None had liver transplantation (LT) within 6-month follow-up. We determined safety, efficacy and mortality predictors for PE managed with standard medical treatment (SMT), thoracentesis, catheter drainage and TIPS. RESULTS: Of 1149 cirrhotics with PE (mean Child-Pugh 10.6 ± 1.8 and MELD 21.2 ± 7.4), 82.6% had hepatic hydrothorax (HH) and 12.3% were suspected tubercular PE (TBPE). Despite comparable HVPG and MELD scores, patients with HH developed more AKI, encephalopathy and septic shock (all P < .01) on follow-up. Among HH, 73.5% were symptomatic, 53.2% isolated right-sided PE and 21.3% had SBE. Presence of SBP [Odd's ratio, OR: 4.5] and catheter drainage [OR: 2.1] were independent predictors for SBE. In 70.3% of admissions, HH responded to SMT alone, 12.9% required thoracentesis and 11.5% underwent catheter drainage. Fifty-one patients were selected for TIPS [lower mean CTP 9.9 ± 1.6 and MELD score 18.7 ± 5.4]. Despite reduction in pressure gradient from 23.1 ± 3.8 mm Hg to 7.2 ± 2.5 mm Hg, 25 patients had partial response, 10 had complete HH resolution. Major post-TIPS complications were portosystemic encephalopathy (eight patients, six resolved) and ischaemic hepatitis (four patients, two resolved). Overall, 35.9% patients with HH had 6-month mortality and independent predictors were MELD > 25, SBP and septic shock. CONCLUSION: Refractory PE in cirrhosis requiring interventions including TIPS has poor outcome. The role of haemodynamics in predicting post-TIPS response and complications is limited. Early referral for LT is imperative.

Predictors of Outcomes After Thoracic Surgery in Orthotopic Liver Transplant Recipients With Pleural Disease.

Orthotopic liver transplant (OLT) recipients are at high risk for postoperative pulmonary complications. We aim to determine factors associated with morbidity and mortality in OLT recipients that required thoracic surgery for pleural space complications. A retrospective review was performed of 42 patients who underwent thoracic surgery after OLT between 2005 and 2015. Preoperative data and postoperative outcomes were reviewed. Time to mortality was summarized using Kaplan-Meier curves. Outcomes associated with 30-day morbidity and mortality as well as long-term mortality were analyzed with univariate analysis. Between 2005 and 2015, 1735 OLTs were performed at our institution. We identified 42 patients who required thoracic surgery. Of these 42 OLT recipients, 33 patients required thoracic surgery for pleural space complications. The median interval between OLT and thoracic surgery for pleural space complications was 5.7 months (interquartile range 2.2-14.1). The most common surgical indications were chronic pleural effusion (n = 12, 36.4%) and empyema (n = 10, 30.3%). The most common thoracic operations were decortication and empyema evacuation. The 30-day morbidity was 69.7%. Bilirubin and empyema were significantly associated with 30-day morbidity (odds ratio [OR] = 2.3, P = 0.023; OR = 16.3, P = 0.015). The 30-day, 1-year, and 5-year mortality rates were 15.2%, 57.6%, and 70.2%, respectively. Vasopressor requirement was significantly associated with 30-day mortality (OR = 10.2, P = 0.031). The development of pleural space complications requiring surgery in OLT recipients suggests a poor prognosis. Hyperbilirubinemia and pleural space infections were associated with high postoperative morbidity in OLT recipients requiring thoracic surgery for pleural space complications.

Fetal primary pleural effusions: Prenatal diagnosis and management.

Fetal pleural effusions can be associated with significant perinatal morbidity and mortality. When diagnosed antenatally, referral to a tertiary fetal medicine center is recommended for a detailed ultrasound evaluation for additional structural abnormalities or features suggestive of congenital infections or fetal anemia. The effusions should be characterized as unilateral or bilateral, and presence of hydrops and/or mediastinal shift should be documented. Additional testing should include fetal echocardiography, maternal testing for blood group and screen, hemoglobinopathies, and congenital infections. Invasive genetic testing is recommended with infectious testing on amniotic or pleural fluid. Pleuroamniotic shunting is recommended for large primary pleural effusions with significant mediastinal shift or hydrops, as several large series have demonstrated improvement in perinatal survival, particularly in hydropic fetuses. Delivery should occur in a tertiary care center with neonatal expertise, and infants should be followed up long-term for respiratory and neurodevelopmental outcomes.

Long-Term Neurodevelopmental and Respiratory Outcome after Intrauterine Therapy for Fetal Thoracic Abnormalities.

INTRODUCTION: The aim of this study is to evaluate long-term neurodevelopmental and respiratory outcome after fetal therapy for fetal pleural effusion, congenital cystic adenomatoid malformation, and bronchopulmonary sequestration. METHODS: Children ≥18 months of age underwent an assessment of neurologic, motor, and cognitive development. Medical records were reviewed to determine respiratory outcome. Behavioral outcome was assessed using the Child Behavioral Checklist. RESULTS: Between 2001 and 2016, 63 fetuses with fetal hydrops secondary to thoracic abnormalities were treated at our center. Overall perinatal survival was 64% (40/63). Twenty-six children were included for follow-up (median age 55 months). Severe neurodevelopmental impairment (NDI) was detected in 15% (4/26). Three out of 4 children with severe NDI had associated causes contributing to the impairment. Overall adverse outcome, including perinatal mortality or NDI, was 55% (27/49). Fifteen percent (4/26) had severe respiratory sequelae. Parents did not report more behavioral problems than Dutch norms. DISCUSSION: Our results suggest that severe NDI in this specific high-risk cohort occurs in 15%, which is above the range of the incidence of NDI reported in case series treated with other fetal therapies (5-10%). Large multicenter studies and an international web-based registry are warranted to prospectively gather outcome data at fixed time points.

Tuberculous Pleural Effusion: Clinical Characteristics of 320 Patients. / Derrame pleural tuberculoso: características clínicas de 320 pacientes.

OBJECTIVES: To analyze the clinical and radiological characteristics and features of pleural fluid (PF) in patients with tuberculous pleural effusion (TPE). METHODS: Retrospective analysis of TPEs treated in our clinic over the last 23years. RESULTS: We included 320 patients with TPE (70% men; median age 33years). Mycobacterium tuberculosis was identified in the sputum or PF of 36% of the patients by microscopic examination, solid and liquid media cultures, or nucleic acid amplification tests. The greatest percentage of positive microbiological findings were associated with human immunodeficiency virus (HIV) co-infection (OR: 3.27), and with the presence in PF of proteins <4g/dL (OR: 3.53), neutrophils >60% (OR: 3.23), and glucose <40mg/dL (OR: 3.17). Pleural adenosine deaminase <35U/L was associated with TPEs that occupied less than half of the hemithorax (OR: 6.36) and with PF lactate dehydrogenase levels <500U/L (OR: 8.09). Radiological pulmonary opacities (30%) were more common in TPE occupying less than half of the hemithorax (OR: 2.73), in bilateral TPE (OR: 4.48), and in older patients (OR: 1.02). Factors predicting mortality were: HIV co-infection (OR: 24), proteins in PF <5g/dL (OR: 10), and greater age (OR: 1.05). CONCLUSIONS: Patients with TPE and HIV co-infection and those with lower concentrations of proteins in PF had higher rates of positive microbiological results and death. Moreover, older patients had more pulmonary opacities and a higher incidence of death.

Long-Term Outcomes After Thoracoamniotic Shunt for Pleural Effusions With Secondary Hydrops.

BACKGROUND: Congenital pleural effusion is a rare condition with an incidence of approximately one per 15,000 pregnancies. The development of secondary hydrops is a poor prognostic indicator and such cases can be managed with a thoracoamniotic shunt (TAS). Our objective is to describe postnatal outcomes in survivors after TAS placement for congenital pleural effusions. MATERIALS AND METHODS: A retrospective study of all cases with fetal pleural effusions treated between 2006 and 2016. Patients with dominant unilateral or bilateral pleural effusions complicated by secondary hydrops fetalis received TAS placement. The results are reported as median (range). RESULTS: A total of 29 patients with pleural effusion with secondary hydrops underwent TAS placement. The gestational age at the initial TAS placement was 27.6 (20.3-36.9) wk. Before delivery, hydrops resolved in 17 (58.6%) patients. The delivery gestational age was 35.7 (25.4-41.0) wk and the overall survival rate was 72.4%. Among the 21 survivors, 19 (90.5%) required admission to the neonatal intensive care unit for 15 (5-64) d. All 21 survivors had postnatal resolution of the pleural effusions. All 21 children were long-term survivors, with a median age of survivorship of 3 y 3 mo (9 mo-7 y 6 mo) at the time of last reported follow-up. CONCLUSIONS: Thoracoamniotic shunting in fetuses with a dominant pleural effusion(s) and secondary hydrops resulted in a 72% survival rate. Nearly all survivors required admission to the neonatal intensive care unit. However, a majority did not have significant long-term morbidity.

Pleural effusion as an indicator of short term mortality in acute pulmonary embolism.

INTRODUCTION: Pulmonary embolism (PE) is known as one of the major causes of cardiovascular morbidity and mortality. Identification of high risk patients for short term and long-term mortality is crucial. The purpose of this study is to demonstrate the prognostic importance of simplified pulmonary embolism severity index (sPESI), radiological investigations and comorbidities in terms of short-term mortality by simultaneous assessment of sPESI score, pulmonary computed tomography (CT) angiography findings and underlying comorbidities in patients diagnosed with acute pulmonary embolism. MATERIALS AND METHODS: We retrospectively evaluated 570 patients diagnosed with acute PE confirmed by computer tomography pulmonary angiography (CTPA). Comorbidities were recorded, pulmonary embolism severity index scores were calculated and CTPA data were evaluated as predictors for short-term mortality. RESULT: The study population consisted of 570 patients, 292 (51.2%) patients were female and 74 patients (12.9%) died within 30 days due to PE diagnosis. In univariate analysis male gender (p= 0.031), congestive heart failure (CHF)(p< 0.029), main pulmonary artery involvement (p= 0.045), presence of pleural effusion (p= 0.001) and pericardial effusion (p= 0.004) at time of diagnosis and high risk sPESI group (p< 0.001) had a significant influence on mortality. In the multivariate analysis, pleural effusions (HR, 1.67; CI, 1.05-2.66; p< 0.030) and sPESI high risk group (HR, 9.56; CI, 4.71-19.43; p< 0.001) were remained significant and independent prognostic factors for survival. CONCLUSIONS: The present study underlined that presence of pleural effusion at the time of diagnosis in patients with massive pulmonary embolism and a high sPESI score in other patients were significant predictors of short-term mortality.

Continuation of gefitinib beyond progression in patients with EGFR mutation-positive non-small-cell lung cancer: A phase II single-arm trial.

OBJECTIVES: Several studies have demonstrated the promise of continuation of epidermal growth factor receptor (EGFR) tyrosine kinase inhibitor (TKI) beyond progression in patients with EGFR-mutant non-small-cell lung cancer (NSCLC). The aim of the present study is to clarify the efficacy of continuation of gefitinib in patients with NSCLC beyond progression. MATERIALS AND METHODS: A total of 50 patients with EGFR-mutant NSCLC who progressed based on Response Evaluation Criteria in Solid Tumors (RECIST) 1.1 criteria during gefitinib treatment were eligible. The primary endpoint was progression-free survival-2 (PFS2; time from first gefitinib dose to off-gefitinib progression). Secondary endpoints were PFS1 (time from first gefitinib dose to RECIST 1.1 progression); the difference between PFS2 and PFS1 (PFS2-PFS1); overall survival (OS); and safety. Patients received gefitinib 250 mg/d orally until symptomatic progression or at the investigator's discretion. RESULTS: Between January 2016 and March 2017, 50 patients were enrolled in this study. One patient withdrew consent, leaving a total of 49 patients to be evaluated. The median PFS2-PFS1 was 5.1 months (95% CI, 2.5-7.8), and the median PFS2 was 27.7 months (95% CI, 21.6-33.9). Twelve patients (24.4%) continued gefitinib therapy for 14 months (median value, range 7.2-20.3 months) after RECIST 1.1 progression. The median OS was not reached. Patients were classified by the characteristics of progression at the time of enrollment. PFS2-PFS1 was significantly shorter in patients with pleural metastasis or pleural effusion compared with the other types of progression (1.8 months vs. 7.1 months, p-value = 0.005). CONCLUSION: In patients with EGFR-mutant NSCLC who experience progression, it is beneficial to maintain gefitinib treatment with local treatment such as radiotherapy until symptomatic progression. However, in patients with pleural metastasis or effusion, continuation of gefitinib beyond progression should be carefully determined on a case by case basis.

Macrophage mannose receptor, CD206, predict prognosis in patients with pulmonary tuberculosis.

Tuberculosis (TB) remains a leading cause of fatal infectious disease. Accumulations of macrophages are found in infected sites; thus, we hypothesized that a marker of activated macrophages may be related to prognosis of pulmonary TB (PTB). This study investigated serum soluble macrophage mannose receptor, sCD206, in PTB and examined its clinical significance. First, the concentration of sCD206 was measured in the sera of 96 patients with PTB (Tenryu cohort), and in pleural effusions from 29 patients with TB pleurisy. These were verified in another independent cohort (Shizuoka cohort). We found increased concentrations of sCD206 in sera, but not in pleural effusions of PTB patients. Notably, PTB patients with poor prognosis showed significantly higher levels of serum sCD206. At a cut-off value of 1,600 ng/mL in the Tenryu cohort, sCD206 predicted prognosis of PTB with area under the curve 0.847, sensitivity 77.3%, and specificity 86.5%. These results were validated in the Shizuoka cohort. Pathological analyses showed concordance of enhanced CD206 expression in lung and pleural tissues with caseating granuloma in TB. Serum sCD206 increased in PTB and was associated with prognosis. sCD206 is a potential biomarker for PTB.

Risk Stratification in Patients with Complicated Parapneumonic Effusions and Empyema Using the RAPID Score.

PURPOSE: Complicated parapneumonic effusions and empyema are a leading cause of morbidity in the United States with over 1 million admissions annually and a mortality rate that remains high in spite of recent advances in diagnosis and treatment. The identification of high risk patients is crucial for improved management and the provision of cost-effective care. The RAPID score is a scoring system comprised of the following variables: renal function, age, purulence, infection source, and dietary factors and has been shown to predict outcomes in patients with pleural space infections. METHODS: In a single center retrospective study, we evaluated 98 patients with complicated parapneumonic effusions and empyema who had tube thoracostomy (with or without Intrapleural fibrinolytic therapy) and assessed treatment success rates, mortality, length of hospital stay, and direct hospitalization costs stratified by three RAPID score categories: low-risk (0-2), medium risk (3-4), and high-risk (5-7) groups. RESULTS: Treatment success rate was 71%, and the 90 day mortality rate was 12%. There was a positive-graded association between the low, medium and high RAPID score categories and mortality, (5.3%, 8.3% and 22.6%, respectively), length of hospital stay (10, 21, 19 days, respectively), and direct hospitalization costs ($19,909, $36,317 and $43,384, respectively). CONCLUSION: Our findings suggest that the RAPID score is a robust tool which could be used to identify patients with complicated parapneumonic effusions and empyema who may be at an increased risk of mortality, prolonged hospitalization, and who may incur a higher cost of treatment. Randomized controlled trials identifying the most effective initial treatment modality for medium- and high-risk patients are needed.