How to Enhance the Diagnosis of Early Stages of Chronic Obstructive Pulmonary Disease (COPD)? The Role of Mobile Spirometry in COPD Screening and Diagnosis-A Systematic Review.

COPD is the third leading cause of death worldwide. Its diagnosis can be made with spirometry, which is underused due to its limited accessibility. Portable spirometry holds promise for enhancing the efficacy of COPD diagnoses. The study aimed to estimate COPD prevalence diagnosed with a portable spirometer in high-risk patients and compare it with COPD prevalence based on data from conventional, on-site spirometry. We also evaluated the strategy of a proactive approach to identify COPD in high-risk individuals. We conducted a systematic review of original studies on COPD targeted screening and diagnosis with portable and conventional spirometers selected from 8496 publications initially found in three databases: Cochrane, PubMed, and Embase. The inclusion criteria were met by 28 studies. COPD prevalence evaluated with the use of portable spirometers reached 20.27% and was lower compared to that estimated with the use of conventional spirometers (24.67%). In 11 included studies, postbronchodilator tests were performed with portable spirometers, which enabled a bedside COPD diagnosis. Portable spirometers can be successfully used in COPD targeted screening and diagnosis and thus enhance the detection of COPD at early stages.

Metabolomic Analysis of Respiratory Epithelial Lining Fluid in Patients with Chronic Obstructive Pulmonary Disease-A Systematic Review.

Chronic obstructive pulmonary disease (COPD), as the third leading cause of death among adults, is a significant public health problem around the world. However, about 75% of smokers do not develop the disease despite the severe smoking burden. COPD is a heterogeneous disease, and several phenotypes, with differences in their clinical picture and response to treatment, have been distinguished. Metabolomic studies provide information on metabolic pathways, and therefore are a promising tool for understanding disease etiopathogenesis and the development of effective causal treatment. The aim of this systematic review was to analyze the metabolome of the respiratory epithelial lining fluid of patients with COPD, compared to healthy volunteers, refractory smokers, and subjects with other lung diseases. We included observational human studies. Sphingolipids, phosphatidylethanolamines, and sphingomyelins distinguished COPD from non-smokers; volatile organic compounds, lipids, and amino acids distinguished COPD from smokers without the disease. Five volatile organic compounds were correlated with eosinophilia and four were associated with a phenotype with frequent exacerbations. Fatty acids and ornithine metabolism were correlated with the severity of COPD. Metabolomics, by searching for biomarkers and distinguishing metabolic pathways, can allow us to understand the pathophysiology of COPD and the development of its phenotypes.

Evaluation of patients' satisfaction with bronchoscopy procedure.

BACKGROUND: The bronchoscopy (BS) experience provokes anxiety amongst some patients. It can have a negative impact on the course of the procedure and on the willingness of patients to undergo the next BS in the future. OBJECTIVE: We aimed to identify factors influencing patients' satisfaction with BS. METHODS: The prospective study had been conducted between January and June 2019. It included patients hospitalized in our Department, who underwent elective BS. Patients assessed their anxiety and satisfaction level before and after BS using the Visual Analogue Scale (VAS). Data concerning the course of the bronchoscopy was collected. RESULTS: The median level of anxiety prior to the procedure was moderate, higher in women (p<0.0001). The majority of patients (116/125, 93%) were satisfied with appropriate information before the procedure. Almost one-third of the interviewees (39/125, 31%) declared complete satisfaction (VAS = 0) with their procedure, 17 patients (14%) were dissatisfied (VAS >5/10). Overall 113 (90%) patients declared unconditional consent for future bronchoscopy. Multivariate linear regression analysis revealed two factors affecting patients' satisfaction with bronchoscopy: anxiety prior to BS (standardized regression coefficient ß = 0.264, p = 0.003) and discomfort (ß = 0.205, p = 0.018). Neither age, degree of amnesia, duration of the procedure nor its type added any significant value as factors affecting patient satisfaction. The most common factors inducing patients' discomfort during BS were local anesthesia of the throat (56/125, 45%) and cough (47/125, 38%). CONCLUSIONS: Low anxiety level before bronchoscopy and reduced discomfort during the procedure are associated with better patient satisfaction. Thus, it is important to reduce patient anxiety and discomfort during the procedure.

Analysis of Clinicopathological Factors Influencing Survival in Patients with Renal Cell Carcinoma and Venous Tumor Thrombus.

This study aimed to define patients with renal cell cancer and coexisting tumor thrombus in order to address concerns regarding survival and prognostic factors after radical surgery. Several prognostic factors for overall survival (OS) were assessed in patients treated surgically at five institutions from 2012 to 2018. Univariate and multivariate analyses were used to determine the independent risk factors of OS. A total of 142 patients were eligible for further analysis (mean age of 64.75 years, 56% males). Most patients presented with clear cell carcinoma (95%). The Mayo stage was predominantly 0-1 (88%). Distant visceral metastases at the time of diagnosis were present in 36 patients (25%), whereas nodal metastases were present in 24 patients (16.9%). During the follow-up period (mean of 32.5 months), the 3-year OS rate reached 68.2%. The majority of patients received no adjuvant treatment (n = 107). In a multivariable model predicting OS, regional lymph node status (p < 0.001), distant metastases (p = 0.009), tumor grade (p = 0.002), duration of hospitalization (p = 0.016), and Clavien-Dindo grade (p = 0.047) were identified as independent prognostic factors. A subgroup of patients with specific clinicopathological factors may benefit most from the radical surgery, including patients without regional lymph node or distant metastases and with low tumor grades, whereas short hospitalization and low Clavien-Dindo grades represent additional independent prognostic factors.

Primary human mesothelial cell culture in the evaluation of the inflammatory response to different sclerosing agents used for pleurodesis.

The mechanisms of chemical pleurodesis are still not fully explained. We aimed to evaluate the feasibility of using primary biopsy-derived human mesothelial cells to establish an in vitro culture and to assess the response of pleural mesothelial cells to different sclerosing agents. Talc, povidone-iodine, doxycycline, and TGF-ß were used at different doses to stimulate pleural mesothelial cells. After 6 and 24 h, mRNA expression of interleukin (IL)-1ß, IL-6, IL-8, TGF-ß, MCP-1, IL-17A, and MMP9 was measured in cultured cells, and the protein level of IL-1ß, IL-6, and IL-8 was measured in the culture supernatant. The most pronounced response was observed after talc exposure. It was expressed as an increase in IL-1ß concentration in culture supernatant after 24 h of higher talc dose stimulation compared to 6 h of stimulation (17.14 pg/ml [11.96-33.32 pg/ml] vs. 1.84 pg/ml [1.81-1.90 pg/ml], p = 0.02). We showed that culture pleural mesothelial cells isolated from pleura biopsy specimens is feasible. Inflammatory responses of mesothelial cells to different sclerosants were highly variable with no consistent pattern of mesothelium reaction neither in terms of different sclerosing agents nor in the time of the most significant reaction. We demonstrated that pro-inflammatory mesothelial response includes an increase in IL-1ß mRNA expression and protein production. This may suggest the role of IL-1ß in the formation and maintenance of the inflammatory response during pleurodesis.

Active screening for COPD among hospitalized smokers - a feasibility study.

BACKGROUND: Spirometry is a primary tool for early chronic obstructive pulmonary disease (COPD) detection in patients with risk factors, for example, cigarette smoking. The aim of this study was to evaluate the strategy of an active screening for COPD among smokers admitted to the pulmonary and cardiology department. METHODS: This prospective study was conducted between February and March 2019. All hospitalized smokers aged 40 years and older completed an original questionnaire and had spirometry measurement with a bronchial reversibility test (if applicable) performed by medical students using a portable spirometer. RESULTS: One hundred and eighty-eight patients were eligible to participate in the study. Seventy (37%) subjects refused to participate. Eventually, 116 (62%) patients were included in the final analysis and 94 (81%) performed spirometry correctly. In total, 32 (34 %) patients were found to have COPD. Nine (28%) of these patients were newly diagnosed, 89% of them had mild-to-moderate airway obstruction. Patients with newly diagnosed COPD were significantly younger [age 63 (56-64) versus 69 (64-78) years], had a longer smoking-free period [17 (13-20) versus 9 (2-12) years], had fewer symptoms and had a better lung function compared with patients with a previous diagnosis of COPD (p < 0.05 for all comparisons). CONCLUSION: The proposed diagnostic strategy can be successfully used to improve COPD detection in the inpatient setting. The majority of the newly diagnosed COPD patients had mild-to-moderate airway obstruction. Patients who should be particularly screened for COPD include ex-smokers with less pronounced respiratory symptoms.

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.

Impact of age on the diagnostic yield of four different biomarkers of tuberculous pleural effusion.

The diagnostic value of pleural fluid biomarkers in tuberculous pleurisy (TP) is firmly established. However, it is less clear whether patients' age affects the diagnostic accuracy of TP biomarkers. The aim of the study was to assess the impact of age, on the predictive value of ADA, IFN-γ, IP-10 and Fas ligand in patients with pleural effusion. The study included 222 patients, median age 64.5 (54-77) years, 58.6% men, with pleural effusion: TPE (60 patients; 27.0%), malignant PE (90 patients; 40.5%), parapneumonic effusion/pleural empyema (35 patients; 15.8%), pleural transudate (30 patients, 13.5%) and other causes of PE (7 patients; 3.2%). The odds ratio for the diagnosis of TPE significantly decreased with increasing age (OR = 0.62/10 years) and significantly increased with increasing level of all evaluated pleural fluid biomarkers. Age affected the diagnostic accuracy of ADA with a trend towards reduction in OR for TPE in older patients (P = 0.077, 95% CI 0.59-1.03). Younger age and high pleural fluid ADA level are associated with very high probability of TP. This probability significantly decreases not only with decreasing pleural fluid ADA, but also with increasing age. Patient's age does not affect the diagnostic yield of pleural fluid IFN-γ, IP-10 and sFas.

Cancer ratio and other new parameters for differentiation between malignant and nonmalignant pleural effusions.

Introduction In contrast to tuberculous pleurisy (TP), no accurate and commonly accepted biochemical marker of malignant pleural effusion (MPE) has been established. Objectives We aimed to evaluate the ability of a previously reported cancer ratio (CR) to discriminate between MPEs and non-MPEs; to test whether age may have additional value in differentiating MPEs from non-MPEs; and if so, to combine lactate dehydrogenase (LDH) and age with other TP biomarkers in search of an index useful in the identification of MPEs. Patients and methods A retrospective analysis of data from 140 patients with malignant (n = 74), tuberculous (n = 37), and parapneumonic (n = 29) pleural effusions was performed. The diagnostic performance of a test to discriminate between MPEs and non-MPEs was evaluated using the receiver operating characteristic curve analysis. Results Three ratios showed the largest area under the curve (AUC): serum LDH to pleural fluid soluble Fas ligand, age to pleural fluid adenosine deaminase (ADA), and serum LDH to pleural fluid interleukin 18; moreover, the ratios were characterized by high sensitivity (95%, 93.2%, and 92.9%, respectively) and fair specificity (64.8%, 71.2%, and 58.5%, respectively) for differentiating MPEs from non-MPEs. The AUC for CR was lower and showed a sensitivity of 94.6% and a specificity of 68.2%. Conclusions Our study showed a lower specificity of the CR for discriminating between MPEs and non-MPEs than previously reported. We demonstrated that the combinations of serum LDH with other pleural fluid biomarkers of TP have a similar diagnostic performance. We also found that age might be an important factor differentiating between MPEs and non-MPEs and proposed a new age to pleural fluid ADA ratio which has a discriminative potential similar to that of the CR.

Patterns of pleural pressure amplitude and respiratory rate changes during therapeutic thoracentesis.

BACKGROUND: Although the impact of therapeutic thoracentesis on lung function and blood gases has been evaluated in several studies, some physiological aspects of pleural fluid withdrawal remain unknown. The aim of the study was to assess the changes in pleural pressure amplitude (Pplampl) during the respiratory cycle and respiratory rate (RR) in patients undergoing pleural fluid withdrawal. METHODS: The study included 23 patients with symptomatic pleural effusion. Baseline pleural pressure curves were registered with a digital electronic manometer. Then, the registrations were repeated after the withdrawal of consecutive portions of pleural fluid (200 ml up to 1000 ml and 100 ml above 1000 ml). In all patients the pleural pressure curves were analyzed in five points, at 0, 25%, 50%, 75% and 100% of the relative volume of pleural effusion withdrawn in particular patients. RESULTS: There were 11 and 12 patients with right sided and left sided pleural effusion, respectively (14 M, 9F, median age 68, range 46-85 years). The most common cause of pleural effusion were malignancies (20 pts., 87%). The median total volume of withdrawn pleural fluid was 1800 (IQR 1500-2400) ml. After termination of pleural fluid withdrawal Pplampl increased in 22/23 patients compared to baseline. The median Pplampl increased from 3.4 (2.4-5.9) cmH2O to 10.7 (8.1-15.6) cmH2O (p < 0.0001). Three patterns of Pplampl changes were identified. Although the patterns of RR changes were more diversified, a significant increase between RR at baseline and the last measurement point was found (p = 0.0097). CONCLUSIONS: In conclusion, therapeutic thoracentesis is associated with significant changes in Pplampl during the respiratory cycle. In the vast majority of patients Pplampl increased steadily during pleural fluid withdrawal. There was also an increase in RR. The significance of these changes should be elucidated in further studies. TRIAL REGISTRATION: ClinicalTrial.gov, registration number: NCT02192138 , registration date: July 1st, 2014.

Comparative Study of IL-33 and IL-6 Levels in Different Respiratory Samples in Mild-to-Moderate Asthma and COPD.

IL-6 and IL-33 are involved in the inflammatory process in obstructive lung diseases. In contrast to IL-6, few data on the expression of IL-33 in different biological samples from asthma and COPD patients are available. The aim was to evaluate the expressions of IL-33 and IL-6 in bronchial mucosa and to compare these expressions with the concentrations of both cytokines in various respiratory samples from patients with mild-to-moderate asthma and COPD. Serum, induced sputum and exhaled breath condensate IL-6 and IL-33 levels, as well as their expression in bronchial mucosa were evaluated in 22 asthma and 33 COPD patients. There were significant differences between bronchial mucosa IL-6, but not IL-33 expression in asthma and COPD. Serum and IS IL-6 concentrations were higher in COPD than in asthma (3.4 vs. 2.02 pg/mL, p = 0.002 and 16.5 vs. 12.7 pg/mL, p = 0.007, respectively); IL-33 levels reached similar values in asthma and COPD in all investigated samples. In both diseases, the lowest levels of IL-6 and IL-33 were found in EBC. EBC levels of both cytokines did not correlate with their expression in other materials. The IL-33 and IL-6 are detectable in serum, IS and EBC not only in asthma but also in COPD patients. In the COPD group, serum and IS IL-6 concentrations were statistically higher than in the asthma group. The tissue expression of IL-33 and IL-33 concentrations in the investigated biological samples were on a comparable level in both diseases. Our findings may suggest that IL-33 activation is a common pathway in asthma and COPD.

Public spirometry campaign in chronic obstructive pulmonary disease screening - hope or hype?

INTRODUCTION: Underdiagnosis of COPD seems to be a relevant clinical and social problem. We hypothesized that active public spirometry campaign may help identify subjects with airflow limitation consistent with COPD. The aim of the study was (1) to evaluate the willingness of random smokers to undergo public spirometry, (2) to assess the ability to obtain an acceptable quality spirometry during a public campaign, and (3) to assess the relationships between the presence and severity of respiratory symptoms and readiness to undergo spirometry. MATERIAL AND METHODS: Pedestrians aged > 40 years and a smoking history >10 pack-years were recruited by medical students to fill a questionnaire and perform spirometry. Those with obstructive or borderline ventilatory insuffciency were invited and encouraged to undergo stationary spirometry in a pulmonary outpatient department. RESULTS: Nine hundred and five subjects meeting the inclusion criteria were invited to the study. Only 178 subjects agreed to complete the questionnaire and undergo spirometry. Airway obstruction and borderline spirometry result (classified as possible airway obstruction) were found in 22 and 37 subjects, respectively. Of these, only 15 patients attended follow-up visit to verify public spirometry results. Extrapolation of the limited data showed the incidence of newly diagnosed airway obstruction as 10.7%. CONCLUSION: Public spirometry campaign does not seem to be an effective way of COPD screening. Smokers are reluctant to undergo complimentary spirometry even in the presence of pronounced respiratory symptoms. Our observations may be helpful in elaborating future screening programs for COPD.

Comparison of endobronchial ultrasound and high resolution computed tomography as tools for airway wall imaging in asthma and chronic obstructive pulmonary disease.

INTRODUCTION: Airway remodeling in asthma and chronic obstructive pulmonary disease (COPD) results in bronchial wall thickening. Bronchial wall thickness (BWT) can be assessed in high-resolution computed tomography (HRCT) and endobronchial ultrasound (EBUS). AIMS: To compare BWT measured by EBUS and HRCT in patients with mild-to-moderate asthma and COPD, and to evaluate the relationship between the BWT and pulmonary function. METHODS: The study included patients with mild-to-moderate asthma (n = 24), COPD (n = 36) and controls (n = 12). Bronchoscopy with EBUS (radial probe) and HRCT were performed to measure the BWT in the segmental bronchus. RESULTS: Good overall agreement between EBUS and HRCT measurements of BWT was demonstrated. Median HRCT-BWT did not reveal any significant differences between individuals with asthma and COPD, and control subjects: 1.56 (1.27-1.70) mm, 1.62 (1.45-1.90) mm, and 1.63 (1.41-1.77) mm, respectively (p = 0.315). In contrast, median BWT measured by EBUS was significantly higher in asthma and COPD groups when compared to controls: 1.20 (1.02-1.41) mm, 1.19 (1.10-1.48) mm, and 0.99 (0.90-1.08) mm, respectively (p = 0.006). There were no differences in BWT in mild-to-moderate asthma and COPD or significant correlations between BWT and the results of pulmonary function tests. CONCLUSIONS: The use of EBUS to assess BWT in asthma and COPD is feasible and it shows good compatibility with HRCT. A tendency towards lower BWT values in EBUS when compared to HRCT was observed. The finding that EBUS measurements demonstrated the differences between BWT in patients with obstructive lung diseases and controls, may suggest that EBUS is a more sensitive method to study the BWT than HRCT.

MR Imaging of Pulmonary Nodules: Detection Rate and Accuracy of Size Estimation in Comparison to Computed Tomography.

OBJECTIVE: The aims of this study were to assess the sensitivity of various magnetic resonance imaging (MRI) sequences for the diagnosis of pulmonary nodules and to estimate the accuracy of MRI for the measurement of lesion size, as compared to computed tomography (CT). METHODS: Fifty patients with 113 pulmonary nodules diagnosed by CT underwent lung MRI and CT. MRI studies were performed on 1.5T scanner using the following sequences: T2-TSE, T2-SPIR, T2-STIR, T2-HASTE, T1-VIBE, and T1-out-of-phase. CT and MRI data were analyzed independently by two radiologists. RESULTS: The overall sensitivity of MRI for the detection of pulmonary nodules was 80.5% and according to nodule size: 57.1% for nodules ≤4mm, 75% for nodules >4-6mm, 87.5% for nodules >6-8mm and 100% for nodules >8mm. MRI sequences yielded following sensitivities: 69% (T1-VIBE), 54.9% (T2-SPIR), 48.7% (T2-TSE), 48.7% (T1-out-of-phase), 45.1% (T2-STIR), 25.7% (T2-HASTE), respectively. There was very strong agreement between the maximum diameter of pulmonary nodules measured by CT and MRI (mean difference -0.02 mm; 95% CI -1.6-1.57 mm; Bland-Altman analysis). CONCLUSIONS: MRI yielded high sensitivity for the detection of pulmonary nodules and enabled accurate assessment of their diameter. Therefore it may be considered an alternative to CT for follow-up of some lung lesions. However, due to significant number of false positive diagnoses, it is not ready to replace CT as a tool for lung nodule detection.

Comparative study of periostin expression in different respiratory samples in patients with asthma and chronic obstructive pulmonary disease.

INTRODUCTION: Periostin is considered to be a marker of eosinophilic inflammation in patients with asthma. However, there are no literature data on periostin in patients with chronic obstructive pulmonary disease (COPD). OBJECTIVES The aim of the study was to evaluate periostin expression and to compare its concentrations in various materials in patients with mild-to-moderate asthma and COPD, as well as to evaluate the potential association between periostin and clinical features of both diseases. PATIENTS AND METHODS: Using an enzyme-linked immunosorbent assay, we measured periostin concentrations in serum, induced sputum (IS), exhaled breath condensate (EBC), and bronchoalveolar lavage fluid (BALF) as well as periostin expression in bronchial biopsy samples in 24 patients with asthma, 36 patients with COPD, and 12 controls. Correlations between periostin levels in different materials were also analyzed and periostin concentrations were compared between patients with asthma and those with COPD. RESULTS: Periostin levels were detectable in serum, IS, EBC, and BALF from patients with asthma, COPD, and controls. EBC periostin levels correlated with tissue periostin expression and were significantly higher in asthma than in COPD (P = 0.04). Periostin expression in bronchial mucosa was higher in asthma than in COPD (P <0.001), as well as in asthma and COPD patients compared with controls (P <0.001). No significant correlations between tissue periostin expression and BALF, IS, or serum periostin levels were found. There were no differences in serum, IS, BALF, or EBC periostin concentrations between patients with different phenotypes of both diseases. CONCLUSIONS: Periostin may be detected not only in serum, IS, and airway tissue samples, but also in EBC and BALF. EBC periostin levels and tissue periostin expression are higher in patients with asthma than in those with COPD. EBC periostin levels may serve as a potential surrogate marker for tissue periostin expression.

Pleural Effusion in Meigs' Syndrome-Transudate or Exudate?: Systematic Review of the Literature.

Although Meigs' syndrome is regarded as a well-defined entity, contradictory data on pleural fluid characteristics have been presented, with some papers classifying it as a transudate, whereas others stating that it is an exudate.The aims of the study were: (1) to evaluate pleural fluid characteristics in patients with Meigs' syndrome and (2) to analyze the prevalence of transudative and exudative pleural effusion in relation to the applied definition of the syndrome.We performed a search through medical databases (MEDLINE, EMBASE, SCOPUS, and GOOGLE SCHOLAR) to identify papers on Meigs' syndrome published between 1940 and 2013. Two authors independently reviewed each paper searching for prespecified data: (1) signs and symptoms, (2) tumor characteristics, (3) clinical and laboratory data on ascites, (4) clinical, radiological, and laboratory data on pleural fluid, (5) clinical course after tumor removal. All case reports were reclassified according to a new unequivocal classification of Meigs' syndrome-related entities.A total of 653 papers were initially identified, and 454 articles reporting 541 patients were included in the final analysis. After reclassification according to our case definitions, there were 196, 113, and 108 patients defined as classic Meigs' syndrome, nonclassic Meigs' syndrome, and pseudo-Meigs' syndrome, respectively. Significantly more patients presented with right-sided than left-sided and bilateral pleural effusions (P < 0.001). Median volume of withdrawn pleural fluid was 2950 (1500-6000) mL. The classification of pleural effusion with the use of Light's criteria was possible in only 7 patients. In 6 of these patients pleural effusion met the criteria for an exudate. When the protein concentration > 3.0 g/dL was applied as a criterion of pleural exudate, 88.8% (80/90) of effusions were classified as exudates. Increasing the cut-off level to 3.5 g/dL resulted in only a modest decrease in the percentage of exudative effusions (81%, 73/90).Surprisingly few reports on Meigs' syndrome present data reliably defining the character of pleural effusion. The available data indicate, however, that the majority of pleural effusions in patients with this entity are exudates. This finding may be a prerequisite for the verification of some earlier presented concepts.

A pitfall during endobronchial ultrasound-guided transbronchial forceps biopsy of the mediastinal lymph nodes.

The high diagnostic yield and favorable safety profile of endobronchial ultrasound-guided transbronchial forceps biopsy of the mediastinal lymph nodes have been recently demonstrated. We report an unusual technical problem during endobronchial ultrasound-guided transbronchial forceps biopsy that could be a prerequisite for severe complications. A rupture of the steering band precluded closure of the forceps jaws opened in the subcarinal lymph node. A solution to the problem is presented, together with other procedure-related complications reported in the literature. The report emphasizes that a dysfunction of the forceps steering band can result in severe complications when it occurs during transbronchial sampling of mediastinal lesions.

Use of pleural fluid levels of adenosine deaminase and interferon gamma in the diagnosis of tuberculous pleuritis.

PURPOSE OF REVIEW: This review aims to define the role of adenosine deaminase (ADA) and interferon gamma (IFN-gamma) in the differential diagnosis of pleural effusion with special attention to their source, mechanism of release and methods of measurement in pleural fluid. The diagnostic performance of ADA and IFN-gamma is analyzed, and the advantages and limitations of their use in differentiating between tuberculous and nontuberculous pleural effusion are discussed. RECENT FINDINGS: Several potential biomarkers of tuberculous pleurisy have been evaluated, but none have been found to be clearly superior to pleural fluid level of ADA or IFN-gamma. The majority of recent studies confirm the high diagnostic utility of pleural fluid ADA and IFN-gamma measurement; hence, these markers are included in different diagnostic algorithms for patients suspected of tuberculous pleurisy. Other relatively new tests show a high variability [nucleic acid amplification tests (NAATs)] or are technically demanding, costly and give equivocal results in patients with active tuberculosis [IFN-gamma releasing assays (IGRAs)]. SUMMARY: Pleural fluid ADA and IFN-gamma are both sensitive and specific biomarkers of tuberculous pleurisy. Their diagnostic accuracy across the different studies shows a smaller variability than that of other tests, for example NAATs. There is also no convincing evidence that IGRAs are superior to pleural fluid ADA or IFN-gamma measurement. Hence, the role of ADA and IFN-gamma in the differential diagnosis of tuberculous pleurisy is pivotal.