Analysis of the quality of e-Consultations in chronic obstructive pulmonary disease.

INTRODUCTION: The quality of e-Consultations in the COPD is unknown. The objectives of this study were (i) to evaluate the quality of referrals; (ii) to define the characteristics of patients referred from Primary Care (PC) to the Unit of Pulmonology; and (iii) to describe differences between accepted and rejected patients. METHODS: A retrospective, observational study of e-Consultations requested by PC for suspected COPD throughout 2022. To quantify the quality of the e-Consultations, an arbitrary scale of 12 variables (score 0-10) was created. RESULTS: In total, 384 e-Consultations were reviewed, of which 167 (43.5 %) resulted in a face-to-face visit, and 217 (56.5 %) were rejected. No differences were observed between the two types of patients, except for confirmations of diagnostic suspicion of COPD [significantly higher in accepted patients (p = 0.042)]; physical examination data of rejected patients (more data provided; p = 0.015); and lung function (significantly better in rejected patients). The mean quality of referrals was acceptable (5.6 ± 2.1 score): 121 (31.3 %) had insufficient quality; 118 (30.5 %) acceptable; 75 (19.4 %) good, and 30 (7.8 %) excellent. Quality was low in half of the variables analyzed (6/12); acceptable in 3, and good in another 3. The capacity of resolution of referrals was good (one e-Consultation) in 199 requests (66.1 %); deficient (two e-Consultations) in 72 (23.9 %), and poor (≥3 e-Consultations) in 30 (10 %). Overdiagnosis was 40.2 % (86/214 e-Consultations). The risk could be classified in 247 patients (64.3 %; 135 low-risk; 90 high-risk). CONCLUSIONS: When adequate information is provided, e-Consultations help identify different levels of severity. However, the quality and capacity of resolution of referrals were suboptimal, with a high percentage of overdiagnoses.

Characteristics of pleural effusion due to amyloidosis.

The characteristics of patients with pleural amyloidosis (PA) are poorly known. A systematic review was performed of studies reporting clinical findings, pleural fluid (PF) characteristics, and the most effective treatment of PA. Case descriptions and retrospective studies were included. The review included 95 studies with a total sample of 196 patients. The mean age was 63 years, male/female ratio was 1.6:1, and 91.9% of patients were >50 years. The most common symptom was dyspnea (88 patients). PF was generally serious (63%), predominantly lymphocytic, and with the biochemical characteristics of transudates (43.4%) or exudates (42.6%). Pleural effusion was generally bilateral (55%) and <1/3 of the hemithorax (50%), although in 21% pleural effusion (PE) exceeded 2/3. Pleural biopsy was performed in 67 patients (yield: 83.6%; 56/67) and was positive in 54% of exudates and 62.5% of unilateral effusions. Of the 251 treatments prescribed, only 31 were effective (12.4%). The combination of chemotherapy and corticosteroids was effective in 29.6% of cases, whereas talc pleurodesis was effective in 21.4% and indwelling pleural catheter in 75% of patients (only four patients). PA is more frequent in adults from 50 years of age. PF is usually bilateral, serous, and indistinctly a transudate or exudate. A pleural biopsy can aid in diagnosis if effusion is unilateral or an exudate. Treatments are rarely effective and there may be definitive therapeutic options for PE in these patients.

Response to inhaled ceftazidime in patients with non-cystic fibrosis bronchiectasis and chronic bronchial infection unrelated to Pseudomonas aeruginosa.

INTRODUCTION: Inhaled antibiotics reduce the frequency of exacerbations. The objective was to assess the efficacy of inhaled ceftazidime in patients with non-cystic fibrosis bronchiectasis (NCFB) and concomitant chronic bronchial infection (CBI) caused by potentially pathogenic microorganisms (PPM) other than Pseudomonas aeruginosa (PA). MATERIAL AND METHOD: Quasi-experimental study in 21 patients with exacerbations who developed CBI by a PPM other than PA. RESULTS: Bacterial infection was resolved in 85.7% patients. Rehospitalizations, length of hospital stay, moderate exacerbations and blood levels of CRP decreased significantly. In addition, SGRQ questionnaire also decreased more than 4 points in 57.1% of the patients. CONCLUSION: The results suggest that inhaled ceftazidime in NCFB unrelated to PA is a plausible alternative to the standard therapies used in clinical practice.

Evaluation of the impact of an integrated care pathway for pulmonary embolism: a quasi-experimental pre-post study.

BACKGROUND: An integrated care pathway (ICP) is intended to improve the management of prevalent resource-consuming, life-threatening diseases. The purpose of this study was to determine whether the quality of patient care improved with the establishment of a dedicated unit for pulmonary embolism (PE). METHODS: A quasi-experimental pre-post study (pre: years 2010-2013; post: 2015-2020; year 2014, "washing" period) of PE patients ≥18 years (January 2010-June 2020). The intervention involved the implementation of an ICP for PE. RESULTS: The sample was composed of 1,142 patients (510 pre-intervention and 612 post-intervention) without significant differences between the two populations. In the post-intervention period, significant reductions were observed in the median length of hospital stay (LOS) (8 vs. 6 days); time to start of oral anticoagulation therapy (4.5 vs. 3.5 days; P<0.001); and the percentage of patients with high-risk PE in whom recanalization was not contraindicated (66.7% vs. 96%; P=0.009). In-hospital and 30-day mortality decreased, although not significantly (4.5% vs. 2.8%; P=0.188; 6.1% vs. 5.2%; P=0.531, respectively). Multivariate logistic regression analysis showed that the median LOS intervention decreased significantly according to the service where patients were referred to, and with the use of the simplified PESI. During follow-up, lifelong anticoagulation was prescribed to a higher proportion of patients in the post-intervention period (30.7% vs. 69.3%; P<0.001). CONCLUSIONS: Although an ICP for PE does not reduce mortality significantly, it improves the quality of patient care.

Impacto del síndrome de apnea-hipopnea del sueño en la neuropatía diabética. Revisión sistemática / Impact of sleep apnoea-hypopnoea syndrome on diabetic neuropathy. A systematic review

Introducción: La diabetes mellitus y el síndrome de apnea-hipopnea del sueño parecen estar relacionados, pero no está bien definido si en los pacientes con ambas enfermedades existe un mayor riesgo de neuropatía periférica. Para ello, realizamos una revisión sistemática.MétodosBúsqueda bibliográfica en 3 bases de datos electrónicas usando una estrategia predefinida y la metodología PRISMA. Solamente se incluyeron estudios originales (cualquier tipo de diseño) y publicados a partir del año 2000 en inglés, francés, portugués o español. Se estableció una escala de calidad de los estudios.ResultadosSe seleccionaron 12 artículos, de los que 6 estudiaban pacientes diabéticos tipo 2. La prevalencia global de síndrome de apnea-hipopnea del sueño fue del 43,7% (1.559/3.564 pacientes). La neuropatía diabética fue más frecuente en los pacientes con síndrome de apnea-hipopnea del sueño en 9 estudios, aunque solo en 4 de manera significativa (60 vs. 27%, p<0,001; 64,5 vs. 36%, p=0,03; 37 vs. 23,4%, p<0,02; 66,6 vs. 0%, p=0,007). En un estudio, la neuropatía diabética fue más frecuente en los pacientes sin síndrome de apnea-hipopnea del sueño (aunque sin significación estadística) y en 2 no se hizo la comparación entre pacientes con/sin síndrome de apnea-hipopnea del sueño.ConclusionesLos resultados observados indican una relación entre diabetes mellitus y síndrome de apnea-hipopnea del sueño en la aparición de neuropatía diabética.

Introduction: Diabetes mellitus and sleep apnoea-hypopnoea syndrome appear to be related, but it is not well defined whether there is an increased risk of peripheral neuropathy in patients with both diseases. For this reason, we conducted a systematic review.MethodsBibliographic search in 3 electronic databases using a predefined strategy and the PRISMA methodology. Only original studies (any type of design) published from 2000 onwards in English, French, Portuguese or Spanish were included. A study quality scale was established.ResultsTwelve articles were selected, of which six studied type 2 diabetic patients. The overall prevalence of sleep apnoea-hypopnoea syndrome was 43.7% (1,559/3,564 patients). Diabetic neuropathy was more frequent in patients with sleep apnoea-hypopnoea syndrome in nine studies, although significantly only in four (60% vs 27%, P<.001; 64.5% vs 36%, P=.03; 37% vs 23.4%, P<.02; 66.6% vs 0%, P=.007). In one study, diabetic neuropathy was more frequent in patients without sleep apnoea-hypopnoea syndrome (although not statistically significant) and in 2 no comparison was made between patients with/without sleep apnoea/hypopnoea syndrome.ConclusionsThe observed results suggest a relationship between diabetes mellitus and sleep apnoea-hypopnoea syndrome in the occurrence of diabetic neuropathy. (AU)

Impact of sleep apnoea-hypopnoea syndrome on diabetic neuropathy. A systematic review. / Impacto del síndrome de apnea-hipopnea del sueño en la neuropatía diabética. Revisión sistemática.

INTRODUCTION: Diabetes mellitus and sleep apnoea-hypopnoea syndrome appear to be related, but it is not well defined whether there is an increased risk of peripheral neuropathy in patients with both diseases. For this reason, we conducted a systematic review. METHODS: Bibliographic search in 3 electronic databases using a predefined strategy and the PRISMA methodology. Only original studies (any type of design) published from 2000 onwards in English, French, Portuguese or Spanish were included. A study quality scale was established. RESULTS: Twelve articles were selected, of which six studied type 2 diabetic patients. The overall prevalence of sleep apnoea-hypopnoea syndrome was 43.7% (1,559/3,564 patients). Diabetic neuropathy was more frequent in patients with sleep apnoea-hypopnoea syndrome in nine studies, although significantly only in four (60% vs 27%, P<.001; 64.5% vs 36%, P=.03; 37% vs 23.4%, P<.02; 66.6% vs 0%, P=.007). In one study, diabetic neuropathy was more frequent in patients without sleep apnoea-hypopnoea syndrome (although not statistically significant) and in 2 no comparison was made between patients with/without sleep apnoea/hypopnoea syndrome. CONCLUSIONS: The observed results suggest a relationship between diabetes mellitus and sleep apnoea-hypopnoea syndrome in the occurrence of diabetic neuropathy.

Impact of cardiovascular risk factors on the clinical presentation and survival of pulmonary embolism without identifiable risk factor.

BACKGROUND: The nature of pulmonary embolism (PE) without identifiable risk factor (IRF) remains unclear. The objective of this study is to investigate the potential relationship between cardiovascular risk factors (CVRFs) and PE without IRF (unprovoked) and assess their role as markers of disease severity and prognosis. METHODS: A case-control study was performed of patients with PE admitted to our hospital [2010-2019]. Subjects with PE without IRF were included in the cohort of cases, whereas patients with PE with IRF were allocated to the control group. Variables of interest included age, active smoking, obesity, and diagnosis of arterial hypertension, dyslipidemia or diabetes mellitus. RESULTS: A total of 1,166 patients were included in the study, of whom 64.2% had PE without IRF. The risk for PE without IRF increased with age [odds ratio (OR): 2.68; 95% confidence interval (CI): 1.95-3.68], arterial hypertension (OR: 1.63; 95% CI: 1.27-2.07), and dyslipidemia (OR: 1.63; 95% CI: 1.24-2.15). The risk for PE without IRF was higher as the number of CVRF increased, being 3.99 (95% CI: 2.02-7.90) for subjects with ≥3 CVRF. The percentage of high-risk unprovoked PE increased significantly as the number of CVRF rose [0.6% for no CVRF; 23.8% for a CRF, P<0.001 (OR: 9.92; 95% CI: 2.82-34.9); 37.5% for two CRFs, P<0.001 (OR: 14.8; 95% CI: 4.25-51.85); and 38.1% for ≥3, P<0.001 (OR: 14.1; 95% CI: 4.06-49.4)]. No significant differences were observed in 1-month survival between cases and controls, whereas differences in 24-month survival reached significance. CONCLUSIONS: A relationship was observed between CVRF and PE without IRF, as the risk for unprovoked PE increased with the number of CVRF. In addition, the number of CVRF was associated with PE without IRF severity, but not with prognosis.

Factores que influyen en la estancia hospitalaria por embolia pulmonar. Un estudio de cohortes / Factors Influencing Hospital Stay for Pulmonary Embolism. A Cohort Study

Introducción: El objetivo de este estudio fue analizar qué factores influyen en la estancia hospitalaria tras una embolia pulmonar. Métodos: Se diseñó un estudio retrospectivo de cohortes en pacientes ingresados entre 2010 y 2015 por embolia pulmonar. Los enfermos se identificaron utilizando los códigos de información registrados en los informes de alta hospitalaria (códigos CIE-9-CM 415.11 y 415.19). Resultados: Se incluyó a 965 pacientes. La mediana de la estancia fue 8 días (rango intercuartílico 6-13 días). Las puntuaciones más altas en el Pulmonary Embolism Severity Index simplificado (sPESI) se asociaron con mayor probabilidad de aumento de la estancia hospitalaria. En comparación con la derivación al Servicio de Neumología, la odds ratio (OR) de una estancia hospitalaria superior a la mediana fue de 8,65 (IC 95%: 5,42-13,79) para los pacientes derivados al Servicio de Medicina Interna y de 1,54 (95%CI: 1,07-2,24) para los pacientes hospitalizados en otros servicios. Los pacientes con grado 3 en la escala de disnea modificada de la Medical Research Council tenían una OR de 1,63 (IC 95%: 1,07-2,49). La probabilidad de una estancia hospitalaria más larga que la mediana fue de 1,72 (IC 95%: 0,85-3,48) cuando la anticoagulación oral se inició 2-3 días después del ingreso y 2,43 (IC 95%: 1,16-5,07) cuando se inició los días 4-5, en comparación con la iniciada los días 0-1 desde el ingreso. Conclusiones: El grado de sPESI, el servicio de derivación desde Urgencias, el grado de disnea y el momento de inicio de la anticoagulación oral se asociaron con una estancia hospitalaria más larga (AU)

Introduction: The aim of this study was to identify factors influencing hospital stay due to pulmonary embolism. Methods: We performed a retrospective cohort study of patients hospitalized between 2010 and 2015. Patients were identified using information recorded in hospital discharge reports (ICD-9-CM codes 415.11 and 415.19). Results: We included 965 patients with a median stay of 8 days (IQR 6-13 days). Higher scores on the simplified Pulmonary Embolism Severity Index (sPESI) were associated with increased probability of longer hospital stay. The probability of a hospital stay longer than the median was 8.65 (95% CI 5.42-13.79) for patients referred to the Internal Medicine Department and 1.54 (95% CI 1.07-2.24) for patients hospitalized in other departments, compared to those referred to the Pneumology Department. Patients with grade 3 on the modified Medical Research Council dyspnea scale had an odds ratio of 1.63 (95% CI: 1.07-2.49). The likelihood of a longer than median hospital stay was 1.72 (95% CI: 0.85-3.48) when oral anticoagulation (OAC) was initiated 2-3 days after admission, and 2.43 (95% CI: 1.16-5.07) when initiated at 4-5 days, compared to OAC initiation at 0-1 days. Conclusions: sPESI grade, the department of referral from the Emergency Department, the grade of dyspnea and the time of initiating OAC were associated with a longer hospital stay (AU)

Urinothorax: a systematic review.

BACKGROUND: The characteristics of patients with urinothorax (UT) are poorly defined. METHODS: A systematic review was performed searching for studies reporting clinical findings, pleural fluid (PF) characteristics, and the most effective treatment of UT. Case descriptions and retrospective studies were included. RESULTS: The review included 78 studies with a total of 88 patients. Median age was 45 years, male/female ratio was 1.6:1 and in 76% of cases the etiology was trauma. Pleural effusion (PE) was predominantly unilateral (87%) and occupied over 2/3 of the hemithorax in most cases (64.4%). PF was straw-colored (72.7%) or hematic (27.3%) with urine-like odor in all cases. PF was transudate in 56.2% of cases (18/32) and among 14 exudates (43.8%), 3 were concordant exudates, 1 protein-discordant and 10 LDH-discordant, with lymphocyte (44.4%) and neutrophil (38.5%) predominance. The PF/serum (PF/S) creatinine ratio was >1 in all cases except one (97.9%). The diagnosis was established on the basis of PF/S creatinine ratio >1 (56.6%), urinary tract contrast extravasation (12%), abnormal computed tomography (8.4%), laparotomy findings (6%), and association of obstructive uropathy with PE (6%). The outcome was favorable (74/77; 96.1%) when treatment was direct towards the uropathy (alone or associated with thoracentesis/thoracic drainage). Outcome was unfavorable in the 15 patients who were only treated with thoracentesis/thoracic drainage. CONCLUSIONS: UT is usually traumatic, unilateral, and PF does not have a specific pattern or cellularity predominance, with a PF/S creatinine ratio almost always >1. Treatment should include the uropathy, with or without PF evacuation.

Predictive models of malignant transudative pleural effusions.

BACKGROUND: There are no firm recommendations when cytology should be performed in pleural transudates, since some malignant pleural effusions (MPEs) behave biochemically as transudates. The objective was to assess when would be justified to perform cytology on pleural transudates. METHODS: Consecutive patients with transudative pleural effusion (PE) were enrolled and divided in two groups: malignant and non-MPE. Logistic regression analysis was used to estimate the probability of malignancy. Two prognostic models were considered: (I) clinical-radiological variables; and (II) combination of clinical-radiological and analytical variables. Calibration and discrimination [receiver operating characteristics (ROC) curves and area under the curve (AUC)] were performed. RESULTS: A total of 281 pleural transudates were included: 26 malignant and 255 non-malignant. The AUC obtained with Model 1 (left PE, radiological images compatible with malignancy, absence of dyspnea, and serosanguinous appearance of the fluid), and Model 2 (the variables of Model 1 plus CEA) were 0.973 and 0.995, respectively. Although no false negatives are found in Models 1 and 2 to probabilities of 11% and 14%, respectively, by applying bootstrapping techniques to not find false negatives in 95% of other possible samples would require lowering the cut-off points for the aforementioned probabilities to 3% (Model 1) and 4% (Model 2), respectively. The false positive results are 32 (Model 1) and 18 (Model 2), with no false negatives. CONCLUSIONS: The applied models have a high discriminative ability to predict when a transudative PE may be of neoplastic origin, being superior to adding an analytical variable to the clinic-radiological variables.

Factors Influencing Hospital Stay for Pulmonary Embolism. A Cohort Study. / Factores que influyen en la estancia hospitalaria por embolia pulmonar. Un estudio de cohortes.

INTRODUCTION: The aim of this study was to identify factors influencing hospital stay due to pulmonary embolism. METHODS: We performed a retrospective cohort study of patients hospitalized between 2010 and 2015. Patients were identified using information recorded in hospital discharge reports (ICD-9-CM codes 415.11 and 415.19). RESULTS: We included 965 patients with a median stay of 8 days (IQR 6-13 days). Higher scores on the simplified Pulmonary Embolism Severity Index (sPESI) were associated with increased probability of longer hospital stay. The probability of a hospital stay longer than the median was 8.65 (95% CI 5.42-13.79) for patients referred to the Internal Medicine Department and 1.54 (95% CI 1.07-2.24) for patients hospitalized in other departments, compared to those referred to the Pneumology Department. Patients with grade 3 on the modified Medical Research Council dyspnea scale had an odds ratio of 1.63 (95% CI: 1.07-2.49). The likelihood of a longer than median hospital stay was 1.72 (95% CI: 0.85-3.48) when oral anticoagulation (OAC) was initiated 2-3 days after admission, and 2.43 (95% CI: 1.16-5.07) when initiated at 4-5 days, compared to OAC initiation at 0-1 days. CONCLUSIONS: sPESI grade, the department of referral from the Emergency Department, the grade of dyspnea and the time of initiating OAC were associated with a longer hospital stay.

Characteristics of patients with pseudochylothorax-a systematic review.

BACKGROUND: Pseudochylothorax (PCT) (cholesterol pleurisy or chyliform effusion) is a cholesterol-rich pleural effusion (PE) that is commonly associated with chronic inflammatory disorders. Nevertheless, the characteristics of patients with PCT are poorly defined. METHODS: A systematic review was performed across two electronic databases searching for studies reporting clinical findings, PE characteristics, and the most effective treatment of PCT. Case descriptions and retrospective studies were included. RESULTS: The review consisted of 62 studies with a total of 104 patients. Median age was 58 years, the male/female ratio was 2.6/1, and in the 88.5% of cases the etiology was tuberculosis (TB) or rheumatoid arthritis (RA). PE was usually unilateral (88%) and occupied greater than one-third of the hemithorax (96.3%). There was no evidence of pleural thickening in 20.6% of patients, and 14 patients had a previous PE. The pleural fluid (PF) was an exudate, usually milky (94%) and with a predominance of lymphocytes (61.1%). The most sensitive tests to establish the diagnosis were the cholesterol/triglycerides ratio (CHOL/TG ratio) >1, and the presence of cholesterol crystals (97.4% and 89.7%, respectively). PF culture for TB was positive in the 34.1% of patients. Favorable outcomes with medical treatment, therapeutic thoracentesis, decortication/pleurectomy, pleurodesis, thoracic drainage and thoracoscopic drainage were achieved in 78.9%, 47.8%, 86.7%, 66.6%, 37.5% and 42.9%, respectively. CONCLUSIONS: PCT is usually tuberculous or rheumatoid, unilateral and the PF is a milky exudate. The presence of cholesterol crystals and a CHOL/TG ratio >1 are the most sensitive test for the diagnosis. The lack of pleural thickening does not rule out PCT. Treatment should be sequential, treating the underlying causes, and assessing the need for interventional techniques.

Characteristics of Patients with Lymphangioleiomyomatosis and Pleural Effusion: A Systematic Review.

The characteristics of patients with lymphangioleiomyomatosis (LAM) are poorly defined, as they may present with or without pleural effusion (PE). We performed a systematic review across four electronic databases searching for studies reporting clinical findings, PE characteristics, and the most effective treatment of LAM. Case descriptions and retrospective studies were included, unrestricted by year of publication. The review consisted of 94 studies (199 patients) spanning a period of nearly 55 years. The median age was 38 years (range: 1 month to 69 years), and 79.7% were between 21 and 50 years old. All cases had dyspnea, 95% had a cough, and 87.5% had chest pain. PE was exudative chylothorax, usually unilateral (76%) and right-sided, predominantly lymphocytic, and with proportionately higher levels of proteins than lactate dehydrogenase. Sirolimus was effective in all cases, completely in 87%, and partially in 13%, although the number of patients receiving sirolimus was small. The present study confirmed that LAM and PE mainly occur in women of childbearing age (third to fifth decade of life). PE was usually unilateral and presented as a lymphocyte-predominant chylous exudate. The most effective treatment for PE seems to be sirolimus, although studies with larger series are needed to confirm this.

Predicting malignant and tuberculous pleural effusions through demographics and pleural fluid analysis of patients.

INTRODUCTION: The differential diagnosis of malignant and tuberculous pleural effusion is frequently difficult. OBJECTIVES: The aim of our study is to determine the discrimination value of demographic parameters and different biological markers in pleural fluid. METHODS: In pleural fluid obtained from 106 patients with tuberculous, 250 with malignant and 218 with miscellaneous pleural effusion, clinical and analytical parameters were analysed, applying polytomous regression analysis and the receiver operating characteristic (ROC) curves. RESULTS: The three groups could be differentiated using the measured markers. Age, tumour necrosing factor-alpha, lactate dehydrogenase (LDH), adenosine deaminase (ADA), C-reactive protein (CRP) and carcinoembryonic antigen (CEA) were significant predictors for discriminating tuberculous from malignant pleural effusions; nucleated cells, lymphocytes, cholesterol, LDH, ADA, CRP, CEA and CA15.3 distinguish between malignant and miscellaneous pleural effusions. The ROC areas (95% confidence interval) were, 0.973 (0.953, 0.992) for tuberculous, 0.922 (0.900, 0.943) for miscellaneous, and 0.927 (0.907, 0.948) for malignant pleural effusion. The polytomous model correctly classified a significantly high proportion of patients with tuberculosis (85.8%) and cancer (81.6%). The incorrect classification rate was 17.8%, which increased to 19.5% in the correction using bootstrap. CONCLUSIONS: The results obtained to estimate the probability of tuberculous and malignant pleural effusion confirm that this model achieves a high diagnostic accuracy. This model should be applied to determine which patients with a pleural effusion of unknown origin would not benefit from further invasive procedures.

Characteristics of patients with yellow nail syndrome and pleural effusion.

Yellow nail syndrome (YNS) can be associated with a pleural effusion (PE) but the characteristics of these patients are not well defined. We performed a systematic review across four electronic databases for studies reporting clinical findings, PE characteristics, and most effective treatment of YNS. Case descriptions and retrospective studies were included, unrestricted by year of publication. We reviewed 112 studies (150 patients), spanning a period of nearly 50 years. The male/female ratio was 1.2/1. The median age was 60 years (range: 0-88). Seventy-eight percent were between 41-80 years old. All cases had lymphoedema and 85.6% had yellow nails. PEs were bilateral in 68.3%. The appearance of the fluid was serous in 75.3%, milky in 22.3% and purulent in 3.5%. The PE was an exudate in 94.7% with lymphocytic predominance in 96% with a low count of nucleated cells. In 61 of 66 (92.4%) of patients, pleural fluid protein values were >3 g/dL, and typically higher than pleural fluid LDH. Pleurodesis and decortication/pleurectomy were effective in 81.8% and 88.9% of cases, respectively, in the treatment of symptomatic PEs. The development of YNS and PE occurs between the fifth to eighth decade of life and is associated with lymphoedema. The PE is usually bilateral and behaves as a lymphocyte-predominant exudate. The most effective treatments appear to be pleurodesis and decortication/pleurectomy.

Interleukin 27 could be useful in the diagnosis of tuberculous pleural effusions.

BACKGROUND: The diagnosis of tuberculous pleural effusion (TBPE) has some limitations. We studied the efficacy of interleukin-27 (IL-27) in the diagnosis of TBPE. METHODS: We measured IL-27, adenosine deaminase (ADA), ADA-2, interferon-gamma (IFNγ), and the ADA·IL-27 and ADA-2·IL-27 products in all the pleural effusion fluids. The diagnostic yield of IL-27 was evaluated with receiver operating characteristic curves. RESULTS: Of 431 pleural effusions, 70 were tuberculous, 146 were neoplastic, 58 were parapneumonic, 28 were empyemas, 88 were transudates, and 41 were other types. With a cutoff point of 0.55 ng/mL, IL-27 had a sensitivity of 91.4% and a specificity of 85.1%, which were significantly less than ADA, ADA-2, IFNγ, ADA·IL-27, or ADA-2·IL-27. The area under the receiver operating characteristic curve for IL-27 (0.963) was also significantly lower than that for the other markers, except for IFNγ. However, IL-27 improved the sensitivity of ADA and ADA-2 through ADA·IL-27 and ADA-2·IL-27 products (100% for both). CONCLUSIONS: IL-27 is less efficient than ADA and ADA-2 in the diagnosis of TBPE. However, ADA·IL-27 and ADA-2·IL-27 improve the diagnostic sensitivity of ADA and ADA-2, and thus could be useful in situations of high clinical suspicion and low ADA level. A value above the cutoff point of the latter is practically diagnostic of TBPE.

Combining clinical and analytical parameters improves prediction of malignant pleural effusion.

PURPOSE: The usefulness of a panel of tumour markers and clinical-radiological criteria for diagnosing malignant pleural effusion (MPE) is not clearly stated. Our purpose was to assess the performance of those parameters in the diagnosis of MPE. METHODS: Consecutive patients with exudative PE were enrolled and divided into two groups: MPE and non-MPE. Logistic regression analysis was used to estimate the probability of MPE. Four prognostic models were considered: (1) clinical-radiological variables; (2) analytical variables; (3) combination of clinical and analytical variables; and (4) simpler model removing some analytical variables. Calibration and discrimination (receiver operating characteristics curves and AUC) were performed. RESULTS: A total of 491 pleural exudates were included: tuberculous (n = 72), malignant (n = 211), parapneumonic (n = 115), empyemas (n = 32), or miscellaneous (n = 61). The AUC obtained with Model 1 (absence of chest pain and fever and radiological images compatible with malignancy), Model 2 (CEA, NSE, CYFRA 21-1, and TPS), Model 3 (sum of the variables of models 1 and 2), and Model 4 (the variables of model 1 plus CEA) were 0.918, 0.832, 0.952 (all with a P < 0.05), and 0.939 (P < 0.01 compared to models 1 and 2), respectively. The correct classification rate for Models 1, 2, 3, and 4, was 87.2, 79.5, 88.4, and 87.6 %, respectively. CONCLUSIONS: All models analysed had a good diagnostic yield for MPE, being greater in those that combined radiological and analytical criteria. Although Model 3 obtained a higher yield, the simplest model (Model 4) is very attractive due to its simplicity of use in daily practice.

Role of blind closed pleural biopsy in the managment of pleural exudates.

INTRODUCTION: The performance of blind closed pleural biopsy (BCPB) in the study of pleural exudates is controversial. OBJECTIVE: To assess the diagnostic yield of BCPB in clinical practice and its role in the study of pleural exudates. METHODS: Data were retrospectively collected on all patients who underwent BCPB performed between January 1999 and December 2011. RESULTS: A total of 658 BCPBs were performed on 575 patients. Pleural tissue was obtained in 590 (89.7%) of the biopsies. A malignant pleural effusion was found in 35% of patients. The cytology and the BCPB were positive in 69.2% and 59.2% of the patients, respectively. Of the patients with negative cytology, 21 had a positive BCPB (diagnostic improvement, 15%), which would have avoided one pleuroscopy for every seven BCPBs that were performed. Of the 113 patients with a tuberculous effusion, granulomas were observed in 87 and the Lowenstein culture was positive in an additional 17 (sensitivity 92%). The overall sensitivity was 33.9%, with a specificity and positive predictive value of 100%, and a negative predictive value of 71%. Complications were recorded in 14.4% of patients (pneumothorax 9.4%; chest pain 5.6%; vasovagal reaction, 4.1%; biopsy of another organ 0.5%). CONCLUSIONS: BCPB still has a significant role in the study of a pleural exudate. If an image-guided technique is unavailable, it seems reasonable to perform BCPB before resorting to a pleuroscopy. These results support BCPB as a relatively safe technique.

Recent epidemiological trends in tuberculous pleural effusion in Galicia, Spain.

OBJECTIVE: Knowledge on the distribution and determinants of tuberculous pleural effusions (TBPE) is incomplete. We aimed to describe the epidemiological trends and individual characteristics of TBPE in Galicia, Spain, over a 10-year period (2000-2009). DESIGN: A retrospective, observational study based on epidemiological data obtained from the Galician Tuberculosis Register. RESULTS: There were 1835 cases of TBPE (16.3% of the total 11,241 TB cases reported). The number and incidence of TBPE decreased significantly during the study period, from (262 and 9.6/100,000 inhabitants in 2000, to 133 and 4.8 in 2009, respectively; P<.001 for both). The mean annual decrease in TBPE incidence was 6.9%, and 50% overall. TBPE mainly affected males (63.5%), precisely 61.2% young males between 15 and 44 years. Twenty-five percent had lung involvement (chest X-ray), and 41.7% had a positive sputum culture. A significant increase (P<.001) was observed during the study in the percentage of patients who had more TB risk factors. CONCLUSIONS: The incidence of TBPE decreased significantly during the study period, with no changes in epidemiological characteristics, and with trends similar to the total number of TB cases. The introduction of the Galician Prevention and Control Plan (GPCP) for tuberculosis appears to be effective for better control of TB.

Valor diagnóstico de los niveles del N-terminal pro-póptido natriurótico cerebral en los derrames pleurales de origen cardiaco / Diagnostic Value of N-Terminal Pro-Brain Natriuretic Peptide in Pleural Effusions of Cardiac Origin

Introducción: El diagnóstico del derrame pleural (DP) cardiogénico plantea dificultades con frecuencia.El objetivo de nuestro estudio fue evaluar la utilidad diagnóstica en el DP en pacientes con insuficienciacardíaca, de los niveles del fragmento N terminal del pro-póptido natriurítico cerebral (NT-proBNP),tanto en líquido pleural (LP) como en sangre (S), y compararlo con los criterios de Light, el colesterol en líquido pleural (COL LP) y en suero (COL S).Pacientes y método: Todos los biomarcadores fueron evaluados en 398 DP (26,9% trasudados). El ¨¢rea bajola curva (ABC) cuantificó la precisión diagnóstica global; y mediante curvas ROC se evaluó la precisión diagnóstica de los diversos parámetros. Resultados: El ABC ROC para el NT-proBNP pleural fue 0,894, sin diferencias significativas con el COL LP(0,914) ni con los criterios de Light (0,896). La sensibilidad, especificidad, razón de probabilidad positiva(RPP) y razón de probabilidad negativa (RPN) fueron 85,1% (94,1% para COL LP), 79,9% (90,2% para loscriterios de Light), 4,24 (7,27 para los criterios de Light) y 0,19 (0,07 para COL LP), respectivamente. La combinación del NT-proBNP en LP ¡Ý 276 pg/ml y COL LP ¡Ü 57 mg/dL consiguieron clasificar el mayorn¨²mero de DP correctamente (sensibilidad 97,8%, especificidad 85,4%). Conclusiones: El rendimiento diagnóstico del NT-proBNP en DP cardiogónicos no es superior al COL LP nia los criterios de Light, aunque pudiera ser diagnóstico en trasudados de otro origen (AU)

Introduction: The diagnosis of cardiogenic pleural effusion (PE) is often difficult to make. The objectiveof our study was to evaluate the diagnostic usefulness of N-terminal pro-brain natriuretic peptide (NTproBNP)levels in PE patients with heart failure, in pleural fluid (PF) and blood (B), and to compare thecholesterol in pleural fluid (CHOL PF) and in serum (CHOL S) with the Light criteria.Patients and methods: All the biomarkers were evaluated in 398 PF (26.9% transudates). The area underthe curve (AUC) quantified the overall diagnostic precision. The diagnostic precision of the different parameters was also assessed using the ROC curves.Results: The AUC of the ROC for pleural fluid NT-proBNP was 0.894, with no significant differences withCHOL LP (0.914) or with the Light criteria (0.896). The sensitivity, specificity, the positive probabilityratio (PPR) and negative probability ratio (NPR) were 85.1% (94.1% for CHOL LP), 79.9% (90.2% for the Lightcriteria), 4.24 (7.27 for the Light criteria) and 0.19 (0.07 for CHOL LP), respectively. The combination of NTproBNPin PF ¡Ý 276 pg/ml and CHOL LP ¡Ü 57 mg/dL managed to classify the highest number PE correctly(sensitivity 97.8%, specificity 85.4%). Conclusions. The diagnostic yield of NT-proBNP in cardiogenic PE isnot superior to the CHOL LP or the Light criteria, although it could be diagnostic in transudates of anotherorigin(AU)