Journal Club October 2022

The Biological Role of Pleural Fluid PAI-1 and Sonographic Septations in Pleural Infection: Analysis of a Prospectively Collected Clinical Outcome Study. 

Bedawi EO, et al.

Am J Respir Crit Care Med.

PMID: 36191254

This paper represents a really important advance in pleural diagnostics and our understanding of pleural infection pathophysiology. The investigators analysed pleural fluid samples collected at the time of diagnosis of pleural infection within the PILOT study. From the 546 patients within that study, 243 had samples available for analysis. A Luminex assay was used to assess 6 potential biomarkers of pleural infection as well as a quantitative measure of protein expression using a Nanodrop.

The study has demonstrated several interesting findings that represent a significant advance in our understanding of pleural loculation and its impact (or not) on clinical outcomes. Using a validated ultrasound scoring system they have shown that PAI-1 had reasonable utility at differentiating between loculation severity. More importantly, PAI-1 had the ability to predict hospital length of stay and mortality in a multivariable analysis that included loculations.  

ERS/ESTS statement on the management of pleural infection in adults. 

Bedawi EO, et al.

Eur Respir J.

PMID: 36229045

The eagerly awaited ERS guidelines on pleural infection have been published in the ERJ this month. The writers concentrate on main questions of the epidemiology of pleural infection, the optimal antibiotic strategy, diagnostic parameters for chest tube drainage, the status of intrapleural therapies, the role of surgery and the current place of outcome prediction in management.

Always worth a read.

Differentiation of malignant from benign pleural effusions based on artificial intelligence. 

Wang S, et al.

Thorax. 2022.

PMID: 36180066

Published in Thorax this month, Wang et al present the development (n=918 scans) and subsequent validation (n=362 scans) of a artificial intelligence (AI) model to differentiate between benign and malignant pleural effusions.

Without being able to critique the technological elements the final model had a

sensitivity and specificity 89.4% (95% CI 84.4% to 93.2%) and 65.1% (95% CI 57.3% to 72.3%) in the external testing cohort. This is impressive given the previous work from Hallifax et al demonstrating that a conventionally reported scan had a sensitivity and specificity of 68% and 78% respectively.

Analysis of antibiotic use and clinical outcomes in adults with known and suspected pleural empyema. 

Avner BS, et al.

PMID: 36224539 

Antibiotic choice and duration in pleural infection is a challenging area of study with a scant evidence base. Avner and colleagues attempt to address some of the outstanding questions with a retrospective analysis of 355 adult inpatients who had pleural drainage, via either chest tube or surgical intervention, for known or suspected empyema.

Clearly retrospective data has significant limitations in this area but several findings were of interest including a reduction in readmission in those of a longer course of antibiotics. Longer duration of anti-anaerobic antibiotics was associated with both lower all-cause readmission.

Counseling after primary spontaneous pneumothorax: Opportunities to reduce recurrence risk. 

Schindler E, Hayden R, Menzione N, Park T, Fischer A, Lichtstein D.

Am J Med. 2022 Oct 14:S0002-9343(22)00738-0. doi: 10.1016/j.amjmed.2022.09.024. Online ahead of print.

PMID: 36252712 No abstract available.

A case study and narrative around the importance of the ‘teachable moment’ of smoking cessation post pneumothorax. Unfortunately, I cannot get past the paywall but someone might.

Clinical Implications of the Controlling Nutritional Status Score on Short-term Outcomes in Patients with Pleural Infection. 

Oh J, et al.

Intern Med.

PMID: 36288983

Similar to the RAPID score the CONUT score includes several markers of poor nutritional status and frailty. Namely, serum albumin concentration, lymphocyte count, and total cholesterol concentration. Unlike, the RAPID score it does not include any disease specific markers for pleural infection. In this single centre retrospective case series of 335 patients with pleural infection the CONUT score was an independent (including RAPID) predictor of 90-day survival.

Although unlikely to be embraced in clinical practice given the existence of a validated disease specific score, it does stress the importance of optimal nutrition in patients who present with pleural infection.