Aureli Esquerda

Diagnostic performance of adenosine deaminase activity in pleural fluid: a single-center experience with over 2100 consecutive patients.

OBJECTIVE To determine the diagnostic utility of adenosine deaminase (ADA) in a large series of pleural effusions of different etiologies. METHODS A retrospective study of 2104 consecutive patients presenting with pleural effusion was carried out at a Spanish university hospital. ADA levels in pleural fluid were determined using a non-Giusti automatic kinetic assay, and a receiver operating characteristics curve analysis was applied to estimate their discriminative properties. RESULTS Pleural tuberculosis (TB) accounted for 221 (10.5%) effusions. Pleural fluid ADA >35U/L yielded 93% sensitivity, 90% specificity, a positive likelihood ratio (LR) of 10.05 and a negative LR of 0.07 for the diagnosis of TB among lymphocytic exudates. The ADA activity was significantly higher in neutrophil- (111.6U/L) than in lymphocyte-rich (62.4U/L; p=0.002) TB effusions. Overall, more than 40% of parapneumonics and half of lymphomatous effusions exceeded the cutoff set for TB. These were the only causes of ADA activity above 250U/L. When the prevalence of TB as a cause of exudative effusions is low (e.g., 1%), the estimated positive predictive value of the ADA test may be as low as 7%, although the negative predictive value remains high (99.9%). CONCLUSION Where available, pleural ADA should be routinely used to rule TB in or out in areas with moderate to high or low TB prevalence, respectively. A high ADA level is a characteristic not only of lymphocytic, but also of neutrophilic TB effusions. An extremely high ADA activity should raise suspicion of empyema or lymphoma.

Etiología del derrame pleural: análisis de más de 3.000 toracocentesis consecutivas

OBJECTIVE To investigate the etiology of pleural effusions (PE) in adults and the accuracy of pleural fluid (PF) cytology and cultures in malignant and infectious PE, respectively. PATIENTS AND METHODS Retrospective analysis of all consecutive patients with PE undergoing diagnostic thoracentesis during the last 19 years in a university hospital. RESULTS The leading causes of PE among the 3,077 patients were: cancer (27%), heart failure (21%), pneumonia (19%), tuberculosis (9%), abdominal surgery (4%), pericardial diseases (4%) and cirrhosis (3%). Tuberculosis was the most common etiology in patients <34 years of age (52%), whereas heart failure predominated in octogenarians (45%). The most common primary tumors in malignant PE were lung (37%) and breast (16%). The overall accuracy of PF cytology was 59%, although it was significantly lower in mesotheliomas (27%) and squamous cell lung cancer (25%). In infectious PE, only 30% of cultures yielded positive results, a percentage which increased two-fold (66%) in purulent fluids (empyemas). Viridans streptococci were the most commonly isolated pathogens (25.5%). The sensitivity of solid media cultures of PF for Mycobacterium tuberculosis was low (18.5%). CONCLUSIONS Three-quarters of patients with PE in whom a diagnostic thoracentesis was indicated had cancer, heart failure, pneumonia or tuberculosis. PF cytology and cultures give false negative results in a significant number of cases.

Prognostic significance of pleural fluid data in patients with malignant effusion.

BACKGROUND To determine the effects of the biochemical and cytological properties of the pleural fluid (PF) on the survival of patients with malignant pleural effusion (MPE). METHODS A retrospective study of 284 patients with MPE was performed, which measured overall survival, survival of patients with different types of primary tumors, and survival as a function of PF biochemical variables transformed into quartiles. RESULTS Median overall survival of MPE patients was 5.4 months following diagnosis. Survival varied significantly depending on the type of the primary tumor: 17.4 months for mesothelioma, 13.2 months for breast cancer, 7 months for lymphoma and 2.6 months for lung cancer. A multivariate analysis of PF biochemical parameters showed that survival was lower as the concentration of lactate dehydrogenase (LDH) increased (11.3 months if LDH was between 140 U/L and 358 U/L vs 2.8 months if LDH was between 1027 U/L and 10,110 U/L) or the concentration of pleural proteins decreased (9.4 months if proteins were between 4.92 g/dL and 7.94 g/dL vs 2.2 months if proteins were between 0.97 g/dL and 3.85 g/dL). We also found that when mesotheliomas were excluded from the analysis, survival was lower in patients with a PF pH lower than 7.3 (2.4 months vs 6.8 months, p=0.03). CONCLUSIONS Tumor type as well as some biochemical features of the pleural fluid, such as pH and concentrations of proteins and LDH, influence survival in patients with MPE.

Analysis of pleural effusions in acute pulmonary embolism: radiological and pleural fluid data from 230 patients.

Background and objective:  The aims of this study were to describe the frequency and radiographical characteristics of pleural effusions in a large population of patients with acute pulmonary embolism (PE) and characterize the pleural fluid biochemistry in those patients who underwent diagnostic thoracentesis.

Comparing serum and pleural fluid pro-brain natriuretic peptide (NT-proBNP) levels with pleural-to-serum albumin gradient for the identification of cardiac effusions misclassified by Light's criteria.

Background and objectives:  To assess the diagnostic performance of the amino‐terminal fragment of pro‐brain natriuretic peptide (NT‐proBNP) in pleural fluid and serum for the identification of pleural effusions owing to heart failure, and to determine if these measurements allow better categorization of cardiac effusions that have been misclassified by Lights criteria, than do serum‐pleural fluid albumin and protein gradients.

Solving the Light's criteria misclassification rate of cardiac and hepatic transudates

Background and objective:  Pleural transudates are most commonly due to heart failure (HF) or hepatic hydrothorax (HH), but a number of these effusions are misclassified as exudates by standard (Lights) criteria. The aim of this study was to determine the prevalence of mislabelled transudates and to establish simple alternative parameters to correctly identify them.

Pleural fluid C-reactive protein contributes to the diagnosis and assessment of severity of parapneumonic effusions

BACKGROUND AND AIMS Prompt identification of parapneumonic effusions has immediate therapeutic benefits. We aimed to assess whether C-reactive protein (CRP) and routine biochemistries in pleural fluid are accurate markers of parapneumonic effusions, and to evaluate their properties as indicators for drainage (complicated parapneumonic effusion). METHODS A retrospective review of 340 non-purulent parapneumonic effusions and 1,659 non-parapneumonic exudates from a single center was performed and the discriminative properties of pleural fluid routine biochemistries and, when available, CRP were evaluated. CRP, along with classical fluid parameters, was also applied to classify patients as having complicated or uncomplicated parapneumonic effusions. ROC analysis established the threshold of CRP for discriminating between groups. RESULTS Pleural fluids with neutrophilic predominance and CRP levels >45 mg/dL were most likely to be parapneumonic in origin (likelihood ratio=7.7). When attempting to differentiate non-purulent complicated from uncomplicated effusions, a CRP >100mg/L had the same performance characteristics (area under the curve=0.81) as the widely accepted biochemistries pH and glucose. Combinations of CRP with pH or glucose resulted in incrementally discriminating values, pertaining to either sensitivity (75-80%) or specificity (97%), for complicated effusions. CONCLUSION Pleural fluid CRP may be a useful adjunctive test in pleural effusions, both as a marker of parapneumonics and, particularly, as a differentiator between complicated and uncomplicated effusions.

Pleural fluid interleukin‐8 and C‐reactive protein for discriminating complicated non‐purulent from uncomplicated parapneumonic effusions

Background and objective:  This study was designed to test the hypothesis that measurement of IL‐8 and CRP in pleural fluid could improve the identification of patients with non‐purulent parapneumonic effusions that ultimately require chest tube drainage.

Latent autoimmune diabetes in adults is perched between type 1 and type 2: evidence from adults in one region of Spain

The aim of this study was to characterize the clinical characteristics and insulin secretion in adults with latent autoimmune diabetes in adults (LADA). We also compared these characteristics in subjects with antibody‐negative type 2 diabetes (T2DM) or adult‐onset type 1 diabetes (T1DM) to subjects with LADA.

Revaluación del método estándar (criterios de Light) para identificar exudados pleurales

Fundamento y objetivos: Los criterios de Light se consideran el mejor metodo para diferenciar los exudados de los trasudados pleurales. Nos proponemos evaluar sus caracteristicas operativas, asi como las que resultan de eliminar el cociente de lactatodeshidrogenasa (LDH) entre liquido pleural y suero de los criterios originales (criterios de Light abreviados), en una serie amplia de pacientes. Asimismo buscamos la mejor combinacion de parametros bioquimicos del liquido pleural (entre ellas proteinas, LDH y colesterol), capaz de identificar exudados. Pacientes y metodo: Se analizo retrospectivamente a 1.490 pacientes consecutivos con derrame pleural a quienes se habia realizado una toracentesis. El diagnostico final fue de exudado en 1.192 y de trasudado en 298. Se calcularon la sensibilidad, especificidad, area bajo la curva de eficacia diagnostica y odds ratio tanto de parametros individuales como combinados del liquido pleural. Resultados: La sensibilidad y especificidad de los criterios de Light fueron del 97,5 y el 80%, respectivamente. Tanto los criterios de Light abreviados (sensibilidad del 95,4% y especificidad del 83,3%) como la combinacion, con una regla en «o», de las proteinas y LDH del liquido pleural (sensibilidad del 95,4% y especificidad del 80,2%) tuvieron la misma capacidad discriminatoria que los criterios estandar. Conclusiones: La identificacion de los exudados pleurales se puede realizar con los criterios de Light abreviados cuando no se dispone del valor de la LDH serica. Por otro lado, si la extraccion sanguinea no es posible (circunstancia infrecuente), la combinacion de proteinas y LDH pleurales serviria tambien como criterio diagnostico alternativo a los criterios clasicos de Light.