BACKGROUND:Indwelling pleural catheters are an effective treatment option for patients with malignant pleural effusions. Despite their popularity, there remains a paucity of data on the patient experience and key patient-centred outcomes.OBJECTIVE:To investigate the experience of patients receiving an indwelling pleural catheter to better inform and identify potential areas for improvement in care.METHODS:This was a multicentre survey study at three academic, tertiary-care centres in Canada. Patients with a diagnosis of malignant pleural effusion who had an indwelling pleural catheter inserted were included. An adapted questionnaire specific to indwelling pleural catheters was used with responses recorded on a 4-point Likert scale. Patients completed the questionnaire in-person or by phone at 2-week and 3-month follow-up appointments.RESULTS:A total of 105 patients were enrolled in the study with 84 patients included in the final analysis. At the 2-week follow-up, patient-reported improvements in dyspnoea and quality of life from indwelling pleural catheter were high at 93% and 87%, respectively. The predominant issues identified were discomfort at time of insertion (58%), itching (49%), difficulty with sleeping (39%), discomfort with home drainage (36%) and the pleural catheter reminding patients of their disease (63%). Avoiding hospitalisation for the management of dyspnoea was important to 95% of patients. Findings were similar at 3 months.CONCLUSIONS:Indwelling pleural catheters are an effective intervention to directly improve dyspnoea and quality of life but have important disadvantages for some; clinicians and patients should be aware of these when making an informed decision regarding treatment.

Background Chylothorax is an uncommon medical condition for which limited data are available regarding the contemporary aetiology, management and outcomes. The goal of this study was to better define these poorly characterised features. Methods The medical records of adult patients diagnosed with chylothorax at 12 centres across Europe, America and South Africa from 2009–2021 were retrospectively reviewed. Descriptive and inferential statistics were performed. Results 77 patients (median age 69 years, male to female ratio 1.5) were included. Subacute dyspnoea was the most typical presenting symptom (66%). The commonest cause of chylothorax was malignancy (68.8%), with lymphoma accounting for 62% of these cases. Other aetiologies were trauma (13%), inflammatory/miscellaneous conditions (11.7%) and idiopathic cases (6.5%). At the initial thoracentesis, the pleural fluid appeared milky in 73%, was exudative in 89% and exhibited triglyceride concentrations >100 mg·dL−1 in 88%. Lymphangiography/lymphoscintigraphy were rarely ordered (3%), and demonstration of chylomicrons in pleural fluid was never ascertained. 67% of patients required interventional pleural procedures. Dietary measures were infrequently followed (36%). No patient underwent thoracic duct ligation or embolisation. Morbidity included infections (18%), and thrombosis in malignant aetiologies (16%). The 1-year mortality was 47%. Pleural fluid protein >3.5 mg·dL−1 (sub-distribution hazard ratio (SHR) 4.346) or lactate dehydrogenase <500 U·L−1 (SHR 10.21) increased the likelihood of effusion resolution. Pleural fluid protein ≤3.5 mg·dL−1 (HR 4.047), bilateral effusions (HR 2.749) and a history of respiratory disease (HR 2.428) negatively influenced survival. Conclusion Chylothoraces have a poor prognosis and most require pleural interventions. Despite the standard recommendations, lymphatic imaging is seldom used, nor are dietary restrictions followed.

ObjectiveTransbronchial lung biopsy (TBB) is a commonly performed procedure to obtain parenchymal lung tissue during bronchoscopy. Pneumothorax is among the most common serious complications of TBB. The objective of this study was to assess whether location of TBB correlated with development of post-procedural pneumothorax. We also sought to identify additional risk factors associated with pneumothorax development.This was a single-centre, retrospective cohort study. All TBB performed between 2010 and 2020 underwent subsequent chart review. The primary outcome was radiologist reported pneumothorax on post-procedure chest x-ray. Multivariable logistic regression model was created with included variables chosen a priori based on clinical significance.ResultsThere were a total of 222 TBB performed that met inclusion criteria. Radiographic evidence of pneumothorax was reported in 38 patients (15.4%). Ten patients (4.1%) required a chest tube. In the multivariable analysis, risk of pneumothorax was significantly higher for biopsies obtained from the left upper lobe (OR 3.3; 95% CI 1.3-9.1). There was an increased risk of pneumothorax following TBB when obtained from the left upper lobe. Clinicians should be aware of the increased risk and should consider alternative locations in patients with diffuse lung disease.

Introduction We present findings from the International Collaborative Effusion database, a European Respiratory Society clinical research collaboration. Nonspecific pleuritis (NSP) is a broad term that describes chronic pleural inflammation. Various aetiologies lead to NSP, which poses a diagnostic challenge for clinicians. A significant proportion of patients with this finding eventually develop a malignant diagnosis. Methods 12 sites across nine countries contributed anonymised data on 187 patients. 175 records were suitable for analysis. Results The commonest aetiology for NSP was recorded as idiopathic (80 out of 175, 44%). This was followed by pleural infection (15%), benign asbestos disease (12%), malignancy (6%) and cardiac failure (6%). The malignant diagnoses were predominantly mesothelioma (six out of 175, 3.4%) and lung adenocarcinoma (four out of 175, 2.3%). The median time to malignant diagnosis was 12.2 months (range 0.8–32 months). There was a signal towards greater asbestos exposure in the malignant NSP group compared to the benign group (0.63 versus 0.27, p=0.07). Neither recurrence of effusion requiring further therapeutic intervention nor initial biopsy approach were associated with a false-negative biopsy. A computed tomography finding of a mass lesion was the only imaging feature to demonstrate a significant association (0.18 versus 0.01, p=0.02), although sonographic pleural thickening also suggested an association (0.27 versus 0.09, p=0.09). Discussion This is the first multicentre study of NSP and its associated outcomes. While some of our findings are reflected by the established body of literature, other findings have highlighted important areas for future research, not previously studied in NSP.

Background Research in treatment of non-small cell lung cancer (NSCLC) has shown promising results with stereotactic ablative radiotherapy (SABR) of oligometastatic disease, wherein distant disease may be limited to one or a few distant organs by host factors. Traditionally, PET/CT has been used in detecting metastatic disease and avoiding futile surgical intervention, however, sensitivity and specificity is limited to only 81 and 79%, respectively. Mediastinal staging still identifies occult nodal disease in up to 20% of NSCLC patients initially thought to be operative candidates. Endobronchial ultrasound and transbronchial needle aspiration (EBUS-TBNA) is a minimally invasive tool for the staging and diagnosis of thoracic malignancy. When EBUS is combined with endoscopic ultrasound using the same bronchoscope (EUS-B), the diagnostic sensitivity and negative predictive value increase to 84 and 97%, respectively. Endoscopic staging in patients with advanced disease has never been studied, but may inform treatment if a curative SABR approach is being taken. Methods This is a multi-centre, prospective, cohort study with two-stage design. In the first stage, 10 patients with oligometastatic NSCLC (lung tumour ± hilar/mediastinal lymphadenopathy) with up to 5 synchronous metastases will be enrolled An additional 19 patients will be enrolled in the second stage if rate of treatment change is greater than 10% in the first stage. Patients will be subject to EBUS or combined modality EBUS/EUS-B to assess bilateral lymph node stations using a N3 to N2 to N1 progression. Primary endpoint is defined as the rate of change to treatment plan including change from SABR to conventional dose radiation, change in mediastinal radiation field, and change from curative to palliative intent treatment. Discussion If a curative approach with SABR for oligometastatic disease is being explored, invasive mediastinal staging may guide treatment and prognosis. This study will provide insight into the use of endoscopic mediastinal staging in determining changes in treatment plan of NSCLC. Results will inform the design of future phase II trials. Trial registration Clinicaltrials.gov identifier NCT04852588. Date of registration: April 19, 2021. Protocol version: 1.1 on December 9, 2021.

RATIONALE Malignant Pleural Effusions (MPE) are a known complication of hematological malignancies and can lead to dyspnea, impaired quality of life and hospitalization. Patients with hematological malignancies are often immunocompromised due to immunosuppressive chemotherapy or disease process itself. There is often hesitancy with the use of indwelling pleural catheters in this population due to the concern of infection. OBJECTIVE Our study examines this risk of infection and other complications associated with the use of indwelling pleural catheters (IPCs) in a Canadian cohort of patients with hematological malignancy. METHODS In this retrospective cohort study, we analyzed data from a pleural disease clinic at a tertiary-care center in Ottawa, Canada between 2006 and 2015. All patients who had an IPC inserted for the management of a symptomatic MPE due to a hematological malignancy (lymphoma, leukemia, multiple myeloma) were included. RESULTS Eighty-one patients were included in the cohort. Five patients (6%) had an infectious complication related to their IPC with no attributable deaths from an IPC. Most patients (81%) had symptomatic relief following IPC insertion. The median time to IPC removal was 51 days (IQR 28 - 116 days) in the 58% of patients who had their IPC removed. Patients with lymphoma had the highest likelihood of catheter removal. CONCLUSIONS The use of IPCs in patients with hematological malignancies is generally safe with an acceptable risk of infection given the clinical benefit. Definitive management of rapidly re-accumulating and symptomatic MPEs with an IPC can be considered for palliation of dyspnea in patients with hematological malignancy.

Background: Suction and capillary pull are 2 biopsy techniques used in endobronchial ultrasound-guided transbronchial needle aspiration (EBUS-TBNA). Although these techniques have been shown to perform comparably in terms of overall diagnostic yield, we hypothesized that the capillary pull technique would be associated with improved rapid on-site evaluation (ROSE) adequacy rates thus allowing for a shorter procedure time. Methods: One hundred eighteen patients undergoing EBUS-TBNA for any indication were randomized to suction or capillary pull techniques for the first biopsy pass; the technique used for all subsequent passes was based on operator preference and was not recorded. The first pass was subjected to ROSE and an adequacy assessment was given. ROSE slides were also scored for cellularity of diagnostic/lesional cells and blood contamination. The overall procedure time was also recorded. Results: There were no significant differences between suction and capillary pull techniques in terms of ROSE adequacy rates. Cellularity of diagnostic/lesional cells and blood contamination scores were also comparable. There was no significant difference in procedure time for the 2 techniques. Conclusion: This study suggests no differences in ROSE outcomes between suction and capillary pull techniques in EBUS-TBNA. The technique used should therefore be left to the discretion of the operator.

BackgroundPleural fluid cytology is an important diagnostic test used for the investigation of pleural effusions. There is considerable variability in the reported sensitivity for the diagnosis of malignant pleural effusions (MPE) in the literature.ObjectiveThe purpose of this review is to determine the diagnostic sensitivity of pleural fluid cytology for MPE, both overall and by tumour type, to better inform the decision-making process when investigating pleural effusions.Data sourcesA literature search of EMBASE and MEDLINE was performed by four reviewers. Articles satisfying inclusion criteria were evaluated for bias using the QUADAS-2 tool.Data extractionFor quantitative analysis, we performed a metaanalysis using a binary random-effects model to determine pooled sensitivity. Subgroup analysis was performed based on primary cancer site and meta-regression by year of publication.SynthesisThirty-six studies with 6057 patients with MPE were included in the meta-analysis. The overall diagnostic sensitivity of pleural fluid cytology for MPE was 58.2% (95% CI 52.5% to 63.9%; range 20.5%–86.0%). There was substantial heterogeneity present among studies (I295.5%). For primary thoracic malignancies, sensitivity was highest in lung adenocarcinoma (83.6%; 95% CI 77.7% to 89.6%) and lowest in lung squamous cell carcinoma (24.2%; 95% CI 17.0% to 31.5%) and mesothelioma (28.9%; 95% CI 16.2% to 41.5%). For malignancies with extrathoracic origin, sensitivity was high for ovarian cancer (85.2%; 95% CI 74.2% to 96.1%) and modest for breast cancer (65.3%; 95% CI 49.8% to 80.8%).ConclusionsPleural fluid cytology has an overall sensitivity of 58.2% for the diagnosis of MPE. Clinicians should be aware of the high variability in diagnostic sensitivity by primary tumour type as well as the potential reasons for false-negative cytology results.PROSPERO registration numberCRD42021231473.

Nonexpanding lung is a mechanical complication in which part of the lung is unable to expand to the chest wall, preventing apposition of the visceral and parietal pleura. This can result from various visceral pleural disease processes, including malignant pleural effusion and empyema. Nonexpanding lung can be referred to as trapped lung or lung entrapment, both with distinct clinical features and management strategies. Early evaluation of pleural effusions is important to address underlying causes of pleural inflammation and to prevent the progression from lung entrapment to trapped lung. Some patients with trapped lung will not experience symptomatic relief with pleural fluid removal. Therefore, misrecognition of trapped lung can result in patients undergoing unnecessary procedures with significant cost and morbidity. We reviewed the current understanding of nonexpanding lung, which included causes, common presentations, preventative strategies, and recommendations for clinical care. CHEST 2021; 160(3):1131-1136

BACKGROUND: Hospital readmissions are costly to health-care systems and represent a measure of quality care. Patients with cancer with malignant pleural effusions (MPEs) are at high risk for rehospitalization; however, risk factors for readmissions in this population are not well described. Understanding the incidence and risk factors for readmission could facilitate the development of a readmission reduction strategy in this patient population. METHODS: We conducted a retrospective cohort study using the Nationwide Readmissions Database (NRD) (2014 sample) to determine the proportion of all-cause, unplanned, 30-day readmissions to hospital among patients with MPEs. Survey weighting methods that accounted for the NRD sampling design were used to generate nationally representative estimates. We used multivariable logistic regression to determine predictors of early readmission. RESULTS: There were 27,900 unplanned readmissions after 108,824 index hospitalizations for MPEs, a rate of 25.6% (95% CI, 25.0%-26.3%). The mortality rate during readmission to hospital was 17.3% (n = 4,840; 95% CI, 16.6%-18.1%). Mean cost per readmission was $15,452 +/- $415, with total aggregate costs of > $400 million. Predictors of early readmission included having Medicaid insurance status, treatment with thoracentesis only, and discharge to a care facility or home health care. CONCLUSIONS: One in four patients with cancer and MPEs are readmitted to hospital within 30 days of discharge, and nearly one in five die during the readmission. Nondefinitive management with thoracentesis led to more readmissions. A further understanding of factors that drive preventable readmissions could significantly improve quality of care in this population.

Background: Indwelling pleural catheters (IPC) are commonly used in the management of malignant pleural effusions (MPE). The effect of systemic chemotherapy on IPC removal has not been reported previously. Objectives: The purpose of this study is to identify the effect of chemotherapy on the removal of IPCs in breast cancer patients with MPEs. Methods: In this retrospective cohort study at an academic tertiary-care center, patients with breast cancer and MPE who received an IPC between 2006 and 2016 were identified from a prospectively collected database. Patient chemotherapy data were obtained, as well estrogen receptor (ER) and human epidermal growth factor receptor-2 status at the time of diagnosis. Patients receiving chemotherapy while their IPC was in situ were compared to those who did not. The primary outcome was time to IPC removal. All patients were followed until IPC removal or death. Results: A total of 207 patients and 216 IPCs were included in the analysis. There was no difference in time to IPC removal between the chemotherapy and no-chemotherapy groups (HR 0.73, 95% CI 0.50–1.07, p = 0.10) or rate of IPC removal (OR 1.16, 95% CI 0.68–1.98, p = 0.59). The risk of IPC infection was not different between patients who received chemotherapy and those who did not (RR 0.57, 95% CI 0.06–5.39, p = 0.48). Conclusions: Treatment with chemotherapy with an IPC in situ was not associated with a reduced time to IPC removal in our breast cancer population. IPC insertion in patients receiving chemotherapy is safe and not associated with an increased risk of infection.

A 61-year-old woman with locally advanced, high-grade urothelial cell carcinoma was treated with the anti-programmed death-ligand 1 antibody atezolizumab. She initially received neoadjuvant chemotherapy and surgery that led to clinical and radiographic remission at the time of atezolizumab initiation. Within 3 months she developed new mediastinal and hilar lymphadenopathy as well as pulmonary nodules in a pattern characteristic of pulmonary sarcoidosis. Mediastinal lymph node biopsy by endobronchial ultrasound demonstrated noncaseating granulomas without evidence of malignancy or infection. Within 4 weeks of initiation of prednisone and cessation of atezolizumab there was marked reduction in intrathoracic lymphadenopathy and perilymphatic nodules. This is the first reported case of atezolizumab-induced sarcoid-like granulomatous reaction.

Background: Use of indwelling pleural catheters (IPCs) for the management of symptomatic pleural effusions in patients with mesothelioma has increased in popularity. An important concern with this approach is the potential for the development of catheter tract metastasis (CTM). Objectives: To determine the incidence of IPC-related CTM in patients with malignant pleural mesothelioma (MPM). Methods: In this single-center retrospective cohort study, patients with biopsy-confirmed MPM who had an IPC inserted between May 2006 and July 2017 were identified from a prospectively collected database. Thoracic CT scans following IPC insertion were reviewed to assess for evidence of CTM. Patients were followed until death or last documented patient encounter with a minimum of 6-month follow-up. Results: A total of 90 patients were included in the cohort. CTM was identified in 23 of 90 patients (26%). Median time from IPC insertion to CTM was 408 days (interquartile range 196–721 days). Medical thoracoscopy at the time of IPC insertion did not lead to a significantly increased odds of CTM (OR 2.30; 95% CI 0.66–7.94; p = 0.19). Incidence of CTM was not different between mesothelioma subtypes (p = 0.09). Patient-reported dyspnea scores were improved following IPC insertion in 80% of patients. Conclusions: CTM was identified in over a quarter of MPM patients when follow-up imaging was reviewed. Treating physicians should be cognizant of the possibility of CTM at the site of prior IPC.

: The patent application relates to a method of improving superconductivity, a resultant element, and a compound containing that element or more particularly to a method of raising the superconducting critical temperature (T sub c) of an element or the compound containing the element by isolating a single isotope of the element, the resultant element and the compound containing the element.