Search

Introduction Pleural fluid characteristics may be complimentary in diagnosing pleural disease but tissue histopathology remains the gold-standard for diagnosis, particularly in malignancy. We sought to understand how practice has changed over time with the incorporation of novel techniques in a high-volume centre. Methods A retrospective study of all local anaesthetic thoracoscopies (LAT) and physician performed image guided pleural biopsies (IGPBx) with ultrasound at a single centre from 2014–2019. Results 510 procedures were performed over this period; 67% were LATs (343/510) the remainder were IGPBx (167/510). The proportion of IGPBx rose from 31% of procedures per year in 2014 (26) to 45% of procedures per year in 2018 (44). The number of talc poudrages performed decreased from 46% in 2015 (29) to 9% in 2018 (5). IGPBx was used preferentially in cases of benign pleural disease with 61.2% (98) resulting in a benign diagnosis compared to 46.8% (153) in the LAT group (c2 1df = 8.9, p=0.003). A higher proportion of complications were seen in LATs overall (c2 1df = 8.0, p=0.005) with complications seen in 15% of case (53). The majority were related to pain control (17), followed by vasovagal episodes (8). IGPBx were associated with complications in 6.6% of cases (11) and were largely related to bleeding (7). The sensitivity of LAT biopsies for malignant pleural disease was 87%, compared to 78% for IGPBx. The negative predictive value of both were comparable at 90% for LAT and 87% for IGPBx (figure 1). The majority of false negative biopsies in both groups were seen in Mesothelioma; 11/18 (61.1%) in the LAT group and 9/14 (64.2%) in the IGPBx group. Discussion Physician performed IGPBx offers an alternative choice of procedure to LAT with comparable negative predictive values although direct comparison is limited due to the heterogenous patient groups they were performed in. IGPBx were associated with fewer complications and therefore may be suited to a frailer patient cohort. LAT biopsies have a higher diagnostic yield and therefore thoracoscopic biopsies remain the gold-standard for diagnosing malignant pleural disease.

Background It has been postulated that when the intrapleural tumour burden is high, the resultant obliteration of normal mesothelial cell surface of the pleura results in reduction in pleurodesis success rate.1 This effect has been suggested in the context of worse pleurodesis outcomes in malignant pleural effusion (MPE) secondary to lung cancer or mesothelioma, with more favourable outcomes seen in breast and ovarian cancer.2 This study therefore aimed to assess the hypothesis that tumour burden is associated with higher pleurodesis failure, and that tumour type can affect pleurodesis outcomes. Methods A structured, retrospective review of recorded video footage of local anaesthetic thoracoscopy (LAT) procedures of 45 patients with proven MPE was conducted by 2 independent assessors blinded to the patient medical records. Abnormalities were assessed according to the presence or absence of; nodules, lymphangitis, inflammation, and adhesions on each of the parietal, visceral and diaphragmatic surfaces. A macroscopic score was developed by adding the number of abnormalities in each pleural surface to produce a total score for tumour burden. Two separate assessors correlated the findings with tumour type and pleurodesis outcome from the patient`s clinical records. Results In both mesothelioma (n=21) and non-mesothelioma (n=24), there were no significant differences between the tumour burden score and the outcome of pleurodesis (p=0.188 and 0.173 respectively). The rate of pleurodesis success was higher in the non-mesothelioma group (n=16; 66.7%) compared to the mesothelioma group (n= 9; 42.9%) with no significant difference between both groups (p=0.11) Conclusion In this study, we found no relationship between tumor burden and pleurodesis outcome. While the blinded and detailed analysis of LAT video footage is an important strength of this study, it has significant limitations, namely small numbers and retrospective methodology. Nonetheless it adds important insights that would go against our assumed understanding of this relationship between tumour burden and pleurodesis success. Further prospective evaluation in a larger cohort is underway. Consistent with the reported literature, we found that mesothelioma has a high failure rate of pleurodesis compared to non-mesothelioma patients. References Rodriguez-Panadero F. Respiration 2012; 83(2): 91–98; Bielsa S. Lung 2011;189(2): 151–155.

Background Pleural infection (PI) is a common and complicated disease. Empirical antibiotic usage has been correlated to poor clinical outcomes. Although the identification of the pathogen is essential for successful treatment, conventional culture-based pathogen detection techniques fail in approximately 40% of cases. Therefore, the bacteriology of PI remains incomplete. Next generation sequencing (NGS) is a molecular-based methodology which could be applied to metagenomics studies and improve pathogen recognition. Aim To investigate and characterise the bacterial patterns of PI. Methods Pleural fluid specimens from the ‘Pleural Infection Longitudinal Outcome Study’1 (PILOT, n=243) were subjected to bacterial DNA extraction followed by 16S rRNA NGS. The DADA2 and Phyloseq R packages were used for the analysis of the data. Results We identified 363 distinct species of bacteria, with various abundances among the samples. Diverse patterns between monomicrobial and polymicrobial PI were detected. 131 (54%) samples had one pathogen with abundance over 50% and 89 (36%) samples had at least three pathogens with relative abundance over 10%, suggesting a polymicrobial infection. Discussion We developed a methodology to extract bacterial DNA from pleural fluid specimens derived from patients with PI and the quality was satisfactory to be used for NGS. 16S rRNA gene NGS has the potential to detect the total microbiome of pleural fluid samples1 from complex PI. Funding National Institute for Health Research (NIHR) Oxford Biomedical Research Centre (BRC). Reference Corcoran, J.P., et al. Prospective validation of the RAPID clinical risk prediction score in adult patients with pleural infection: the PILOT study. Eur Respir J ( 2020).

Background: Diagnostic yield (DY) and safety of computed tomography (CT)- and thoracic ultrasound (TUS)-guided biopsies in the diagnosis of pleural lesions have been investigated in a number of studies, but no synthesis of data from the literature has ever been performed. Objectives: We aimed to provide the first systematic review and meta-analysis on the DY and safety of CT- versus TUS-guided biopsy in the diagnosis of pleural lesions. Method: We searched MEDLINE and EMBASE for all studies reporting outcomes of interest published up to April 2018. Two authors reviewed all titles/abstracts and retrieved selected full text to identify studies according to predefined selection criteria. Summary estimates were derived using the random-effects model. Cumulative meta-analysis assessed the influence of increasing adoption of the procedures over time. Results: Thirty original studies were included in the present review; the number of studies on TUS-guided biopsy was almost three-fold higher than those on CT-guided biopsy. The pooled DYs of the 2 procedures were overall excellent and differed Conclusions: Data show that CT- and TUS-guided biopsies in the diagnosis of pleural lesions are both excellent procedures, without meaningful differences in DYs and safety. Considering that TUS is non-ionizing and easily performed at the bedside, it should be the preferred approach in presence of adequate skills.

The incidence of pleural infection is rising, and most clearly in the elderly, where it is associated with the highest mortality. Despite notable limitations in animal models replicating the human pleural space, there has been some progress in our understanding of the evolution of pleural infection. Studies continue to demonstrate that the microbiology is inherently different from pneumonia, emphasising that this is a distinct disease. Great headway has been made in the last decade with regard to optimising drainage. The place of intrapleural enzyme therapy in the therapeutic armamentarium is growing in importance, with research efforts now focused on optimising dosing, administration and exploring new targets. Surgery continues to play an important role, but timing and patient selection remain unclear. An increased awareness of at-risk groups coupled with early aggressive management strategies supported by risk stratification at the time of presentation are likely to be essential components in aiding the healthcare community to improve outcomes of this morbid condition.

Although our understanding of the pathogenesis of empyema has grown tremendously over the past few decades, questions still remain on how to optimally manage this condition. It has been almost a decade since the publication of the MIST2 trial, but there is still an extensive debate on the appropriate use of intrapleural fibrinolytic and deoxyribonuclease therapy in patients with empyema. Given the scarcity of overall guidance on this subject, we convened an international group of 22 experts from 20 institutions across five countries with experience and expertise in managing adult patients with empyema. We did a literature and internet search for reports addressing 11 clinically relevant questions pertaining to the use of intrapleural fibrinolytic and deoxyribonuclease therapy in adult patients with bacterial empyema. This Position Paper, consisting of seven graded and four ungraded recommendations, was formulated by a systematic and rigorous process involving the evaluation of published evidence, augmented with provider experience when necessary. Panel members participated in the development of the final recommendations using the modified Delphi technique. Our Position Paper aims to address the existing gap in knowledge and to provide consensus-based recommendations to offer guidance in clinical decision making when considering the use of intrapleural therapy in adult patients with bacterial empyema.

Background: Pleural infection (PI) is a common and complex disease which can be life threatening for immunocompromised and elderly populations. Prior antibiotic use and special bacterial nutritional requirements hamper the accuracy of bacterial identification using current clinical culture-based techniques. Consequently, PI microbiology remains unclear. Next generation sequencing (NGS) has the potential to improve identification of the total bacterial population of a complex sample. Aim: To discover and characterise the microbial patterns of PI using NGS and bioinformatics techniques. Methods: Pleural fluid samples from the “Pleural Infection Longitudinal Outcome Study” (PILOT, ISRCTN50236700, n=243) underwent bacterial DNA extraction followed by 16S rRNA NGS using Illumina MiSeq. Data were analysed with DADA2 and Phyloseq R packages. Results: Analysis showed diverse microbiological patterns for PI as 391 different pathogens were identified up to the genus level. 131 (54%) samples had one pathogen with relative abundance over 50% and 89 (36%) samples had at least three pathogens with relative abundance over 10%, suggesting a polymicrobial infection. Streptococcus pneumoniae was detected in 40 (16%) and Staphylococcus aureus in 20 (8%) samples. Discussion: We established a methodology to extract bacterial DNA from patients with PI and used it as a template to apply NGS. 16S rRNA gene NGS provides a robust method to investigate the bacteriological patterns in pleural fluid of patients with PI. Funding: National Institute for Health Research, Oxford Biomedical Research Centre

Aim: To assess physical activity in patients with malignant pleural effusions(MPE) undergoing therapeutic interventions Background: There is no data to ascertain whether therapeutic interventions for MPE improve activity levels which are known to have a positive impact on various health related outcomes Methods: In this prospective cohort pilot study,patients undergoing a therapeutic intervention for MPE at the Oxford Pleural Unit were recruited between April 18-Nov 19. Patients with PS 4 or life expectancy Results: 20 patients were enrolled,complete data was available for 16 patients.11 patients underwent IPC insertion,3 had therapeutic aspiration and 2 had thoracoscopy+IPC for MPE management.Median volume of fluid drained was 1200 ml.Median VAS pre and post procedure was 43.5 mm(IQR 19-73) and 31 mm(IQR 19-42)respectively.The SWA was worn for a median of 2 days23hrs42 mins(on body awake time)and median % of time spent in activities worth ≥1.5 MET was 19.5% pre intervention.Post intervention,SWA was worn for a median of 2 days13hrs24mins(on body awake time) and median% of time spent in activities worth ≥1.5 MET was 13.14%.Median number of steps taken by patient pre and post intervention was 1603 and 659 respectively Conclusion: This study shows that pleural intervention didn9t have any impact on physical activity despite changes in VAS.

Background Solitary fibrous tumours of the pleura (SFTP), or pleural fibromas, are rare tumours that generally, but not universally, follow a benign course. Surgical resection is the standard treatment, but there are no evidence-based guidelines regarding the management of these tumours. Methods Five databases were searched from inception to April 1, 2019 for studies reporting on SFTP management. Results Twenty-seven studies met the inclusion criteria (1542 patients, all non-comparative case series); 98% of these patients underwent resection and all SFTP included were pathologically diagnosed. 394 out of 1299 cases (30.5%, 95% CI 27.8–32.8%) were malignant with recurrence rates of between 0% and 42.9%. A pleural effusion was always associated with a negative outcome, but no other features were consistently reported to have negative associations. Preoperative biopsies incorrectly reported malignant histology in two studies. Over 25% of cases of recurrence occurred when a complete (R0) resection had been achieved. The first recurrence occurred >5 years after the initial resection in at least 23% of cases. Conclusions There is strong evidence to support long-term surveillance after surgical resection of SFTP, even where a complete (R0) resection has been achieved; however, there is no clear evidence to inform clinicians regarding the selection of patients who should undergo resection. The rates of malignant SFTP and SFTP recurrence are higher than previously reported. Only those that were pathologically diagnosed or resected were included, which may bias the data towards more aggressive tumours. Data collection on radiologically diagnosed SFTP is required to draw conclusions regarding the timing and need for intervention., Long-term surveillance should be undertaken after a resection of solitary fibrous tumours of the pleura but further work is needed to determine which patients are likely to follow a malignant clinical course to decide timing and necessity of a resection https://bit.ly/2U10SaA

IntroductionThe rising incidence of pleural disease is seeing an international growth of pleural services, with physicians performing an ever-increasing volume of pleural interventions. These are frequently conducted at sites without immediate access to thoracic surgery or interventional radiology and serious complications such as pleural bleeding are likely to be under-reported.AimTo assess whether intercostal vessel screening can be performed by respiratory physicians at the time of pleural intervention, as an additional step that could potentially enhance safe practice.MethodsThis was a prospective, observational study of 596 ultrasound-guided pleural procedures conducted by respiratory physicians and trainees in a tertiary centre. Operators did not have additional formal radiology training. Intercostal vessel screening was performed using a low frequency probe and the colour Doppler feature.ResultsThe intercostal vessels were screened in 95% of procedures and the intercostal artery (ICA) was successfully identified in 53% of cases. Screening resulted in an overall site alteration rate of 16% in all procedures, which increased to 30% when the ICA was successfully identified. This resulted in procedure abandonment in 2% of cases due to absence of a suitable entry site. Intercostal vessel screening was shown to be of particular value in the context of image-guided pleural biopsy.ConclusionIntercostal vessel screening is a simple and potentially important additional step that can be performed by respiratory physicians at the time of pleural intervention without advanced ultrasound expertise. Whether the widespread use of this technique can improve safety requires further evaluation in a multi-centre setting with a robust prospective study.

IntroductionCurrent guidelines recommend an initial pleural aspiration in the investigation and management of suspected malignant pleural effusions (MPEs) with the aim of establishing a diagnosis, identifying non-expansile lung (NEL) and, at times, providing a therapeutic procedure. A wealth of research has been published since the guidelines suggesting that results and outcomes from an aspiration may not always provide sufficient information to guide management. It is important to establish the validity of these findings in a ‘real world’ population.MethodsA retrospective analysis was conducted of all patients who underwent pleural fluid (PF) sampling, in a single centre, over 3 years to determine the utility of the initial aspiration.ResultsA diagnosis of MPE was confirmed in 230/998 (23%) cases, a further 95/998 (9.5%) were presumed to represent MPE. Transudative biochemistry was found in 3% of cases of confirmed MPE. Positive PF cytology was only sufficient to guide management in 45/140 (32%) cases. Evidence of pleural thickening on CT was associated with both negative cytology (χ2 1df=26.27, p2 1df=10.39, p=0.001). In NEL 44.4% of patients did not require further procedures after pleurodesis compared with 72.7% of those with expansile lung (χ2 1df=5.49, p=0.019). In patients who required a combined diagnostic and therapeutic aspiration 106/113 (93.8%) required further pleural procedures.ConclusionsAn initial pleural aspiration does not achieve either definitive diagnosis or therapy in the majority of patients. A new pathway prioritising symptom management while reducing procedures should be considered.

Thoracic ultrasound is increasingly considered to be an essential tool for the pulmonologist. It is used in diverse clinical scenarios, including as an adjunct to clinical decision making for diagnosis, a real-time guide to procedures and a predictor or measurement of treatment response. The aim of this European Respiratory Society task force was to produce a statement on thoracic ultrasound for pulmonologists using thoracic ultrasound within the field of respiratory medicine. The multidisciplinary panel performed a review of the literature, addressing major areas of thoracic ultrasound practice and application. The selected major areas include equipment and technique, assessment of the chest wall, parietal pleura, pleural effusion, pneumothorax, interstitial syndrome, lung consolidation, diaphragm assessment, intervention guidance, training and the patient perspective. Despite the growing evidence supporting the use of thoracic ultrasound, the published literature still contains a paucity of data in some important fields. Key research questions for each of the major areas were identified, which serve to facilitate future multicentre collaborations and research to further consolidate an evidence-based use of thoracic ultrasound, for the benefit of the many patients being exposed to clinicians using thoracic ultrasound.

Pleural infection and malignancy are among the most common causes of pleural disease and form the mainstay of pleural practice. There has been significant research and increase in scientific understanding in these areas in the past decade. With regard to pleural infection, the rising incidence remains worrying. An increased awareness allowing earlier diagnosis, earlier escalation of therapy and the use of validated risk stratification measures may improve outcomes. In pleural malignancy, research has enabled clinicians to streamline patient pathways with focus on reducing time to diagnosis, definitive management of malignant pleural effusion and achieving these with the minimum number of pleural interventions. Trials comparing treatment modalities of malignant pleural effusion continue to highlight the importance of patient choice in clinical decision-making. This article aims to summarise some of the most recent literature informing current practice in these two areas.

Malignant pleural mesothelioma (MPM) is an aggressive cancer, associated with poor prognosis. We assessed the feasibility of patient-derived cell cultures to serve as an ex vivo model of MPM. Patient-derived MPM cell cultures (n=16) exhibited stemness features and reflected intratumour and interpatient heterogeneity. A subset of the cells were subjected to high-throughput drug screening and coculture assays with cancer-specific cytotoxic T cells and showed diverse responses. Some of the biphasic MPM cells were capable of processing and presenting the neoantigen SSX-2 endogenously. In conclusion, patient-derived MPM cell cultures are a promising and faithful ex vivo model of MPM.

Despite having been described over 3,000 years ago, pleural infection continues to be a challenging condition to treat. The last decade has seen a greater understanding of the pathogenesis and microbiology of pleural infection. There are now data to suggest that although the majority of cases are related to pneumonic consolidation, the varied microbiology and radiological findings suggest that primary pleural infection is a distinct entity requiring specific attention.

A 70-year-old male with sarcomatoid renal carcinoma presented to his general practitioner with worsening breathlessness. He was referred to the radiology department for a radiograph of the chest, which showed recurrence of a known right malignant pleural effusion (MPE) (figure 1A). After 4 days, he underwent an uncomplicated right indwelling pleural catheter (IPC) insertion and drainage. The postprocedure radiograph of the chest (figure 1B) showed improved appearances of the right MPE and a new small left pleural effusion that had been seen on the preprocedure ultrasound and likely progressed since his presenting radiograph. The radiographer’s report raised concerns that the right IPC tip …

Introduction and objectives Malignant pleural effusion (MPE) affects 15% of all patients with cancer. (1) Despite this, diagnosis can be difficult and patients are often treated with antibiotics for presumed pleural infection. While many of these cases represent initial misdiagnosis, there is a subset of patients with MPE who have comorbid infection at presentation. We attempted to quantify the proportion of patients with MPE who receive antibiotics at presentation, and evaluate how many had evidence of pleural infection. Methods All pleural fluid samples collected at our centre over the 3 years prior to December 31 2017 were retrospectively reviewed. Patients with MPE were examined to identify those that received antibiotics for pleural infection prior to their pathological diagnosis. The pleural fluid chemistry and microbiology and response to treatment were then reviewed. Results 1352 pleural fluid samples were collected over the 3-year period in 1061 patients. 335 of these individuals were diagnosed with MPE. Preliminary analysis of 67 cases demonstrated that 15 (22%) received antibiotics during hospital presentation with effusion. Of these, none had positive pleural microbiology or macroscopic pus, 1 (6.6%) had a pH Three individuals received a 4–6 week course of antibiotics for presumed comorbid empyema, with 1 demonstrating a significant reduction in inflammatory markers. The remaining 12 (80%) received shorter courses of antibiotics, without clear evidence of infection. Conclusions MPE presents with non-specific symptoms and patients can often have raised inflammatory markers. Even in the tertiary setting our ability to promptly and accurately differentiate malignancy from pleural infection is poor and often leads to unwarranted antibiotic therapy. This is likely to be associated with diagnostic delay, antibiotic related morbidity and increased healthcare costs. In most cases presumptive treatment is commenced well before the involvement of specialist pleural services. Increased education of frontline staff and new strategies, such as the routine addition of serum procalcitonin and increased acquisition of pleural biopsies, should now be studied. Reference Clive AO, Jones HE, Bhatnagar R, Preston NJ, Maskell N. Interventions for the management of malignant pleural effusions: a network meta-analysis (Review). 2018;(5).

Introduction Malignant pleural effusion (MPE) signifies advanced disease and poor prognosis, with median survival ranging from 3 to 12 months. Pleural cytology is a widely used initial investigation for MPE but has a relatively low sensitivity of around 60%1. Negative pleural fluid cytology can result in a delay in diagnosis and treatment pathways. Negative CT findings alone cannot out malignancy. Pleural biopsy provides a definitive diagnosis of malignancy in the majority of cases of MPE,1 but is more invasive and may not be suitable for every patient. Objective The aim of this retrospective analysis was to assess the relationship between CT findings that are often associated with malignancy, and pleural cytology results. Methods We performed a retrospective analysis of all patients who had a pleural aspiration between 2015 and 2017 (n=219) with either positive pleural fluid cytology or a malignant pleural biopsy following negative cytology at a UK tertiary hospital. Patients were divided into two groups according to the cytology results. Chi-Square tests were used to analyse the relationship between CT findings and cytology result. Patients with negative pleural fluid cytology who did not go on to have a pleural biopsy were excluded. Results Of the 219 patients with diagnosed MPE, fluid cytology was positive in 151 (68.9%) patients. The remaining 68 (31.1%) patients had positive pleural biopsy as the initial cytology test was negative. Thoracic lymphadenopathy on CT was associated with positive pleural fluid cytology (odds ratio [OR]=1.82; p=0.042). Pleural nodularity (OR=4.76; p Conclusions This study suggests that pleural nodularity and pleural thickening on CT are associated with negative pleural fluid cytology. In patients with such features on CT and suspected MPE, a ‘straight to pleural biopsy’ approach should be considered. Reference Hooper C, Lee YCG, Maskell Investigation of a unilateral pleural effusion in adults: British Thoracic Society pleural disease guideline 2010.Thorax 2010;65:ii4-ii17.

Background Malignant pleural effusions (MPEs) are a sign of advanced malignant disease associated with high mortality and poor clinical outcome. Management of MPEs focuses on achieving symptomatic and radiological control of pleural fluid. Recent in vitro evidence has implicated the presence of even small volumes of pleural fluid in mesothelioma progression.1 This analysis investigated whether the presence of pleural fluid is associated with poorer survival in all MPE. Methods A review of all patients diagnosed with MPE between 2015–2017 was performed. Patients were grouped as either having achieved fluid control or not from initial radiological diagnosis until death. Kaplan Meier and Cox regression analysis was performed to assess the effect of a) achieving fluid control and b) duration of fluid, on patient survival. Results Analysis of the first 100 patients in our data set included 20 mesotheliomas, 27 breast, 4 gynaecological, 8 GI, 31 lung and 10 other cancers. 27 patients achieved fluid control before death and 70 did not. The group with fluid control comprised of those with IPC removal (3), successful pleurodesis (18) and resolution without pleurodesis (6), whereas the group without fluid control included those with ongoing IPC drainage (21), stable without intervention (2) and no resolution (47) at death. Three had no radiology after the initial aspiration and were thus excluded. Fluid control was associated with greater survival in Kaplan Meier survival curve analysis (p=0.009). Similarly, the Cox regression analysis demonstrated that successful control is associated with survival (p Conclusion Our findings suggest an association between pleural fluid control and greater survival. However, a statistically significant association was also found between time exposed to pleural fluid and greater survival. We cannot exclude the possibility of unknown confounders, and time dependant analysis may demonstrate different results. Further investigations with similar subgroups such as ‘ongoing IPC drainage vs. IPC removal’ may prove useful, and further analysis are ongoing. Reference Cheah HM, et al. Respirology 2017;22:192–199.

Introduction The chest radiograph is used in clinical practice to guide decision-making in the treatment of pleural infection. This outcome was used as the primary endpoint in the randomised second Multicentre Intrapleural Sepsis Trial (MIST-2), defined as the change in area of pleural opacity, measured as the percentage of the ipsilateral hemithorax occupied by effusion, from day 1 to day 7 [1]. The value of this radiographic outcome measure as a surrogate for predicting clinically important outcomes, e.g. time in hospital (LOS), surgery at 3 months and 3-month mortality, has not been directly addressed. Methods Retrospective analyses were conducted using the prospectively collected data from the MIST-2 database (n=210). Regression analyses were modelled with number of days in hospital (linear), and surgery or death at 3 months, both individually and as a combined outcome (yes/no; logistic), as dependent variables. The independent variables were absolute change in chest radiograph opacity (MIST-2 primary endpoint) and relative change, which is more clinically applicable in daily practice (a secondary endpoint in MIST-2). Each of the analyses was corrected for day 1 radiograph appearance to account for baseline variability. SPSS v25 was used for all analyses. Results Absolute and relative change in chest radiograph opacity were associated with hospital LOS and either surgery or death at 3 months (combined outcome) with strong statistical significance (p≤0.01). Analysing the components of the combined outcome individually, absolute and relative change were associated with surgery at 3 months (p≤0.01 and p=0.021 respectively). Absolute and relative change in chest radiograph to death at 3 months alone was borderline significant (p=0.089) and non-significant (p=0.16) respectively. Conclusion These findings demonstrate that change in chest radiograph during the course of treatment of pleural infection is a robust and clinically important surrogate endpoint which appears to predict meaningful outcomes. Although surgery may be decided upon solely on the basis of the radiograph (which would explain this result), change in x-ray appearance predicts other important outcomes (length of stay). This data supports its clinical utility, and suggests its robust use as a research outcome measure.

Introduction Diagnosing pleural infection can be challenging in the clinical setting. Positive microbiology is the gold standard, but pleural fluid culture requires days to establish and can be negative in 40% of patients with pleural infection. Rapid biomarker testing showing low pH, low glucose and very high LDH in pleural fluid is used to diagnose pleural infection in the correct clinical setting. Objectives To establish the diagnostic accuracy of low pH, low glucose and very high LDH in pleural fluid for pleural infection and establish the common alternative diagnoses leading to this biochemical pattern. Methods A retrospective analysis of pleural effusion results from a UK tertiary centre over a three year period. Pleural fluid results with either pH 1000 IU/L (total 173) were assessed to establish the frequency of non-infective final diagnoses and the relative specificity of each parameter calculated for the diagnosis of pleural infection. Results Of effusions with either a low pH, low glucose or LDH>1000 (n=173), the most common causes were infective 51% (n=89), with the most frequent alternative diagnosis malignant pleural effusion (MPE) 31% (n=53). Of note 10% (n=19) had co-existing malignancy and infection. The most common causative MPEs were lung 51%, mesothelioma 32% and breast 16%. In all pleural effusions with a pH 1000 (n=129), 47% were non infective in aetiology, 30% due to MPE. Table 1 illustrates further specific diagnoses within each cohort. Conclusions Pleural effusions with a low pH, low glucose or very high LDH often have a non-infective cause. While it may be appropriate to commence antimicrobial treatment, our results suggest that malignancy should be actively investigated. Pleural fluid pH

Background Pleural infection (PI) is a common and complicated disease, bearing a heavy healthcare burden worldwide. Definitive pathogen identification based on current methods occurs in only 40% of cases, mainly due to prior antibiotic administration and special bacterial nutritional culture requirements. To this end PI microbiology knowledge remains incomplete. Novel deep sequencing techniques could increase the rate of reliable pathogen identification and shed light on the complex polymicrobial patterns of PI. Aim To investigate and further characterise the microbial nature of PI using next generation sequencing (NGS). Methods Pleural fluid samples from the ‘Pleural Infection Longitudinal Outcome Study’ (PILOT, ISRCTN50236700, n=243) underwent bacterial DNA extraction followed by 16S rRNA NGS using Illumina MiSeq. Data were analysed with DADA2 and Phyloseq R packages. Results Bacterial DNA from pleural fluid samples was successfully extracted and sequenced. NGS detected 391 diverse pathogens up to the genus level and analysis showed that PI is a polymicrobial disease. 131 (54%) samples had one pathogen with relative abundance over 50% and 89 (36%) samples had at least 3 pathogens with relative abundance over 10%. Streptococcus Pneumoniae was detected in 40 (16%) and Staphylococcus Aureus in 20 (8%) samples. Discussion It is feasible to extract and sequence bacterial DNA from pleural fluid samples from patients with PI. 16S rRNA NGS is a robust method for investigating the total bacteriology of pleural fluid samples. Funding National Institute for Health Research (NIHR) Oxford Biomedical Research Centre (BRC).

Introduction Light’s criteria is widely utilised to differentiate pleural effusions as exudative or transudative. In a subsect of pleural effusions, there is discordance between protein and lactate dehydrogenase (protein high, LDH low or vice versa). The causes of this biochemical pattern are not well established, nor are the mechanisms well understood. Objectives To establish the incidence of discordant pleural effusions, and determine demographics and common aetiologies leading to discordance. Methods We performed a retrospective analysis of initial pleural fluid samples sent between 2015–2017 (n=995) from a UK tertiary centre. 792 of these were exudative based on Light’s criteria. These were subdivided into concordant or discordant exudates, with analysis of demographics and final diagnoses in each group. Low protein was defined as Results 29% (n= 229) of exudative effusions displayed discordance in either LDH or protein. 33% of these (n=75) had low protein with high LDH and 67% (n= 154) had low LDH with high protein. The median age was significantly higher in the discordant group (75 years vs 70 years). In the discordant group with high protein, the most common diagnoses were malignant pleural effusion (MPE) 38% (n=59), cardiac/osmotic related effusions 13% (n=19), and infection 7% (n=12). The most common diagnoses in the discordant group with high LDH were infection 37% (n=30), MPE 24% (n=18), and cardiac/osmotic related 7% (n=6). In the concordant group (n=486), frequent diagnoses were MPE 42% (n=206), Infection 37% (n=132) with cardiac/osmotic related effusions only representing Figure 1 compares the percentage occurrence of specific diagnoses in concordant and discordant groups. Conclusions A significant proportion of pleural effusions that are initially classified as exudative display discordance between LDH and protein. Discordance occurs in older patients, possibly due to increased capillary permeability with age. Within discordant groups, more effusions occurred secondary to global fluid overloaded states (11% of discordant versus

BackgroundPleural infection (PI) is a major global disease with an increasing incidence, and pleural fluid (PF) drainage is essential for the successful treatment. The MIST2 study demonstrated that intrapleural administration of tissue plasminogen activator (t-PA) and DNase, or t-PA alone increased the volume of drained PF. Mouse model studies have suggested that the volume increase is due to the interaction of the pleura with the t-PA via the monocyte chemoattractant protein 1 (MCP-1) pathway. We designed a study to determine the time frame of drained PF volume induction on intrapleural delivery of t-PA±DNase in humans, and to test the hypothesis that the induction is mediated by the MCP-1 pathway.MethodsData and samples from the MIST2 study were used (210 PI patients randomised to receive for 3 days either: t-PA and DNase, t-PA and placebo, DNase and placebo or double placebo). PF MCP-1 levels were measured by ELISA. One-way and two-way analysis of variance (ANOVA) with Tukey’s post hoc tests were used to estimate statistical significance. Pearson’s correlation coefficient was used to assess linear correlation.ResultsIntrapleural administration of t-PA±DNase stimulated a statistically significant rise in the volume of drained PF during the treatment period (days 1–3). No significant difference was detected between any groups during the post-treatment period (days 5–7). Intrapleural administration of t-PA increased MCP-1 PF levels during treatment; however, no statistically significant difference was detected between patients who received t-PA and those who did not. PF MCP-1 expression was not correlated to the drug given nor the volume of drained PF.ConclusionsWe conclude that the PF volume drainage increment seen with the administration of t-PA does not appear to act solely via activation of the MCP-1 pathway.

Background: The diagnostic yield for malignancy of pleural fluid (PF) cytology in patients with pleural effusion (PE) is well known but there is scarce data in the setting of patients who developed a PE and have a prior diagnosis of cancer. Aim: The aim of our study was to evaluate the negative predictive value (NPV) of cytological examination of the PF in patients who had a background of cancer and developed PE. Method: This was a retrospective, descriptive analysis of consecutive patients who developed PE, between January 2015 to December 2017, and had a background of cancer in the Oxford Pleural Unit. Follow-up was made until death or at least one year. Results: 152 patients were included (79 -51.9%- women; mean age 71±12). 75 (49.3%) patients had a malignant PE; 48.0% of these cases were diagnosed by cytology. Sensitivity of cytological diagnoses on PE was 57.3%, specificity 100%, positive predictive value 100%, and NPV 70.6%. A background of breast cancer was the most common (39 cases) and malignancy was identified in 26 patients (66.6%) whose PF cytology was positive in 22. For patients with prior breast cancer the sensitivity of the cytological samples was 84.6% and NPV was 76.4%. Conclusion: The negative predictive value of pleural effusion cytology in patients with prior diagnosis of cancer is moderate, however, this technique confirmed the diagnosis in approximately one half of the patients with malignant pleural effusion. The negative predictive value of pleural effusion cytology in the setting of patients with previous breast cancer was slightly higher but remains insufficient to make clinical decisions as a stand alone test. Acknowledgement: European Respiratory Society (CTF201804-00345)

Background: SFTP are rare tumours arising from mesothelial parenchymal cells. The majority do not follow a malignant course, but they do have the potential to metastasise, despite the majority being considered histologically benign. Treatment is often surgical resection but there are currently no management guidelines due to the paucity of evidence. We therefore conducted a systematic review of the available literature of management of SFTP. Methods: A broad search strategy of four large databases was undertaken for any articles related to SFTP from inception of the database until November 2017. There were no randomised control trials thus large case series were the mainstay of evidence for the systematic review. Data was collected according to a pre-specified protocol and assessed by two reviewers. Results: 25 papers were suitable for data extraction from an initial review of 3447 abstracts, including a total of 1424 patients. Rates of histological malignancy and tumour recurrence ranged from between 0-57% and 0-42.9% respectively. The operative mortality ranged from 0-3.6% with 11.8% morbidity in one study. The presence of a pleural effusion was reviewed in six studies and found to be predictive of malignancy and poor outcomes in all. Conclusions, regarding the significance of size, tumour origin, pleural attachment or presence of symptoms were contradictory between studies. Malignant histological did not always predict a poor clinical outcome. Conclusions: There is significant heterogeneity between studies regarding the majority of outcomes. SFTP resection has associated morbidity and mortality and if the higher risk patients could be identified, unnecessary surgery may be able to be reduced.

Background and objectivesPleural infection is a major cause of morbidity and mortality among adults. Identification of the offending organism is key to appropriate antimicrobial therapy. It is not known whether the microbiological pattern of pleural infection is variable temporally or geographically. This systematic review aimed to investigate available literature to understand the worldwide pattern of microbiology and the factors that might affect such pattern.Data sources and eligibility criteriaOvid MEDLINE and Embase were searched between 2000 and 2018 for publications that reported on the microbiology of pleural infection in adults. Both observational and interventional studies were included. Studies were excluded if the main focus of the report was paediatric population, tuberculous empyema or post-operative empyema.Study appraisal and synthesis methodsStudies of ≥20 patients with clear reporting of microbial isolates were included. The numbers of isolates of each specific organism/group were collated from the included studies. Besides the overall presentation of data, subgroup analyses by geographical distribution, infection setting (community versus hospital) and time of the report were performed.ResultsFrom 20 980 reports returned by the initial search, 75 articles reporting on 10 241 patients were included in the data synthesis. The most common organism reported worldwide was Staphylococcus aureus. Geographically, pneumococci and viridans streptococci were the most commonly reported isolates from tropical and temperate regions, respectively. The microbiological pattern was considerably different between community- and hospital-acquired infections, where more Gram-negative and drug-resistant isolates were reported in the hospital-acquired infections. The main limitations of this systematic review were the heterogeneity in the method of reporting of certain bacteria and the predominance of reports from Europe and South East Asia.ConclusionsIn pleural infection, the geographical location and the setting of infection have considerable bearing on the expected causative organisms. This should be reflected in the choice of empirical antimicrobial treatment.

A 75-year-old man initially presented to the respiratory service in 2012 with severe chronic obstructive pulmonary disease (COPD) defined as Global Initiative for Chronic Obstructive Lung Disease stage 3. Forced expiratory volume in 1 s (FEV1) was 1.1 L (33% predicted) with FEV1/forced vital capacity 32%. He required long-term oxygen therapy at home at 4 L·min−1 and by 2015 nocturnal high-pressure noninvasive ventilation (NIV) was required due to progressive symptomatic hypercapnic respiratory failure including a carbon dioxide tension (PCO2) of 7.9 kPa and bicarbonate of 28.3 mmol·L−1., Pneumothorax is a well-recognised complication of end-stage COPD, but the management is often complex and may be complicated by other sequelae of advanced respiratory disease including the requirement for NIV http://ow.ly/vkoJ30mB4nZ

Introduction: Pleural infection is a condition that continues to pose a significant challenge to respiratory physicians. We hypothesize that the main barriers to progress include limited understanding of the etiopathogenesis, microbiology,and role of antibiotics in the pleural space. Areas covered: PubMed was searched for articles related to adult pleural infection using the terms ‘pleural infection’, ‘empyema’ and ‘parapneumonic’. The search focused on relevant literature within the last 10 years, with any older citations used only to display context or lack of progress. Tuberculous pleural infection was excluded. We chose to give specific attention to the etiopathogenesis of pleural infection, including recent advances in diagnostics and biomarkers. We discuss our understanding of the pleural microbiome and rationalize the current use of antibiotics in treating this condition. Expert commentary: Understanding of key events in the development of this condition remains limited. The microbiology is unique compared to the lung, and highly variable. Higher culture yields from pleural biopsy may add new insights into the etiopathogenesis. There is little evidence into achievable effective antibiotic concentration within the pleura. Research into issues including the relevance of biofilm formation and significance of pleural thickening is necessary for treatment progress.

Background Thoracic ultrasound (TUS) is widely used in the management of pleural disease due to high sensitivity in diagnosis of pleural pathology and widespread availability. Pleural sliding is a normal TUS finding, abolished by the presence of effusion, pneumothorax and impaired or absent following pleurodesis. Given the importance of lung sliding as a diagnostic test, this study aimed to assess the reliability, ease and interpretation of abnormal pleural sliding in a range of clinicians. Methods Seventeen delegates at a Pleural Diseases teaching course were given a short lecture on pleural sliding on TUS including clips of normal and abnormal sliding. Delegates then watched a series of 14 clips of B-mode TUS in patients who had undergone pleurodesis, and were asked to independently score the degree of sliding using one of three descriptors; present, absent or equivocal. Each clip ranged between 5–10 s and was looped until each candidate was satisfied. Before the session, candidates were divided into 3 groups according to self-rated TUS experience. Group A had advanced experience (6 candidates), group B basic experience (8 candidates) and group C limited or no experience (3 candidates). Two pleural fellows with level 1 Royal College of Radiologists TUS certification agreed on the ‘final’ scoring of the 14 clips on the same scheme as above. Results The ‘final’ score of the clips were: 5 clips showing sliding, 4 showing non-sliding and 5 equivocal. Overall, candidates agreed with the final description in 60% of the clips, with slight differences according to experience (64%, 53%, 59% for groups A, B and C respectively). Table 1 details the percentage of agreement in different sliding categories. Conclusion Overt pleural sliding appears to be relatively reliably identifiable regardless of the degree of experience in TUS. In situations where sliding is impaired to some degree, this can be more challenging. This has important implications on the applicability of using TUS to diagnose diseases such as pneumothorax, which mainly manifests as lack of pleural sliding.

Background SFTP are rare tumours arising from mesothelial parenchymal cells and are often benign, although a proportion may follow a malignant course. Treatment is often surgical resection but there are currently no management guidelines due to the paucity of evidence. We therefore conducted a systematic review of the available literature of management of pleural fibromas. Methods A broad search strategy of four large databases was undertaken for any articles related to the management of SFTP from inception of the database until November 2017. There were no randomised control trials thus large case series were the mainstay of evidence for the systematic review. Data was collected according to a pre-specified protocol and assessed by two reviewers. Results 25 papers were suitable for data extraction from an initial review of 3447 abstracts, including a total of 1424 patients. 15/25 papers only included patients with SFTP who underwent a resection. The majority of papers required a histological diagnosis for the patient to be included in the study. Rates of recurrence ranged from 0% to 42.9% and tumour sizes ranged from 0.3 cm to 39 cm. The follow up interval for the studies was variable. 11/14 studies had no operative mortality, and one reported a mortality of 3.6% and morbidity of 11.8%. 5 studies evaluated whether tumour size affected outcomes, 2 showed poorer outcomes with larger size tumours but 3 did not show any association. 2/6 papers showed that the presence of malignant criteria did not significantly predict a greater likelihood of recurrence, likewise there were conflicting results regarding tumour origin and the type of attachment to the pleura affecting recurrence. Conclusion A number of factors could have affected the wide range of recurrence rates including the duration of follow up, bias due to the nature of patients referred to and operated on in each centre and size of tumour resected. Although the operative mortality is low, the risk exists and published data collected rarely includes patients who underwent conservative management. Information on patients who do not undergo surgical resection and are radiologically followed are poorly represented in the published literarture, and this now needs to be collated to allow clinicians to evaluate the pertinent risks and benefits when considering management of these patients.

Introduction Malignant pleural mesothelioma (MPM) is primarily associated with asbestos exposure. Prognosis is poor, with median survival quoted as 6–12 months. Although uncommon, incidence has been steadily increasing and is predicted to peak in 2020. The National Lung Cancer Audit report on MPM (2015), demonstrated significant variation in management and outcomes across the UK and subsequently lead to the production of the British Thoracic Society Guideline for the investigation and management of MPM (2017). This included the recommendation for regional mesothelioma MDTs. We present the findings from the first 15 months of the regional MDT in Oxford and its impact on other recommendations contained within the guidelines. Method Complete follow up data was collected prospectively from all patients with MPM treated at the Oxford Pleural Unit since 2005. Following the establishment of a mesothelioma MDT in March 2017, 39 patients have been diagnosed and discussed at this meeting. These cases were compared with the 39 preceding cases to assess the impact of the introduction of a specialist MDT. Results Demographics between both groups were similar. Average age was 77.4 in the MDT group versus 73.8. Sex showed a male predominance in both groups of 82.5%. There was some variation in the distribution of histological subtypes within the groups, however there was an improvement in the number of patients with a clinical diagnosis, no histological subtype or those requiring post-mortem, although sample size was inadequate to achieve significance (table 1). There was no difference in the number of patients being considered for enrolment in clinical trials (33% versus 36%) however there were significant increases in the number of patients who had prognostic scores calculated (54% versus 0%) and those who had formal staging documented (56% versus 21%, p=0.001). Discussion Mesothelioma MDTs appear to improve documentation and communication of disease stage and prognosis. Further improvement in this area and in the consideration of enrolment in clinical trials may be possible with the introduction of an MDT proforma. Further work is required to assess the impact on diagnostic accuracy which might be best achieved by joint MDT working to obtain required numbers.

Introduction Indwelling pleural catheters (IPC) are an increasingly attractive option for patients wishing to avoid hospitalisation as they reduce length of stay. However, non-draining IPC-related symptomatic loculation occurs in 8.4%–13.5% of patients,1 and requires further procedures to break down septations and drain fluid more freely.2 Fibrin deposition facilitates autopleurodesis but can also induce septations and loculations within pleural fluid, impairing effective fluid drainage in patients with symptoms of accumulated fluid. Given the larger pleural tumour load and larger area of pleura involved with mesothelioma than with other MPEs,3 mesothelioma may have an increased risk of fibrin deposition. Aim To assess whether mesothelioma is associated with increased rates of IPC-related non-draining symptomatic septated pleural effusion. Method IPC insertion records for MPE between 2008 and April 2017 were analysed retrospectively, and data collected from medical records, including whether prior intrapleural talc was administered or not (since talc may give rise to septated effusion). Fisher’s exact test was used to compare the frequency of complicated septated effusions between patients with mesothelioma (mesothelioma MPEs) and those with other malignancies (non-mesothelioma MPEs). Non-draining symptomatic septated effusions were defined as pleural effusions identified to be septated on ultrasound, associated with shortness of breath and/or cough, and not draining adequately via the IPC. Results 181 IPC insertion cases were analysed. Mean age at IPC insertion was 67.6 years (SD 13.9), 48% were female(n=87). 38 (21%) were mesothelioma MPEs and 143 (79%) were non-mesothelioma MPEs; 3 (7.9%) and 5 (3.5%) developed IPC-related non-draining symptomatic septated effusions respectively (p=0.4). There was no significant difference in rates of IPC-related non-draining symptomatic septated effusions between patients who had received prior ipsilateral talc pleurodesis and those who had not: in mesothelioma MPEs (p=1.0), in non-mesothelioma MPEs (p=1.0). Discussion There was no statistically significant difference in rates of IPC-related symptomatic septated pleural effusion between patients with mesothelioma and non-mesothelioma MPE, although this data is limited by the retrospective study design and by relatively small numbers of non-draining IPC-related symptomatic septated pleural effusions. References Tremblay A, et al. Chest2006;129(2):362–8. Thomas R, et al. Chest2015;148(3):746–51. Fysh ETH, et al. Thorax2013;68:594–6.

Background SFTP are rare tumours arising from mesothelial parenchymal cells. The majority follow a benign course, but these tumours do have the potential to metastasise. England et al developed a set of criteria to define which tumours are malignant including mitotic index, cellularity, pleomorphism, haemorrhage and necrosis. SFTP are heterogenous and a malignant diagnosis can be missed if limited areas are examined, although histologically benign tumours can still follow a malignant course. There is no agreed treatment or management strategy for SFTP – we therefore performed a systematic review of the available literature regarding the diagnosis of benign versus malignant SFTP. Methods A broad search strategy of four large databases was undertaken for any articles related to SFTP from inception of the database until November 2017. There were no randomised control trials thus large case series were the mainstay of evidence for the systematic review. Data was collected according to a pre-specified protocol and assessed by two reviewers. Results 21 papers were suitable for data extraction for this question from an initial review of 3447 abstracts. Rates of malignancy ranged from 0% to 57%. The criteria proposed by England et al was used in 14/21 papers with another 4/21 using part of this criteria. 8/21 studies specifically assessed factors which could help differentiate between malignant and benign tumours. 6/8 studies found that large tumours were more likely to be malignant. 3/3 studies showed that the presence of a pleural effusion was associated with malignancy. Non-visceral origin and sessile attachment were not found to have any association in 3/4 studies. There was no association with age and likelihood of a malignant diagnosis. Further associations were reported in solitary papers such as PET avidity, inverted tumours, hypervascularity, lobulated margins and fibrous adherences. Conclusion Features such as size and the presence of a pleural effusion suggest a SFTP is likely to be histologically malignant. Previous criteria such as sessile attachment and non-visceral origin are not consistently predictive of malignancy. Whilst being able to identify which SFTP are likely to be malignant is important, benign tumours can still follow a malignant course and thus further work is needed to identify all tumours which require a more aggressive management/monitoring strategy.

Background Talc pleurodesis is one of the main treatment lines for malignant pleural effusion (MPE). There is data to suggest that survival is better in MPE patients who receive talc pleurodesis in comparison to patients who do not choose to have this treatment.1 It has been suggested that successful pleurodesis is accompanied by an acute inflammatory response, and this may suggest a possible mechanism of improved survival.2 This is a post-hoc analysis from the TIME1 trial dataset investigating whether there is difference in survival according to the outcome (i.e. success or not) of pleurodesis. Methods Data from the TIME 1 RCT was analysed assessing pleurodesis success and survival. Success was defined as no further pleural procedures for up to 3 months post pleurodesis. Patients had undergone either thoracoscopic talc poudrage or talc slurry via chest drain. Results Data was available for 266 patients, of whom 208 patients (78%) had a successful pleurodesis. The mean age of patients was 72±9 years. The most common malignancies were mesothelioma, lung cancer and breast cancer (25, 22% and 13% respectively). The mean survival time for those with successful pleurodesis was 12 months (95% CI 10.2 to 14 months) months and in those with failed pleurodesis was 7.3 months (95% CI 6–8.6 months). Figure 1 shows the Kaplan-Meier survival curve for the study patients split by pleurodesis outcome (Log rank test: p 0.004). Conclusion Survival appears to be worse in MPE patients who fail pleurodesis. This might suggest a deleterious biological effect of persistent malignant pleural effusion, differences in stage of disease or an intrapleural inflammatory response leading to enhanced immune response to malignant cells. These findings require further exploration. References Korsic M, et al. Talc pleurodesis improves survival of patients with malignant pleural effusions: Case-control study. Wien Klin Wochenschr2015;127(23–24):963–969. Mercer R, et al. Does inflammation predict successful pleurodesis? A post hoc analysis from the TIME 1 trial. Thorax2017;72(Suppl 3):A77.2–A78.

Introduction It is well established that when associated with infection, pleural effusions carry a significant morbidity and mortality. Sonographic septations are assumed to be associated with poor fluid drainage and some clinicians use this radiological parameter as an indication to proceed directly to surgical drainage, but the evidence for this was unclear. We therefore undertook a literature review to assess the relationship between septations and pleural infection outcome. Methods A systematic literature search was conducted using Medline (1946 to present), Embase (1974 to present), Cochrane database of systematic reviews, Cochrane Central Register of Controlled Trials, Scopus and Web of Science Core Collection. The search did not restrict on language and included all age groups. Septated effusions were captured using the following MeSH terms; [septations, septae, locules, loculations, septated pleural effusions, pleural infection, empyema and parapneumonic effusion]. The outcomes assessed included length of hospital stay, mortality, sepsis, surgery, VATS, decortication, intensive care, death and a number of patient centred outcomes. Results The search resulted in a total of 267 publications. After de-duplication, two researchers independently reviewed the remaining 136 papers for inclusion criteria. Only 6 papers examined baseline sonographic appearances and related these to outcomes, and these were further evaluated. Apart from one, these were all retrospective studies (see table 1). Only 2 similar papers from the same group (Chen et al) addressed our question directly and concluded that patients with a complex septated sonographic pattern have a poorer prognosis. Lai et al specifically addressed septations as a predictor of residual pleural thickening in tuberculous pleurisy. Whilst some papers suggested that the presence of loculations carries a prognostic value and possibly indicate need for early surgery (Cheng et al, Bongiolatti et al), others (Kearney et al) concluded that no sonographic findings reliably influence outcomes. Conclusion This systematic review demonstrates that there is a paucity of evidence linking septations and outcome in pleural infection. Previous large pleural infection trials (MIST1 and MIST2) were conducted prior to the era of common ultrasound. The oft-held belief that a septated effusion requires upfront surgical treatment is not currently evidence based and necessitates urgent further prospective studies.

Background Indwelling pleural catheters (IPCs) are used to manage recurring effusions in patients with symptomatic malignant pleural effusion (MPE). A subset of these patients will have had previous failed talc pleurodesis. This study aims to look at the rate of autopleurodesis (and the time to achieve this) in IPC patients who had received previous talc compared to those who had not. Methods All IPC insertion records for MPE between 2008 and April 2017 were analysed retrospectively. Data on previous ipsilateral pleural procedures, including attempted talc pleurodesis performed prior to the IPC insertion, and details about IPC insertion outcomes were collected from the medical records. Autopleurodesis was defined as minimal or no output via IPC, with subsequent IPC removal. Results 181 IPC insertions for MPEs were recorded, but 2 insertions were excluded due to insufficient data about IPC removal date and reason for removal (n=179 analysed further). 68 patients (38%) had received prior talc (60 received talc once; 8 received talc twice); while 111 (62%) had not received prior talc. IPC was subsequently removed due to autopleurodesis in 23 of the 68 (33.8%) who had received prior talc after a median 105 days (IQR 91) (an additional IPC was removed because of pain 4 days after insertion). IPC was subsequently removed due to autopleurodesis in 37 of the 111 (33.3%) who had not received prior talc after a median 104 days (IQR 83.5) (3 more IPCs removed in this group for other reasons). There was no difference in rates of autopleurodesis between patients who had received prior talc and those who had not (X2 0.0045, p=0.946). When comparing time to autopleurodesis, there was no statistically significant difference between the 2 groups (2 tailed Mann Whitney test, p=0.29). Conclusion There does not seem to be a difference in the rate of autopleurodesis between patients who had previous failed talc pleurodesis and those who chose IPC in the first instance. Further studies are needed to investigate whether the pleural space in certain patients is inherently resistant to different forms of pleurodesis.

Introduction: Pleural fluid (PF) cytology was previously sufficient to guide oncological treatment. In the current field of personalised medicine, this may not be the case and it is frequently necessary to obtain a tissue sample even when the PF cytology demonstrates malignant cells. This raises the question of the role of PF cytology in the diagnostic pathway of patients with malignant pleural effusion. Aims & Method: All patients who had a procedure performed by the pleural service between 2015 - 2017 were included. Those with PF demonstrating malignant cells were reviewed to determine whether further tissue was required. Those with concurrent pleural histological samples were excluded. Results: 107 patients had positive PF cytology. No further testing was needed in 49 patients; 33 already had a pathological diagnosis and 16 were too unwell for treatment or followed up elsewhere. PF was sufficient to test for receptor or mutation status in 33/58 (57%) patients, 19 (33%) required further pleural biopsies and 6 (10%) underwent alterative procedures to obtain tissue. 52/58 patients had adenocarcinoma cells in the PF. Conclusions: PF cytology was sufficient for definitive oncological treatment in 57% of patients. Further work is needed to determine characteristics which would highlight which patients are likely to need further tests to guide treatments and in which patients PF will be sufficient.