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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)

Indwelling pleural catheter (IPC)-related pleural infection, though uncommon, remains a major concern. Intrapleural tPA/DNase improved non-IPC pleural infection outcomes and reduced surgical referrals but its use in IPC-related infection has not been reported. A retrospective review of IPC infections treated with tPA/DNase was performed at 6 specialist pleural units across Australia, UK and USA to determine the safety and efficacy of this approach. Demographics, treatment and outcomes are reported. Treatment success is defined as survival to discharge without surgery. tPA/DNase was used to treat 52 IPC-related infections from 2008-2018. Follow-up to death or last clinic post-infection was a median of 91 [30.25–271] days. The majority were malignant effusions (89%). IPC infection occurred at a median of 64 [13–137] days post-insertion. Presenting features included reduced IPC output (61%), fever (54%) and fluid purulence (48%). Pleural fluid cultures were positive in 87% of patients, predominantly S. Aureus (31%) and gram-negative bacilli (42%). All patients were treated with intravenous antibiotics (85% beta lactams) for a median of 15 [11.5–25.5] days. The median number of tPA/DNase doses was 3.5 (2–6). Treatment was successful in 87%. Two patients underwent successful VATS and 5 patients, all of whom had advanced cancer or comorbidities, died. Fifteen patients (28.8%) required a drainage procedure. IPC was removed in 36 patients (77.8% were due to pleurodesis). There were no major complications of treatment. Intrapleural tPA/DNase therapy can be safely administered via IPC for pleural infection and appears to be effective.

Background: Malignant pleural mesothelioma (MPM) is an incurable and aggressive malignancy, which is typically presented with malignant pleural effusion (MPE), bearing severely comprised quality of life and short survival. Since management of MPE remains symptomatic and targeted MPM treatments are not available the development of translational models to improve patients’ stratification are desperately needed. Aim: To establish a panel of patient derived MPM cell lines which can serve as a faithful model for the discovery of novel mutations and the development of targeted treatments. Methods: MPE samples from MPM patients were collected and cultured to establish a pure cancer cell population. To cross-examine the genomic background of the MPM cells between different passages, a proportion of the cells was kept from each passage. Results: We established a panel of 18 primary personalised mesothelioma cell (PMC) lines. Phenotypically PMC lines exhibited pleomorphic, atypical and often multiple nucleoli. In vitro, the cells were immortal and able to form colonies and tumour-spheres. A high-throughput drug screening assay was used to identify the cluster of the most potent anticancer drugs, demonstrating a heterogeneous response for each PMC line. Genome profiling revealed no major differences for important cancer genes among the passages. T cells from the MPEs were isolated, cultured and examined regarding their cellular and molecular phenotype. Conclusions: We developed a methodology to establish patient derived MPM cell lines which could potentially be used as tools to refine patients’ management.

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: Echogenic swirling (ES) is commonly seen on ultrasound (US) examination of malignant pleural effusion (MPE) and has been hypothesised to be related to enhanced intrapleural fibrinolytic activity.(1) Pleurodesis is commonly offered to MPE patients. Previous markers studied for prediction of pleurodesis outcome (e.g. glucose, pH) were not found to be robust. This study aimed to investigate if ES is associated with effusion recurrence. Methods: Patients with MPE, who had pleurodesis at our unit between 2016-2017 and had assessable US videos or images were included. Cases with non-expandable lung following fluid evacuation were excluded. Pleurodesis failure was defined as fluid recurrence on one month X-ray or need for further interventions in 3 months. Results: 37 cases met inclusion criteria. The primary cancer was mesothelioma in 18 patients, breast in 7 and lung in 6. Failure rate of pleurodesis was 48%. ES was seen in 14/18 cases with failed pleurodesis, while it was seen in 5/19 cases with successful pleurodesis (Chi square 9.7, p value 0.003). There was no significant difference in fluid protein level (median (IQR) of 46 (42-48) g/L in success group vs 40 (35-44) g/L in failure group) or LDH level (median (IQR) 270 (182-432) IU/L in success group vs 188 (99-940) IU/L in failure group). No significant difference in pleurodesis outcome was noted according to the primary tumour. Conclusion: ES seems to be associated with a higher rate of pleurodesis failure in patients with MPE. This needs to be validated in prospective fashion in a larger patient cohort and to be correlated to other variables such as cytological positivity and degree of pleural thickening.

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.

Background: Pleural effusion echogenicity on ultrasound has previously been suggested to allow identification of exudates. A case series suggested that homogenously echogenic effusions are always exudates. With modern imaging techniques and more advanced ultrasound technology, this may no longer be true. Objectives: This study aims to prospectively assess the predictive value of echogenicity in the identification of exudates. Method: Patients undergoing thoracic ultrasound before pleural fluid sampling were analysed prospectively (n = 140). Pleural fluid was classified as an exudate if both fluid total protein (TP) > 29 g/L and fluid lactate dehydrogenase (LDH) > 2/3 upper limit of normal serum LDH (which is 255 IU/L in females and 235 IU/L in males) were present. If only one of these criteria was met, the effusion was considered to have discordant biochemistry. Results: Fifty-five (39%) patients had non-echogenic and 85 (61%) had echogenic effusions. Six (7.1%) patients with echogenic effusions had transudates; the median fluid TP for this group was 18.5 g/L (IQR 9.75) and median LDH 63.0 IU/L (IQR 40.3). The specificity of echogenicity identifying exudates from transudates, excluding patients with discordant biochemistry, was 57.1%, positive predictive value (PPV) 90.3%, sensitivity 65.1%, and negative predictive value (NPV) 21.0%. The specificity of echogenicity identifying exudates (including discordant biochemistry) from transudates was 57.1%, PPV 92.9%, sensitivity 62.7%, and NPV 14.5%. Conclusions: Echogenicity of a pleural effusion has a low specificity for identifying an underlying exudate, and the echogenic qualities of the fluid should not influence clinical decision-making.

Introduction: Patients with malignant pleural effusions (MPE) have a poor life expectancy and a high symptom burden. Definitive management strategies include chest drain and pleurodesis or placement of an indwelling pleural catheter. A meta analysis showed that 76% - 82% of patients had a successful pleurodesis with sterile talc. It has been postulated that patients who experience a greater inflammatory response or experience more pain are more likely to have a successful pleurodesis. Trapped lung is associated with a lower rate of pleurodesis success and it is thought that the number of previous interventions may be related to the development of trapped lung. Methods: A post hoc analysis from the TIME 1 trial was undertaken to establish the accuracy of these hypotheses. 320 patients were included who had a diagnosis of MPE. Results: There was a correlation between the number of previous ipsilateral aspirations and the incidence of trapped lung (p=0.015). Conclusion: Inflammation may play a factor in pleurodesis success as patients with a greater rise in CRP were more likely to have a successful pleurodesis. There is no evidence to support the hypothesis that patients who have more pain are more likely to have a successful pleurodesis. The correlation between the incidence of trapped lung and previous pleural interventions needs further study into whether or not there is a causal relationship.

Background: Malignant pleural effusion (MPE) is a common cause of a recurrent pleural effusion, and a common indication for indwelling pleural catheter (IPC) insertion. The relationship between treatment time with IPC and survival has never been investigated in patients with MPE. Aim: To analyse survival times in patients with MPE from the date of symptomatic effusion requiring IPC insertion, according to when the IPC was inserted in the treatment course. Method: Details of patients who had IPC insertions for MPE between the years 2008-2015 were collected from our procedure database and analysed against the clinical records. Results: 146 cases (72 female; mean age 68 years) were studied. The commonest primary malignancies were lung (25%), breast (21%), and mesothelioma (20%). 34 cases were excluded due to incomplete data, 11 were still alive. In the remaining 101, 41.6% had a primary malignancy diagnosed prior to pleural effusion being diagnosed (Group A), 58.4% had the first pleural effusion diagnosed prior to the malignancy being diagnosed (Group B). 93% of the study population had died by January 2017. Overall survival time was a mean of 453 days after IPC insertion. In Groups A and B, there was a mean of 136.1 days and 214.9 days respectively between IPC insertion and death ( p Conclusion: Time between IPC insertion and death varies significantly between patient groups according to whether malignant effusion is diagnosed prior to the diagnosis of malignancy elsewhere or if MPE is the primary cause of diagnosis. Further analysis by tissue type, chemotherapy and performance status is required to identify factors that influence survival time in patients treated with IPC.

Malignant pleural mesothelioma (MPM) is an aggressive and fatal disease that typically presents with breathlessness, chest pain or both [1] and is usually a unilateral disease but 3% of patients have malignant disease bilaterally at presentation [2]. The latency period between exposure to asbestos and MPM development is between 20–40 years. Footnotes This manuscript has recently been accepted for publication in the European Respiratory Journal . It is published here in its accepted form prior to copyediting and typesetting by our production team. After these production processes are complete and the authors have approved the resulting proofs, the article will move to the latest issue of the ERJ online. Please open or download the PDF to view this article. Conflict of interest: Dr. Hassan has nothing to disclose. Conflict of interest: Dr. Tsikrika has nothing to disclose. Conflict of interest: Dr. Asciak has nothing to disclose. Conflict of interest: Dr. Mercer has nothing to disclose. Conflict of interest: Dr. El-Ganady has nothing to disclose.

IntroductionRespiratory trainees in the UK face challenges in meeting current Royal College of Radiologists (RCR) Level 1 training requirements for thoracic ultrasound (TUS) competence, specified as attending ‘at least one session per week over a period of no less than 3 months, with approximately five scans per session performed by the trainee (under supervision of an experienced practitioner)’. We aimed to clarify where TUS training opportunities currently exist for respiratory registrars.MethodsData were collected (over a 4-week period) to clarify the number of scans (and therefore volume of training opportunities) within radiology departments and respiratory services in hospitals in the South West, North West deaneries and Oxford.Results14 hospitals (including three tertiary pleural centres) provided data. Of 964 scans, 793 (82.3%) were conducted by respiratory teams who performed a mean of 17.7 scans per week, versus 3.1 TUS/week in radiology departments. There was no radiology session in any hospital with ≥5 TUS performed, whereas 8/14 (86%) of respiratory departments conducted such sessions. Almost half (6/14) of radiology departments conducted no TUS scans in the period surveyed.ConclusionsThe currently recommended exposure of regularly attending a list or session to undertake five TUS is not achievable in radiology departments. The greatest volume of training opportunities exists within respiratory departments in a variety of scheduled and unscheduled settings. Revision of the competency framework in TUS, and where this is delivered, is required.

Background Mesothelioma is an aggressive and incurable malignancy which typically presents with malignant pleural effusion (MPE) and is strongly associated with shortened life expectancy and compromised quality of life. Management of MPE remains symptomatic and current mesothelioma chemotherapy regiments only prolong survival by approximately 10 weeks. The development of novel treatments and translational models to improve patients’ management are desperately needed. Aim To develop a panel of human mesothelioma cell lines suitable for high-throughput drug screening and discovery of novel therapies. Methods MPE samples from patients with mesothelioma who underwent pleural fluid aspiration were collected and cultured for at least 20 passages to establish a pure cancer cell population. The cells were grown until 70%–80% confluency before passaging. Between every passage a proportion of the cells was frozen and kept as a backup to cross-examine the genetic profile. T-cells from the MPEs were isolated and cultured to examine the potency of anticancer immunotherapies. To enrich our panel, early passage primary cells derived from pleural biopsies (MesobanK, UK) were grown to pure cancer cell lines. Results We established a panel of 30 primary personalised mesothelioma cell (PMC) lines, with a success rate of 65% (30/48). The cells were immortal, exhibited colony formation, pale cytoplasm and nuclear atypia. An anticancer drug library was used to perform a preliminary high-throughput drug screening assay on 3 of the PMC lines (figure 1). Cell viability was measured 48 hours post treatment and each agent’s response was compared to pemetrexed/cisplatin (z-score). Average Z-Factor for responsive cell lines was 0.6 suggesting the screen performed as expected. Results demonstrated the heterogeneous drug response between different patients. T-cells were successfully cultured from MPEs with a potential to examine T-cell antigen specific treatments. Conclusions We designed and developed a methodology to establish patient derived mesothelioma cell lines that can be used as tools for the discovery of novel treatments and to refine management.

Background Pleural infection (PI) is a major global disease with an increasing incidence. Pleural fluid (PF) drainage is essential for the successful treatment of PI. The MIST 2 study showed that the intrapleural administration of t-PA and DNase, or t-PA alone increases the volume of drained PF. A mouse study suggested that the volume increase is due to the interaction of the pleura with the t-PA via the MCP-1 pathway. Aim To test the hypothesis that PF volume induction is mediated by the MCP-1 pathway. Methods For the MIST 2 study 210 PI patients were randomised to receive for 3 days either: t-PA and DNase, t-PA and placebo, DNase and placebo or double placebo. Daily PF drainage was recorded and samples of PF were stored. PF MCP-1 levels were measured by ELISA. Results During treatment (days 1–3) t-PA +DNase and t-PA +placebo significantly increased (ANOVA p 0.05) between any of the groups during the post-treatment period (days 5–7). t-PA +DNase and t-PA groups triggered significantly higher (ANOVA p Conclusions Intrapleural administration of t-PA (±DNase) stimulated a statistically significant rise of the volume of drained PF. The MCP-1 pathway did not correlate with PF volume output. We conclude that the PF increment seen with the administration of t-PA does not occur solely via activation of the MCP-1 pathway. Funding National Institute for Health Research (NIHR) Oxford Biomedical Research Centre (BRC).

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.

Introduction Malignant pleural effusion (MPE) is common and indicates advanced malignancy. Indwelling pleural catheters (IPC) are used in recurrent MPE. To date, there has not yet been a reliable mouse model of MPE utilising IPC, and such model would be useful especially since intrapleural therapy for malignancy is a burgeoning area of research, and IPC provides direct access to the pleural space with the potential of testing novel treatment agents. Aim To design the first experimental mouse model with IPC. Method 250,000 Lewis lung carcinoma (LLC) cells were injected into the pleural space of anaesthetised C57BL/6 mice. 7–9 days are required for development of MPE from time of LLC intrapleural injection,1 so on day 7, the IPCs were inserted: 3 punctures were made at distal end of a polyurethane tube (PU-40) to enhance catheter flow; a small puncture was made through the 7th rib space in mid-axillary line of the mice. PU-40 was advanced 1.5 cm into the pleural space. A 16G needle was used to puncture the dorsum between scapulae, and advanced through subcutaneous tissue towards catheter insertion site. Proximal end of PU-40 tube was then passed through needle and out between the scapulae, leaving IPC tunnelled through the subcutaneous space. MPE was drained while mice were still under anaesthesia. Results Mean volume of fluid drained (n=19) was 188 ul (range 0–770 uL). Post-mortem dissection demonstrated bulky tumour with minimal residual MPE (n=17). Occasionally, IPC was enveloped by tumour, blocking MPE drainage, with resulting residual MPE within pleural space (n=2). IPC was also useful to allow intrapleural drug delivery. Potential agents could be injected through IPC using a 22G syringe by means of a syringe accessible port. A typical volume of 100 uL phosphate buffer solution was well tolerated by mice. Discussion This novel mouse model seeks to mimic MPE drainage using an IPC in humans, and allows MPE aspiration as well as drug delivery to the pleural space. This model will enable the testing of the use and effectiveness of intrapleural therapies in the treatment of MPE. Reference Stathopoulos GT, et al. AJRCMB2006;34(2):142–50.

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.

Malignant pleural effusion (MPE) is an indicator of advanced stage malignancy. There are an estimated 150 000 to 200 000 cases of MPE diagnosed annually in the USA [1]. During the past 10 years, the types of cancer treatment and pleural procedures available for MPE have expanded leading to improved stratification and better individualisation of treatment [2]. A recently published prognostic score (PROMISE score) improved prediction of the 3 month risk of death in patients with MPE, thereby improving the selection of appropriate management strategies [3]., This novel mouse model mimics malignant pleural effusion drainage using an indwelling pleural catheter in humans, and provides direct access to the pleural space potentially enabling the testing of intrapleural therapies in the treatment of MPE. bit.ly/2W2kzO0

Introduction Malignant Pleural Mesothelioma (MPM) is the only malignancy which develops primarily in the pleural space and is a common cause of a malignant pleural effusion (MPE). MPE associated with MPM is managed similarly to any other malignancy, but it is unclear if the underlying mechanisms of fluid accumulation are the same and whether different treatment strategies should therefore be employed. The TIME 1 trial enrolled patients with MPE who underwent pleurodesis. This post hoc analysis compares the outcomes of patients with MPM to the rest of the trial population. Methods 298 patients had available data on their final diagnosis. A number of different variables were compared, including pleurodesis success, systemic inflammation, the prevalence of trapped lung, total fluid volume drained and baseline pain Visual Analogue Score (VAS). Results Of the 298 patients included in the analysis 110 patients had mesothelioma (36.9%). Post pleurodesis, MPM patients had a significantly greater rise in CRP than those with other underlying pathologies but had a significantly lower rate of successful pleurodesis. Patients with MPM had a lower pain VAS score on enrolment. There was no significant difference in the rates of trapped lung, the total volume of pleural fluid drained or the change in White Cell Count (WCC) between the groups. Conclusion There are significant differences in the outcomes of patients with MPM and those with other MPE. Patients with MPM had a lower pleurodesis rate but a significantly greater change in C-reactive protein levels post pleurodesis, signifying a higher inflammatory response to pleurodesis, which has been assumed to associate with pleurodesis success. The mechanisms causing the increased inflammatory response in MPM are unclear. The basis for the lower rates of pleurodesis is unexplained, especially as there was no significant different in the rates of trapped lung. Patients with MPM had a lower level of pain VAS scores on enrolment but further analyses are needed to determine whether this is clinically relevant and reproducible. These data indicate that MPM behaves differently to other forms of MPE and treatment strategies should be tailored towards MPM as a separate entity.

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.

Background: Pleural infection is an important cause of morbidity. Timely start of antibiotic treatment is necessary. Successful empiric treatment relies on knowledge of local bectoriologic pattern of infection. The bacteriologic niche is known to differ between hospital acquired (HA) and community acquired (CA) infections. Methods: We conducted a literature search on pleural infection bacteriology. MEDLINE and EMBASE were searched for all papers on the subject between 1997-2017. Papers reporting on paediatric or tuberculous patients were excluded. Results: 275 papers were found to include novel and relevant microbiology data. Of those, 11 papers specified what the setting of the infection was (CA vs. HA). The total number of patients reported was 1523 (1097 with CA vs 426 with HA infection). The median (IQR) per cent positivity of pleural fluid culture was 69% (48-77%). The median (IQR) of the mean ages of patients was 64 (55-66) years. Table one displays a comparison between the 2 groups. The Viridans Strept. group comprises the Strept. milleri subgroup and other microaerophilic strept. Conclusion: There are considerable differences of bacteriology pattern between CA and HA pleural infections. Streptococcal infection is the most common in CA, while Staph. aureus and enteric bacteria are more common in the hospital setting.

Background: Chest drains often become displaced and require replacement, adding unnecessary risks to patients. Simple measures such as suturing of the drain may reduce fall-out rates; however, there is no direct data to demonstrate this and no standardized recommended practice that is evidence based. Objectives: The study aimed to analyze the rate of chest drain fall out according to suturing practice. Methods: Retrospective analysis of all chest drain insertions (radiology and pleural teams) in 2015–2016. Details of chest drain fall out were collected from patient electronic records. Drain “fall out” was pre-hoc defined as the drain tip becoming dislodged outside the pleural cavity unintentionally before a clinical decision was taken to remove the drain. Results: A total of 369 chest drains were inserted: sutured (n = 106, 28.7%; 44 male [41.5%], median age 74 [interquartile range (IQR) 21] years), and unsutured (n = 263, 71.3%; 139 male [52.9%], median age 68 [IQR 21] years). Of the sutured drains, 7 (6.6%) fell out after a mean of 3.3 days (SD 2.6) compared to 39 (14.8%; p = 0.04) unsutured drains falling out after a mean of 2.7 days (SD 2.0; p = 0.8). Conclusions: Within the limits of this retrospective analysis, these results ­suggest that suturing of drains is associated with lower fall-out rates.

Maged Hassan (MH): I would like to present three cases of patients who presented with symptoms of lower respiratory tract infection, fever and cough productive of small amount of sputum. The three patients had complained of symptoms for at least 2 weeks before presentation. The chest X-rays showed large encysted collections (figure 1A) which required chest CT to delineate the source of the abnormality. The CT studies (case 1: figure 1B, C; case 2: figure 2A and case 3: figure 2C) caused prolonged discussion between the treating clinicians with opinions divided on the nature of the lesion in each case being either an encysted empyema or a large peripheral lung abscess. Clinically, the differentiation between empyema and lung abscess was important because empyema is treated with tube drainage which is only resorted to in limited situations in lung abscess with the attendant risk of creating a bronchopleural fistula or extending the infection to the pleura. Figure 1 Case 1. (A) Chest X-ray shows right side cavity with air-fluid level. (B) Chest CT with contrast, axial cut, shows right side spherical lesion with air-fluid level causing lung collapse at the hilum (hollow arrow). Note pleural enhancement and extrapleural fat hypertrophy (arrowheads). (C) Chest CT, coronal reconstruction in lung window shows the acute angle the lesion makes with the chest wall and the pushed distorted airways proximal to the lesion (hollow arrow). (D) Thoracic ultrasound shows multiple hyperechoic shadows inside an echogenic collection. (E) Follow chest X-ray 48 hours after chest tube insertion (seen in situ) shows lung re-expansion. Figure 2 Case 2. (A) Baseline CT chest with contrast, coronal cut showing large left collection that is making an acute angle with chest wall (arrow) and uniformly thin wall with smooth inner margins (hollow arrows). (B) Chest X-ray following chest tube removal. Note thickened visceral pleura (hollow arrows). …

Background Pleural infection is a common complication of pneumonia associated with high mortality and poor clinical outcome. Treatment of pleural infection relies on the use of broad-spectrum antibiotics because reliable pathogen identification occurs infrequently. We performed a feasibility interventional clinical study assessing the safety and significance of ultrasound (US)-guided pleural biopsy culture to increase microbiological yield. In an exploratory investigation, the 16S ribosomal RNA technique was applied to assess its utility on increasing speed and accuracy vs standard microbiological diagnosis. Methods Twenty patients with clinically established pleural infection were recruited. Participants underwent a detailed US scan and US-guided pleural biopsies before chest drain insertion, alongside standard clinical management. Pleural biopsies and routine clinical samples (pleural fluid and blood) were submitted for microbiological analysis. Results US-guided pleural biopsies were safe with no adverse events. US-guided pleural biopsies increased microbiological yield by 25% in addition to pleural fluid and blood samples. The technique provided a substantially higher microbiological yield compared with pleural fluid and blood culture samples (45% compared with 20% and 10%, respectively). The 16S ribosomal RNA technique was successfully applied to pleural biopsy samples, demonstrating high sensitivity (93%) and specificity (89.5%). Conclusions Our findings demonstrate the safety of US-guided pleural biopsies in patients with pleural infection and a substantial increase in microbiological diagnosis, suggesting potential niche of infection in this disease. Quantitative polymerase chain reaction primer assessment of pleural fluid and biopsy appears to have excellent sensitivity and specificity.

Background Mesothelioma is an aggressive tumour of the pleura that is closely related to asbestos exposure. Asbestos is known to cause benign pleural thickening, effusion and plaques and the majority of patients with these abnormalities do not develop mesothelioma. It has been noted, however, that asbestos-exposed patients who have pleural plaques are at increased risk of mesothelioma.[1] This study aimed to describe the range of pleural abnormalities seen on CT done at some time before the diagnosis of mesothelioma was made. Methods Electronic radiological records of all patients who were diagnosed with mesothelioma in the trust from 2009 till June 2017 were screened for any chest CT (or abdomen CT with at least half of the thorax imaged) obtained at least 6 months prior to the CT that triggered the diagnosis of mesothelioma. CTs were examined for the presence of pleural plaques, thickening, nodules and/or effusion. CT studies were divided into 3 time periods: within one year (A), 1–3 years before (B), and more than 3 years before (C) the diagnostic CT. Results 170 patients were screened. 39 patients had one or more pre-diagnosis CTs. A total of 53 CTs were available for comparison. Effusion was the most common abnormality seen in 23/53 CTs followed by thickening seen in 17/53, then plaques 15/53 and pleural nodules in 5/53. Four nodules (2 in period A and 2 in period B) progressed to tumour later on. Effusion was seen in 50% of studies from periods A and B. Pleural thickening and plaques were noticeable in around 40% of CTs from periods A and B. 13 studies did not show any pleural abnormality (3 studies in period A, 4 in period B and 6 in period C). Conclusion Mesothelioma is a rapidly progressive disease that can be difficult to track in radiological studies done before clinical presentation. Pleural effusion, followed by smooth thickening and plaques, are fairly common abnormalities in pre-diagnosis CTs. Reference Pairon J-C, Laurent F, Rinaldo M, et al. Pleural plaques and the risk of pleural mesothelioma. J Natl Cancer Inst 2013;105:293–301. doi:10.1093/jnci/djs513

Introduction Malignant pleural effusions are a common complication of advanced malignancy, have a poor prognosis and have a significant impact on quality of life. Treatment strategies include chest drain and pleurodesis, or insertion of an indwelling pleural catheter. Successful pleurodesis is thought to be due to the body’s inflammatory response resulting in pleural symphysis. This post hoc analysis of data from the TIME 1 was conducted to address assess whether there is a correlation between the pleurodesis and a systemic inflammatory response. Methods A total of 282 patients from the TIME 1 trial had data on pleurodesis success, which was defined as no further pleural procedures for up to 3 months after pleurodesis. Patients who had undergone thoracosopy and poudrage as well as those who had undergone chest drain with pleurodesis were included. Sterile talc was used in all patients. The difference in the white cell count (WCC) and C-reactive protein (CRP) levels was calculated between the day of pleurodesis (Day 0) and Day 1. The data are normally distributed thus independent t test was used for analysis. The CRP Day 0 and 1 data were not normally distributed, and therefore were log transformed to produce a normal distribution. Results Two hundred and eighty two patients were included in the analysis with a mean age of 71 in both groups. 229 had a successful pleurodesis and 53 patients required a further pleural procedure on the ipsilateral side signifying failed pleurodesis. 193 patients had CRP levels and 220 patients had WCC levels recorded on both Day 0 and Day 1. Patients who had a successful pleurodesis had a significantly greater rise in CRP than those who failed pleurodesis. There was no significant difference in the change in WCC between the groups. There was also no significant difference in Day 0 and Day 1 WCC or CRP levels between the two groups. Conclusions This analysis demonstrates that systemic rise in CRP as an indicator of inflammation is a better predictor of pleurodesis success than the WCC. These data support the hypothesis that higher levels of inflammation are associated with pleurodesis success.

Background Over 50 000 patients with malignant pleural effusion (MPE) are seen annually in the UK. The majority develop recurrent symptomatic disease requiring definitive treatment. MPE is most frequently managed with talc slurry pleurodesis via intercostal chest drain. This involves a lengthy inpatient stay and has a success rate of around 70%, with no means of predicting which patients will suffer pleurodesis failure. Thoracic ultrasound (TUS) is widely used by respiratory physicians, and data from animal and human studies suggest it can identify pleural adhesions (through the absence of normal lung sliding) in a range of conditions. By extension, TUS may allow clinicians to diagnose the presence or absence of adhesions post-pleurodesis in MPE, identifying patients suitable for discharge or needing further intervention. Method We recruited 18 adult patients with MPE undergoing drainage and talc slurry pleurodesis to a prospective single-centre cohort study. Patients underwent standardised TUS assessment pre- and post-pleurodesis, evaluating pleural sliding and adhesions at nine points (three anterior, three lateral, three posterior) across the affected hemithorax. Lung sliding was graded as per Zhu et al.,1 creating a total pleurodesis score out of 18. Pleurodesis failure was defined as radiological and symptomatic fluid recurrence in the same hemithorax requiring further intervention at any point up to 3 months post-pleurodesis. Patients also completed a questionnaire addressing satisfaction with TUS assessment. Results 3/18 patients (16.7%) died before 1 month follow-up. Of 15 patients seen at one month, 11 (73.3%) had successful pleurodesis and 4 (26.7%) had failed. No patient had delayed pleurodesis failure between 1 and 3 month follow-up. There was a significant difference observed in the day 1 TUS pleurodesis score between patients who went on to have successful pleurodesis and those who failed during follow-up (table 1). TUS assessment was acceptable to patients, with none considering it either time-consuming or unwilling to have it again if needed. Conclusion Our data suggest TUS assessment 24 hours post-pleurodesis for MPE predicts success or failure of this intervention, with significant implications for clinical care. A larger randomised study is now underway to further evaluate this hypothesis. Reference Chest2005;128(2):934–9.

Aim To audit the pleural on-call service referrals and outcome. Method Our unit instituted the provision of a “pleural phone” and pleural email service as a central point of contact for pleural related questions, both internally for our large Trust, and externally including local GPs, to facilitate a more open model of care, increase efficiency of the diagnostic pathway and prevent unnecessary admissions or procedures. All documented pleural phone (9 am-5 pm,Monday-Friday) and email (any time) referrals between March 2016-February 2017 were analysed. Results 506 cases were discussed via email (n=257) or via phone calls (n=249), and this only included logged phone calls (mean 1.9 referrals per working day). This is an underestimation of the number of calls received because phone calls documented on the electronic patient record were not accessible and therefore not included. The number of cases discussed via email is not a reflection of the number of emails, as each case may have involved several emails. Table 1 shows the reasons for referral. The outcome of the referrals included advice (33.6%,n=170), advice and pleural clinic follow up (23.7%,n=120), advice and scheduling for a pleural procedure (42.7%,n=216). Of the 216 scheduled for procedures, 49.1% (n=106) were scheduled for a procedure by the pleural team (n=29 pleural one-stop-shop appointments for procedure and review), 49.1% (n=106) were scheduled for a procedure by the radiology team, 1.4% (n=3) were scheduled for an initial procedure by the radiology team (pleural fluid aspiration) then a further procedure by the pleural team (indwelling pleural catheter insertion(n=2), medical thoracoscopy(n=1)), 0.5% (n=1) were scheduled for bronchoscopy. An analysis of the referrals revealed that 22 unnecessary procedures and clinic appointments were avoided after discussion with the pleural team including new pleural outpatient referrals (n=4), follow up pleural outpatient appointment(n=10), pleural procedure appointment (n=5), referral to another clinic(n=2), CT scan(n=1). Advice given on the most appropriate investigation, such as advising large volume aspiration rather than chest drain insertion and hospital admission for a new undiagnosed pleural effusion, was not quantifiable in this retrospective study. Discussion Pleural on-call service is beneficial and can help avoid unnecessary clinic and procedure list appointments.

Pleural disease is increasing in frequency and is associated with more specialist evidence-based treatments. Over the last 5 years, the Oxford Pleural Unit has operated a pleural on-call service by instituting the provision of a pleural phone and e-mail service as a central point of contact for pleural-related questions, internally for the hospital trust, and externally for local general practitioners and district nurses. The phone is held during working hours, and the e-mail service is monitored daily by a member of the pleural team (consultants or pleural fellows).

This study was performed to assess the management of adult patients presenting to the Mater Dei Hospital Accident and Emergency (A&E) department with acute asthma. Subjects and Methods: Asthmatic patients age 14 or older who presented to A&E department between January and October 2010 with asthma exacerbations were included. Data were collected from the clinical notes and analyzed. Results: A total of 244 patients (67.2% females) were included, 126 (51.6%) were admitted, 97 (39.8%) discharged and 21 (8.6%) discharged themselves against medical advice. There was a decline in the presentations between January and July, followed by an upward trend until October (P = 0.42). Pulse oximetry was performed in 207 patients (84.8%), arterial blood gases in 133 (54.5%), peak expiratory flow rate in 106 (43.4%) and chest radiography in 206 (84.4%) patients. The respiratory rate was documented in 151 (61.8%), heart rate in 204 (83.6%) and ability to complete sentences in 123 (50.4%) patients. One hundred and ninety six patients (80.3%) were given nebulized bronchodilators, 103 (42.2%) intravenous corticosteroids, 7 (2.87%) oral corticosteroids, 109 (44.7%) oxygen, 28 (11.5%) antibiotics and 9 (3.69%) magnesium. Systemic corticosteroids and antibiotics were more commonly prescribed to patients admitted (P < 0.001). Conclusion: Management of acute asthma in Malta requires optimization in order to compare with international guidelines., peer-reviewed