The authors report a case of pleural lipoma which was found incidentally in a thoracic roentgenogram. The radiographic studies were inconclusive about the nature of the lesion. The diagnosis was established by histologic study of the tumor excised by thoracotomy, after an inconclusive cytologic study obtained by transthoracic fine needle aspiration.

Keywords: Lipoma. Pleura.

Objective: To evaluate the experience in diagnosing and treating malignant pleural mesothelioma (MPM) accumulated over 5 years in a tertiary public hospital. Methods: The medical charts of the patients diagnosed with MPM between January of 2000 and February of 2005 were evaluated retrospectively. Results: Of the 17 patients analyzed, 14 were male and 3 were female. The mean age was 54.1 years (range, 13-75 years). The biopsy specimens for histopathological examination were obtained through thoracoscopy in 9 patients (53%), Cope needle in 5 (29.5%), and open pleural biopsy in 3 (17.5%). The following histological types were identified: epithelial, in 14 patients (82%); sarcomatoid, in 1 (6%); and biphasic, in 2 (12%). The therapeutic approaches used were as follows: multimodal (pleuropneumonectomy and adjuvant radiotherapy and chemotherapy) in 6 patients (35%); chemotherapy and radiotherapy in 6 (35%); radiotherapy alone in 3 (17.5%); and chemotherapy alone in 2 (12%). The mean survival was 11 months (range, 1-26 months). Conclusions: In the cases studied, an integrated multidisciplinary approach was used, and a highly complex hospital infrastructure was available for the diagnosis and treatment of MPM, as recommended in the literature. However, the mean survival was only 11 months, reflecting the aggressiveness of the disease.

Keywords: Mesothelioma; Pleura; Surgery; Diagnosis.

Objectives: Pleural tuberculosis (PlTB) diagnosis is a challenge due to its paucibacillary nature and to the need of invasive procedures. This study aimed to identify easily available variables and build a predictive model for PlTB diagnosis which may allow earlier and affordable alternative strategy to be used in basic health care units. Methods: An observational cross-sectional study compared PlTB and non-TB patients followed at a tertiary Brazilian hospital between 2010 and 2018. Unconditional logistic regression analysis was performed and a Decision Tree Classifier (DTC) model was validated and applied in additional PlTB patients with empiric diagnosis. The accuracy (Acc), sensitivity (Se), specificity (Sp), positive and negative predictive values were calculated. Results: From 1,135 TB patients, 160 were considered for analysis (111 confirmed PlTB and 49 unconfirmed PlTB). Indeed, 58 non-TB patients were enrolled as controls. Hyporexia [adjusted odds ratio (aOR) 27.39 (95% CI 6.26 - 119.89)] and cellular/biochemical characteristics on pleural fluid (PF) (polimorphonuclear in two categories: 3-14% aOR 26.22, 95% CI 7.11 - 96.68 and < 3% aOR 28.67, 95% CI 5.51 - 149.25; and protein = 5g/dL aOR 7.24, 95% CI 3.07 - 17.11) were associated with higher risk for TB. The DTC constructed using these variables showed Acc=87.6%, Se=89.2%, Sp=84.5% for PlTB diagnosis and was successfully applied in unconfirmed PlTB patients. Conclusion: The DTC model showed an excellent performance for PlTB diagnosis and can be considered as an alternative diagnostic strategy by using clinical patterns in association with PF cellular/biochemical characteristics, which were affordable and easily performed in basic health care units.

Keywords: Pleural tuberculosis; Diagnosis; Decision tree classifier.

This is a prospective study of benign and malignant pleural effusions carried out to determine the diagnostic yield of standard cytopathology compared to findings of DNA ploidy obtained by flow cytometry. Twenty-six samples of pleural effusion obtained by thoracocentesis were analyzed by cytopathology and flow cytometry. Final diagnosis was confirmed in all instances by histopathology of pleural biopsies. Ten samples were excluded from the analysis due to technical reasons, and the remaining 16 were used in the study. There were 13 malignant and 3 benign pleural effusions. Cytopathology revealed 9 malignant effusions and 7 benign effusions (4 false negatives). Flow cytometry findings have shown euploid DNA content in all 3 benign effusions (positive predictive value and specificity of 100%) and in 8 malignant effusions (positive value and specificity of 100%) and in 8 malignant effusions (sensitivity of 38.4% and negative predictive value of 27.2%). Cytopathology showed specificity of 100%, sensitivity of 69.2%, and positive and negative predictive values of 100% and 42.8%, respectively. The authors concluded that in this study the low sensitivity and negative value of flow cytometry in comparison to conventional cytopathology have limited the usefulness of flow cytometry to the finding of euploid DNA contents in benign pleural effusions.

Keywords: Flow cytometry. Cytopathology. DNA ploidy. Pleural effusion.

Objective: To evaluate Brazilian studies by summarizing the accuracy of adenosine deaminase in the diagnosis of the pleural tuberculosis, with the objective of lending support to the movement to make the test part of the routine in the investigation of pleural effusions. Methods: A search for Brazilian studies related to the determination of adenosine deaminase levels in the pleural liquid was carried out. These studies were evaluated and included in this study. The data were analyzed using summary receiver operating characteristic (SROC) curves, which enabled the studies to be collected and evaluated regarding the accuracy of the diagnosis. As for the global values of sensitivity and specificity, the Bayes' theorem was applied to calculate the post-test probabilities in different prevalences of the disease. Results: Twenty-five studies dating from 1987 to 2005 and including enough information to be used in the meta-analysis were identified. After evaluation, nine studies were included, totaling 1674 patients. According to the SROC curve, a sensitivity of 91.8% (95% CI: 89.8‑93.6%) and a specificity of 88.4% (95% CI: 86.0-90.5%) were found, with an area of 0.969 below the curve. The overall odds ratio was 112.0 (95% CI: 51.6-243.2). Considering a prevalence of tuberculosis of 50% (considered neutral), the post-test probability was 88.7% for a positive test and 91.5% for a negative test. Conclusion: Despite the differences found among studies, it is possible to conclude that the determination of adenosine deaminase levels has high accuracy in the diagnosis of the pleural tuberculosis and should be used as a routine test in its investigation.

Keywords: Pleural effusion; Tuberculosis; Diagnosis; Adenosine deaminase; Meta-analysis.

Objective: To determine the efficacy of thoracoscopy in the management of children with complicated parapneumonic pleural effusion at the fibrinopurulent stage. Methods: Retrospective study of 99 children submitted to thoracoscopy for the treatment of complicated parapneumonic pleural effusion at the fibrinopurulent stage between November of 1995 and July of 2005. The mean age was 2.6 years (range, 0.4-12 years), and 60% were males. Thoracoscopy was performed at three different hospitals following the same treatment algorithm. Results: Thoracoscopy was effective for 87 children (88%). In 12 (12%), a second surgical procedure was required: another thoracoscopy (n = 6) or thoracotomy/thoracostomy (n = 6). Mean duration of chest tube drainage following successful thoracoscopy was 3 days vs. 10 days in patients submitted to a second procedure (p < 0.001). In all of the children, the pleural infection resolved after treatment. Thoracoscopy-related complications included air leak (30%), chest tube bleeding (12%), subcutaneous emphysema associated with trocar insertion (2%) and surgical wound infection (2%). None of the children required additional surgical procedures due to the complications. Conclusions: The effectiveness of thoracoscopy in children with parapneumonic pleural effusion at the fibrinopurulent stage was 88%. The procedure was safe, with a low rate of severe complications. Thoracoscopy should be the first-choice treatment for children with parapneumonic pleural effusion at the fibrinopurulent stage.

Keywords: Thoracoscopy; Pleural effusion; Empyema, pleural.

Objective: To develop a multimedia educational computer program designed to teach pleural drainage techniques to health professionals, as well as to evaluate its efficacy. Methods: We planned and developed a program, which was evaluated by 35 medical students, randomized into two groups. Group 1 comprised 18 students who studied using the program, and group 2 comprised 17 students who attended a traditional theoretical class given by an experienced teacher. Group 1 students were submitted to two subjective evaluations using questionnaires, and both groups took an objective theoretical test with multiple-choice questions and descriptive questions. The results of the theoretical test were compared using the Mann-Whitney test. Results: The subjective evaluation of the technological aspects and content of the program ranged from excellent to very good and good. The software was considered highly instructive by 16 students (88.9%), and 17 students (94.4%) thought it might partially substitute for traditional classes. Between the two groups, there was no significant difference in the multiple-choice test results, although there was such a difference in the descriptive question results (p < 0.001), group 1 students scoring higher than did those in group 2. Conclusions: The computer program developed at the Federal University of São Paulo Paulista School of Medicine proved to be a feasible means of teaching pleural drainage techniques. The subjective evaluation of this new teaching method revealed a high level of student satisfaction, and the objective evaluation showed that the program was as efficacious as is traditional instruction.

Keywords: Teaching; Thoracic surgery; Multimedia; Drainage; Pleural diseases.

Some techniques used in respiratory therapy are not based on sound scientific evidence. The misuse of such techniques can be harmful in terms of adverse effects and may not be cost-effective. A systematic review of the literature was performed using the Oldmedline, Medline, Cinahl and Lilacs databases, as well as the registry of clinical trials registered by the Cochrane Library and National Institutes of Health. The focus of the review was on trials addressing the efficacy of respiratory therapy in treating pleural empyema in children, adolescents and adults. No such trials were found. We can conclude that there is a lack of data regarding the efficacy of respiratory therapy in pleural empyema. In order to provide such data, clinical trials are warranted.

Keywords: Empyema pleural/rehabilitation; Evidence-based medicine; Physical therapy techniques; Review [Publication Type]; Randomized controlled trials

Objective: To identify how pediatric surgeons manage children with pneumonia and parapneumonic pleural effusion in Brazil. Methods: An online cross-sectional survey with 27 questions was applied to pediatric surgeons in Brazil through the Brazilian Association of Pediatric Surgery. The questionnaire had questions about type of treatment, exams, hospital structure, and epidemiological data. Results: A total of 131 respondents completed the questionnaire. The mean age of respondents was 44 ± 11 years, and more than half (51%) had been practicing pediatric surgery for more than 10 years. The majority of respondents (33.6%) reported performing chest drainage and fibrinolysis when facing a case of fibrinopurulent parapneumonic pleural effusion. A preference for video-assisted thoracic surgery instead of chest drainage plus fibrinolysis was noted only in the Northeast region. Conclusions: Chest drainage plus fibrinolysis was the treatment adopted by most of the respondents in this Brazilian sample. There was a preference for large drains; in contrast, smaller drains were preferred by those who perform chest drainage plus fibrinolysis. Respondents would rather change treatment when facing treatment failure or in critically ill children.

Keywords: Empyema, pleural; Thoracic surgery, video-assisted; Fibrinolysis; Surveys and questionnaires; Pediatric surgery .

Objective: Talc pleurodesis is a widely used treatment option for malignant pleural effusion (MPE). However, the optimal form of administration remains controversial. Thus, we performed a systematic review and meta-analysis to assess the effectiveness of talc slurry (TS) in comparison with thoracoscopic talc insufflation/poudrage (TTI) for MPE treatment. Methods: We searched PubMed, EMBASE, and Cochrane Library databases for studies that compared TS with TTI in patients with MPE. We used a random-effects model with a 95% CI to pool the data. Heterogeneity was assessed with I² statistics. Results: We included eight studies involving 1,163 patients, 584 of whom (50.21%) underwent TS. Pleurodesis failure rates were similar between the procedures (OR = 1.07; 95% CI: 0.56-2.06; p = 0.83; I² = 62%); and 68% of patients (95% CI: 0.31-1.47; p = 0.33; I² = 58%) had postoperative complications, which were lower in patients in the TS group than in the TTI group. In a subgroup analysis considering only randomized clinical trials, the failure rate was significantly lower in the TS treatment group (OR = 0.62; 95% CI: 0.42-0.90; p = 0.01; I² = 0%). Similarly, dyspnea was less common in the TS group (OR = 0.74; 95% CI: 0.41-1.34; p = 0.32; I² = 55%). Adverse effects were reported in 86 patients, and no significant difference was seen between the TS and TTI groups: empyema (OR = 1.43; 95% CI: 0.36-5.64; p = 0.86; I² = 0%), pain (OR = 1.22 (95% CI: 0.67-2.21; p = 0.51; I² = 38%), and pneumonia (OR = 1.15; 95% CI: 0.30-4.46; p = 0.86; I² = 27%). Conclusions: Our findings suggest that TS is an effective treatment for MPE, with no significant increase in adverse events. Results suggest equivalent efficacy and safety for both procedures.

Keywords: Talc; Pleurodesis; Pleural effusion, malignant.

Background: The decision to drain parapneumonic pleural effusion in children is still controversial. An indicative scoring system to assess the need for chest-tube drainage arose from a partnership between pediatricians and surgeons. Objective: To evaluate the utility of the score in indicating whether drainage should be performed in pediatric patients with parapneumonic effusion. Method: A cross-sectional study involving 250 inpatients with parapneumonic effusion, treated in a tertiary-care hospital between 1994 and 1999. The following variables were analyzed: clinical presentation, chest X-rays, pleural fluid culture and biochemical analysis of the pleural fluid, as well as the score and treatment. The score was based on four categories: general appearance of the pleural fluid, chest X-rays, laboratory findings, and the second thoracentesis. Drainage was recommended for patients scoring higher than 5.5. Results: Of 941 children with pneumonia, parapneumonic effusion occurred in 304 (32.2%), 250 of which were included in the study. Of those, 146 (58.4%) were male, with mean of age of 3 years (median, 2 years). The cutoff points (determined through receiver operating characteristic curve analysis) for suggesting pleural drainage were pH < 7.29 (89.2% sensitivity and 76.5% specificity), score > 5.0 (68.7% sensitivity and 81.7% specificity). These values were more strongly correlated with the need for drainage (p = 0.001), as were those reported in the literature (pH = 7.0 and glucose < 40). The lactate dehydrogenase did not prove to be a good parameter for indicating a need for drainage. Conclusion: In addition to the purulent aspect, pH = 7.29 and score were the best indicators of the need for chest-tube drainage in pediatric patients with parapneumonic effusion. However, we suggest that some score variables be readjusted to improve the usefulness of this particular scoring system.

Keywords: Empyema. Pleural effusion. Pneumonia.

Objective: To propose a new classification criterion for the differentiation between pleural exudates and transudates-quantifying total proteins in pleural fluid (TP-PF) and lactate dehydrogenase in pleural fluid (LDH-PF) exclusively-as well as to compare this new criterion with the classical criterion in terms of diagnostic yield. Methods: This was an observational, cross-sectional study with a within-subject design, comprising 181 patients with pleural effusion treated at two university hospitals in the state of Rio de Janeiro, Brazil, between 2003 and 2006. The diagnostic parameters included in the classical criterion were identified, as were those included in the new criterion. Results: Of the 181 patients, 152 and 29 were diagnosed with pleural exudates and pleural transudates, respectively. For the classical criterion, the sensitivity, specificity, and accuracy for the diagnosis of pleural exudates were, respectively, 99.8%, 68.6%, and 94.5%, whereas the corresponding values for the diagnosis of pleural transudates were 76.1%, 90.1%, and 87.6%. For the new criterion (cut-off points set at 3.4 g/dL for TP-PF and 328.0 U/L for LDH-PF), the sensitivity, specificity, and accuracy for the diagnosis of exudates were, respectively, 99.4%, 72.6%, and 99.2%, whereas the corresponding values for the diagnosis of transudates were 98.5%, 83.4%, and 90.0%. The accuracy of the new criterion for the diagnosis of pleural exudates was significantly greater than was that of the classical criterion (p = 0.0022). Conclusions: The diagnostic yield was comparable between the two criteria studied. Therefore, the new classification criterion can be used in daily practice.

Keywords: Pleural effusion/diagnosis; Pleural effusion/classification; Exudates and transudates.

Ovarian hyperstimulation syndrome (OHSS) is an iatrogenic complication that occurs in the luteal phase of an induced hormonal cycle. In most cases, the symptoms are self-limited and spontaneous regression occurs. However, severe cases are typically accompanied by acute respiratory distress. The objective of the present study was to describe the clinical presentation, treatment, and outcome of pleural effusion associated with OHSS in three patients undergoing in vitro fertilization. The patients ranged in age from 27 to 33 years. The onset of symptomatic pleural effusion (bilateral in all cases) occurred, on average, 43 days (range, 27-60 days) after initiation of hormone therapy for ovulation induction. All three patients required hospitalization for massive fluid resuscitation, and two required noninvasive mechanical ventilation. Although all three patients initially underwent thoracentesis, early recurrence of symptoms and pleural effusion prompted the use of drainage with a pigtail catheter. Despite the high output from the pleural drain (mean, 1,000 mL/day in the first week) and prolonged drainage (for 9-22 days), the outcomes were excellent: all three patients were discharged from hospital. Although pleural effusion secondary to OHSS is probably underdiagnosed, the associated morbidity should not be underestimated, especially because it affects potentially pregnant patients. In this study, early diagnosis and appropriate supportive measures yielded favorable results, limiting the surgical approach to adequate pleural drainage.

Keywords: Fertilization in vitro; Ovarian hyperstimulation syndrome; Pleural effusion.

Malignant mesotheliomas are rare types of cancers that affect the mesothelial surfaces, usually the pleura and peritoneum. They are associated with asbestos exposure, but due to a latency period of more than 30 years and difficult diagnosis, most cases are not detected until they reach advanced stages. Treatment options for this tumor type are very limited and survival ranges from 12 to 36 months. This review discusses the molecular physiopathology, current diagnosis, and latest therapeutic options for this disease.

Keywords: Pleural Mesothelioma; Treatment; Molecular Alterations.