Estudio de coste-efectividad del manejo diagnóstico del derrame pleural en una unidad de patología pleural ambulatoria

Objective

To evaluate the diagnostic efficacy of pleural procedures, safety, delay and cost of the diagnosis of pleural effusion (PE) by analysing the parameters that are dependent on the area of patient management (outpatient or inpatient).

Patients and Methods

Prospective non-randomized study. Two groups were established depending on whether they were managed in a specific outpatient unit or as a conventional hospital inpatient, with the rest of the criteria being the same for the study of the PE.

Results

We included 60 outpatients and 34 inpatients. The median number of visits as an outpatient was 2 (range 2–3), and the time an inpatient was hospitalized was 13 (range 7.7–25–2) days. The number of analytical and imaging studies was significantly higher in the inpatient group. There were no differences in the number of cytology and pleural biopsies, or complications between groups. There were no differences in time to performing computed tomography. The number of days until the pleural biopsy and the time until to obtain a diagnosis was lower in the outpatient group. Mean total cost for an outpatient was €1.352 and €9.793,2 for inpatients.

Conclusions

Management of ambulatory diagnosis of PE patients is highly cost-effective. The effectiveness and safety of forms of the study is at least similar. In this study, the mean cost for a hospitalised inpatient for a PE was 7.2 times higher than outpatient management.     

Normativa sobre el diagnóstico y tratamiento del derrame pleural. Actualización

Although during the last few years there have been several important changes in the diagnostic or therapeutic methods, pleural effusion is still one of the diseases that the respiratory specialist have to evaluate frequently. The aim of this paper is to update the knowledge about pleural effusions, rather than to review the causes of pleural diseases exhaustively. These recommendations have a longer extension for the subjects with a direct clinical usefulness, but a slight update of other pleural diseases has been also included. Among the main scientific advantages are included the thoracic ultrasonography, the intrapleural fibrinolytics, the pleurodesis agents, or the new pleural drainages techniques.     

Biopsia pleural con aguja Tru-cut y citología como primer procedimiento en el estudio del derrame pleural

Introduction and objectives

The evaluation of pleural effusion (PE) includes various techniques, including pleural biopsy (PB). Our aim was to study the diagnostic yield of Tru-Cut needle PB (TCPB) and to define clinical/radiological situations in which TCPB might be indicated as an initial procedure.

Methodology

Retrospective study of TCPB in a hospital centre (2010-2012). Cases of pleural lesions without effusion were excluded. Clinical and radiological variables, diagnostic yield, TCPB complications and factors associated with the diagnostic yield of the combination of TCPB and thoracocentesis as initial procedure were analysed.

Results

One hundred and twenty-seven (127) TCPB were reviewed: 29.1% were cases of malignant PE and in 18.9% the cause of the PE could not be determined. The diagnostic yield of TCPB for tuberculosis was 76.5% (13/17) and 54% (20/37) for malignant PE. Complications occurred in 4.7% of the cases. In 72 patients with a final definitive diagnosis, TCPB was performed at the same time as the initial thoracocentesis. Diagnostic yield for the combination of TCPB/cytology as an initial technique was 43% (31/72) compared to 12.5% (9/72) for cytology only (p = 0.01). The only predictive variable for the indication of TCBP as an initial technique was a PE volume > 2/3 (P = .04).

Conclusions

TCPB is safe and provides an acceptable diagnostic yield, particularly when combined with simultaneous cytology in the evaluation of PE of various aetiologies. Radiological criteria may help guide the selection of patients who could benefit from this technique as an initial procedure combined with thoracocentesis.     

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

Objective

To investigate the etiology of pleural effusions (PE) in adults and the accuracy of pleural fluid (PF) cytology and cultures in malignant and infectious PE, respectively.

Patients and methods

Retrospective analysis of all consecutive patients with PE undergoing diagnostic thoracentesis during the last 19 years in a university hospital.

Results

The leading causes of PE among the 3,077 patients were: cancer (27%), heart failure (21%), pneumonia (19%), tuberculosis (9%), abdominal surgery (4%), pericardial diseases (4%) and cirrhosis (3%). Tuberculosis was the most common etiology in patients < 34 years of age (52%), whereas heart failure predominated in octogenarians (45%). The most common primary tumors in malignant PE were lung (37%) and breast (16%). The overall accuracy of PF cytology was 59%, although it was significantly lower in mesotheliomas (27%) and squamous cell lung cancer (25%). In infectious PE, only 30% of cultures yielded positive results, a percentage which increased two-fold (66%) in purulent fluids (empyemas). Viridans streptococci were the most commonly isolated pathogens (25.5%). The sensitivity of solid media cultures of PF for Mycobacterium tuberculosis was low (18.5%).

Conclusions

Three-quarters of patients with PE in whom a diagnostic thoracentesis was indicated had cancer, heart failure, pneumonia or tuberculosis. PF cytology and cultures give false negative results in a significant number of cases.     

Diagnóstico y manejo de los trasudados pleurales

Various clinical trials have been published on the optimal clinical management of patients with pleural exudates, particularly those caused by malignant tumors, while little information is available on the diagnosis and treatment of pleural transudates.The etiology of pleural transudates is wide and heterogeneous, and they can be caused by rare diseases, sometimes constituting a diagnostic challenge. Analysis of the pleural fluid can be a useful procedure for establishing diagnosis. Treatment should target not only the underlying disease, but also management of the pleural effusion itself.In cases refractory to medical treatment, invasive procedures will be necessary, for example therapeutic thoracentesis, pleurodesis with talc, or insertion of an indwelling pleural catheter. Little evidence is currently available and no firm recommendations have been made to establish when to perform an invasive procedure, or to determine the safest, most efficient approach in each case.This article aims to describe the spectrum of diseases that cause pleural transudate, to review the diagnostic contribution of pleural fluid analysis, and to highlight the lack of evidence on the efficacy of invasive procedures in the management and control of pleural effusion in these patients.     

La medicina integrativa en el manejo de la dispepsia funcional. Papel del preparado herbal STW 5

Functional dyspepsia is defined as a group of symptoms, whether related or unrelated to intake, localized in the upper abdomen, that manifest in the form of discomfort or epigastric pain, postprandial fullness and early satiety, in the absence of any demonstrable organic or structural anomaly. The etiopathogenesis and physiopathology of the process are unknown but factors that may be involved include gastric motility disorders, visceral hypersensitivity, psychological and genetic factors, Helicobacter pylori infection, and gastric acid hypersecretion. There is still no etiological treatment and consequently treatment is empirical and based on symptoms. This article reviews the main therapeutic options currently available, with special emphasis on the use of certain phytoceuticals (STW 5), in an attempt to integrate with traditional scientific medicine. This article also proposes an integrative therapeutic algorithm.     

Meningitis aséptica en la población adulta. Etiología y utilidad de las técnicas moleculares en el manejo clínico del paciente

Objective

This study describes the epidemiological, clinical and microbiological features of acute aseptic meningitis (AAM) in an adult population, and evaluates the impact of microbiological results on the clinical management of patients.

Patients and methods

Cases of AAM were prospectively collected between 2007 and 2010 among immunocompetent patients over 14 years-old. Enteroviruses and herpes viruses were determined using nucleic acids detection in CSF. Demographic and clinical data were retrospectively collected from medical records.

Results

A total of 94 patients were included, of whom 84 were diagnosed with viral meningitis (VM). The annual incidence of VM ranged from 2.4 to 15.3 cases per 100,000 inhabitants. An aetiological diagnosis was obtained in 76.2% of the patients with VM, 55 enterovirus, 4 HSV-2, 3 VZV, one HSV-1, and one EBV. Forty five per cent of patients were admitted to hospital and 65.8% of them received antibiotic treatment. A positive result prompted immediate discharge of 80% of inpatients and discontinuation of antibiotic therapy in 94.1% of them. The median duration of admission to hospital in these patients was 2.8 ± 2.9 days. Patients without available results during admission completed the antibiotic treatment, and the median hospital stay was 11.6 ± 4.6 days.

Conclusions

The annual incidence of AAM is variable. Enteroviruses were the main aetiological agent. Molecular tests revealed the aetiology in 76.2% of cases. Almost half of the patients required hospitalisation, and in these cases a positive result can lead to the immediate discharge of patients, and the diagnostic and therapeutic interventions can be reduced.