Curr Opin Pulm Med

Do we measure pleural fluid pH correctly?

May 162013

Do we measure pleural fluid pH correctly?

Curr Opin Pulm Med. 2013 May 13;

Authors: Putnam B, Elahi A, Bowling MR

Abstract
PURPOSE OF REVIEW: This review analyzes the current literature available on appropriate measurement of pleural fluid pH and currently used methods of measurement. RECENT FINDINGS: Current literature continues to support the superiority of blood gas analyzers (BGAs) in the accurate measurement of pleural fluid pH. Despite the compelling evidence, roughly 30-50% of the laboratories across the United States continue to use inaccurate methods for pleural fluid pH measurement. Nearly 40% of pulmonologists were incorrect in believing their laboratory uses BGA for the analysis of pleural fluid pH. SUMMARY: It is apparent that the clinical utility of pleural fluid pH is often undermined by its inappropriate measurement. Physicians must be made aware of their laboratory's method of measurement if pleural fluid pH is to be used in the evaluation of pleural diseases. If pleural fluid pH measurement is not done accurately, then other pleural fluid characteristics may be used to aid the clinician.

PMID: 23673451 [PubMed - as supplied by publisher]

Link to Article at PubMed

Management of malignant pleural effusions: questions that need answers.

Curr Opin Pulm Med Start a Discussion »

May 162013

Management of malignant pleural effusions: questions that need answers.

Curr Opin Pulm Med. 2013 May 13;

Authors: Davies HE, Lee YC

Abstract
PURPOSE OF REVIEW: Malignant pleural effusion (MPE) is common. However, regardless of the differences between patients, their underlying cancer type, and pleural fluid characteristics, management options are often limited. These have not advanced significantly over the last 80 years since pleurodesis was first described. Correspondingly, patient-related outcome measures have been neglected. The evidence (or lack of) behind the current treatment recommendations is reviewed and key research questions are described. RECENT FINDINGS: Talc continues to be the most effective sclerosant available for pleurodesis in MPE. A recent randomized controlled trial comparing talc pleurodesis and indwelling pleural catheter insertion as first-line therapy suggests these approaches are equally effective, and utilized a patient-based symptom score as the primary outcome. The need to acknowledge the advances in translational medicine and oncological therapies to measure patient-related trial outcomes and to target pleural fluid formation in MPE is discussed. SUMMARY: Pulmonologists should be aware of the staggering lack of progress in the evidence that supports the current 'recommended' management of MPE. The need for a re-think about MPE management with a focus on alternative therapeutic targets and treatment objectives should be appreciated, in order to optimize future patient care.

PMID: 23673450 [PubMed - as supplied by publisher]

Link to Article at PubMed

Treatment of pulmonary tuberculosis.

Curr Opin Pulm Med Start a Discussion »

Mar 272013

Treatment of pulmonary tuberculosis.

Curr Opin Pulm Med. 2013 May;19(3):273-9

Authors: Nunn A, Phillips PP, Abubakar I

Abstract
PURPOSE OF REVIEW: Despite reduction in incidence in several regions, tuberculosis (TB) remains a pandemic of world-wide significance. There is an urgent need to develop better regimens, to shorten treatment and to effectively manage both drug-sensitive and drug-resistant disease.
RECENT FINDINGS: There has been a substantial increase in numbers of drugs in the development pipeline and two of the candidates are expected to receive widespread accelerated approval for the treatment of multidrug-resistant TB (MDR-TB). An important determining factor in the choice of regimens for phase III is the speed with which patients become culture negative during treatment, measured as either time to culture conversion or culture negativity at a given time point. It is impossible to consider the treatment of TB in sub-Saharan Africa without considering the patients who are coinfected with HIV, and the decision of when to commence treatment with antiretrovirals is critical. What, if any, is the role of adjunctive treatments such as vitamin D?
SUMMARY: In this review, we describe the encouraging data on a number of drugs which are about to enter phase II or phase III trials, results from trials of standard regimens in close to programme conditions and a series of trials highlighting the importance of an early commencement of antiretroviral treatment.

PMID: 23528955 [PubMed - in process]

Link to Article at PubMed

Diagnosis of pulmonary tuberculosis.

Curr Opin Pulm Med Start a Discussion »

Mar 272013

Diagnosis of pulmonary tuberculosis.

Curr Opin Pulm Med. 2013 May;19(3):280-8

Authors: Lawn SD

Abstract
PURPOSE OF REVIEW: This review summarizes the recent literature on the developments in diagnostics for pulmonary tuberculosis (TB).
RECENT FINDINGS: A growing body of literature regarding the Xpert MTB/RIF assay confirms the high diagnostic accuracy in a range of clinical settings, including amongst inpatients, those with HIV coinfection and in children with culture-positive disease. Early experiences with operational implementation are now being reported from South Africa. Initial small-scale evaluations suggest that newer versions of line-probe assays have diagnostic accuracy similar to that of the Xpert MTB/RIF assay. Next-generation fully automated molecular assays that use isothermal amplification may in the future be more readily implemented at the point of care. The first low-cost, lateral-flow (strip-test) assay for lipoarabinomannan in urine shows promise as a rapid point-of-care test for TB amongst HIV-infected patients who have advanced immunodeficiency. A range of other diagnostic tools are also at various stages of development.
SUMMARY: There is continued momentum and optimism regarding the developments in TB diagnostics. However, studies of clinical and programmatic impact and operational research are needed to guide implementation and scale-up of new assays in resource-limited settings. Further concerted efforts are needed to develop point-of-care assays which are desperately needed to accelerate progress in TB control.

PMID: 23528956 [PubMed - in process]

Link to Article at PubMed

Identifying transudates misclassified by Light’s criteria.

Curr Opin Pulm Med Start a Discussion »

Mar 202013

Identifying transudates misclassified by Light's criteria.

Curr Opin Pulm Med. 2013 Mar 14;

Authors: Porcel JM

Abstract

PURPOSE OF REVIEW: Light's criteria combine three dichotomous tests into a decision rule that is considered positive if any one of the tests is positive. This strategy clearly maximizes sensitivity, although at the expense of specificity. Although Light's criteria identify 98% of pleural exudates, they misclassify about 25% of transudates as exudates. The way to overcome this limitation is discussed in this review. RECENT FINDINGS: Traditionally, measurement of the protein gradient between the serum and pleural fluid has been recommended to decrease the misclassification rate of Light's criteria. A recent study demonstrated that a gradient between the albumin levels in the serum and the pleural fluid more than 1.2?g/dl performs significantly better than a protein gradient more than 3.1?g/dl to correctly categorize mislabeled cardiac effusions (83 vs. 55%). On the other hand, the accuracy of a pleural fluid to serum albumin ratio less than 0.6 excelled when compared with albumin and protein gradients in patients with miscategorized hepatic hydrothoraces (77 vs. 62 vs. 61%). SUMMARY: The simplest strategy to reveal the true transudative nature of heart failure-related effusions, labeled as exudates by Light's criteria, is to calculate the serum to pleural fluid albumin gradient. Conversely, for misclassified hepatic hydrothoraces, measurement of the pleural to serum albumin ratio is recommended. The serum to pleural fluid protein gradient should no longer be considered the preferred test for this purpose.

PMID: 23508114 [PubMed - as supplied by publisher]

Link to Article at PubMed

Respiratory bacterial infections in cystic fibrosis.

Curr Opin Pulm Med Start a Discussion »

Mar 022013

Respiratory bacterial infections in cystic fibrosis.

Curr Opin Pulm Med. 2013 Feb 27;

Authors: Ciofu O, Hansen CR, Høiby N

Abstract

PURPOSE OF REVIEW: Bacterial respiratory infections are the main cause of morbidity and mortality in patients with cystic fibrosis (CF). Pseudomonas aeruginosa remains the main pathogen in adults, but other Gram-negative bacteria such as Achromobacter xylosoxidans and Stenotrophomonas maltophilia as well as nontuberculous mycobacteria have been shown to play an important role in the lung disease. The purpose of this review is to summarize the knowledge on disease and treatment of infection with CF-related pathogens. RECENT FINDINGS: The role of the paranasal sinuses as a source of infection and site of bacterial adaptation has been recognized. This review will focus on the different conditions encountered by the bacteria in sinuses and lung, as well as the principles of treatment in the different infection sites. SUMMARY: Chronic, pulmonary infections remain the single most prominent cause of the increased morbidity and mortality in CF. After the increasing efficiency of anti-P. aeruginosa treatment, newer pathogens have been identified, with individual clinical characteristics. Microbiological surveillance is very important in keeping the patients stable. Samples from both the lower and upper respiratory tract (nasal sampling) should be investigated and both infection sites should be treated.

PMID: 23449384 [PubMed - as supplied by publisher]

Link to Article at PubMed

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