Introduction : Les traumatismes thoraciques sont, selon leur sévérité, une cause fréquente de mortalité, de morbidité, d'hospitalisation et d'incapacité en traumatologie. Les traumatismes thoraciques mineurs fermés (TTM) sont souvent traités dans un contexte ambulatoire. Une complication potentielle est le développement d’un hémothorax retardé. Il n'existe actuellement aucun consensus sur la meilleure façon de classifier les hémothorax retardés. L’objectif de l’étude est d’évaluer l’accord inter et intra-observateur, et donc la fiabilité, de trois méthodes de classification d’hémothorax retardé chez des patients se présentant à l’urgence pour un traumatisme thoracique mineur fermé (TTM) qui développent un hémothorax entre une et deux semaines suivant le traumatisme. Méthodes : Cette étude est une analyse secondaire d’une étude de cohorte multicentrique prospective de patients s’étant présentés dans un de quatre départements d’urgence canadiens. Un échantillon aléatoire de 50 radiographies pulmonaires a été sélectionné parmi les patients recrutés suite à un TTM entre novembre 2006 et novembre 2010. Les radiographies pulmonaires postéro-antérieures (PA) et latérales ont été soumises à huit médecins évaluateurs (deux par groupe), de quatre spécialités différentes (urgence, chirurgie, radiologie et médecine familiale), pour interprétation utilisant chacune des trois méthodes de classification mise à l’étude. Ensuite, au moins deux semaines plus tard, un médecin de chacune des spécialités a réinterprété de nouveau les mêmes radiographies pulmonaires, en utilisant ces mêmes trois méthodes de classification. Des coefficients de corrélation intraclasse (ICC) ont par la suite été calculés afin de déterminer l’accord inter et intra-observateur pour chacune des trois méthodes de classification. Résultats : Nous avons déterminé que deux des trois méthodes de classification, soit celle utilisée par Misthos et al. (1) - pour les vues radiographiques postéro-antérieures – ainsi que celle basée sur le calcul de ratios – pour les vues latérales – démontraient des accords inter-observateurs plus élevés. La méthode de Misthos et al. (1) démontre, cependant, une meilleure homogénéité, avec des intervalles de confiance plus étroits ICC global 0.56 (0.47-0.64). De plus, nous avons démontré que la troisième méthode de classification à l’étude, soit celle basée sur l’impression subjective du clinicien, qui est aussi celle qui représente la façon actuelle de fonctionner en clinique, démontre le plus faible accord entre observateurs ICC global 0.44 (0.34-0.53). Cependant, nous n’avons pu démontrer de différence iv statistiquement significative entre ces valeurs lorsque soumises à des épreuves statistiques (p = 0.7319). Conclusion : Cette étude n’a pu démontrer une différence statistiquement significative entre les méthodes de classification évaluées. Cependant, on note des valeurs d’accord plus élevées pour celle basée sur une étude par Misthos et al. (1) ainsi que celle basée sur le calcul des ratios. La troisième méthode, basée sur l’impression subjective du clinicien, démontre la plus faible valeur d’accord au travers différentes spécialités d’évaluateurs. Une future étude, avec un échantillon plus important de radiographies, pourrait déterminer si une différence statistiquement significative existe entre ces méthodes de classification et advenant le cas, la possibilité d’une relation entre la méthode plus fiable de classifier les hémothorax post-traumatiques retardés et des mesures cliniques objectivables, dans le but de valider sa capacité d’aider à prédire quels sont les patients les plus à risque de se détériorer sur le plan fonctionnel et qui bénéficieraient donc d’un suivi plus étroit par leur professionnel de la santé. / Introduction: Thoracic trauma is, depending on severity, a frequent cause of mortality, morbidity, hospitalization and incapacity. Minor closed thoracic injuries are often treated on an outpatient basis. One potential complication is the development of a delayed hemothorax. Currently, there is no consensus on the classification of delayed hemothoraces. The goal of this study is to evaluate the level of inter and intra-rater agreement, and therefore reliability, with respect to three classification methods for delayed hemothoraces in patients presenting to the emergency department for minor closed thoracic trauma who develop a hemothorax between one and two weeks following the trauma. Methods: This study is a secondary analysis of a prospective multicenter cohort study of patients presenting to one of four Canadian ED. A random sample of 50 chest x-rays was selected among patients presenting with minor closed thoracic trauma between November 2006 and November 2010. The postero-anterior (PA) and lateral chest x-rays were submitted to eight physicians (two per group), from four different specialties (emergency medicine, surgery, radiology and family medicine), for interpretation using each of the three classification methods under study. One physician from each of the specialties also reinterpreted the same x-rays, using each of the three classification methods, at least two weeks later. Intraclass correlation coefficients (ICC) were then calculated to determine inter and intra-rater agreement for each of the three classification methods. Results : We determined that two of the three classification methods, one based on a study by Misthos et al. (1) – for postero-anterior radiographic vues – as well as one based on ratio calculations – for lateral vues – demonstrated the highest inter-rater agreement values. However, the method based on the study by Misthos et al. (1) showed better homogeneity, with narrower confidence intervals Global ICC 0.56 (0.47-0.64). Moreover, we also determined that the third classification method of the study, based on the subjective impression of the clinician, which is also the method currently used in the clinical setting, shows the weakest agreement between observers Global ICC 0.44 (0.34-0.53). These results, however, were not shown to be significantly different from each other, once subjected to statistical testing (p = 0.7319). Conclusion: This study was unable to demonstrate a statistically significant difference between the classification methods evaluated. However, we observed higher inter-rater vi agreement values for the methods based on a study by Misthos et al, (1) as well as on ratio calculations. The third method, based on the subjective impression of the clinician, shows the lowest inter-rater agreement between evaluators of different specialties. A future study, conducted on a larger sample size, could determine whether there exists a statistically significant difference between these classification methods and if so, the possible relationship between this more reliable method for classifying post-traumatic delayed hemothoraces and objective clinical markers, the goal being to validate its capacity to assist in predicting which patients are most at risk for functional deterioration and whom would benefit from tighter follow up from their healthcare professional.

Introdução: A pleurodese com talco é o método mais popular para controle sintomático do derrame pleural maligno recidivante. A administração intrapleural do talco pode ser por videotoracoscopia ou dreno de tórax e qual o melhor método é uma questão controversa. Ainda que a expansão pulmonar seja um dos principais critérios de sucesso do procedimento, suas características pós-pleurodese ainda são pouco estudadas. Objetivo: Avaliar a expansão pulmonar após dois diferentes métodos de pleurodese com talco (dreno de tórax ou videotoracoscopia) em pacientes com derrame pleural maligno recidivante, considerando a evolução radiológica, diferença entre os métodos e correlação com desfecho clínico. O objetivo secundário foi comparar ambos os métodos quanto a: efetividade clínica, segurança, qualidade de vida e sobrevivência. Método: Estudo prospectivo randomizado que incluiu 60 pacientes (45 Mulheres, 15 Homens, idade média: 55,2 anos) com derrame pleural maligno recidivante entre janeiro de 2005 e janeiro de 2008. Os pacientes foram alocados em dois grupos: videotoracoscopia com insuflação de talco (VT) ou instilação de talco por dreno de tórax (DT). A expansão pulmonar imediata e a evolução da expansão pulmonar foram avaliadas através de tomografias de tórax obtidas nos primeiros 7 dias, 1, 3 e 6 meses após a pleurodese, as quais foram analisadas por dois observadores independentes. Efetividade clínica (considerada como ausência de necessidade de novos procedimentos pleurais durante o seguimento), complicações, tempo de drenagem e de internação hospitalar e qualidade de vida (questionários gerais e específicos) foram também analisados. A análise estatística foi realizada através dos testes de Qui-quadrado e Fisher para as variáveis categóricas e Mann-Whitney para variáveis contínuas não paramétricas. A sobrevivência foi analisada através do método de Kaplan- Meier e o teste de log-Rank para foi usado para identificar fatores que interferissem na sobrevida. Os resultados dos questionários de qualidade de vida foram avaliados através de ANOVA de duplo-fator. Resultados: Não houve diferença significativa entre os grupos nas variáveis clínicas préoperatórias. A expansão imediata total (>90%) foi observada em 27 (45%) pacientes e foi mais freqüente no grupo VT (60 vs. 30%, p=0.027). Durante o seguimento, 71% dos pacientes estudados tiveram melhora ou ao menos mantiveram a expansão pulmonar observada na 1ª tomografia, fato que ocorreu de forma semelhante entre os grupos (p=0,58). Novos procedimentos pleurais foram necessários em 9(15%) pacientes (5 recidivas no grupo VT e 4 no grupo DT, p=0.999). Não foram encontradas diferenças entre os grupos quanto a: complicações, tempo e de internação. A análise dos questionários de qualidade de vida revelou resultados semelhantes para ambos os grupos. A expansão pulmonar imediata não se correlacionou com recidiva radiológica, recidiva clínica ou complicações (p= 0.60, 0.15 e 0.20, respectivamente). A sobrevida após ambos os procedimentos foi semelhante, porém a ocorrência de recidivas foi um fator relacionado a sobrevida mais curta (p=0,02). Conclusão: Expansão pulmonar imediata parcial foi freqüente, particularmente no grupo DT. Contudo, manutenção do quadro radiológico e até melhora radiológica ocorreram na maioria dos casos. Não foi encontrada correlação entre expansão pulmonar imediata e desfecho clínico neste estudo. / Introduction: Talc pleurodesis is the most popular method to control recurrent malignant pleural effusion symptoms. Two methods may be used to deliver talc into the pleural space: videothoracoscopy or talc slurry through a chest tube ; which is the best method is still controversial. Although lung expansion is the most accepted pleurodesis outcome variable, its features are poorly studied. Objective: To analyze and compare radiological lung expansion after talc pleurodesis performed either by videothoracoscopy or chest tube and correlate it with clinical outcome. Secondary endpoints evaluated were: clinical efficacy, safety, quality of life and survival. Methods: Prospective randomized study that included 60 patients (45 Female, 15 Male, mean age: 55,2 years) with recurrent malignant pleural effusion, between January, 2005 and January, 2008. They were enrolled into two groups: videothoracoscopic talc poudrage (VT) and talc slurry through a chest tube (TS). Lung expansion was evaluated through chest CT scans obtained in the first 7 days and 1, 3 and 6 months after pleurodesis. All examinations were revised by two independent observers. Clinical efficacy (considered as lack of new procedures during follow up), complications, drainage duration, hospital stay and quality of life (general and specific questionnaires) were also analyzed. Categorical variables were compared with the Chi-Square test or Fisher´s exact test for small samples. Mann-Whitney test was used to compare continuous non parametric variables. Survival curves were calculated according to the Kaplan-Meier method and Log-rank test was used to identify factors that could interfere with survival. Double factor ANOVA was used to compare quality of life questionnaires results. Results: No significant difference in pre-procedure clinical variables was observed between groups. Postoperative lung expansion was total (>90%) in 27 (45%) patients and was more frequent in VT group (60% vs. 30%, p=0.027). During follow-up 71% of the patients showed unaltered or improved lung expansion and lung expansion evolution was similar in both groups (p=0.58). Nine (15%) patients needed new pleural procedures (5 recurrences in VT group and 4 in DT group, p=0.999). No statistical difference was found between groups regarding complications, drainage time and hospital stay. Quality of life questionnaires were evaluated but no difference between study arms was observed. There was no correlation between initial lung expansion and clinical recurrence, radiological recurrence or complications (p = 0.60, 0.15 and 0.20, respectively). No difference in survival between study arms was observed, but a shorter survival was observed in patients that developed clinical recurrence (p=0.02). Conclusion: Immediate partial lung expansion was a frequent finding and was more frequent in TS group. However, maintenance of the radiological image and even radiological improvement occurred in most cases. No correlation between immediate lung expansion and clinical outcome was found in this study

Introdução: O derrame pleural, reduzindo a capacidade funcional pulmonar, torna os pacientes incapacitados para o desenvolvimento de suas atividades habituais. A retirada do líquido pleural através da toracocentese pode reverter este quadro, porém seu impacto especialmente na capacidade ao exercício não foi totalmente estabelecido. Objetivos: Avaliar o impacto da toracocentese de alívio na capacidade funcional ao exercício, no comportamento da função pulmonar e na força dos músculos respiratórios 48 horas pós toracocentese. Casuística e Método: Foram incluídos no estudo 25 pacientes com derrame pleural unilateral, documentado por radiografia de tórax. O teste de caminhada de seis minutos (TC6M), a escala modificada de dispnéia de Borg, as variáveis espirométricas: Capacidade Vital Forçada (CVF), Volume Expiratório Forçado no Primeiro Segundo (VEF1) e as medidas de Pressão Inspiratória Máxima (Pimax) e Pressão Expiratória Máxima (Pemax) foram analisados antes e 48 horas após a retirada de volumes superiores a 600 mL. Resultados: Foram removidos 1564 + 695 mL de líquido pleural. Os valores da distância percorrida, da CVF, do VEF1, da Pimax e da Pemax aumentaram (p < 0,001) enquanto o escore de dispnéia diminuiu (p < 0,001) após o procedimento. Observaram-se correlações estatísticas (p < 0.001) entre a distância percorrida e a CVF (r = 0.725) e VEF1 (r = 0.661) avaliadas 48 horas pós toracocentese e entre a variação da distância percorrida e a variação porcentual da CVF (r = 0,450) e do VEF1 (r = 0,472), corrigidos pelo volume de líquido retirado (p < 0,05). Conclusão: Embora ocorra melhora da função pulmonar após a toracocentese, os benefícios observados são mais evidentes em situações de esforço, o que possibilita melhor readaptação dos pacientes às suas atividades rotineiras. / Introduction: Pleural effusion reducing pulmonary functional capacity hinders patients in carrying out their habitual activities. Pleural fluid removal by thoracentesis reverts the clinical situation but its impact especially on exercise capacity has not yet been determined. Objectives: To evaluate the impact of thoracentesis in functional exercise capacity on pulmonary function and on muscle strength 48 hours after thoracentesis. Methods: Twenty five patients with unilateral pleural effusion documented by chest X-ray were included. The 6 minute walk test (TC6M), Borg\'s modified dyspnea scale, spirometric variables: CVF (forced vital capacity), VEF1 (forced expiratory volume in the first second), Maximum Inspiratory Pressure (Pimax) and Maximum Expiratory Pressure (Pemax) were analyzed before and 48 hours after the removal of volumes greater than 600 mL. Results: The mean of pleural effusion removed was 1564 + 695 mL. After the procedure values of walked distance, CVF, VEF1, Pimax and Pemax covered increased (p < 0.001) while dyspnea decreased (p < 0.001). Statistical correlations (p < 0.001) between the walked distance and FVC (r = 0.725) and VEF1 (r = 0.661) were established noted measured 48 hours post thoracentesis and between the variation of the distance walked and the percentage of variation of CVF (r = 0.450) and VEF1 (r = 0.472), corrected by the volume of fluid removed (p < 0.05). Conclusions: Despite an improvement in lung function after thoracentesis, the benefits noted are more evident in effort situations of exertion, allowing a better readaptation of patients to their routine activities.

O presente estudo tem como principal objetivo o emprego da reação em cadeia da polimerase (PCR) na elucidação da etiologia dos derrames pleurais dos pacientes com suspeita de pleurite tuberculosa, comparando-o com as técnicas diagnósticas disponíveis na atualidade. O diagnóstico da tuberculose pleural costuma ser feito por meio dos dados clínicos e radiológicos, teste tuberculínico, exames bioquímicos, microbiológicos, e citológicos do líquido pleural e da histopatologia de fragmento de pleura obtido por punção-biópsia. Ainda assim estes métodos apresentam muitas limitações, dentre as quais a baixa sensibilidade e o longo período necessário para a confirmação do diagnóstico. Estudamos 58 amostras de 45 pacientes. Destes, 16 pacientes tiveram diagnóstico clínico ou laboratorial confirmado de tuberculose, totalizando 22 amostras. Consideramos como caso de tuberculose todos os pacientes com baciloscopia, cultura ou histopatológico positivos no líquido pleural ou outro material biológico, ou que tenham apresentado melhora clínica após a introdução do tratamento empírico. Das 22 amostras com o diagnóstico de tuberculose, a PCR foi positiva em 6 amostras de 6 pacientes. A reação foi positiva em 1 amostra de um paciente em que o diagnóstico de tuberculose foi descartado. A sensibilidade, especificidade e os valores preditivo positivo e negativo nos 16 pacientes com diagnóstico de tuberculose foram 31,3%, 96,6%, 83% e 71% respectivamente. A PCR, apesar de ter apresentado uma baixa sensibilidade, demonstrou uma especificidade ótima em relação aos métodos convencionais. Está técnica pode ter utilidade como método complementar às técnicas disponíveis, na tentativa de obter um diagnóstico mais precoce e preciso nos casos de tuberculose pleural. / The present study evaluates the use of the polimerase chain reaction (PCR) to confirm the etiology of pleural effusions in patients with suspicion of pleural tuberculosis, comparing it to the current available techniques. The diagnosis of pleural tuberculosis is made through the combination of clinical data, radiologic findings, biochemical, microbiological and cytological examination of the pleural fluid and by the pathology of pleural fragment obtained by biopsy. However, these methods present a lot of limitations, including a low sensitivity and a long incubation period to confirm the diagnosis by culture. We studied 58 samples of 45 patients with pleural effusion. Of these, 16 patients had clinical diagnosis or confirmed by laboratory, in a total of 22 samples. We defined as case of tuberculosis all patients with culture or positive pathology in the fluid pleural or other biological material and those with clinical improvement after empirical treatment. Of the 22 samples with the tuberculosis diagnosis PCR was positive in 6 samples of 6 patients. The reaction was positive in a sample of a patient whose diagnosis of tuberculosis was later discarded. The sensitivity, specificity, positive predictive value and negative predictive value in the 16 patients with tuberculosis diagnosis were 31,3%, 96,6%, 83% and 71% respectively. In spite of having presented a low sensitivity, PCR specificity was greater than the conventional methods. This technique can be useful as an additional method to the available techniques, in the attempt of obtaining a more precocious and precise diagnosis in the cases of pleural tuberculosis.

by Mo-Lung Chen. / Thesis (M.Sc.)--Chinese University of Hong Kong, 1998. / Includes bibliographical references (leaves 70-75). / Abstract also in Chinese. / ABBREVIATIONS --- p.iv / LIST OF TABLES --- p.v / LIST OF FIGURES --- p.vii / ACKNOWLEDGEMENT --- p.ix / ABSTRACT --- p.xi / Chapter CHAPTER 1. --- INTRODUCTION --- p.1 / Chapter CHAPTER 2. --- BACKGROUND --- p.4 / Chapter 2.1 --- Production of pleural fluid --- p.4 / Chapter 2.2 --- Pathophysiology of pleural effusion --- p.5 / Chapter 2.3 --- Separating exudate from transudate --- p.8 / Chapter 2.4 --- Receiver operating characteristic curve --- p.9 / Chapter CHAPTER 3. --- ADENOSINE DEAMINASE --- p.12 / Chapter 3.1 --- Background --- p.12 / Chapter 3.2 --- Differentiation of tuberculous and non-tuberculous pleural effusion --- p.12 / Chapter CHAPTER 4. --- MATERIALS AND METHODS --- p.17 / Chapter 4.1 --- Patients --- p.17 / Chapter 4.2 --- Collection and handling of specimens --- p.17 / Chapter 4.3 --- Diagnostic criteria --- p.18 / Chapter 4.4 --- Methods --- p.19 / Chapter 4.4.1 --- Routine chemistries --- p.19 / Chapter 4.4.2 --- Protein zone electrophoresis --- p.19 / Chapter 4.4.3 --- Adenosine deaminase --- p.19 / Chapter 4.4.3.1 --- Instrumentation --- p.22 / Chapter 4.4.3.2 --- Optimization of reaction time --- p.24 / Chapter 4.4.4 --- Analytical performance --- p.24 / Chapter 4.4.4.1 --- Imprecision --- p.24 / Chapter 4.4.4.2 --- Recovery --- p.26 / Chapter 4.4.4.3 --- Lowest detection limit --- p.26 / Chapter 4.4.4.4 --- Linearity --- p.26 / Chapter 4.4.4.5 --- Interference by ammonia --- p.26 / Chapter 4.4.4.6 --- Interference by turbidity --- p.28 / Chapter 4.4.4.7 --- Interference by haemoglobin --- p.28 / Chapter 4.4.4.8 --- Interference by bilirubin --- p.29 / Chapter 4.4.4.9 --- Storage stability of ADA at -80°C --- p.29 / Chapter 4.4.5 --- Statistical analysis --- p.30 / Chapter CHAPTER 5. --- RESULTS OF OPTIMIZATION AND EVALUATION EXPERIMENTS --- p.31 / Chapter 5.1 --- Optimization of reaction time --- p.31 / Chapter 5.2 --- Analytical performance --- p.31 / Chapter 5.2.1 --- Imprecision --- p.31 / Chapter 5.2.1.1 --- Within-run --- p.31 / Chapter 5.2.1.2 --- Between-run --- p.31 / Chapter 5.2.2 --- Recovery --- p.31 / Chapter 5.2.3 --- Lowest detection limit --- p.34 / Chapter 5.2.4 --- Linearity --- p.34 / Chapter 5.2.5 --- Interference by / Chapter 5.2.5.1 --- ammonia --- p.34 / Chapter 5.2.5.2 --- turbidity --- p.34 / Chapter 5.2.5.3 --- haemoglobin --- p.37 / Chapter 5.2.5.4 --- bilirubin --- p.37 / Chapter 5.2.6 --- Storage stability of ADA at -80°C --- p.37 / Chapter CHAPTER 6. --- TRANSUDATIVE AND EXUDATIVE PLEURAL EFFUSION --- p.39 / Chapter 6.1 --- Results of routine chemistries --- p.39 / Chapter 6.2 --- Decision thresholds by ROC curve --- p.39 / Chapter 6.3 --- Discussion --- p.39 / Chapter 6.4 --- Results of protein zone electrophoresis --- p.49 / Chapter 6.5 --- Discussion --- p.51 / Chapter 6.6 --- Comparison of protein zone electrophoresis and Light's criteria --- p.55 / Chapter 6.7 --- Discussion --- p.55 / Chapter CHAPTER 7. --- TUBERCULOUS AND NON-TUBERCULOUS EXUDATIVE PLEURAL EFFUSION --- p.59 / Chapter 7.1 --- Results of adenosine deaminase assay --- p.59 / Chapter 7.2 --- Combinations of analysis --- p.59 / Chapter 7.3 --- Decision thresholds by ROC curve --- p.64 / Chapter 7.4 --- Discussion --- p.64 / Chapter CHAPTER8. --- GENERAL DISCUSSION --- p.69 / REFERENCES --- p.70

Introdução: O derrame pleural, reduzindo a capacidade funcional pulmonar, torna os pacientes incapacitados para o desenvolvimento de suas atividades habituais. A retirada do líquido pleural através da toracocentese pode reverter este quadro, porém seu impacto especialmente na capacidade ao exercício não foi totalmente estabelecido. Objetivos: Avaliar o impacto da toracocentese de alívio na capacidade funcional ao exercício, no comportamento da função pulmonar e na força dos músculos respiratórios 48 horas pós toracocentese. Casuística e Método: Foram incluídos no estudo 25 pacientes com derrame pleural unilateral, documentado por radiografia de tórax. O teste de caminhada de seis minutos (TC6M), a escala modificada de dispnéia de Borg, as variáveis espirométricas: Capacidade Vital Forçada (CVF), Volume Expiratório Forçado no Primeiro Segundo (VEF1) e as medidas de Pressão Inspiratória Máxima (Pimax) e Pressão Expiratória Máxima (Pemax) foram analisados antes e 48 horas após a retirada de volumes superiores a 600 mL. Resultados: Foram removidos 1564 + 695 mL de líquido pleural. Os valores da distância percorrida, da CVF, do VEF1, da Pimax e da Pemax aumentaram (p < 0,001) enquanto o escore de dispnéia diminuiu (p < 0,001) após o procedimento. Observaram-se correlações estatísticas (p < 0.001) entre a distância percorrida e a CVF (r = 0.725) e VEF1 (r = 0.661) avaliadas 48 horas pós toracocentese e entre a variação da distância percorrida e a variação porcentual da CVF (r = 0,450) e do VEF1 (r = 0,472), corrigidos pelo volume de líquido retirado (p < 0,05). Conclusão: Embora ocorra melhora da função pulmonar após a toracocentese, os benefícios observados são mais evidentes em situações de esforço, o que possibilita melhor readaptação dos pacientes às suas atividades rotineiras. / Introduction: Pleural effusion reducing pulmonary functional capacity hinders patients in carrying out their habitual activities. Pleural fluid removal by thoracentesis reverts the clinical situation but its impact especially on exercise capacity has not yet been determined. Objectives: To evaluate the impact of thoracentesis in functional exercise capacity on pulmonary function and on muscle strength 48 hours after thoracentesis. Methods: Twenty five patients with unilateral pleural effusion documented by chest X-ray were included. The 6 minute walk test (TC6M), Borg\'s modified dyspnea scale, spirometric variables: CVF (forced vital capacity), VEF1 (forced expiratory volume in the first second), Maximum Inspiratory Pressure (Pimax) and Maximum Expiratory Pressure (Pemax) were analyzed before and 48 hours after the removal of volumes greater than 600 mL. Results: The mean of pleural effusion removed was 1564 + 695 mL. After the procedure values of walked distance, CVF, VEF1, Pimax and Pemax covered increased (p < 0.001) while dyspnea decreased (p < 0.001). Statistical correlations (p < 0.001) between the walked distance and FVC (r = 0.725) and VEF1 (r = 0.661) were established noted measured 48 hours post thoracentesis and between the variation of the distance walked and the percentage of variation of CVF (r = 0.450) and VEF1 (r = 0.472), corrected by the volume of fluid removed (p < 0.05). Conclusions: Despite an improvement in lung function after thoracentesis, the benefits noted are more evident in effort situations of exertion, allowing a better readaptation of patients to their routine activities.

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Introdução: Empiema pleural em geral decorre de complicação de pneumonias e, se não identificado e tratado precocemente, pode ocasionar aumento morbidade ou mesmo mortalidade. A identificação de marcadores no líquido pleural de efusões parapneumônicas que mostrem a presença ou a evolução precoce para empiema tem significância clínica. Neste cenário, dosagens das concentrações de frações ativadas do complemento no líquido pleural podem ajudar no diagnóstico precoce do empiema. Objetivos: Comparar as concentrações de frações ativadas do complemento (C3a, C5a e C5b9) em efusões pleurais induzidas em ratos por inoculação intrapleural de bactérias ou por irritante químico estéril (terebentina). Métodos: Trinta e nove ratos Wistar machos, peso médio de 414g (290 a 546g), realizaram anestesia geral com isofluorano inalatório por máscara, e toracocentese no 4º espaço intercostal com abocath conectado a oscilômetro de pressão para confirmar posição intrapleural. Os animais foram divididos em 3 grupos: SA (n=17) - inoculação de Staphylococcus aureus; SP (n=12) - inoculação de Streptococcus pneumoniae; C (n=10) – inoculação de terebintina (efusão pleural estéril, controle). Doze horas após a inoculação intrapleural foi coletado liquido pleural por toracocentese, sob controle ecográfico, e realizadas dosagens de C3a, C5a e C5b9 pelo método ELISA. Resultados: A dosagem de C3a foi de 1066,82 μg/ml (937,29 – 1196,35 μg/ml) no grupo SA, 1188,28 μg/ml (1095,65 – 1280,92 μg/ml) no SP, e de 679,13 μg/ml (601,29 – 756,98 μg/ml) no C (p<0,001). A dosagem de C5a foi de 55.727 ng/ml (41,22 – 70,23 ng/ml) no grupo SA, 520.107 ng/ml (278,92-761,3 ng/ml) no SP, e de 5.268 ng/ml (1,68 – 8,85 ng/ml) no C (p<0,001). A dosagem de C5b9 foi de 15,02 ng/ml (13,1 – 16,94 ng/ml) no SA, de 16,63 ng/ml (14,37 – 18,9 ng/ml) no SP, e de 14,05 ng/ml (9,8 – 18,29 ng/ml) no C (p=0,692). A avaliação das curvas ROC demonstrou área sob a curva de 0,987 (IC95% 0,953-1) para o C3a; 1 para C5a (1-1) e 0,757 (0,523-0,990). Conclusões: As frações ativadas dos complementos C3a e C5a foram significativamente maiores nos empiemas induzidos experimentalmente por inoculação intrapleural de Staphylococcus aureus e Streptococcus pneumoniae do que com aquelas observadas após inoculação intrapleural de terebentina. A dosagem elevada destas frações ativadas do complemento foi útil para o diagnóstico do empiema pleural induzido em ratos. / Background Pleural empyema is a well-known complication of pneumonia. If treatment is delayed, empyema may increase morbidity and mortality in affected patients. Therefore, the identification of empyema biomarkers in parapneumonic pleural effusion is desirable. Previous research has suggested complement activation products as candidate empyema markers. Objective To compare the levels of complement activation products C3a, C5a, and C5b9 in pleural effusion induced by Staphylococcus aureus (SA), Streptococcus pneumoniae (SP), or turpentine (control). Method Thirty-nine male Wistar rats (mean weight 414g; 290-546g) were allocated as follows: 17 animals in the SA group, 12 in the SP group, and 10 in the control group. Bacteria or turpentine were injected into the pleural space. After 12h, intrapleural fluid was collected using ultrasound-guided thoracentesis. Levels of complement activation products were determined using ELISA kits. Results Two SA and 1 SP animals died before 12h. Mean levels were as follows: C3a: 1066.82 μg/mL (937.29-1196.35 μg/mL) in SA, 1188.28 μg/mL (1095.65-1280.92 μg/mL) in SP, and 679.13 μg/mL (601.29-756.98 μg/mL) in controls (p<0.001); C5a: 55.727 ng/mL (41.22-70.23 ng/mL) in SA, 520.107 ng/mL (278.92-761.3 ng/mL) in SP, and 5.268 ng/mL (1.68-8.85 ng/mL) in controls (p<0.001); C5b9: 15.02 ng/mL (13.1-16.94 ng/mL) in SA, 16.63 ng/mL (14.37-18.9 ng/mL) in SP, and 14.05 ng/mL (9.8-18.29 ng/mL) in controls (p=0.692). ROC analysis revealed an area under the curve of 0.987 (95%CI: 0.953-1) for C3a; 1 (1-1) for C5a; and 0.757 for C5b9 (0.523-0.990). Conclusions In the present rat model, complement activation fragments C3a and C5a accurately detected infected pleural effusion.

BACKGROUND: Malignant and paramalignant pleural effusions are important complications of many malignancies. The two main management options debated in the literature are: 1) insertion of an indwelling pleural catheter (IPC) to achieve chronic drainage of the effusion, or 2) hospitalization with tube thoracostomy and subsequent chemical pleurodesis (CP) with talc or doxycycline to prevent fluid reaccumulation. We aimed to describe a large series of patients with malignant pleural effusions managed with an IPC, identify and validate factors identified in the literature as predictors of spontaneous pleurodesis in the IPC group and compare the group managed with IPC to patients managed with CP. METHODS: We designed a retrospective cohort study comparing patients with malignant and paramalignant pleural effusions managed either with CP between March 1, 2003 and February 28, 2006 or IPC insertion between May 1, 2006 and April 1, 2009. The CP group was identified through the prescription of talc or doxycycline and the IPC group from the IPC clinic database. Data were collected from paper and electronic records and from the Government of Ontario. RESULTS: We identified 193 consecutive patients with an ECOG performance status of less than 4 (ECOG less than 4 means that the patient is not completely disabled and confined to bed or chair) having undergone IPC insertion and 168 who were managed with CP. None of the variables we tested were significant predictors of spontaneous pleurodesis in the IPC group. Pleural effusion control rates at 6 months were higher in the IPC group than in the CP group (52.7% vs 34.0%, p<0.01) but the rate of freedom from pleural effusion at 180 days and catheter removal at 90 days was not significantly different (25.8% in the IPC group and 34.0% in the CP group p=0.14). Patients in the IPC group had a significantly longer median survival (148 days measured from the date of catheter insertion vs 133 days in the CP group, log-rank p<0.05). CONCLUSION: We found an intriguing possible survival benefit favouring management of malignant or paramalignant effusions with an IPC. Given possible biases due to the design of this study and uncertain explanatory mechanism, this needs to be confirmed in a randomized controlled trial. Quality of life, an important measure of success for these palliative procedures, should also be measured.

BACKGROUND: Malignant and paramalignant pleural effusions are important complications of many malignancies. The two main management options debated in the literature are: 1) insertion of an indwelling pleural catheter (IPC) to achieve chronic drainage of the effusion, or 2) hospitalization with tube thoracostomy and subsequent chemical pleurodesis (CP) with talc or doxycycline to prevent fluid reaccumulation. We aimed to describe a large series of patients with malignant pleural effusions managed with an IPC, identify and validate factors identified in the literature as predictors of spontaneous pleurodesis in the IPC group and compare the group managed with IPC to patients managed with CP. METHODS: We designed a retrospective cohort study comparing patients with malignant and paramalignant pleural effusions managed either with CP between March 1, 2003 and February 28, 2006 or IPC insertion between May 1, 2006 and April 1, 2009. The CP group was identified through the prescription of talc or doxycycline and the IPC group from the IPC clinic database. Data were collected from paper and electronic records and from the Government of Ontario. RESULTS: We identified 193 consecutive patients with an ECOG performance status of less than 4 (ECOG less than 4 means that the patient is not completely disabled and confined to bed or chair) having undergone IPC insertion and 168 who were managed with CP. None of the variables we tested were significant predictors of spontaneous pleurodesis in the IPC group. Pleural effusion control rates at 6 months were higher in the IPC group than in the CP group (52.7% vs 34.0%, p<0.01) but the rate of freedom from pleural effusion at 180 days and catheter removal at 90 days was not significantly different (25.8% in the IPC group and 34.0% in the CP group p=0.14). Patients in the IPC group had a significantly longer median survival (148 days measured from the date of catheter insertion vs 133 days in the CP group, log-rank p<0.05). CONCLUSION: We found an intriguing possible survival benefit favouring management of malignant or paramalignant effusions with an IPC. Given possible biases due to the design of this study and uncertain explanatory mechanism, this needs to be confirmed in a randomized controlled trial. Quality of life, an important measure of success for these palliative procedures, should also be measured.