Controversy exists regarding the clinical utility of pleural fluid pH,lactate dehydrogenase (LDH), and glucose for identifying complicated parapneumonic effusions that require drainage. In this report, we performed a meta-analysis of pertinent studies, using receiver operating characteristic (ROC) techniques, to assess the diagnostic accuracy of these tests, to determine appropriate decision thresholds, and to evaluate the quality of the primary studies. Seven primary studies reporting values for pleural fluid pH (n = 251), LDH (n = 114), or glucose (n = 135) in pneumonia patients were identified. We found that pleural fluid pH had the highest diagnostic accuracy for all patients with parapneumonic effusions as measured by the area under the ROC curve (AUC = 0.92) compared with pleural fluid glucose (AUC = 0.84) or LDH (AUC = 0.82). After excluding patients with purulent effusions, pH (AUC = 0.89) retained the highest diagnostic accuracy. Pleural fluid pH decision thresholds varied between 7.21 and 7.29 depending on cost-prevalence considerations. The quality of the primary studies was the major limitation in determining the value of pleural fluid chemical analysis. We conclude that meta-analysis of the available data refines the application of pleural fluid chemical analysis but a clearer understanding of the usefulness of these tests awaits more rigorous primary investigations. Heffner JE, Brown LK, Barbieri C, Deleo JM. Pleural fluid chemical analysis in parapneumonic effusions: a meta-analysis. Am J Resplr Crit Care Med 1995;151:1700-8.Parapneumonic effusions occur in 20% to 57% of patients hospitalized for community-acquired bacterial pneumonia (1-3). These effusions may either resolve with antibiotic therapy alone or folIowa complicated course requiring tube thoracostomy or thoracotomy. Because the progression from a free-flowing parapneumonic effusion to the formation of intrapleural pus may occur rapidly (4), most experts recommend prompt pleural drainage when a complicated course appears likely (5-7).No clinical or radiograph findings, however, offer sufficient diagnostic accuracy to establish the need for pleural drainage in patients with parapneumonic effusions (2,4,8,9). Consequently, thoracentesis with pleural fluid analysis is employed to select patients for chest tube placement. The detection by thoracentesis of intrapleural pus or nonpurulent fluid with a positive Gram stain for pathogens is an accepted indication for instituting immediate pleural fluid drainage. Because the diagnostic sensitivities of these findings are low (5), determinations of pleural fluid pH, glucose, and lactate dehydrogenase (LDH) are recommended by expert statements and standard textbooks to assist in the decision to drain parapneumonic effusions (5, 7, 10-13). No general consensus exists, however, regarding the clinical utility of these criteria (8, 14-16).It appears that this lack of consensus derives at least partially from the small sample sizes of the individual primary studies that examine pleural fluid chemical ana...

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This study has identified many significant intercenter differences within Scotland. We believe this to be the first study to identify nontumor factors independent of performance status that together limit the ability to deliver radical, possibly curative, therapy to our lung cancer population. It is only by identifying such factors that we can hope to improve on the relatively poor outlook for the majority of Scottish patients with lung cancer.

Background. Prediction of survival in patients diagnosed with lung cancer remains problematical. The aim of the present study was to examine the clinical utility of an established objective marker of the systemic inflammatory response, the Glasgow Prognostic Score, as the basis of risk stratification in patients with lung cancer. Methods. Between 2005 and 2008 all newly diagnosed lung cancer patients coming through the multidisciplinary meetings (MDTs) of four Scottish centres were included in the study. The details of 882 patients with a confirmed new diagnosis of any subtype or stage of lung cancer were collected prospectively. Results. The median survival was 5.6 months (IQR 4.8–6.5). Survival analysis was undertaken in three separate groups based on mGPS score. In the mGPS 0 group the most highly predictive factors were performance status, weight loss, stage of NSCLC, and palliative treatment offered. In the mGPS 1 group performance status, stage of NSCLC, and radical treatment offered were significant. In the mGPS 2 group only performance status and weight loss were statistically significant. Discussion. This present study confirms previous work supporting the use of mGPS in predicting cancer survival; however, it goes further by showing how it might be used to provide more objective risk stratification in patients diagnosed with lung cancer.

Dysphagia is a common morbidity and cause of mortality following traumatic brain injury (TBI). Despite this, there is a paucity of evidence demonstrating the efficacy of dysphagia management strategies and treatments in this population. Typically, subjects with dysphagia following TBI are placed into non-specific 'neurogenic' dysphagia subject groups, which include subjects with degenerative neurological diseases, neurological cancers, and cerebrovascular accident. However, dysphagia following TBI has a multifactorial presentation, with causative and contributory factors including cognitivecommunication, behavioral, neurological, and mechanical issues. As such, the management for dysphagia post-TBI must be multifactorial, team-based and involve the patients' families and carers. Much of the research regarding the management and treatment of dysphagia in general is in its infancy: larger and more rigorous studies are required to demonstrate treatment efficacy. More studies specifically examining dysphagia and its management in the TBI population are required to ensure the future efficacy and accuracy of treatment.

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IntroductionEndobronchial ultrasound-guided transbronchial needle aspiration (EBUS-TBNA) is a pivotal test in lung cancer staging and diagnosis, mandating robust audit and performance monitoring of EBUS services. We present the first regional cancer alliance EBUS performance audit against the new National EBUS specification.MethodsAcross the five EBUS centres in the Greater Manchester Cancer Alliance, data are recorded at the point of procedure, when pathological results are available and at 6 months postprocedure to review any further pathological sampling (eg, at surgical resection) and the outcome of clinical–radiological follow-up. Outcomes across all five centres were compared with national standards for all lung cancer EBUS procedures from 01 January 2017 to 31 December 2018.Results1899 lung cancer staging or diagnostic EBUS procedures were performed across the five centres during the study period; 1309 staging EBUS procedures and 590 diagnostic EBUS procedures. Major complications were seen in six cases (<1%). All five trusts demonstrated performance above that set national standards in key metrics for both staging and diagnostic EBUS, however the provision of adequate tissue for predictive marker testing was below national standards at one trust. Across Greater Manchester, 72% and 64% of patients had their EBUS procedure performed within 7 days of referral in 2017 and 2018, respectively. Only one out of five trusts met the national targets of >85% of procedures performed within 7 days of referral.ConclusionThe National EBUS service specification is an important framework to drive the quality of EBUS services across the UK. Our data provide assurance of appropriate performance and safety while also highlighting specific areas for attention that can be addressed with the support of the cancer alliance.