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Incidence and Risk Factors of Chest Wall Metastasis at Biopsy Sites in Patients with Malignant Pleural Mesothelioma. Cancers (Basel) 2022; 14:cancers14184356. [PMID: 36139517 PMCID: PMC9497080 DOI: 10.3390/cancers14184356] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/11/2022] [Revised: 09/04/2022] [Accepted: 09/04/2022] [Indexed: 11/16/2022] Open
Abstract
To investigate the incidence and risk factors of chest wall metastasis (CWM) at biopsy sites in patients with malignant pleural mesothelioma (MPM). This retrospective cohort study was conducted in 262 consecutive MPM patients who underwent multimodal treatment in which including neoadjuvant chemotherapy (NAC) and curative-intent surgery, from August 2009 to March 2021. CWM was evaluated radiologically (r-CWM) and pathologically (p-CWM). We also investigated the risk factors of p-CWM and the consistency between r-CWM and p-CWM. Of 262 patients, 25 patients were excluded from analysis due to missing data or impossibility of evaluation. Of the eligible 237 patients, pleural biopsy was performed via video-assisted thoracoscopic surgery in 197 (83.1%) and medical thoracoscopy in 40 (16.9%). Pleurodesis was performed after pleural biopsy in 74 patients (31.2%). All patients received NAC followed by curative-intent surgery. Radiological examination showed r-CWM in 43 patients (18.1%), while pathological examination showed p-CWM in 135 patients (57.0%). The incidence of p-CWM was significantly higher in the patients who received pleurodesis after pleural biopsy (77.0% vs. 47.9%, <0.001). Multivariate logistic regression analysis for p-CWM revealed that pleurodesis is an independent risk factor of p-CWM (adjusted hazard ratio, 3.46; 95% confidence interval, 1.84−6.52, <0.001). CWM at the biopsy site was pathologically proven in more than half of the patients (57.0%) who received NAC followed by curative-intent surgery, which was higher than the numbers diagnosed by radiological examinations (p-CWM: 57.0% vs. r-CWM: 18.1%). Pleurodesis after pleural biopsy is an independent risk factor of p-CWM.
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Omoregbee BI, Okugbo S. Pleurodesis with povidone iodine in patients with malignant pleural effusion in a tertiary center in Nigeria. Pan Afr Med J 2021; 38:169. [PMID: 33995776 PMCID: PMC8077678 DOI: 10.11604/pamj.2021.38.169.22405] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/19/2020] [Accepted: 02/06/2021] [Indexed: 11/11/2022] Open
Abstract
INTRODUCTION malignant pleural effusion occurs as a consequence of a primary or metastatic malignant process involving the pleura. The aim of pleurodesis is to prevent re-accumulation of the effusion and avoid the need for repeated hospitalization. Povidone iodine has been used in other climes for pleurodesis with good results. The aim of this study is to assess the efficacy and safety of povidone iodine in producing pleurodesis as compared to tetracycline. METHODS the study is a prospective experimental study. The patients are randomized into two groups A (tetracycline-control) and B (povidone iodine). All patients are assessed with chest X-ray after 1 week and 1 month. The responses were ascribed as complete, partial or failure. RESULTS thirty patients were recruited into this study, 15 patients in each group A (tetracycline) and B (povidone iodine). The mean age was 45.7±14.24 years. The commonest primary malignancy was Breast cancer (70%) followed by bronchogenic cancer (10%). Seventy three (73%) of the patients in this study had complete response and in 7% pleurodesis failed whilst 20% has partial response. In the povidone group the success rate was 93.4% and in the tetracycline group was 93.3% with a p-value of 0.716. There was no statistical difference in the responses based on the agents used. CONCLUSION malignant pleural effusion is a devastating condition as it heralds the end-of-life processes of a primary malignancy. Povidone iodine is a safe, cheap, effective, widely available and effective pleurodesing agent for use in patients with malignant pleural effusion.
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Affiliation(s)
- Benjamin Irene Omoregbee
- Department of Cardiothoracic Surgery, Castle Hill Hospital, Cottingham, United Kingdom
- Cardiothoracic Surgery Unit, Department of Surgery, University of Benin Teaching Hospital, Benin City, Nigeria
| | - Stanley Okugbo
- Cardiothoracic Surgery Unit, Department of Surgery, University of Benin Teaching Hospital, Benin City, Nigeria
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Lui MMS, Thomas R, Lee YCG. Complications of indwelling pleural catheter use and their management. BMJ Open Respir Res 2016; 3:e000123. [PMID: 26870384 PMCID: PMC4746457 DOI: 10.1136/bmjresp-2015-000123] [Citation(s) in RCA: 71] [Impact Index Per Article: 8.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/24/2015] [Accepted: 01/05/2016] [Indexed: 11/23/2022] Open
Abstract
The growing utilisation of indwelling pleural catheters (IPCs) has put forward a new era in the management of recurrent symptomatic pleural effusions. IPC use is safe compared to talc pleurodesis, though complications can occur. Pleural infection affects <5% of patients, and is usually responsive to antibiotic treatment without requiring catheter removal or surgery. Pleural loculations develop over time, limiting drainage in 10% of patients, which can be improved with intrapleural fibrinolytic therapy. Catheter tract metastasis can occur with most tumours but is more common in mesothelioma. The metastases usually respond to analgaesics and/or external radiotherapy. Long-term intermittent drainage of exudative effusions or chylothorax can potentially lead to loss of nutrients, though no data exist on any clinical impact. Fibrin clots within the catheter lumen can result in blockage. Chest pain following IPC insertion is often mild, and adjustments in analgaesics and drainage practice are usually all that are required. As clinical experience with the use of IPC accumulates, the profile and natural course of complications are increasingly described. We aim to summarise the available literature on IPC-related complications and the evidence to support specific strategies.
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Affiliation(s)
- Macy M S Lui
- Division of Respiratory and Critical Care Medicine, Department of Medicine, Queen Mary Hospital, University of Hong Kong, Hong Kong; Department of Respiratory Medicine, Sir Charles Gairdner Hospital, Perth, Western Australia, Australia
| | - Rajesh Thomas
- Department of Respiratory Medicine, Sir Charles Gairdner Hospital, Perth, Western Australia, Australia; Pleural Medicine Unit, Institute of Respiratory Health, Perth, Western Australia, Australia; Centre for Respiratory Health, School of Medicine & Pharmacology, University of Western Australia, Perth, Western Australia, Australia
| | - Y C Gary Lee
- Department of Respiratory Medicine, Sir Charles Gairdner Hospital, Perth, Western Australia, Australia; Pleural Medicine Unit, Institute of Respiratory Health, Perth, Western Australia, Australia; Centre for Respiratory Health, School of Medicine & Pharmacology, University of Western Australia, Perth, Western Australia, Australia
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Sweatt AJ, Sung A. Interventional pulmonologist perspective: treatment of malignant pleural effusion. Curr Treat Options Oncol 2015; 15:625-43. [PMID: 25240411 DOI: 10.1007/s11864-014-0312-6] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/24/2022]
Abstract
OPINION STATEMENT The management of known malignant pleural effusions focuses around the initial thoracentesis and subsequent objective and subjective findings. A completely reexpanded lung after fluid removal and with symptomatic improvement predicts successful pleurodesis. Pleurodesis method depends on center expertise as well as patient preference. Medical thoracoscopy does not require the operating room setting and is performed on the spontaneously breathing patient with similar success rate to surgical thoracoscopy in the appropriately selected patients. However, it is not widely available. Talc insufflation is preferred for even distribution of sprayed particles to pleural surfaces. Most often, patients can be discharged home within 24 to 48 hours after continuous chest tube suction. Indwelling pleural catheter has become popular given the ease of insertion and patient centered home drainage. Coordinated care with good patient and family education and support is paramount to maximizing the beneficial potential of the catheter. Complications are minimal, and catheters are easily removed if patients can no longer benefit from drainage, or if pleurodesis has occurred. In the setting of trapped lung as a result of visceral pleura encasement from tumor, indwelling catheter can still be useful if the patient improves with thoracentesis. However, if no subjective improvement is seen after thoracentesis for trapped lung, then no procedure is recommended and other modes of palliation should be sought.
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Affiliation(s)
- Andrew J Sweatt
- Division of Pulmonary and Critical Care Medicine, Stanford University, Stanford, CA, USA,
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Mehta D, Gupta A, Singhal S, Bansal S. Indwelling pleural drain for mobile management of malignant pleural effusion-combining benefits of both methods. Lung India 2015; 32:64-6. [PMID: 25624601 PMCID: PMC4298924 DOI: 10.4103/0970-2113.148455] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/04/2022] Open
Abstract
Malignant pleural effusion is a leading cause of morbidity in lung cancer patients requiring repeated pleural aspirations or persistent intercostal drainage tube. Using an indigenous method of putting icd tube of smaller size with subcutaneous tunneling would allow draining fluid from lungs easily and painlessly when needed and avoid the need for repeated injections and chest tube insertion every time the fluid is to be drained.
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Affiliation(s)
- Dinesh Mehta
- Department of Respiratory Medicine, Maharishi Markandeshwar Institute of Medical Sciences and Research, Ambala, Haryana, India
| | - Anshu Gupta
- Department of Pharmacology, Maharishi Markandeshwar Institute of Medical Sciences and Research, Ambala, Haryana, India
| | - Sameer Singhal
- Department of Respiratory Medicine, Maharishi Markandeshwar Institute of Medical Sciences and Research, Ambala, Haryana, India
| | - Sachin Bansal
- Department of Respiratory Medicine, Maharishi Markandeshwar Institute of Medical Sciences and Research, Ambala, Haryana, India
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Thomas R, Francis R, Davies HE, Lee YCG. Interventional therapies for malignant pleural effusions: the present and the future. Respirology 2014; 19:809-22. [PMID: 24947955 DOI: 10.1111/resp.12328] [Citation(s) in RCA: 44] [Impact Index Per Article: 4.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/09/2014] [Revised: 05/01/2014] [Accepted: 05/01/2014] [Indexed: 11/29/2022]
Abstract
The approach to management of malignant pleural effusions (MPE) has changed over the past few decades. The key goals of MPE management are to relieve patient symptoms using the least invasive means and in the most cost-effective manner. There is now a realization that patient-reported outcome measures should be the primary goal of MPE treatment, and this now is the focus in most clinical trials. Efforts to minimize patient morbidity are complemented by development of less invasive treatments that have mostly replaced the more aggressive surgical approaches of the past. Therapeutic thoracentesis is simple, effective and generally safe, although its benefits may only be temporary. Pleurodesis is the conventional and for a long time the only definitive therapy available. However, the efficacy and safety of talc pleurodesis has been challenged. Indwelling pleural catheter (IPC) drainage is increasingly accepted worldwide and represents a new concept to improve symptoms without necessarily generating pleural symphysis. Recent studies support the effectiveness of IPC treatment and provide reassurance regarding its safety. An unprecedented number of clinical trials are now underway to improve various aspects of MPE care. However, choosing an optimal intervention for MPE in an individual patient remains a challenge due to our limited understanding of the underlying pathophysiology of breathlessness in MPE and a lack of predictors of survival and pleurodesis outcome. This review provides an overview of common pleural interventional procedures used for MPE management, controversies and limitations of current practice, and areas of research most needed to improve practice in future.
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Affiliation(s)
- Rajesh Thomas
- Department of Respiratory Medicine, Sir Charles Gairdner Hospital, Perth, Western Australia, Australia; School of Medicine and Pharmacology, University of Western Australia, Perth, Western Australia, Australia; Pleural Disease Unit, Lung Institute of Western Australia, Perth, Western Australia, Australia
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Ried M, Hofmann HS. The treatment of pleural carcinosis with malignant pleural effusion. DEUTSCHES ARZTEBLATT INTERNATIONAL 2013; 110:313-8. [PMID: 23720697 DOI: 10.3238/arztebl.2013.0313] [Citation(s) in RCA: 18] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/27/2022]
Abstract
BACKGROUND Pleural carcinosis is caused by tumors of the chest (e.g., lung and breast cancer) or elsewhere in the body (e.g., ovarian carcinoma) that metastasize to the visceral and/or parietal pleura. Recurrent malignant pleural effusion due to pleural carcinosis is one of the most common findings in oncology. It affects about 56 000 patients per year in Germany alone. METHODS This review is based on pertinent literature retrieved by a selective search of the Medline database (key words: malignant pleural effusion, pleural carcinosis) and on the authors' clinical experience. RESULTS Although many retrospective studies have been published, there has been only one randomized controlled trial of treatment, in which permanent pleural catheters were compared with talcum pleurodesis. Patients with pleural carcinosis have a median survival of less than 12 months. Many are suffering from progression of their underlying disease, with generalized tumor involvement; thus, the symptomatic treatment of pain and dyspnea is often the main therapeutic issue. The underlying tumor, usually an adenocarcinoma, can be diagnosed either by histology or by cytology. The main complication is progressive respiratory failure. The treatment is palliative, rather than curative. The main approaches are drainage of the effusion (by thoracocentesis or with permanent pleural catheters) and pleurodesis (obliteration of the pleural space by causing the visceral and parietal pleura to adhere to each other). CONCLUSION Pleural carcinosis with symptomatic malignant pleural effusion is treated palliatively. The appropriate treatment in each case should be determined through discussion with the patient, with the goal of improving the patient's quality of life.
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Affiliation(s)
- Michael Ried
- Department of Thoracic Surgery, University Hospital Regensburg, Regensburg, Germany.
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Abstract
Malignant pleural effusions are a cause of significant symptoms and distress in patients with end-stage malignancies and portend a poor prognosis. Management is aimed at symptom relief, with minimally invasive interventions and minimal requirement for hospital length of stay. The management options include watchful waiting if no symptoms are present, repeat thoracentesis, medical or surgical thoracoscopic techniques to achieve pleurodesis, pleuroperitoneal shunts, placement of tunneled pleural catheters, or a combination of modalities. To determine the best modality for management, patients must be assessed individually with concern for symptoms, functional status, prognosis, and their social and financial situations.
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Affiliation(s)
- Justin M Thomas
- Division of Pulmonary and Critical Care, Department of Medicine, National Jewish Health, Denver, CO 80206, USA
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Hogg JR, Caccavale M, Gillen B, McKenzie G, Vlaminck J, Fleming CJ, Stockland A, Friese JL. Tube thoracostomy: a review for the interventional radiologist. Semin Intervent Radiol 2012; 28:39-47. [PMID: 22379275 DOI: 10.1055/s-0031-1273939] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/06/2023]
Abstract
Small-caliber tube thoracostomy is a valuable treatment for various pathologic conditions of the pleural space. Smaller caliber tubes placed under image guidance are becoming increasingly useful in numerous situations, are less painful than larger surgical tubes, and provide more accurate positioning when compared with tubes placed without image guidance. Basic anatomy and physiology of the pleural space, indications, and contraindications of small caliber tube thoracostomy, techniques for image-guided placement, complications and management of tube thoracostomy, and fundamental principles of pleurodesis are discussed in this review.
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Van Meter MEM, McKee KY, Kohlwes RJ. Efficacy and safety of tunneled pleural catheters in adults with malignant pleural effusions: a systematic review. J Gen Intern Med 2011; 26:70-6. [PMID: 20697963 PMCID: PMC3024099 DOI: 10.1007/s11606-010-1472-0] [Citation(s) in RCA: 203] [Impact Index Per Article: 15.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/16/2010] [Revised: 06/29/2010] [Accepted: 07/12/2010] [Indexed: 12/31/2022]
Abstract
BACKGROUND Malignant pleural effusions (MPE) are a frequent cause of dyspnea and discomfort at the end of cancer patients' lives. The tunneled indwelling pleural catheter (TIPC) was approved by the FDA in 1997 and has been investigated as a treatment for MPE. OBJECTIVE To systematically review published data on the efficacy and safety of the TIPC for treatment of MPE. DESIGN We searched the MEDLINE, EMBASE, and ISI Web of Science databases to identify studies published through October 2009 that reported outcomes in adult patients with MPE treated with a TIPC. Data were aggregated using summary statistics when outcomes were described in the same way among multiple primary studies. MAIN MEASURES Symptomatic improvement and complications associated with use of the TIPC. KEY RESULTS Nineteen studies with a total of 1,370 patients met criteria for inclusion in the review. Only one randomized study directly compared the TIPC with the current gold standard treatment, pleurodesis. All other studies were case series. Symptomatic improvement was reported in 628/657 patients (95.6%). Quality of life measurements were infrequently reported. Spontaneous pleurodesis occurred in 430/943 patients (45.6%). Serious complications were rare and included empyema in 33/1168 patients (2.8%), pneumothorax requiring a chest tube in 3/51 (5.9%), and unspecified pneumothorax in 17/439 (3.9%). Minor complications included cellulitis in 32/935 (3.4%), obstruction/clogging in 33/895 (3.7%) and unspecified malfunction of the catheter in 11/121 (9.1%). The use of the TIPC was without complication in 517/591 patients (87.5%). CONCLUSIONS Based on low-quality evidence in the form of case series, the TIPC may improve symptoms for patients with MPE and does not appear to be associated with major complications. Prospective randomized studies comparing the TIPC to pleurodesis are needed before the TIPC can be definitively recommended as a first-line treatment of MPE.
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Affiliation(s)
- Margaret E M Van Meter
- Division of Cancer Medicine, The University of Texas MD Anderson Cancer Center, 1515 Holcombe Blvd, Unit 10, Houston, TX 77030-4009, USA.
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Daddi N, Vannucci J, Maggio C, Giontella A, Bravi I, Marziani F, Capozzi R, Ragusa M, Bufalari A, Puma F. Efficacy of tigecycline pleurodesis: a comparative experimental study. J Surg Res 2010; 169:e109-18. [PMID: 20934718 DOI: 10.1016/j.jss.2010.07.001] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/08/2010] [Revised: 06/08/2010] [Accepted: 07/01/2010] [Indexed: 11/19/2022]
Abstract
BACKGROUND We investigated whether tigecycline (TIGE) is more effective than talc in inducing pleurodesis in rabbits. METHODS Fifty-six New Zealand rabbits were utilized in a two-phase study: Effects at 14 d (phase I) and at 28 d (phase II) were assessed. Saline solution (SAL n = 3), talc slurry (TALC 200 mg/kg, n = 5), and TIGE at different concentrations (mg/kg): TIGE0.5 (n = 5); TIGE1 (n = 5); TIGE3 (n = 5); TIGE25 (n = 5); TIGE50 (n = 5) were randomly injected, for each phase, through a right chest drainage. TIGE0.5 and TIGE1 were ineffective during phase I and were thus excluded from further investigation. At post mortem examination, pleurodesis was graded grossly and microscopically by three observers blinded to treatment groups. RESULTS Phase I: pleurodesis was more effective in TIGE25 and TIGE50 (P < 0.001); TALC was better than TIGE0.5 (P < 0.001), and TIGE1 (P = 0.49), macroscopically. Pleural thickness was significantly higher in TIGE25 compared with SAL, TALC, TIGE0.5, TIGE1, and TIGE3 (P < 0.01). No significant differences were evident between TALC and TIGE3, both macroscopically (P = 0.90) and microscopically (inflammation P = 0.99, fibrosis P = 0.96, pleural thickness P = 0.99). Phase II: better effectiveness of TIGE50 compared with all other groups (P < 0.001) except TIGE 25 (P = 0.29); results similar to phase I for TALC and TIGE3 (P = 0.99), macroscopically. Microscopically greater inflammation in TALC compared with TIGE3 (P < 0.05) and in TIGE50 to TIGE3 (P = 0.05). Significant complications occurred in all TIGE50 group. One of TIGE25 and one of TIGE50 died of respiratory distress and of right hemothorax+ascites, respectively. CONCLUSIONS Intrapleural TIGE3 mg/kg is as effective as talc in inducing pleurodesis in rabbits. The intrapleural TIGE toxicity threshold was reached at TIGE25 mg/kg concentration.
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Affiliation(s)
- Niccolò Daddi
- Thoracic Surgery Unit in Perugia and Terni, University of Perugia, Italy.
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Allibone L. Assessment and management of patients with pleural effusion. BRITISH JOURNAL OF NURSING (MARK ALLEN PUBLISHING) 2008; 17:1382-8. [PMID: 19057496 DOI: 10.12968/bjon.2008.17.22.31862] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/11/2022]
Abstract
Pleural effusions are a common medical condition with a significant source of morbidity, and there are wide variations in management. Over the past 5 years there has been rapid advancement in the knowledge and treatment of pleural diseases and effusions. This article provides an overview of the anatomy and physiology of the pleural space and pleural membranes, and an update on assessment and management of patients with pleural effusions in line with new developments and related national guidelines.
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Affiliation(s)
- Liz Allibone
- Nursing Development, Royal Brompton and Harefield NHS Trust, London
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