1
|
Bedawi EO, Stavroulias D, Hedley E, Blyth KG, Kirk A, De Fonseka D, Edwards JG, Internullo E, Corcoran JP, Marchbank A, Panchal R, Caruana E, Kadwani O, Okiror L, Saba T, Purohit M, Mercer RM, Taberham R, Kanellakis N, Condliffe AM, Lewis LG, Addala DN, Asciak R, Banka R, George V, Hassan M, McCracken D, Sundaralingam A, Wrightson JM, Dobson M, West A, Barnes G, Harvey J, Slade M, Chester-Jones M, Dutton S, Miller RF, Maskell NA, Belcher E, Rahman NM. Early Video-assisted Thoracoscopic Surgery or Intrapleural Enzyme Therapy in Pleural Infection: A Feasibility Randomized Controlled Trial. The Third Multicenter Intrapleural Sepsis Trial-MIST-3. Am J Respir Crit Care Med 2023; 208:1305-1315. [PMID: 37820359 PMCID: PMC10765402 DOI: 10.1164/rccm.202305-0854oc] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/22/2023] [Accepted: 10/11/2023] [Indexed: 10/13/2023] Open
Abstract
Rationale: Assessing the early use of video-assisted thoracoscopic surgery (VATS) or intrapleural enzyme therapy (IET) in pleural infection requires a phase III randomized controlled trial (RCT). Objectives: To establish the feasibility of randomization in a surgery-versus-nonsurgery trial as well as the key outcome measures that are important to identify relevant patient-centered outcomes in a subsequent RCT. Methods: The MIST-3 (third Multicenter Intrapleural Sepsis Trial) was a prospective multicenter RCT involving eight U.K. centers combining on-site and off-site surgical services. The study enrolled all patients with a confirmed diagnosis of pleural infection and randomized those with ongoing pleural sepsis after an initial period (as long as 24 h) of standard care to one of three treatment arms: continued standard care, early IET, or a surgical opinion with regard to early VATS. The primary outcome was feasibility based on >50% of eligible patients being successfully randomized, >95% of randomized participants retained to discharge, and >80% of randomized participants retained to 2 weeks of follow-up. The analysis was performed per intention to treat. Measurements and Main Results: Of 97 eligible patients, 60 (62%) were randomized, with 100% retained to discharge and 84% retained to 2 weeks. Baseline demographic, clinical, and microbiological characteristics of the patients were similar across groups. Median times to intervention were 1.0 and 3.5 days in the IET and surgery groups, respectively (P = 0.02). Despite the difference in time to intervention, length of stay (from randomization to discharge) was similar in both intervention arms (7 d) compared with standard care (10 d) (P = 0.70). There were no significant intergroup differences in 2-month readmission and further intervention, although the study was not adequately powered for this outcome. Compared with VATS, IET demonstrated a larger improvement in mean EuroQol five-dimension health utility index (five-level edition) from baseline (0.35) to 2 months (0.83) (P = 0.023). One serious adverse event was reported in the VATS arm. Conclusions: This is the first multicenter RCT of early IET versus early surgery in pleural infection. Despite the logistical challenges posed by the coronavirus disease (COVID-19) pandemic, the study met its predefined feasibility criteria, demonstrated potential shortening of length of stay with early surgery, and signals toward earlier resolution of pain and a shortened recovery with IET. The study findings suggest that a definitive phase III study is feasible but highlights important considerations and significant modifications to the design that would be required to adequately assess optimal initial management in pleural infection.The trial was registered on ISRCTN (number 18,192,121).
Collapse
Affiliation(s)
- Eihab O. Bedawi
- Oxford Respiratory Trials Unit, Nuffield Department of Medicine
- National Institute for Health and Care Research Oxford Biomedical Research Centre
- Oxford Centre for Respiratory Medicine and
- Department of Infection, Immunity and Cardiovascular Disease, University of Sheffield, Sheffield, United Kingdom
- Academic Directorate of Respiratory Medicine
| | - Dionisios Stavroulias
- Department of Cardiothoracic Surgery, John Radcliffe Hospital, Oxford University Hospitals National Health Service (NHS) Foundation Trust, Oxford, United Kingdom
| | - Emma Hedley
- Oxford Respiratory Trials Unit, Nuffield Department of Medicine
| | - Kevin G. Blyth
- School of Cancer Sciences, University of Glasgow, Glasgow, United Kingdom
- Department of Respiratory Medicine, Queen Elizabeth University Hospital, Glasgow, United Kingdom
| | - Alan Kirk
- Department of Thoracic Surgery, Golden Jubilee National Hospital, Glasgow, United Kingdom
| | | | - John G. Edwards
- Department of Thoracic Surgery, Northern General Hospital, Sheffield Teaching Hospitals NHS Foundation Trust, Sheffield, United Kingdom
| | - Eveline Internullo
- Department of Thoracic Surgery, Bristol Royal Infirmary, University Hospitals Bristol NHS Foundation Trust, Bristol, United Kingdom
| | | | - Adrian Marchbank
- Department of Cardiothoracic Surgery, Derriford Hospital, University Hospitals Plymouth NHS Trust, Plymouth, United Kingdom
| | - Rakesh Panchal
- Department of Respiratory Medicine, Glenfield Hospital, University Hospitals of Leicester NHS Trust, Leicester, United Kingdom
| | - Edward Caruana
- Department of Thoracic Surgery, Glenfield Hospitals, University Hospitals of Leicester, Leicester, United Kingdom
| | | | - Lawrence Okiror
- Department of Thoracic Surgery, Guy’s and St Thomas’ NHS Foundation Trust, London, United Kingdom
| | | | - Manoj Purohit
- Department of Cardiothoracic Surgery, Blackpool Teaching Hospitals NHS Foundation Trust, Blackpool, United Kingdom
| | - Rachel M. Mercer
- Portsmouth Hospitals NHS Trust, Queen Alexandra Hospital, Portsmouth, United Kingdom
| | - Rhona Taberham
- Department of Cardiothoracic Surgery, John Radcliffe Hospital, Oxford University Hospitals National Health Service (NHS) Foundation Trust, Oxford, United Kingdom
| | - Nikolaos Kanellakis
- Oxford Respiratory Trials Unit, Nuffield Department of Medicine
- National Institute for Health and Care Research Oxford Biomedical Research Centre
- Laboratory of Pleural and Lung Cancer Translational Research
- Chinese Academy of Medical Sciences Oxford Institute, Nuffield Department of Medicine, and
| | - Alison M. Condliffe
- Department of Infection, Immunity and Cardiovascular Disease, University of Sheffield, Sheffield, United Kingdom
- Academic Directorate of Respiratory Medicine
| | | | - Dinesh N. Addala
- Oxford Respiratory Trials Unit, Nuffield Department of Medicine
- National Institute for Health and Care Research Oxford Biomedical Research Centre
- Oxford Centre for Respiratory Medicine and
| | - Rachelle Asciak
- Portsmouth Hospitals NHS Trust, Queen Alexandra Hospital, Portsmouth, United Kingdom
| | - Radhika Banka
- Department of Respiratory Medicine, PD Hinduja National Hospital, Mumbai, India
| | - Vineeth George
- Department of Respiratory and Sleep Medicine, John Hunter Hospital, Newcastle, New South Wales, Australia
- Hunter Medical Research Institute, Newcastle, New South Wales, Australia
| | - Maged Hassan
- Chest Diseases Department, Alexandria University, Alexandria, Egypt
| | - David McCracken
- Royal Victoria Hospital, Belfast Health and Social Care Trust, Belfast, Northern Ireland
| | - Anand Sundaralingam
- Oxford Respiratory Trials Unit, Nuffield Department of Medicine
- Oxford Centre for Respiratory Medicine and
| | - John M. Wrightson
- Oxford Respiratory Trials Unit, Nuffield Department of Medicine
- Oxford Centre for Respiratory Medicine and
| | - Melissa Dobson
- Oxford Respiratory Trials Unit, Nuffield Department of Medicine
- National Institute for Health and Care Research Oxford Biomedical Research Centre
| | - Alex West
- Department of Respiratory Medicine and
| | | | - John Harvey
- Department of Respiratory Medicine, North Bristol NHS Trust, Bristol, United Kingdom
- Academic Respiratory Unit, University of Bristol, Bristol, United Kingdom
| | - Mark Slade
- Department of Respiratory Medicine, Gloucestershire Hospitals NHS Foundation Trust, Gloucester, United Kingdom; and
| | - Mae Chester-Jones
- Oxford Centre for Statistics in Medicine, University of Oxford, Oxford, United Kingdom
| | - Susan Dutton
- Oxford Centre for Statistics in Medicine, University of Oxford, Oxford, United Kingdom
| | - Robert F. Miller
- Institute for Global Health, University College London, London, United Kingdom
| | - Nick A. Maskell
- Department of Respiratory Medicine, North Bristol NHS Trust, Bristol, United Kingdom
- Academic Respiratory Unit, University of Bristol, Bristol, United Kingdom
| | - Elizabeth Belcher
- Department of Cardiothoracic Surgery, John Radcliffe Hospital, Oxford University Hospitals National Health Service (NHS) Foundation Trust, Oxford, United Kingdom
| | - Najib M. Rahman
- Oxford Respiratory Trials Unit, Nuffield Department of Medicine
- National Institute for Health and Care Research Oxford Biomedical Research Centre
- Laboratory of Pleural and Lung Cancer Translational Research
- Chinese Academy of Medical Sciences Oxford Institute, Nuffield Department of Medicine, and
- Oxford Centre for Respiratory Medicine and
| |
Collapse
|
2
|
Dipper A, Sundaralingam A, Hedley E, Tucker E, White P, Bhatnagar R, Moore A, Dobson M, Luengo-Fernandez R, Mills J, Sowden S, Harvey JE, Dobson L, Miller RF, Munavvar M, Rahman N, Maskell N. The randomised thoracoscopic talc poudrage+indwelling pleural catheters versus thoracoscopic talc poudrage only in malignant pleural effusion trial (TACTIC): study protocol for a randomised controlled trial. BMJ Open Respir Res 2023; 10:10/1/e001682. [PMID: 37253535 DOI: 10.1136/bmjresp-2023-001682] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/22/2023] [Accepted: 05/05/2023] [Indexed: 06/01/2023] Open
Abstract
INTRODUCTION Malignant pleural effusion (MPE) is common, with 50 000 new cases per year in the UK. MPE causes disabling breathlessness and indicates advanced disease with a poor prognosis. Treatment approaches focus on symptom relief and optimising quality of life (QoL). Patients who newly present with MPE commonly require procedural intervention for both diagnosis and therapeutic benefit.Thoracoscopic pleural biopsies are highly sensitive in diagnosing pleural malignancy. Talc poudrage may be delivered at thoracoscopy (TTP) to prevent effusion recurrence by effecting pleurodesis. Indwelling pleural catheters (IPCs) offer an alternative strategy for fluid control, enabling outpatient management and are often used as 'rescue' therapy following pleurodesis failure or in cases of 'trapped lung'. It is unknown whether combining a TTP with IPC insertion will improve patient symptoms or reduce time spent in the hospital.The randomised thoracoscopic talc poudrage + indwelling pleural catheters versus thoracoscopic talc poudrage only in malignant pleural effusion trial (TACTIC) is the first randomised controlled trial (RCT) to examine the benefit of a combined TTP and IPC procedure, evaluating cost-effectiveness and patient-centred outcomes such as symptoms and QoL. The study remains in active recruitment and has the potential to radically transform the pathway for all patients presenting with MPE. METHODS AND ANALYSIS TACTIC is an unblinded, multicentre, RCT comparing the combination of TTP with an IPC to TTP alone. Co-primary outcomes are time spent in the hospital and mean breathlessness score over 4 weeks postprocedure. The study will recruit 124 patients and aims to define the optimal pathway for patients presenting with symptomatic MPE. ETHICS AND DISSEMINATION TACTIC is sponsored by North Bristol NHS Trust and has been granted ethical approval by the London-Brent Research Ethics Committee (REC ref: 21/LO/0495). Publication of results in a peer-reviewed journal and conference presentations are anticipated. TRIAL REGISTRATION ISRCTN 11058680.
Collapse
Affiliation(s)
| | | | - Emma Hedley
- Oxford Respiratory Trials Unit, University of Oxford, Oxford, UK
| | - Emma Tucker
- Academic Respiratory Unit, University of Bristol, Bristol, UK
| | - Paul White
- School of Data and Mathematics, University of the West of England, Bristol, UK
| | - Rahul Bhatnagar
- Academic Respiratory Unit, University of Bristol, Bristol, UK
- Respiratory Medicine, North Bristol NHS Trust, Bristol, UK
| | - Andrew Moore
- Translational Health Sciences Musculoskeletal Research Unit, University of Bristol Medical School, Bristol, UK
| | - Melissa Dobson
- Oxford Respiratory Trials Unit, University of Oxford, Oxford, UK
| | | | - Janet Mills
- Respiratory Medicine, Lancashire Teaching Hospitals NHS Foundation Trust, Preston, UK
| | - Sandra Sowden
- Respiratory Medicine, Lancashire Teaching Hospitals NHS Foundation Trust, Preston, UK
| | - John E Harvey
- Respiratory Medicine, North Bristol NHS Trust, Bristol, UK
| | - Lee Dobson
- Respiratory Medicine, Royal Devon and Exeter NHS Foundation Trust Hospital, Exeter, UK
| | - Robert F Miller
- Institute for Global Health, University College London, London, UK
| | - Mohammed Munavvar
- Respiratory Medicine, Lancashire Teaching Hospitals NHS Foundation Trust, Preston, UK
- School of Medicine, University of Central Lancashire, Preston, UK
| | - Najib Rahman
- Oxford Respiratory Trials Unit, University of Oxford, Oxford, UK
- Oxford NIHR Biomedical Research Centre, Oxford, UK
| | - Nick Maskell
- Academic Respiratory Unit, University of Bristol, Bristol, UK
| |
Collapse
|
3
|
Sundaralingam A, Rahman NM, Shojaee S. The Case for Specialist Pleural Services: If Not Now, When? J Bronchology Interv Pulmonol 2023; 30:96-98. [PMID: 37005379 DOI: 10.1097/lbr.0000000000000910] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 04/04/2023]
Affiliation(s)
- Anand Sundaralingam
- Oxford Respiratory Trials Unit, Nuffield Department of Medicine, University of Oxford
| | - Najib M Rahman
- Oxford Respiratory Trials Unit, Nuffield Department of Medicine, University of Oxford
- NIHR Biomedical Research Centre
- Chinese Academy of Medical Sciences (CAMS) Oxford Institute (COI), Oxford, UK
| | - Samira Shojaee
- Vanderbilt University Medical Center, Division of Allergy, Department of Internal Medicine, Pulmonary and Critical Care Medicine, Nashville, TN
| |
Collapse
|
4
|
Bedawi EO, Kanellakis NI, Corcoran JP, Zhao Y, Hassan M, Asciak R, Mercer RM, Sundaralingam A, Addala DN, Miller RF, Dong T, Condliffe AM, Rahman NM. The Biological Role of Pleural Fluid PAI-1 and Sonographic Septations in Pleural Infection: Analysis of a Prospectively Collected Clinical Outcome Study. Am J Respir Crit Care Med 2023; 207:731-739. [PMID: 36191254 PMCID: PMC10037470 DOI: 10.1164/rccm.202206-1084oc] [Citation(s) in RCA: 6] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/08/2022] [Accepted: 10/03/2022] [Indexed: 11/16/2022] Open
Abstract
Rationale: Sonographic septations are assumed to be important clinical predictors of outcome in pleural infection, but the evidence for this is sparse. The inflammatory and fibrinolysis-associated intrapleural pathway(s) leading to septation formation have not been studied in a large cohort of pleural fluid (PF) samples with confirmed pleural infection matched with ultrasound and clinical outcome data. Objectives: To assess the presence and severity of septations against baseline PF PAI-1 (Plasminogen-Activator Inhibitor-1) and other inflammatory and fibrinolysis-associated proteins as well as to correlate these with clinically important outcomes. Methods: We analyzed 214 pleural fluid samples from PILOT (Pleural Infection Longitudinal Outcome Study), a prospective observational pleural infection study, for inflammatory and fibrinolysis-associated proteins using the Luminex platform. Multivariate regression analyses were used to assess the association of pleural biological markers with septation presence and severity (on ultrasound) and clinical outcomes. Measurements and Main Results: PF PAI-1 was the only protein independently associated with septation presence (P < 0.001) and septation severity (P = 0.003). PF PAI-1 concentrations were associated with increased length of stay (P = 0.048) and increased 12-month mortality (P = 0.003). Sonographic septations alone had no relation to clinical outcomes. Conclusions: In a large and well-characterized cohort, this is the first study to associate pleural biological parameters with a validated sonographic septation outcome in pleural infection. PF PAI-1 is the first biomarker to demonstrate an independent association with mortality. Although PF PAI-1 plays an integral role in driving septation formation, septations themselves are not associated with clinically important outcomes. These novel findings now require prospective validation.
Collapse
Affiliation(s)
- Eihab O. Bedawi
- Oxford Pleural Unit, Oxford Centre for Respiratory Medicine, Oxford University Hospitals NHS Foundation Trust, Oxford, United Kingdom
- Oxford Respiratory Trials Unit
- National Institute for Health Research Oxford Biomedical Research Centre
- Department of Infection, Immunity, and Cardiovascular Disease, University of Sheffield, Sheffield, United Kingdom
| | - Nikolaos I. Kanellakis
- Oxford Pleural Unit, Oxford Centre for Respiratory Medicine, Oxford University Hospitals NHS Foundation Trust, Oxford, United Kingdom
- Oxford Respiratory Trials Unit
- National Institute for Health Research Oxford Biomedical Research Centre
- Laboratory of Pleural and Lung Cancer Translational Research, Nuffield Department of Medicine
- Chinese Academy of Medical Sciences Oxford Institute, Nuffield Department of Medicine, and
| | - John P. Corcoran
- Department of Respiratory Medicine, Derriford Hospital, University Hospitals Plymouth NHS Trust, Plymouth, United Kingdom
| | - Yu Zhao
- Laboratory of Pleural and Lung Cancer Translational Research, Nuffield Department of Medicine
| | - Maged Hassan
- Oxford Pleural Unit, Oxford Centre for Respiratory Medicine, Oxford University Hospitals NHS Foundation Trust, Oxford, United Kingdom
- Chest Diseases Department, Alexandria University Faculty of Medicine, Alexandria, Egypt
| | - Rachelle Asciak
- Queen Alexandra Hospital, Portsmouth Hospitals NHS Trust, Portsmouth, United Kingdom; and
| | - Rachel M. Mercer
- Queen Alexandra Hospital, Portsmouth Hospitals NHS Trust, Portsmouth, United Kingdom; and
| | - Anand Sundaralingam
- Oxford Pleural Unit, Oxford Centre for Respiratory Medicine, Oxford University Hospitals NHS Foundation Trust, Oxford, United Kingdom
- Oxford Respiratory Trials Unit
| | - Dinesh N. Addala
- Oxford Pleural Unit, Oxford Centre for Respiratory Medicine, Oxford University Hospitals NHS Foundation Trust, Oxford, United Kingdom
- Oxford Respiratory Trials Unit
| | - Robert F. Miller
- Institute for Global Health, University College London, London, United Kingdom
| | - Tao Dong
- Chinese Academy of Medical Sciences Oxford Institute, Nuffield Department of Medicine, and
- Medical Research Council Human Immunology Unit, Medical Research Council Weatherall Institute of Molecular Medicine, University of Oxford, Oxford, United Kingdom
| | - Alison M. Condliffe
- Department of Infection, Immunity, and Cardiovascular Disease, University of Sheffield, Sheffield, United Kingdom
| | - Najib M. Rahman
- Oxford Pleural Unit, Oxford Centre for Respiratory Medicine, Oxford University Hospitals NHS Foundation Trust, Oxford, United Kingdom
- Oxford Respiratory Trials Unit
- National Institute for Health Research Oxford Biomedical Research Centre
- Laboratory of Pleural and Lung Cancer Translational Research, Nuffield Department of Medicine
- Chinese Academy of Medical Sciences Oxford Institute, Nuffield Department of Medicine, and
| |
Collapse
|
5
|
Sundaralingam A, Aujayeb A, Jackson KA, Pellas EI, Khan II, Chohan MT, Joosten R, Boersma A, Kerkhoff J, Bielsa S, Porcel JM, Rozman A, Marc-Malovrh M, Welch H, Symonds J, Anevlavis S, Froudrakis M, Mei F, Zuccatosta L, Gasparini S, Gonnelli F, Dhaliwal I, Mitchell MA, Fjaellegaard K, Petersen JK, Ellayeh M, Rahman NM, Burden T, Bodtger U, Koegelenberg CF, Maskell NA, Janssen J, Bhatnagar R. Investigation and outcomes in patients with non-specific pleuritis: Results from the International Collaborative Effusion (ICE) database. ERJ Open Res 2023; 9:00599-2022. [PMID: 37057081 PMCID: PMC10086737 DOI: 10.1183/23120541.00599-2022] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/08/2022] [Accepted: 01/04/2023] [Indexed: 03/18/2023] Open
Abstract
IntroductionWe present findings from the International Collaborative Effusion database, an ERS clinical research collaboration. Non-specific pleuritis (NSP) is a broad term that describes chronic pleural inflammation. Various aetiologies lead to NSP, which poses a diagnostic challenge for clinicians. A significant proportion of patients with this finding eventually develop a malignant diagnosis.Methods12 sites across 9 countries contributed anonymised data on 187 patients. 175 records were suitable for analysis.ResultsThe commonest aetiology for NSP was recorded as Idiopathic (80/175, 44%). This was followed by pleural infection (15%), benign asbestos disease (12%), malignancy (6%) and cardiac failure (6%). The malignant diagnoses were predominantly mesothelioma (6/175, 3.4%) and lung adenocarcinoma (4/175, 2.3%). The median time to malignant diagnosis was 12.2 months (range 0.8–32). There was a signal towards greater asbestos exposure in the malignant NSP group compared to the benign group (0.63versus0.27, p=0.07). Recurrence of effusion requiring further therapeutic intervention, nor initial biopsy approach were associated with a false negative biopsy. A computed tomography finding of a mass lesion was the only imaging feature to demonstrate a significant association (0.18versus0.01, p=0.02), though sonographic pleural thickening also suggested an association (0.27versus0.09, p= 0.09).DiscussionThis is the first multi-centre study of NSP and its associated outcomes. Whilst some of our findings are reflected by the established body of literature, other findings have highlighted important areas for future research, not previously studied in NSP.
Collapse
|
6
|
Fotis T, Kioskli K, Sundaralingam A, Fasihi A, Mouratidis H. Co-creation in a digital health living lab: A case study. Front Public Health 2023; 10:892930. [PMID: 36733280 PMCID: PMC9887018 DOI: 10.3389/fpubh.2022.892930] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/09/2022] [Accepted: 12/13/2022] [Indexed: 01/18/2023] Open
Abstract
Co-creation in healthcare, especially in developing digital health solutions, has been widely identified as a fundamental principle for person-centered technologies that could accelerate the adaptation of innovation. A Digital Health Living Lab based on community offers a sustainable and real-life environment to ideate, develop, and evaluate digital health solutions addressing the needs of multiple stakeholders. This article presents the experience of the School of Sport and Health Sciences at the University of Brighton in establishing a Digital Health Living Lab. In addition, we share a proposed step-by-step approach to establishing such a living lab in the community, supplemented by a case study of product development.
Collapse
Affiliation(s)
- Theofanis Fotis
- School of Sport and Health Sciences, University of Brighton, Brighton, United Kingdom,*Correspondence: Theofanis Fotis ✉
| | - Kitty Kioskli
- School of Computer Science and Electronic Engineering, Institute of Analytics and Data Science (IADS), University of Essex, Essex, United Kingdom,Trustilio B.V., Amsterdam, Netherlands
| | - Anand Sundaralingam
- Oxford Respiratory Trials Unit, Nuffield Department of Medicine, University of Oxford, Oxford, United Kingdom
| | | | - Haralambos Mouratidis
- School of Computer Science and Electronic Engineering, Institute of Analytics and Data Science (IADS), University of Essex, Essex, United Kingdom
| |
Collapse
|
7
|
Addala DN, Denniston P, Sundaralingam A, Rahman NM. Optimal diagnostic strategies for pleural diseases and identifying high-risk patients. Expert Rev Respir Med 2023; 17:15-26. [PMID: 36710423 DOI: 10.1080/17476348.2023.2174527] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/31/2023]
Abstract
INTRODUCTION Pleural diseases encompass a broad range of conditions with diverse and heterogenous etiologies. Diagnostics in pleural diseases thus represents a challenging field with a wide array of available testing to distinguish between the numerous causes of pleural disease. Nonetheless, deploying best practice diagnostics in this area is essential in reducing both duration o the investigation pathway and symptom burden. AREAS COVERED This article critically appraises the optimal diagnostic strategies and pathway in patients with pleural disease, reviewing the latest evidence and key practice points in achieving a treatable diagnosis in patients with pleural disease. We also cover future and novel directions that are likely to influence pleural diagnostics in the near future. PubMed was searched for articles related to pleural diagnostics (search terms below), with the date ranges including June 2012 to June 2022. EXPERT OPINION No single test will ever be sufficient to provide a diagnosis in pleural conditions. The key to reducing procedure burden and duration to diagnosis lies in personalizing the investigation pathway to patients and deploying tests with the highest diagnostic yield early (such as pleural biopsy in infection and malignancy). Novel biomarkers may also allow earlier diagnostic precision in the near future.
Collapse
Affiliation(s)
- D N Addala
- Oxford Respiratory Trials Unit, Nuffield Department of Medicine, Oxford University, Oxford, UK.,Department of Respiratory Medicine, Oxford Pleural Unit, Oxford University Hospitals, Oxford, UK
| | - P Denniston
- Oxford Respiratory Trials Unit, Nuffield Department of Medicine, Oxford University, Oxford, UK.,Department of Respiratory Medicine, Oxford Pleural Unit, Oxford University Hospitals, Oxford, UK
| | - A Sundaralingam
- Oxford Respiratory Trials Unit, Nuffield Department of Medicine, Oxford University, Oxford, UK.,Department of Respiratory Medicine, Oxford Pleural Unit, Oxford University Hospitals, Oxford, UK
| | - N M Rahman
- Oxford Respiratory Trials Unit, Nuffield Department of Medicine, Oxford University, Oxford, UK.,Department of Respiratory Medicine, Oxford Pleural Unit, Oxford University Hospitals, Oxford, UK.,Oxford Biomedical Research Centre, National Institute for Health Research, Oxford, UK.,Chinese Academy of Medical Science Oxford Institute, Nuffield Department of Medicine, Medical Sciences Division, University of Oxford, Oxford, UK
| |
Collapse
|
8
|
Mei F, Rota M, Bonifazi M, Zuccatosta L, Porcarelli FM, Sediari M, Bedawi EO, Sundaralingam A, Addala D, Gasparini S, Rahman NM. Efficacy of Small versus Large-Bore Chest Drain in Pleural Infection: A Systematic Review and Meta-Analysis. Respiration 2023; 102:247-256. [PMID: 36693327 DOI: 10.1159/000529027] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/17/2022] [Accepted: 01/04/2023] [Indexed: 01/25/2023] Open
Abstract
BACKGROUND Pleural infection represents a significant clinical challenge worldwide. Although prompt drainage of pleural fluid is thought to play a key role in pleural infection management, the optimal size of intrapleural catheter has yet to be defined. OBJECTIVES The aim of this systematic review and meta-analysis was to summarize data on efficacy and complications of small-bore drain (SBD), defined as ≤14F, in comparison to large-bore drain (LBD) in patients with pleural infection. METHOD We searched MEDLINE and Embase for all studies reporting outcomes of interest published up to October 2021. Two authors reviewed selected full text to identify studies according to predefined eligibility criteria. Summary estimates were derived using the random-effects model. RESULTS Twelve original studies were included for qualitative analysis and 7 of these for quantitative analysis. The surgical referral rate of SBD and LBD were, respectively, 0.16 (95% confidence interval [CI], 0.12-0.21) and 0.20 (95% CI, 0.10-0.32), the pooled mortality were 0.12 (95% CI, 0.05-0.21) and 0.20 (95% CI, 0.10-0.32), and the length of hospital stay was 24 days in both groups. Data on complications suggest similar proportions of tube dislodgement. Intensity of pain was evaluated in one study only, reporting higher scores for LBD. CONCLUSIONS This systematic review and meta-analysis provide the first synthesis of data on performance of SBD and LBD in management of pleural infection, and, overall, clinical outcomes and complications did not substantially differ, although the limited number of studies and the absence of dedicated randomized trials does limit the reliability of results.
Collapse
Affiliation(s)
- Federico Mei
- Respiratory Diseases Unit, Department of Internal Medicine, Azienda Ospedaliero-Universitaria Ospedali Riuniti, Ancona, Italy
- Department of Biomedical Sciences and Public Health, Università Politecnica delle Marche, Ancona, Italy
| | - Matteo Rota
- Department of Molecular and Translational Medicine, Università degli Studi di Brescia, Brescia, Italy
| | - Martina Bonifazi
- Respiratory Diseases Unit, Department of Internal Medicine, Azienda Ospedaliero-Universitaria Ospedali Riuniti, Ancona, Italy
- Department of Biomedical Sciences and Public Health, Università Politecnica delle Marche, Ancona, Italy
| | - Lina Zuccatosta
- Respiratory Diseases Unit, Department of Internal Medicine, Azienda Ospedaliero-Universitaria Ospedali Riuniti, Ancona, Italy
| | - Francesco M Porcarelli
- Respiratory Diseases Unit, Department of Internal Medicine, Azienda Ospedaliero-Universitaria Ospedali Riuniti, Ancona, Italy
- Department of Biomedical Sciences and Public Health, Università Politecnica delle Marche, Ancona, Italy
| | - Michele Sediari
- Respiratory Diseases Unit, Department of Internal Medicine, Azienda Ospedaliero-Universitaria Ospedali Riuniti, Ancona, Italy
| | - Eihab O Bedawi
- Oxford Pleural Unit, Oxford University Hospitals NHS Foundation Trust, Churchill Hospital, Oxford, UK
| | - Anand Sundaralingam
- Oxford Pleural Unit, Oxford University Hospitals NHS Foundation Trust, Churchill Hospital, Oxford, UK
| | - Dinesh Addala
- Oxford Pleural Unit, Oxford University Hospitals NHS Foundation Trust, Churchill Hospital, Oxford, UK
| | - Stefano Gasparini
- Respiratory Diseases Unit, Department of Internal Medicine, Azienda Ospedaliero-Universitaria Ospedali Riuniti, Ancona, Italy
- Department of Biomedical Sciences and Public Health, Università Politecnica delle Marche, Ancona, Italy
| | - Najib M Rahman
- Oxford Pleural Unit, Oxford University Hospitals NHS Foundation Trust, Churchill Hospital, Oxford, UK
- Oxford NIHR Biomedical Research Unit, Oxford, UK
- Chinese Academy of Medicine Oxford Institute, Oxford, UK
| |
Collapse
|
9
|
Sundaralingam A, Aujayeb A, Akca B, Tiedeman C, George V, Carling M, Brown J, Banka R, Addala D, Bedawi EO, Hallifax RJ, Iqbal B, Denniston P, Tsakok MT, Kanellakis NI, Vafai-Tabrizi F, Bergman M, Funk GC, Benamore RE, Wrightson JM, Rahman NM. Achieving Molecular Profiling in Pleural Biopsies: A Multicenter, Retrospective Cohort Study. Chest 2022; 163:1328-1339. [PMID: 36410492 DOI: 10.1016/j.chest.2022.11.019] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/28/2022] [Revised: 11/03/2022] [Accepted: 11/12/2022] [Indexed: 11/20/2022] Open
Abstract
BACKGROUND Pleural biopsy findings offer greater diagnostic sensitivity in malignant pleural effusions compared with pleural fluid. The adequacy of pleural biopsy techniques in achieving molecular marker status has not been studied, and such information (termed "actionable" histology) is critical in providing a rational, efficient, and evidence-based approach to diagnostic investigation. RESEARCH QUESTION What is the adequacy of various pleural biopsy techniques at providing adequate molecular diagnostic information to guide treatment in malignant pleural effusions? STUDY DESIGN AND METHODS This study analyzed anonymized data on 183 patients from four sites across three countries in whom pleural biopsy results had confirmed a malignant diagnosis and molecular profiling was relevant for the diagnosed cancer type. The primary outcome measure was adequacy of pleural biopsy for achieving molecular marker status. Secondary outcomes included clinical factors predictive of achieving a molecular diagnosis. RESULTS The median age of patients was 71 years (interquartile range, 63-78 years), with 92 of 183 (50%) male. Of the 183 procedures, 105 (57%) were local anesthetic thoracoscopies (LAT), 12 (7%) were CT scan guided, and 66 (36%) were ultrasound guided. Successful molecular marker analysis was associated with mode of biopsy, with LAT having the highst yield and ultrasound-guided biopsy the lowest (LAT vs CT scan guided vs ultrasound guided: LAT yield, 95%; CT scan guided, 86%; and ultrasound guided, 77% [P = .004]). Biopsy technique and size of biopsy sample were independently associated with successful molecular marker analysis. LAT had an adjusted OR for successful diagnosis of 30.16 (95% CI, 3.15-288.56; P = .003) and biopsy sample size an OR of 1.18 (95% CI, 1.02-1.37) per millimeter increase in tissue sample size (P < .03). INTERPRETATION Although previous studies have shown comparable overall diagnostic yields, in the modern era of targeted therapies, this study found that LAT offers far superior results to image-guided techniques at achieving molecular profiling and remains the optimal diagnostic tool.
Collapse
Affiliation(s)
- Anand Sundaralingam
- Oxford Pleural Unit, John Radcliffe Hospital, Oxford University Hospitals NHS Foundation Trust, Oxford, UK; Oxford Centre for Respiratory Medicine, and Department of Radiology, John Radcliffe Hospital, Oxford University Hospitals NHS Foundation Trust, Oxford, UK.
| | - Avinash Aujayeb
- Respiratory Department, Northumbria Healthcare NHS Trust, Newcastle, UK
| | - Baki Akca
- Karl Landsteiner Institute for Lung Research and Pulmonary Oncology, Klinik Ottakring, Vienna, Austria
| | - Clare Tiedeman
- Department of Respiratory and Sleep Medicine, John Hunter Hospital, NSW, Australia
| | - Vineeth George
- Department of Respiratory and Sleep Medicine, John Hunter Hospital, NSW, Australia
| | - Michael Carling
- Respiratory Department, Northumbria Healthcare NHS Trust, Newcastle, UK
| | - Jennifer Brown
- Department of Histopathology, Nuffield Orthopaedic Centre, Oxford, UK
| | - Radhika Banka
- PD Hinduja National Hospital and Medical Research Centre
| | - Dinesh Addala
- Oxford Pleural Unit, John Radcliffe Hospital, Oxford University Hospitals NHS Foundation Trust, Oxford, UK; Oxford Centre for Respiratory Medicine, and Department of Radiology, John Radcliffe Hospital, Oxford University Hospitals NHS Foundation Trust, Oxford, UK
| | - Eihab O Bedawi
- Oxford Respiratory Trials Unit, University of Oxford, Oxford, UK
| | - Rob J Hallifax
- Oxford Pleural Unit, John Radcliffe Hospital, Oxford University Hospitals NHS Foundation Trust, Oxford, UK; Oxford Respiratory Trials Unit, University of Oxford, Oxford, UK
| | - Beenish Iqbal
- Oxford Pleural Unit, John Radcliffe Hospital, Oxford University Hospitals NHS Foundation Trust, Oxford, UK
| | - Poppy Denniston
- Oxford Pleural Unit, John Radcliffe Hospital, Oxford University Hospitals NHS Foundation Trust, Oxford, UK
| | - Maria T Tsakok
- Oxford Centre for Respiratory Medicine, and Department of Radiology, John Radcliffe Hospital, Oxford University Hospitals NHS Foundation Trust, Oxford, UK
| | - Nikolaos I Kanellakis
- Nuffield Department of Medicine, Chinese Academy of Medical Sciences (CAMS) Oxford Institute (COI), University of Oxford, Oxford, UK; Nuffield Department of Medicine, Laboratory of Pleural and Lung Cancer Translational Research, University of Oxford, Oxford, UK; Nuffield Department of Medicine, and the National Institute for Health Research Oxford Biomedical Research Centre, University of Oxford, Oxford, UK
| | - Florian Vafai-Tabrizi
- Karl Landsteiner Institute for Lung Research and Pulmonary Oncology, Klinik Ottakring, Vienna, Austria
| | - Michael Bergman
- Karl Landsteiner Institute for Lung Research and Pulmonary Oncology, Klinik Ottakring, Vienna, Austria
| | - Georg-Christian Funk
- Karl Landsteiner Institute for Lung Research and Pulmonary Oncology, Klinik Ottakring, Vienna, Austria
| | - Rachel E Benamore
- Oxford Centre for Respiratory Medicine, and Department of Radiology, John Radcliffe Hospital, Oxford University Hospitals NHS Foundation Trust, Oxford, UK
| | - John M Wrightson
- Oxford Pleural Unit, John Radcliffe Hospital, Oxford University Hospitals NHS Foundation Trust, Oxford, UK
| | - Najib M Rahman
- Oxford Pleural Unit, John Radcliffe Hospital, Oxford University Hospitals NHS Foundation Trust, Oxford, UK; Oxford Respiratory Trials Unit, University of Oxford, Oxford, UK; Nuffield Department of Medicine, Chinese Academy of Medical Sciences (CAMS) Oxford Institute (COI), University of Oxford, Oxford, UK; Nuffield Department of Medicine, Laboratory of Pleural and Lung Cancer Translational Research, University of Oxford, Oxford, UK; Nuffield Department of Medicine, and the National Institute for Health Research Oxford Biomedical Research Centre, University of Oxford, Oxford, UK
| |
Collapse
|
10
|
Kanellakis NI, Wrightson JM, Gerry S, Ilott N, Corcoran JP, Bedawi EO, Asciak R, Nezhentsev A, Sundaralingam A, Hallifax RJ, Economides GM, Bland LR, Daly E, Yao X, Maskell NA, Miller RF, Crook DW, Hinks TSC, Dong T, Psallidas I, Rahman NM. The bacteriology of pleural infection (TORPIDS): an exploratory metagenomics analysis through next generation sequencing. Lancet Microbe 2022; 3:e294-e302. [PMID: 35544066 PMCID: PMC8967721 DOI: 10.1016/s2666-5247(21)00327-x] [Citation(s) in RCA: 16] [Impact Index Per Article: 8.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Figures] [Subscribe] [Scholar Register] [Received: 06/28/2021] [Revised: 11/08/2021] [Accepted: 11/17/2021] [Indexed: 11/27/2022]
Abstract
BACKGROUND Pleural infection is a common and severe disease with high morbidity and mortality worldwide. The knowledge of pleural infection bacteriology remains incomplete, as pathogen detection methods based on culture have insufficient sensitivity and are biased to selected microbes. We designed a study with the aim to discover and investigate the total microbiome of pleural infection and assess the correlation between bacterial patterns and 1-year survival of patients. METHODS We assessed 243 pleural fluid samples from the PILOT study, a prospective observational study on pleural infection, with 16S rRNA next generation sequencing. 20 pleural fluid samples from patients with pleural effusion due to a non-infectious cause and ten PCR-grade water samples were used as controls. Downstream analysis was done with the DADA2 pipeline. We applied multivariate Cox regression analyses to investigate the association between bacterial patterns and 1-year survival of patients with pleural infection. FINDINGS Pleural infection was predominately polymicrobial (192 [79%] of 243 samples), with diverse bacterial frequencies observed in monomicrobial and polymicrobial disease and in both community-acquired and hospital-acquired infection. Mixed anaerobes and other Gram-negative bacteria predominated in community-acquired polymicrobial infection whereas Streptococcus pneumoniae prevailed in monomicrobial cases. The presence of anaerobes (hazard ratio 0·46, 95% CI 0·24-0·86, p=0·015) or bacteria of the Streptococcus anginosus group (0·43, 0·19-0·97, p=0·043) was associated with better patient survival, whereas the presence (5·80, 2·37-14·21, p<0·0001) or dominance (3·97, 1·20-13·08, p=0·024) of Staphylococcus aureus was linked with lower survival. Moreover, dominance of Enterobacteriaceae was associated with higher risk of death (2·26, 1·03-4·93, p=0·041). INTERPRETATION Pleural infection is a predominantly polymicrobial infection, explaining the requirement for broad spectrum antibiotic cover in most individuals. High mortality infection associated with S aureus and Enterobacteriaceae favours more aggressive, with a narrower spectrum, antibiotic strategies. FUNDING UK Medical Research Council, National Institute for Health Research Oxford Biomedical Research Centre, Wellcome Trust, Oxfordshire Health Services Research Committee, Chinese Academy of Medical Sciences, and John Fell Fund.
Collapse
Affiliation(s)
- Nikolaos I Kanellakis
- Oxford Centre for Respiratory Medicine, Churchill Hospital, Oxford University Hospitals NHS Foundation Trust, Oxford, UK; Laboratory of Pleural and Lung Cancer Translational Research, Nuffield Department of Medicine, University of Oxford, Oxford, UK; Chinese Academy of Medical Sciences, China Oxford Institute, Nuffield Department of Medicine, University of Oxford, Oxford, UK; National Institute for Health Research Oxford Biomedical Research Centre, University of Oxford, Oxford, UK.
| | - John M Wrightson
- Oxford Centre for Respiratory Medicine, Churchill Hospital, Oxford University Hospitals NHS Foundation Trust, Oxford, UK
| | - Stephen Gerry
- Centre for Statistics in Medicine, Nuffield Department of Orthopaedics, Rheumatology and Musculoskeletal Sciences, University of Oxford, Oxford, UK
| | - Nicholas Ilott
- Oxford Centre for Microbiome Studies, Kennedy Institute of Rheumatology, University of Oxford, Oxford, UK
| | - John P Corcoran
- Oxford Centre for Respiratory Medicine, Churchill Hospital, Oxford University Hospitals NHS Foundation Trust, Oxford, UK
| | - Eihab O Bedawi
- Oxford Centre for Respiratory Medicine, Churchill Hospital, Oxford University Hospitals NHS Foundation Trust, Oxford, UK
| | - Rachelle Asciak
- Oxford Centre for Respiratory Medicine, Churchill Hospital, Oxford University Hospitals NHS Foundation Trust, Oxford, UK,Laboratory of Pleural and Lung Cancer Translational Research, Nuffield Department of Medicine, University of Oxford, Oxford, UK
| | - Andrey Nezhentsev
- Laboratory of Pleural and Lung Cancer Translational Research, Nuffield Department of Medicine, University of Oxford, Oxford, UK
| | - Anand Sundaralingam
- Oxford Centre for Respiratory Medicine, Churchill Hospital, Oxford University Hospitals NHS Foundation Trust, Oxford, UK
| | - Rob J Hallifax
- Oxford Centre for Respiratory Medicine, Churchill Hospital, Oxford University Hospitals NHS Foundation Trust, Oxford, UK
| | - Greta M Economides
- Laboratory of Pleural and Lung Cancer Translational Research, Nuffield Department of Medicine, University of Oxford, Oxford, UK
| | - Lucy R Bland
- Laboratory of Pleural and Lung Cancer Translational Research, Nuffield Department of Medicine, University of Oxford, Oxford, UK
| | - Elizabeth Daly
- Laboratory of Pleural and Lung Cancer Translational Research, Nuffield Department of Medicine, University of Oxford, Oxford, UK
| | - Xuan Yao
- Chinese Academy of Medical Sciences, China Oxford Institute, Nuffield Department of Medicine, University of Oxford, Oxford, UK,MRC Human Immunology Unit, MRC Weatherall Institute of Molecular Medicine, University of Oxford, Oxford, UK
| | - Nick A Maskell
- Academic Respiratory Unit, University of Bristol Medical School Translational Health Sciences, Bristol, UK,North Bristol Lung Centre, North Bristol NHS Trust, Bristol, UK
| | - Robert F Miller
- Institute for Global Health, University College London, London, UK
| | - Derrick W Crook
- Nuffield Department of Medicine, University of Oxford and John Radcliffe Hospital, Oxford, UK,National Institute of Health Research Oxford Biomedical Research Centre, John Radcliffe Hospital, Oxford, UK
| | - Timothy S C Hinks
- Oxford Centre for Respiratory Medicine, Churchill Hospital, Oxford University Hospitals NHS Foundation Trust, Oxford, UK,Respiratory Medicine Unit, Nuffield Department of Medicine, University of Oxford, Oxford, UK,National Institute for Health Research Oxford Biomedical Research Centre, University of Oxford, Oxford, UK
| | - Tao Dong
- Chinese Academy of Medical Sciences, China Oxford Institute, Nuffield Department of Medicine, University of Oxford, Oxford, UK,MRC Human Immunology Unit, MRC Weatherall Institute of Molecular Medicine, University of Oxford, Oxford, UK
| | - Ioannis Psallidas
- Oxford Centre for Respiratory Medicine, Churchill Hospital, Oxford University Hospitals NHS Foundation Trust, Oxford, UK,Laboratory of Pleural and Lung Cancer Translational Research, Nuffield Department of Medicine, University of Oxford, Oxford, UK
| | - Najib M Rahman
- Oxford Centre for Respiratory Medicine, Churchill Hospital, Oxford University Hospitals NHS Foundation Trust, Oxford, UK,Laboratory of Pleural and Lung Cancer Translational Research, Nuffield Department of Medicine, University of Oxford, Oxford, UK,Chinese Academy of Medical Sciences, China Oxford Institute, Nuffield Department of Medicine, University of Oxford, Oxford, UK,National Institute for Health Research Oxford Biomedical Research Centre, University of Oxford, Oxford, UK
| |
Collapse
|
11
|
Evans S, Elder P, Shoulder R, Sundaralingam A, Kewalramani N, Porter B, Flight W, Hardinge M, Rahman NM, Miller M. What can we Learn from Patients who Died from Covid-19 Following Escalation to a Respiratory High Dependency Unit for Trial of Non-Invasive Respiratory Support? J Palliat Care 2022; 37:310-316. [PMID: 35138202 PMCID: PMC9344193 DOI: 10.1177/08258597221078381] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/10/2023]
Abstract
Background: Covid-19 infection is associated with significant risk of death, particularly in older, comorbid patients. Emerging evidence supports use of non-invasive respiratory support (CPAP and high-flow nasal oxygen [HFNO]) in this context, but little is known about its use in patients receiving end-of-life care. Methods: This was a retrospective study of 33 patients who died of Covid-19 on the Respiratory High Dependency Unit at the John Radcliffe Hospital, Oxford between 28/03/20 and 20/05/20. Data was sourced via retrospective review of electronic patient records and drug charts. Results: Patients dying from Covid-19 on the Respiratory HDU were comorbid with median Charlson Comorbidity Index 5 (IQR 4-6); median age 78 (IQR 72-85). Respiratory support was trialled in all but one case with CPAP being the most common form of first line respiratory support (84.8%) however, was only tolerated in 44.8% of patients. Median time to death was 10.7 days from symptom onset (IQR 7.5-14.6) and 4.9 days from hospital admission (IQR 3.1-8.3). 48.5% of patients remained on respiratory support at the time of death. Conclusions: End-of-life care for patients with Covid-19 remains a challenge. Patients tend to be frail and comorbid with a rapid disease trajectory. Non-Invasive Respiratory Support may play a key role in symptom management in select patients, however, further work is needed in order to identify patients who will most benefit from Respiratory Support and those for whom withdrawal may prevent unnecessary distress at the end of life or potential prolongation of suffering.
Collapse
Affiliation(s)
- S Evans
- Oxford University Hospitals NHS Foundation Trust, Oxford, UK
| | - P Elder
- Oxford University Hospitals NHS Foundation Trust, Oxford, UK
| | - R Shoulder
- Oxford University Hospitals NHS Foundation Trust, Oxford, UK
| | - A Sundaralingam
- Oxford University Hospitals NHS Foundation Trust, Oxford, UK
| | - N Kewalramani
- Oxford University Hospitals NHS Foundation Trust, Oxford, UK
| | - B Porter
- Oxford University Hospitals NHS Foundation Trust, Oxford, UK
| | - W Flight
- Oxford University Hospitals NHS Foundation Trust, Oxford, UK
| | - M Hardinge
- Oxford University Hospitals NHS Foundation Trust, Oxford, UK
| | - N M Rahman
- Oxford University Hospitals NHS Foundation Trust, Oxford, UK.,University of Oxford, Oxford, UK.,Oxford NIHR Biomedical Research Centre, Oxford, UK
| | - M Miller
- Oxford University Hospitals NHS Foundation Trust, Oxford, UK
| |
Collapse
|
12
|
Sundaralingam A, Bedawi EO, Harriss EK, Munnavar M, Rahman NM. The Frequency, Risk Factors and Management of Complications from Pleural Procedures. Chest 2021; 161:1407-1425. [PMID: 34896096 DOI: 10.1016/j.chest.2021.11.031] [Citation(s) in RCA: 11] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/19/2021] [Revised: 11/11/2021] [Accepted: 11/14/2021] [Indexed: 10/19/2022] Open
Abstract
Pleural disease is a common presentation and spans a heterogenous population across broad disease entities but a common feature is the requirement for interventional procedures. Despite the frequency of such procedures, there is little consensus on rates of complications and risk factors associated with such complications. Here follows a narrative review based on a structured search of the literature. Searches were limited to 2010 onwards, in recognition of the sea-change in procedural complications following the mainstream use of thoracic ultrasound (US). Procedures of interest were limited to thoracocentesis, intercostal drains (ICD), indwelling pleural catheters (IPC) and local anaesthetic thoracoscopy (LAT). 4308 studies were screened, to identify 48 studies for inclusion. Iatrogenic pneumothorax (PTX) remains the commonest complication following thoracocentesis: 3.3% (95% CI, 3.2-3.4), though PTX requiring intervention was rare: 0.3% (95% CI, 0.2-0.4) when the procedure was US guided. Drain blockage and displacement are the commonest complications following ICD insertion (6.3%, and 6.8%, respectively). IPC related infections can be a significant problem: 5.8% (95% CI, 5.1-6.7), however most cases can be managed without removal of the IPC. LAT has an overall mortality of 0.1% (95% CI, 0.03-0.3). Data on safety and complication rates in procedural interventions are limited by methodological problems and novel methods to study this topic bears consideration. Whilst complications remain rare events, once encountered, they have the potential to rapidly escalate. It is of paramount importance for operators to prepare and have in place plans for such events, to ensure high quality and above all, safe care.
Collapse
Affiliation(s)
- Anand Sundaralingam
- Oxford Pleural Unit, Oxford Centre for Respiratory Medicine, Churchill Hospital.
| | - Eihab O Bedawi
- Oxford Pleural Unit, Oxford Centre for Respiratory Medicine, Churchill Hospital
| | | | | | - Najib M Rahman
- Oxford Pleural Unit, Oxford Centre for Respiratory Medicine, Churchill Hospital; University of Oxford, NIHR Oxford Biomedical Research Centre
| |
Collapse
|
13
|
Ellayeh M, Bedawi E, Banka R, Sundaralingam A, George V, Kanellakis N, Hallifax R, Abdelwahab H, Rezk N, Hewidy A, Ali R, Wrightson J, Rahman N. Objective Thoracoscopic Criteria in Differentiation between Benign and Malignant Pleural Effusions. Respiration 2021; 101:46-56. [PMID: 34515216 DOI: 10.1159/000517910] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/15/2021] [Accepted: 06/15/2021] [Indexed: 11/19/2022] Open
Abstract
BACKGROUND Thoracoscopy is the "gold standard" diagnostic modality for investigation of suspected pleural malignancy. It is postulated that meticulous assessment of the pleural cavity may be adequate to indicate malignancy through the macroscopic findings of nodules, pleural thickening, and lymphangitis. We attempted to critically assess this practice, by precisely defining objective macroscopic criteria which might differentiate benign from malignant pleural diseases according to intrapleural pattern and anatomical location, and thereby to explore the predilection of abnormalities to specific sites on pleural surfaces. METHODS A structured review of recorded video footage from medical thoracoscopy procedures in 96 patients was conducted by 2 independent assessors. Abnormalities were scored on agreed, objective criteria for the presence of nodules, lymphangitis and inflammation on each of the costoparietal, visceral and diaphragmatic surfaces. The costoparietal pleura was divided into 6 levels (apical, middle, and inferior surfaces of the lateral and posterior parietal pleura). The anterior surface of the costoparietal pleura was excluded from analysis after interim review as this surface was rarely seen. RESULTS In the benign group, inflammation was the predominant finding in 65% (n = 33; costoparietal), 44% (n = 21; visceral), and 42% (n = 15; diaphragmatic). Nodules were detected in 24% (n = 12; costoparietal), 8% (n = 4; visceral), and 8% (n = 3; diaphragmatic). The most affected surfaces with inflammation were the middle lateral (60%) and the inferior lateral (57.8%) parts of the costoparietal pleura. In the malignant group, nodules were the predominant finding according to surface in 73% (n = 33; costoparietal), 32% (n = 13; visceral) and 48% (n = 17; diaphragmatic). Inflammation was detected in 44% (n = 20; costoparietal), 25% (n = 10; visceral), and 29% (n = 10; diaphragmatic). The most affected surfaces with nodules were the middle lateral (67.4%) and inferior lateral (66.7%) costoparietal pleural surfaces. CONCLUSION This is the first detailed, anatomical description of abnormalities in the pleural space during thoracoscopy. While nodules were the predominant pattern in malignant pleural effusion, they were detected in 24% of benign diagnoses. Detection of nodules in >1 area of the costoparietal pleura was in favor of a malignant diagnosis. Inflammation was the predominant pattern in benign pleural effusion. Our results suggest that macroscopic nodules in malignant diagnoses have a predilection for the middle and inferior surfaces of the lateral costoparietal pleura.
Collapse
Affiliation(s)
- Mohamed Ellayeh
- University of Oxford Respiratory Trials Unit, Churchill Hospital, Oxford, United Kingdom.,Oxford Centre for Respiratory Medicine, Oxford University Hospitals NHS Trust, Oxford, United Kingdom.,Department of Chest Medicine, Mansoura University, Mansoura, Egypt
| | - Eihab Bedawi
- University of Oxford Respiratory Trials Unit, Churchill Hospital, Oxford, United Kingdom.,Oxford Centre for Respiratory Medicine, Oxford University Hospitals NHS Trust, Oxford, United Kingdom
| | - Radhika Banka
- University of Oxford Respiratory Trials Unit, Churchill Hospital, Oxford, United Kingdom.,Oxford Centre for Respiratory Medicine, Oxford University Hospitals NHS Trust, Oxford, United Kingdom
| | - Anand Sundaralingam
- University of Oxford Respiratory Trials Unit, Churchill Hospital, Oxford, United Kingdom.,Oxford Centre for Respiratory Medicine, Oxford University Hospitals NHS Trust, Oxford, United Kingdom
| | - Vineeth George
- University of Oxford Respiratory Trials Unit, Churchill Hospital, Oxford, United Kingdom.,Oxford Centre for Respiratory Medicine, Oxford University Hospitals NHS Trust, Oxford, United Kingdom
| | - Nikolaos Kanellakis
- University of Oxford Respiratory Trials Unit, Churchill Hospital, Oxford, United Kingdom.,Laboratory of Pleural and Lung Cancer Translational Research, Nuffield Department of Medicine, University of Oxford, Oxford, United Kingdom
| | - Robert Hallifax
- University of Oxford Respiratory Trials Unit, Churchill Hospital, Oxford, United Kingdom.,Oxford Centre for Respiratory Medicine, Oxford University Hospitals NHS Trust, Oxford, United Kingdom
| | - Heba Abdelwahab
- Department of Chest Medicine, Mansoura University, Mansoura, Egypt
| | - Nasef Rezk
- Department of Chest Medicine, Mansoura University, Mansoura, Egypt
| | - Asem Hewidy
- Department of Chest Medicine, Mansoura University, Mansoura, Egypt
| | - Raed Ali
- Department of Chest Medicine, Mansoura University, Mansoura, Egypt
| | - John Wrightson
- University of Oxford Respiratory Trials Unit, Churchill Hospital, Oxford, United Kingdom.,Oxford Centre for Respiratory Medicine, Oxford University Hospitals NHS Trust, Oxford, United Kingdom
| | - Najib Rahman
- University of Oxford Respiratory Trials Unit, Churchill Hospital, Oxford, United Kingdom.,Oxford Centre for Respiratory Medicine, Oxford University Hospitals NHS Trust, Oxford, United Kingdom.,NIHR Oxford Biomedical Research Centre, University of Oxford, Oxford, United Kingdom
| |
Collapse
|
14
|
|
15
|
Abstract
Pleural infection is a millennia-spanning condition that has proved challenging to treat over many years. Fourteen percent of cases of pneumonia are reported to present with a pleural effusion on chest X-ray (CXR), which rises to 44% on ultrasound but many will resolve with prompt antibiotic therapy. To guide treatment, parapneumonic effusions have been separated into distinct categories according to their biochemical, microbiological and radiological characteristics. There is wide variation in causative organisms according to geographical location and healthcare setting. Positive cultures are only obtained in 56% of cases; therefore, empirical antibiotics should provide Gram-positive, Gram-negative and anaerobic cover whilst providing adequate pleural penetrance. With the advent of next-generation sequencing techniques, yields are expected to improve. Complicated parapneumonic effusions and empyema necessitate prompt tube thoracostomy. It is reported that 16-27% treated in this way will fail on this therapy and require some form of escalation. The now seminal Multi-centre Intrapleural Sepsis Trials (MIST) demonstrated the use of combination fibrinolysin and DNase as more effective in the treatment of empyema compared to either agent alone or placebo, and success rates of 90% are reported with this technique. The focus is now on dose adjustments according to the patient's specific 'fibrinolytic potential', in order to deliver personalised therapy. Surgery has remained a cornerstone in the management of pleural infection and is certainly required in late-stage manifestations of the disease. However, its role in early-stage disease and optimal patient selection is being re-explored. A number of adjunct and exploratory therapies are also discussed in this review, including the use of local anaesthetic thoracoscopy, indwelling pleural catheters, intrapleural antibiotics, pleural irrigation and steroid therapy.
Collapse
Affiliation(s)
- Anand Sundaralingam
- Oxford Centre for Respiratory Medicine, Oxford University Hospitals NHS Foundation Trust, Oxford, UK.
| | - Radhika Banka
- Oxford Centre for Respiratory Medicine, Oxford University Hospitals NHS Foundation Trust, Oxford, UK
| | - Najib M Rahman
- Oxford Centre for Respiratory Medicine, Oxford University Hospitals NHS Foundation Trust, Oxford, UK
- Oxford Respiratory Trials Unit, University of Oxford, Oxford, UK
- Oxford NIHR Biomedical Research Centre, Oxford, UK
| |
Collapse
|
16
|
Yao X, Abd Hamid M, Sundaralingam A, Evans A, Karthikappallil R, Dong T, Rahman NM, Kanellakis NI. Clinical perspective and practices on pleural effusions in chronic systemic inflammatory diseases. Breathe (Sheff) 2020; 16:200203. [PMID: 33447289 PMCID: PMC7792825 DOI: 10.1183/20734735.0203-2020] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/15/2022] Open
Abstract
Systemic inflammatory diseases are a heterogeneous family of autoimmune chronic inflammatory disorders that affect multiple systems within the human body. Connective tissue disease (CTD) is a large group within this family characterised by immune-mediated inflammation of the connective tissue. This group of disorders are often associated with pleural manifestations. CTD-induced pleuritis exhibits a wide variety of symptoms and signs including exudative pleural effusions and chest pain. Accurate estimation of prevalence for CTD-related pleuritis is challenging as small effusions are asymptomatic and remain undetected. Rheumatoid arthritis and systemic lupus erythematosus are frequent CTDs and present with pleural pathology in approximately 5–20% and 17–60% of cases, respectively. By contrast, pleural involvement in systemic sclerosis, eosinophilia–myalgia syndrome, mixed connective tissue disease, ankylosing spondylitis, polymyositis and dermatomyositis syndrome is rare. Clinical management depends on the severity of symptoms; however, most effusions resolve spontaneously. In this review we discuss the pathophysiological mechanisms and the clinical considerations of CTD-induced pleuritis. Chronic inflammatory diseases could cause pleural pathology. Clinical management depends on the severity of symptoms, but most effusions resolve spontaneously.https://bit.ly/333euHb
Collapse
Affiliation(s)
- Xuan Yao
- Chinese Academy of Medical Sciences Oxford Institute, Nuffield Dept of Medicine, University of Oxford, Oxford, UK.,MRC Human Immunology Unit, MRC Weatherall Institute of Molecular Medicine, University of Oxford, Oxford, UK.,Both authors contributed equally
| | - Megat Abd Hamid
- Chinese Academy of Medical Sciences Oxford Institute, Nuffield Dept of Medicine, University of Oxford, Oxford, UK.,MRC Human Immunology Unit, MRC Weatherall Institute of Molecular Medicine, University of Oxford, Oxford, UK.,Both authors contributed equally
| | - Anand Sundaralingam
- Oxford Centre for Respiratory Medicine, Churchill Hospital, Oxford University Hospitals NHS Foundation Trust, Oxford, UK
| | - Alice Evans
- Laboratory of Pleural and Lung Cancer Translational Research, Nuffield Dept of Medicine, University of Oxford, Oxford, UK
| | - Roshan Karthikappallil
- Laboratory of Pleural and Lung Cancer Translational Research, Nuffield Dept of Medicine, University of Oxford, Oxford, UK
| | - Tao Dong
- Chinese Academy of Medical Sciences Oxford Institute, Nuffield Dept of Medicine, University of Oxford, Oxford, UK.,MRC Human Immunology Unit, MRC Weatherall Institute of Molecular Medicine, University of Oxford, Oxford, UK
| | - Najib M Rahman
- Oxford Centre for Respiratory Medicine, Churchill Hospital, Oxford University Hospitals NHS Foundation Trust, Oxford, UK.,Laboratory of Pleural and Lung Cancer Translational Research, Nuffield Dept of Medicine, University of Oxford, Oxford, UK.,National Institute for Health Research Oxford Biomedical Research Centre, University of Oxford, Oxford, UK.,Oxford Respiratory Trials Unit, Nuffield Dept of Medicine, University of Oxford, Oxford, UK
| | - Nikolaos I Kanellakis
- Oxford Centre for Respiratory Medicine, Churchill Hospital, Oxford University Hospitals NHS Foundation Trust, Oxford, UK.,Laboratory of Pleural and Lung Cancer Translational Research, Nuffield Dept of Medicine, University of Oxford, Oxford, UK.,National Institute for Health Research Oxford Biomedical Research Centre, University of Oxford, Oxford, UK.,Oxford Respiratory Trials Unit, Nuffield Dept of Medicine, University of Oxford, Oxford, UK
| |
Collapse
|
17
|
Sundaralingam A, Kilic Y, Burman M, Rahman A, White V, Jayasekera N, Darmalingam M, Tiberi S, Kunst H. A Case Series of Pericardial TB in a large European Centre. Tuberculosis (Edinb) 2019. [DOI: 10.1183/13993003.congress-2019.pa2985] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
|
18
|
Abstract
A young Bangladeshi woman presented to the emergency department with vaginal discharge on a history of fevers and rigours. Although initially treated for pelvic inflammatory disease, the patient rapidly developed respiratory failure with acute respiratory distress syndrome. An axillary biopsy and a high-resolution CT of the chest confirmed miliary tuberculosis (TB). She was initiated on anti-TB medication and made a rapid recovery.
Collapse
|
19
|
Sundaralingam A. Endometriosis is associated with an increased risk of ovarian cancer, study shows. BMJ 2012; 344:e1363. [PMID: 22368285 DOI: 10.1136/bmj.e1363] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/04/2022]
|