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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).
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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
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2
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Porcel JM, Bielsa S, Civit C, Aujayeb A, Janssen J, Bodtger U, Fjaellegaard K, Petersen JK, Welch H, Symonds J, Mitchell MA, Grabczak EM, Ellayeh M, Addala D, Wrightson JM, Rahman NM, Munavvar M, Koegelenberg CF, Labarca G, Mei F, Maskell N, Bhatnagar R. Clinical characteristics of chylothorax: results from the International Collaborative Effusion database. ERJ Open Res 2023; 9:00091-2023. [PMID: 37850216 PMCID: PMC10577597 DOI: 10.1183/23120541.00091-2023] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/11/2023] [Accepted: 08/14/2023] [Indexed: 10/19/2023] Open
Abstract
Background Chylothorax is an uncommon medical condition for which limited data are available regarding the contemporary aetiology, management and outcomes. The goal of this study was to better define these poorly characterised features. Methods The medical records of adult patients diagnosed with chylothorax at 12 centres across Europe, America and South Africa from 2009-2021 were retrospectively reviewed. Descriptive and inferential statistics were performed. Results 77 patients (median age 69 years, male to female ratio 1.5) were included. Subacute dyspnoea was the most typical presenting symptom (66%). The commonest cause of chylothorax was malignancy (68.8%), with lymphoma accounting for 62% of these cases. Other aetiologies were trauma (13%), inflammatory/miscellaneous conditions (11.7%) and idiopathic cases (6.5%). At the initial thoracentesis, the pleural fluid appeared milky in 73%, was exudative in 89% and exhibited triglyceride concentrations >100 mg·dL-1 in 88%. Lymphangiography/lymphoscintigraphy were rarely ordered (3%), and demonstration of chylomicrons in pleural fluid was never ascertained. 67% of patients required interventional pleural procedures. Dietary measures were infrequently followed (36%). No patient underwent thoracic duct ligation or embolisation. Morbidity included infections (18%), and thrombosis in malignant aetiologies (16%). The 1-year mortality was 47%. Pleural fluid protein >3.5 mg·dL-1 (sub-distribution hazard ratio (SHR) 4.346) or lactate dehydrogenase <500 U·L-1 (SHR 10.21) increased the likelihood of effusion resolution. Pleural fluid protein ≤3.5 mg·dL-1 (HR 4.047), bilateral effusions (HR 2.749) and a history of respiratory disease (HR 2.428) negatively influenced survival. Conclusion Chylothoraces have a poor prognosis and most require pleural interventions. Despite the standard recommendations, lymphatic imaging is seldom used, nor are dietary restrictions followed.
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Affiliation(s)
- José M. Porcel
- Pleural Medicine Unit, Department of Internal Medicine, Arnau de Vilanova University Hospital, IRBLleida, University of Lleida, Lleida, Spain
| | - Silvia Bielsa
- Pleural Medicine Unit, Department of Internal Medicine, Arnau de Vilanova University Hospital, IRBLleida, University of Lleida, Lleida, Spain
| | - Carmen Civit
- Pleural Medicine Unit, Department of Internal Medicine, Arnau de Vilanova University Hospital, IRBLleida, University of Lleida, Lleida, Spain
| | - Avinash Aujayeb
- Respiratory Department, Northumbria Healthcare Foundation Trust, Cramlington, UK
| | - Julius Janssen
- Respiratory Department, Canisius Wilhelmina Ziekenhuis, Nijmegen, The Netherlands
| | - Uffe Bodtger
- Respiratory Research Unit PLUZ, Department of Respiratory Medicine, Zealand University Hospital, Naestved, Denmark
| | - Katrine Fjaellegaard
- Respiratory Research Unit PLUZ, Department of Respiratory Medicine, Zealand University Hospital, Naestved, Denmark
| | - Jesper Koefod Petersen
- Respiratory Research Unit PLUZ, Department of Respiratory Medicine, Zealand University Hospital, Naestved, Denmark
| | - Hugh Welch
- Academic Respiratory Unit, University of Bristol, Bristol, UK
- Respiratory Department, Southmead Hospital, North Bristol NHS Trust, Bristol, UK
| | - Jenny Symonds
- Respiratory Department, Southmead Hospital, North Bristol NHS Trust, Bristol, UK
| | - Michael A. Mitchell
- Department of Medicine, Schulich School of Medicine and Dentistry, Western University, London, ON, Canada
| | | | - Mohamed Ellayeh
- Department of Chest Medicine, Mansoura University, Mansoura, Egypt
- Oxford Centre for Respiratory Medicine, Oxford University Hospitals NHS Foundation Trust, Oxford, UK
| | - Dinesh Addala
- Oxford Centre for Respiratory Medicine, Oxford University Hospitals NHS Foundation Trust, Oxford, UK
| | - John M. Wrightson
- 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 NIHR Biomedical Research Centre, Oxford, UK
| | - Mohammed Munavvar
- Respiratory Department, Lancashire Teaching Hospitals NHS Trust, Preston, UK
- University of Central Lancashire, Preston, UK
| | - Coenraad F.N. Koegelenberg
- Division of Pulmonology, Department of Medicine, Stellenbosch University and Tygerberg Hospital, Cape Town, South Africa
| | - Gonzalo Labarca
- Division of Internal Medicine, Complejo Asistencial Dr Víctor Ríos Ruiz, Los Angeles, Chile
- Molecular and Translational Immunology Laboratory, Department of Clinical Biochemistry and Immunology, Faculty of Pharmacy, Universidad de Concepcion, Concepcion, Chile
| | - Federico Mei
- Respiratory Disease Unit, Department of Internal Medicine, University Hospital, Ancona, Italy
- Department of Biomedical Sciences and Public Health, Polytechnic University of Marche, Ancona, Italy
| | - Nick Maskell
- Academic Respiratory Unit, University of Bristol, Bristol, UK
- Respiratory Department, Southmead Hospital, North Bristol NHS Trust, Bristol, UK
| | - Rahul Bhatnagar
- Academic Respiratory Unit, University of Bristol, Bristol, UK
- Respiratory Department, Southmead Hospital, North Bristol NHS Trust, Bristol, UK
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3
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Pietersen PI, Bhatnagar R, Rahman NM, Maskell N, Wrightson JM, Annema J, Crombag L, Farr A, Tabin N, Slavicky M, Skaarup SH, Konge L, Laursen CB. Evidence-based training and certification: the ERS thoracic ultrasound training programme. Breathe (Sheff) 2023; 19:230053. [PMID: 37492346 PMCID: PMC10365077 DOI: 10.1183/20734735.0053-2023] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/06/2023] [Accepted: 05/25/2023] [Indexed: 07/27/2023] Open
Abstract
Thoracic ultrasound has developed into an integral part of the respiratory physician's diagnostic and therapeutic toolbox, with high diagnostic accuracy for many diseases causing acute or chronic respiratory symptoms. However, it is vitally important that the operator has received the appropriate education and training to ensure a systematic and thorough examination, correct image interpretation, and that they then have the appropriate skills to integrate all the findings for patient benefit. In this review, we present the new European Respiratory Society thoracic ultrasound training programme, including a discussion of curriculum development, its implementation, and trainee evaluation. This programme enables participants to gain competence in thoracic ultrasound through structured, evidence-based training with robustly validated assessments and certification. The training programme consists of three components: an online, theoretical part (part 1), which is accessible all year; a practical course (part 2), with four courses held each year (two online courses and two on-site courses); and an examination (part 3) comprising an objective structured clinical examination (OSCE), which is hosted each year at the European Respiratory Society Congress.
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Affiliation(s)
- Pia Iben Pietersen
- Department of Radiology, Odense University Hospital – Svendborg, UNIFY – Research and Innovation Unit of Radiology, Odense, Denmark
- Department of Clinical Research, University of Southern Denmark, SimC – Simulation Center, Odense University Hospital, Odense, Denmark
| | - Rahul Bhatnagar
- Academic Respiratory Unit, University of Bristol, Bristol, UK
| | - Najib M. Rahman
- University of Oxford, Oxford NIHR Biomedical Research Centre, Oxford Centre for Respiratory Medicine, Oxford, UK
| | - Nick Maskell
- Academic Respiratory Unit, University of Bristol, Bristol, UK
| | - John M. Wrightson
- Oxford Centre for Respiratory Medicine, Oxford University Hospitals NHS Foundation Trust, Oxford, UK
| | - Jouke Annema
- Department of Respiratory Medicine, Amsterdam University Medical Centres, Amsterdam, The Netherlands
| | - Laurence Crombag
- Department of Respiratory Medicine, Amsterdam University Medical Centres, Amsterdam, The Netherlands
| | - Amy Farr
- Education Department, European Respiratory Society (ERS), Lausanne, Switzerland
| | - Nathalie Tabin
- Education Department, European Respiratory Society (ERS), Lausanne, Switzerland
| | - Marek Slavicky
- Education Department, European Respiratory Society (ERS), Lausanne, Switzerland
| | - Søren Helbo Skaarup
- Department of Respiratory Medicine and Allergy, Aarhus University Hospital, Aarhus, Denmark
| | - Lars Konge
- Copenhagen Academy for Medical Education and Simulation (CAMES), Centre for Human Resources and Education, The Capital Region of Denmark, Copenhagen, Denmark
| | - Christian B. Laursen
- Department of Respiratory Medicine, Odense University Hospital, Odense, Denmark
- Odense Respiratory Research Unit (ODIN) - Department of Clinical Research, University of Southern Denmark, Odense, Denmark
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4
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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.
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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
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5
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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.
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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
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6
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Bedawi EO, Banka R, Gleeson FV, Rahman NM, Wrightson JM. Transposition of the great indwelling pleural catheter. Thorax 2021; 77:633. [PMID: 34716279 DOI: 10.1136/thoraxjnl-2021-217956] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/17/2021] [Accepted: 10/14/2021] [Indexed: 11/04/2022]
Affiliation(s)
- Eihab O Bedawi
- Oxford Centre for Respiratory Medicine, Oxford University Hospitals NHS Foundation Trust, Oxford, UK .,NIHR Oxford Biomedical Research Centre, University of Oxford, Oxford, UK
| | - Radhika Banka
- Oxford Centre for Respiratory Medicine, Oxford University Hospitals NHS Foundation Trust, Oxford, UK.,Department of Respiratory Medicine, P.D. Hinduja National Hospital & Medical Research Centre, Mumbai, India
| | - Fergus V Gleeson
- Departments of Radiology and Nuclear 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.,NIHR Oxford Biomedical Research Centre, University of Oxford, Oxford, UK
| | - John M Wrightson
- Oxford Centre for Respiratory Medicine, Oxford University Hospitals NHS Foundation Trust, Oxford, UK
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7
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Hallifax RJ, Porter BM, Elder PJ, Evans SB, Turnbull CD, Hynes G, Lardner R, Archer K, Bettinson HV, Nickol AH, Flight WG, Chapman SJ, Hardinge M, Hoyles RK, Saunders P, Sykes A, Wrightson JM, Moore A, Ho LP, Fraser E, Pavord ID, Talbot NP, Bafadhel M, Petousi N, Rahman NM. Successful awake proning is associated with improved clinical outcomes in patients with COVID-19: single-centre high-dependency unit experience. BMJ Open Respir Res 2020; 7:7/1/e000678. [PMID: 32928787 PMCID: PMC7490910 DOI: 10.1136/bmjresp-2020-000678] [Citation(s) in RCA: 37] [Impact Index Per Article: 9.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/18/2020] [Revised: 09/03/2020] [Accepted: 09/03/2020] [Indexed: 01/08/2023] Open
Abstract
The SARS-CoV-2 can lead to severe illness with COVID-19. Outcomes of patients requiring mechanical ventilation are poor. Awake proning in COVID-19 improves oxygenation, but on data clinical outcomes is limited. This single-centre retrospective study aimed to assess whether successful awake proning of patients with COVID-19, requiring respiratory support (continuous positive airways pressure (CPAP) or high-flow nasal oxygen (HFNO)) on a respiratory high-dependency unit (HDU), is associated with improved outcomes. HDU care included awake proning by respiratory physiotherapists. Of 565 patients admitted with COVID-19, 71 (12.6%) were managed on the respiratory HDU, with 48 of these (67.6%) requiring respiratory support. Patients managed with CPAP alone 22/48 (45.8%) were significantly less likely to die than patients who required transfer onto HFNO 26/48 (54.2%): CPAP mortality 36.4%; HFNO mortality 69.2%, (p=0.023); however, multivariate analysis demonstrated that increasing age and the inability to awake prone were the only independent predictors of COVID-19 mortality. The mortality of patients with COVID-19 requiring respiratory support is considerable. Data from our cohort managed on HDU show that CPAP and awake proning are possible in a selected population of COVID-19, and may be useful. Further prospective studies are required.
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Affiliation(s)
- Rob J Hallifax
- Oxford Centre for Respiratory Medicine, Oxford University Hospitals NHS Foundation Trust, Oxford, UK .,Respiratory Medicine Unit, Nuffield Department of Medicine, University of Oxford, Oxford, UK
| | - Benedict Ml Porter
- Oxford Centre for Respiratory Medicine, Oxford University Hospitals NHS Foundation Trust, Oxford, UK
| | - Patrick Jd Elder
- Oxford Centre for Respiratory Medicine, Oxford University Hospitals NHS Foundation Trust, Oxford, UK
| | - Sarah B Evans
- Oxford Centre for Respiratory Medicine, Oxford University Hospitals NHS Foundation Trust, Oxford, UK
| | - Chris D Turnbull
- Oxford Centre for Respiratory Medicine, Oxford University Hospitals NHS Foundation Trust, Oxford, UK.,Respiratory Medicine Unit, Nuffield Department of Medicine, University of Oxford, Oxford, UK
| | - Gareth Hynes
- Oxford Centre for Respiratory Medicine, Oxford University Hospitals NHS Foundation Trust, Oxford, UK
| | - Rachel Lardner
- Oxford Centre for Respiratory Medicine, Oxford University Hospitals NHS Foundation Trust, Oxford, UK.,Therapies Clinical Service Unit, Oxford University Hospitals NHS Foundation Trust, Oxford, UK
| | - Kirsty Archer
- Therapies Clinical Service Unit, Oxford University Hospitals NHS Foundation Trust, Oxford, UK
| | - Henry V Bettinson
- Oxford Centre for Respiratory Medicine, Oxford University Hospitals NHS Foundation Trust, Oxford, UK
| | - Annabel H Nickol
- Oxford Centre for Respiratory Medicine, Oxford University Hospitals NHS Foundation Trust, Oxford, UK
| | - William G Flight
- Oxford Centre for Respiratory Medicine, Oxford University Hospitals NHS Foundation Trust, Oxford, UK
| | - Stephen J Chapman
- Oxford Centre for Respiratory Medicine, Oxford University Hospitals NHS Foundation Trust, Oxford, UK
| | - Maxine Hardinge
- Oxford Centre for Respiratory Medicine, Oxford University Hospitals NHS Foundation Trust, Oxford, UK
| | - Rachel K Hoyles
- Oxford Centre for Respiratory Medicine, Oxford University Hospitals NHS Foundation Trust, Oxford, UK
| | - Peter Saunders
- Oxford Centre for Respiratory Medicine, Oxford University Hospitals NHS Foundation Trust, Oxford, UK
| | - Anny Sykes
- Oxford Centre for Respiratory Medicine, Oxford University Hospitals NHS Foundation Trust, Oxford, UK
| | - John M Wrightson
- Oxford Centre for Respiratory Medicine, Oxford University Hospitals NHS Foundation Trust, Oxford, UK
| | - Alastair Moore
- Oxford Centre for Respiratory Medicine, Oxford University Hospitals NHS Foundation Trust, Oxford, UK
| | - Ling-Pei Ho
- Oxford Centre for Respiratory Medicine, Oxford University Hospitals NHS Foundation Trust, Oxford, UK.,Oxford NIHR Biomedical Research Centre, University of Oxford, Oxford, UK
| | - Emily Fraser
- Oxford Centre for Respiratory Medicine, Oxford University Hospitals NHS Foundation Trust, Oxford, UK
| | - Ian D Pavord
- Oxford NIHR Biomedical Research Centre, University of Oxford, Oxford, UK
| | - Nicholas P Talbot
- Oxford Centre for Respiratory Medicine, Oxford University Hospitals NHS Foundation Trust, Oxford, UK.,Oxford NIHR Biomedical Research Centre, University of Oxford, Oxford, UK
| | - Mona Bafadhel
- Oxford Centre for Respiratory Medicine, Oxford University Hospitals NHS Foundation Trust, Oxford, UK.,Respiratory Medicine Unit, Nuffield Department of Medicine, University of Oxford, Oxford, UK
| | - Nayia Petousi
- Oxford Centre for Respiratory Medicine, Oxford University Hospitals NHS Foundation Trust, Oxford, UK.,Oxford NIHR Biomedical Research Centre, University of Oxford, Oxford, UK
| | - Najib M Rahman
- Oxford Centre for Respiratory Medicine, Oxford University Hospitals NHS Foundation Trust, Oxford, UK.,Oxford NIHR Biomedical Research Centre, University of Oxford, Oxford, UK
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8
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Bedawi EO, Talwar A, Hassan M, McCracken DJ, Asciak R, Mercer RM, Kanellakis NI, Gleeson FV, Hallifax RJ, Wrightson JM, Rahman NM. Intercostal vessel screening prior to pleural interventions by the respiratory physician: a prospective study of real world practice. Eur Respir J 2020; 55:13993003.02245-2019. [PMID: 32139459 DOI: 10.1183/13993003.02245-2019] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/27/2019] [Accepted: 02/01/2020] [Indexed: 11/05/2022]
Abstract
INTRODUCTION The rising incidence of pleural disease is seeing an international growth of pleural services, with physicians performing an ever-increasing volume of pleural interventions. These are frequently conducted at sites without immediate access to thoracic surgery or interventional radiology and serious complications such as pleural bleeding are likely to be under-reported. AIM To assess whether intercostal vessel screening can be performed by respiratory physicians at the time of pleural intervention, as an additional step that could potentially enhance safe practice. METHODS This was a prospective, observational study of 596 ultrasound-guided pleural procedures conducted by respiratory physicians and trainees in a tertiary centre. Operators did not have additional formal radiology training. Intercostal vessel screening was performed using a low frequency probe and the colour Doppler feature. RESULTS The intercostal vessels were screened in 95% of procedures and the intercostal artery (ICA) was successfully identified in 53% of cases. Screening resulted in an overall site alteration rate of 16% in all procedures, which increased to 30% when the ICA was successfully identified. This resulted in procedure abandonment in 2% of cases due to absence of a suitable entry site. Intercostal vessel screening was shown to be of particular value in the context of image-guided pleural biopsy. CONCLUSION Intercostal vessel screening is a simple and potentially important additional step that can be performed by respiratory physicians at the time of pleural intervention without advanced ultrasound expertise. Whether the widespread use of this technique can improve safety requires further evaluation in a multi-centre setting with a robust prospective study.
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Affiliation(s)
- Eihab O Bedawi
- Oxford Centre for Respiratory Medicine, Oxford University Hospitals NHS Foundation Trust, Oxford, UK .,Oxford Respiratory Trials Unit, University of Oxford, Oxford, UK.,NIHR Biomedical Research Centre, University of Oxford, Oxford, UK
| | - Ambika Talwar
- Oxford Centre for Respiratory Medicine, Oxford University Hospitals NHS Foundation Trust, Oxford, UK
| | - Maged Hassan
- Oxford Centre for Respiratory Medicine, Oxford University Hospitals NHS Foundation Trust, Oxford, UK.,Oxford Respiratory Trials Unit, University of Oxford, Oxford, UK.,Chest Diseases Dept, Faculty of Medicine, Alexandria University, Alexandria, Egypt
| | - David J McCracken
- Oxford Centre for Respiratory Medicine, Oxford University Hospitals NHS Foundation Trust, Oxford, UK
| | - Rachelle Asciak
- Oxford Centre for Respiratory Medicine, Oxford University Hospitals NHS Foundation Trust, Oxford, UK.,Oxford Respiratory Trials Unit, University of Oxford, Oxford, UK
| | - Rachel M Mercer
- Oxford Centre for Respiratory Medicine, Oxford University Hospitals NHS Foundation Trust, Oxford, UK.,Oxford Respiratory Trials Unit, University of Oxford, Oxford, UK
| | - Nikolaos I Kanellakis
- Oxford Centre for Respiratory Medicine, Oxford University Hospitals NHS Foundation Trust, Oxford, UK.,Oxford Respiratory Trials Unit, University of Oxford, Oxford, UK.,NIHR Biomedical Research Centre, University of Oxford, Oxford, UK.,Laboratory of Pleural Translational Research, Nuffield Dept of Medicine, University of Oxford, Oxford, UK
| | - Fergus V Gleeson
- Oxford Centre for Respiratory Medicine, Oxford University Hospitals NHS Foundation Trust, Oxford, UK.,Dept of Radiology, Churchill Hospital, Oxford University Hospitals NHS Trust, Oxford, UK
| | - Rob J Hallifax
- Oxford Centre for Respiratory Medicine, Oxford University Hospitals NHS Foundation Trust, Oxford, UK.,Oxford Respiratory Trials Unit, University of Oxford, Oxford, UK
| | - John M Wrightson
- Oxford Centre for Respiratory Medicine, Oxford University Hospitals NHS Foundation Trust, Oxford, UK.,Oxford Respiratory Trials Unit, University of Oxford, 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.,NIHR Biomedical Research Centre, University of Oxford, Oxford, UK.,Laboratory of Pleural Translational Research, Nuffield Dept of Medicine, University of Oxford, Oxford, UK
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9
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Kanellakis NI, Wrightson JM, Hallifax R, Bedawi EO, Mercer R, Hassan M, Asciak R, Hedley E, Dobson M, Dong T, Psallidas I, Rahman NM. Biological effect of tissue plasminogen activator (t-PA) and DNase intrapleural delivery in pleural infection patients. BMJ Open Respir Res 2019; 6:e000440. [PMID: 31673364 PMCID: PMC6797395 DOI: 10.1136/bmjresp-2019-000440] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.4] [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] [Received: 04/09/2019] [Revised: 09/07/2019] [Accepted: 09/12/2019] [Indexed: 11/03/2022] Open
Abstract
Background Pleural infection (PI) is a major global disease with an increasing incidence, and pleural fluid (PF) drainage is essential for the successful treatment. The MIST2 study demonstrated that intrapleural administration of tissue plasminogen activator (t-PA) and DNase, or t-PA alone increased the volume of drained PF. Mouse model studies have suggested that the volume increase is due to the interaction of the pleura with the t-PA via the monocyte chemoattractant protein 1 (MCP-1) pathway. We designed a study to determine the time frame of drained PF volume induction on intrapleural delivery of t-PA±DNase in humans, and to test the hypothesis that the induction is mediated by the MCP-1 pathway. Methods Data and samples from the MIST2 study were used (210 PI patients randomised to receive for 3 days either: t-PA and DNase, t-PA and placebo, DNase and placebo or double placebo). PF MCP-1 levels were measured by ELISA. One-way and two-way analysis of variance (ANOVA) with Tukey's post hoc tests were used to estimate statistical significance. Pearson's correlation coefficient was used to assess linear correlation. Results Intrapleural administration of t-PA±DNase stimulated a statistically significant rise in the volume of drained PF during the treatment period (days 1-3). No significant difference was detected between any groups during the post-treatment period (days 5-7). Intrapleural administration of t-PA increased MCP-1 PF levels during treatment; however, no statistically significant difference was detected between patients who received t-PA and those who did not. PF MCP-1 expression was not correlated to the drug given nor the volume of drained PF. Conclusions We conclude that the PF volume drainage increment seen with the administration of t-PA does not appear to act solely via activation of the MCP-1 pathway.
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Affiliation(s)
- Nikolaos I Kanellakis
- Oxford Centre for Respiratory Medicine, Churchill Hospital, Oxford University Hospitals NHS Foundation Trust, Oxford, Oxfordshire, UK.,Laboratory of Pleural and Lung Cancer Translational Research, Nuffield Department of Medicine, University of Oxford, Oxford, Oxfordshire, UK.,National Institute for Health Research Oxford Biomedical Research Centre, University of Oxford, Oxford, Oxfordshire, UK
| | - John M Wrightson
- Oxford Centre for Respiratory Medicine, Churchill Hospital, Oxford University Hospitals NHS Foundation Trust, Oxford, Oxfordshire, UK
| | - Rob Hallifax
- Oxford Centre for Respiratory Medicine, Churchill Hospital, Oxford University Hospitals NHS Foundation Trust, Oxford, Oxfordshire, UK
| | - Eihab O Bedawi
- Oxford Centre for Respiratory Medicine, Churchill Hospital, Oxford University Hospitals NHS Foundation Trust, Oxford, Oxfordshire, UK
| | - Rachel Mercer
- Oxford Centre for Respiratory Medicine, Churchill Hospital, Oxford University Hospitals NHS Foundation Trust, Oxford, Oxfordshire, UK
| | - Maged Hassan
- Oxford Centre for Respiratory Medicine, Churchill Hospital, Oxford University Hospitals NHS Foundation Trust, Oxford, Oxfordshire, UK
| | - Rachelle Asciak
- Oxford Centre for Respiratory Medicine, Churchill Hospital, Oxford University Hospitals NHS Foundation Trust, Oxford, Oxfordshire, UK
| | - Emma Hedley
- Oxford Respiratory Trials Unit, Nuffield Department of Medicine, University of Oxford, Oxford, Oxfordshire, UK
| | - Melissa Dobson
- Oxford Respiratory Trials Unit, Nuffield Department of Medicine, University of Oxford, Oxford, Oxfordshire, UK
| | - Tao Dong
- Centre for Translational Immunology, Chinese Academy of Medical Sciences Oxford Institute, Nuffield Department of Medicine, University of Oxford, Oxford, UK.,MRC Human Immunology Unit, 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, Oxfordshire, UK.,Laboratory of Pleural and Lung Cancer Translational Research, Nuffield Department of Medicine, University of Oxford, Oxford, Oxfordshire, UK
| | - Najib M Rahman
- Oxford Centre for Respiratory Medicine, Churchill Hospital, Oxford University Hospitals NHS Foundation Trust, Oxford, Oxfordshire, UK.,Laboratory of Pleural and Lung Cancer Translational Research, Nuffield Department of Medicine, University of Oxford, Oxford, Oxfordshire, UK.,National Institute for Health Research Oxford Biomedical Research Centre, University of Oxford, Oxford, Oxfordshire, UK
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10
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Mishra EK, Clive AO, Wills GH, Davies HE, Stanton AE, Al-Aloul M, Hart-Thomas A, Pepperell J, Evison M, Saba T, Harrison RN, Guhan A, Callister ME, Sathyamurthy R, Rehal S, Corcoran JP, Hallifax R, Psallidas I, Russell N, Shaw R, Dobson M, Wrightson JM, West A, Lee YCG, Nunn AJ, Miller RF, Maskell NA, Rahman NM. Randomized Controlled Trial of Urokinase versus Placebo for Nondraining Malignant Pleural Effusion. Am J Respir Crit Care Med 2019; 197:502-508. [PMID: 28926296 DOI: 10.1164/rccm.201704-0809oc] [Citation(s) in RCA: 37] [Impact Index Per Article: 7.4] [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: 11/16/2022] Open
Abstract
RATIONALE Patients with malignant pleural effusion experience breathlessness, which is treated by drainage and pleurodesis. Incomplete drainage results in residual dyspnea and pleurodesis failure. Intrapleural fibrinolytics lyse septations within pleural fluid, improving drainage. OBJECTIVES To assess the effects of intrapleural urokinase on dyspnea and pleurodesis success in patients with nondraining malignant effusion. METHODS We conducted a prospective, double-blind, randomized trial. Patients with nondraining effusion were randomly allocated in a 1:1 ratio to intrapleural urokinase (100,000 IU, three doses, 12-hourly) or matched placebo. MEASUREMENTS AND MAIN RESULTS Co-primary outcome measures were dyspnea (average daily 100-mm visual analog scale scores over 28 d) and time to pleurodesis failure to 12 months. Secondary outcomes were survival, hospital length of stay, and radiographic change. A total of 71 subjects were randomized (36 received urokinase, 35 placebo) from 12 U.K. centers. The baseline characteristics were similar between the groups. There was no difference in mean dyspnea between groups (mean difference, 3.8 mm; 95% confidence interval [CI], -12 to 4.4 mm; P = 0.36). Pleurodesis failure rates were similar (urokinase, 13 of 35 [37%]; placebo, 11 of 34 [32%]; adjusted hazard ratio, 1.2; P = 0.65). Urokinase was associated with decreased effusion size visualized by chest radiography (adjusted relative improvement, -19%; 95% CI, -28 to -11%; P < 0.001), reduced hospital stay (1.6 d; 95% CI, 1.0 to 2.6; P = 0.049), and improved survival (69 vs. 48 d; P = 0.026). CONCLUSIONS Use of intrapleural urokinase does not reduce dyspnea or improve pleurodesis success compared with placebo and cannot be recommended as an adjunct to pleurodesis. Other palliative treatments should be used. Improvements in hospital stay, radiographic appearance, and survival associated with urokinase require further evaluation. Clinical trial registered with ISRCTN (12852177) and EudraCT (2008-000586-26).
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Affiliation(s)
- Eleanor K Mishra
- 1 Norfolk and Norwich Pleural Unit, Norfolk and Norwich University Hospital NHS Foundation Trust, Norfolk, United Kingdom
| | - Amelia O Clive
- 2 Academic Respiratory Unit, School of Clinical Sciences, Southmead Hospital, University of Bristol, Bristol, United Kingdom
| | | | - Helen E Davies
- 4 Cardiff and Vale University Health Board, Cardiff, United Kingdom
| | | | - Mohamed Al-Aloul
- 6 University Hospital of South Manchester NHS Foundation Trust, Manchester, United Kingdom
| | - Alan Hart-Thomas
- 7 Calderdale and Huddersfield NHS Foundation Trust, Huddersfield, United Kingdom
| | - Justin Pepperell
- 8 Somerset Lung Centre, Musgrove Park Hospital, Taunton, United Kingdom
| | - Matthew Evison
- 6 University Hospital of South Manchester NHS Foundation Trust, Manchester, United Kingdom
| | - Tarek Saba
- 9 Blackpool Teaching Hospitals NHS Foundation Trust, Blackpool, United Kingdom
| | - Richard Neil Harrison
- 10 North Tees and Hartlepool Hospitals NHS Foundation Trust, North Tees, United Kingdom
| | - Anur Guhan
- 11 University Hospital Ayr, Ayr, United Kingdom
| | | | | | - Sunita Rehal
- 3 Medical Research Council Clinical Trials Unit and
| | - John P Corcoran
- 14 Oxford Respiratory Trials Unit and Oxford Pleural Diseases Unit, Churchill Hospital, Oxford, United Kingdom
| | - Robert Hallifax
- 14 Oxford Respiratory Trials Unit and Oxford Pleural Diseases Unit, Churchill Hospital, Oxford, United Kingdom
| | - Ioannis Psallidas
- 14 Oxford Respiratory Trials Unit and Oxford Pleural Diseases Unit, Churchill Hospital, Oxford, United Kingdom
| | - Nicky Russell
- 14 Oxford Respiratory Trials Unit and Oxford Pleural Diseases Unit, Churchill Hospital, Oxford, United Kingdom
| | - Rachel Shaw
- 14 Oxford Respiratory Trials Unit and Oxford Pleural Diseases Unit, Churchill Hospital, Oxford, United Kingdom
| | - Melissa Dobson
- 14 Oxford Respiratory Trials Unit and Oxford Pleural Diseases Unit, Churchill Hospital, Oxford, United Kingdom
| | - John M Wrightson
- 14 Oxford Respiratory Trials Unit and Oxford Pleural Diseases Unit, Churchill Hospital, Oxford, United Kingdom
| | - Alex West
- 15 Guy's and St. Thomas' NHS Foundation Trust, London, United Kingdom
| | - Y C Gary Lee
- 16 School of Medicine and Pharmacology, University of Western Australia, Perth, Australia; and
| | | | - Robert F Miller
- 17 Research Department of Infection and Population Health, Institute of Epidemiology and Healthcare, University College London, London, United Kingdom
| | - Nick A Maskell
- 2 Academic Respiratory Unit, School of Clinical Sciences, Southmead Hospital, University of Bristol, Bristol, United Kingdom
| | - Najib M Rahman
- 14 Oxford Respiratory Trials Unit and Oxford Pleural Diseases Unit, Churchill Hospital, Oxford, United Kingdom.,18 National Institute for Health Research Oxford Biomedical Research Centre, University of Oxford, Oxford, United Kingdom
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11
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Hassan M, Asciak R, Mercer RM, McCracken DJ, Tsikrika S, Shaarawy H, Elganady A, Wrightson JM, Rahman NM. Echogenic Swirling Seen on Ultrasound and Outcome of Pleurodesis in Malignant Pleural Effusion. Arch Bronconeumol 2019; 55:659-661. [PMID: 31204005 DOI: 10.1016/j.arbres.2019.05.010] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/12/2019] [Revised: 05/07/2019] [Accepted: 05/08/2019] [Indexed: 10/26/2022]
Affiliation(s)
- Maged Hassan
- Oxford Pleural Unit, Oxford University Hospitals NHS Foundation Trust, UK; Chest Diseases Department, Faculty of Medicine, Alexandria University, Egypt.
| | - Rachelle Asciak
- Oxford Pleural Unit, Oxford University Hospitals NHS Foundation Trust, UK
| | - Rachel M Mercer
- Oxford Pleural Unit, Oxford University Hospitals NHS Foundation Trust, UK
| | - David J McCracken
- Oxford Pleural Unit, Oxford University Hospitals NHS Foundation Trust, UK
| | - Stamatoula Tsikrika
- Pulmonary Division, Department of Critical Care, Medical School, National and Kapodistrian University of Athens, Evangelismos General Hospital, Athens, Greece
| | - Hany Shaarawy
- Chest Diseases Department, Faculty of Medicine, Alexandria University, Egypt
| | - Anwar Elganady
- Chest Diseases Department, Faculty of Medicine, Alexandria University, Egypt
| | - John M Wrightson
- Oxford Pleural Unit, Oxford University Hospitals NHS Foundation Trust, UK
| | - Najib M Rahman
- Oxford Pleural Unit, Oxford University Hospitals NHS Foundation Trust, UK; Oxford NIHR Biomedical Research Centre, Oxford, UK
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12
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Flight WG, Tang I, Gates A, Snowball J, Wrightson JM, Mackillop L, Chapman SJ. Massive haemoptysis and ventilatory failure in pregnancy. Thorax 2019; 74:818-820. [PMID: 31152092 DOI: 10.1136/thoraxjnl-2019-213292] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/01/2019] [Revised: 04/11/2019] [Accepted: 04/29/2019] [Indexed: 11/03/2022]
Affiliation(s)
- William G Flight
- Oxford Adult Cystic Fibrosis Centre, Oxford University Hospitals NHS Foundation Trust, Oxford, UK
| | - Ivan Tang
- Oxford Adult Cystic Fibrosis Centre, Oxford University Hospitals NHS Foundation Trust, Oxford, UK
| | - Alison Gates
- Oxford Adult Cystic Fibrosis Centre, Oxford University Hospitals NHS Foundation Trust, Oxford, UK
| | - Joanna Snowball
- Oxford Adult Cystic Fibrosis Centre, Oxford University Hospitals NHS Foundation Trust, Oxford, UK
| | - John M Wrightson
- Oxford Centre for Respiratory Medicine, Oxford University Hospitals NHS Foundation Trust, Oxford, UK
| | - Lucy Mackillop
- Women's Centre, Oxford University Hospitals NHS Foundation Trust, Oxford, UK.,University of Oxford, Oxford, UK
| | - Stephen J Chapman
- Oxford Adult Cystic Fibrosis Centre, Oxford University Hospitals NHS Foundation Trust, Oxford, UK.,University of Oxford, Oxford, UK
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13
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Asciak R, Hassan M, Mercer RM, Hallifax RJ, Wrightson JM, Psallidas I, Rahman NM. Prospective Analysis of the Predictive Value of Sonographic Pleural Fluid Echogenicity for the Diagnosis of Exudative Effusion. Respiration 2019; 97:451-456. [PMID: 30889605 DOI: 10.1159/000496153] [Citation(s) in RCA: 17] [Impact Index Per Article: 3.4] [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: 08/03/2018] [Accepted: 12/10/2018] [Indexed: 11/08/2023] Open
Abstract
BACKGROUND Pleural effusion echogenicity on ultrasound has previously been suggested to allow identification of exudates. A case series suggested that homogenously echogenic effusions are always exudates. With modern imaging techniques and more advanced ultrasound technology, this may no longer be true. OBJECTIVES This study aims to prospectively assess the predictive value of echogenicity in the identification of exudates. METHOD Patients undergoing thoracic ultrasound before pleural fluid sampling were analysed prospectively (n = 140). Pleural fluid was classified as an exudate if both fluid total protein (TP) > 29 g/L and fluid lactate dehydrogenase (LDH) > 2/3 upper limit of normal serum LDH (which is 255 IU/L in females and 235 IU/L in males) were present. If only one of these criteria was met, the effusion was considered to have discordant biochemistry. RESULTS Fifty-five (39%) patients had non-echogenic and 85 (61%) had echogenic effusions. Six (7.1%) patients with echogenic effusions had transudates; the median fluid TP for this group was 18.5 g/L (IQR 9.75) and median LDH 63.0 IU/L (IQR 40.3). The specificity of echogenicity identifying exudates from transudates, excluding patients with discordant biochemistry, was 57.1%, positive predictive value (PPV) 90.3%, sensitivity 65.1%, and negative predictive value (NPV) 21.0%. The specificity of echogenicity identifying exudates (including discordant biochemistry) from transudates was 57.1%, PPV 92.9%, sensitivity 62.7%, and NPV 14.5%. CONCLUSIONS Echogenicity of a pleural effusion has a low specificity for identifying an underlying exudate, and the echogenic qualities of the fluid should not influence clinical decision-making.
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Affiliation(s)
- Rachelle Asciak
- Oxford University Hospitals NHS Foundation Trust, Oxford, United Kingdom,
| | - Maged Hassan
- Oxford University Hospitals NHS Foundation Trust, Oxford, United Kingdom
| | - Rachel M Mercer
- Oxford University Hospitals NHS Foundation Trust, Oxford, United Kingdom
| | - Robert J Hallifax
- Oxford University Hospitals NHS Foundation Trust, Oxford, United Kingdom
| | - John M Wrightson
- Oxford University Hospitals NHS Foundation Trust, Oxford, United Kingdom
| | - Ioannis Psallidas
- Oxford University Hospitals NHS Foundation Trust, Oxford, United Kingdom
| | - Najib M Rahman
- Oxford University Hospitals NHS Foundation Trust, Oxford, United Kingdom
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14
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Asciak R, Mercer RM, Hallifax RJ, Hassan M, Bedawi E, McCracken D, Kanellakis NI, Wrightson JM, Psallidas I, Rahman NM. Does attempting talc pleurodesis affect subsequent indwelling pleural catheter (IPC)-related non-draining septated pleural effusion and IPC-related spontaneous pleurodesis? ERJ Open Res 2019; 5:00208-2018. [PMID: 30723732 PMCID: PMC6355992 DOI: 10.1183/23120541.00208-2018] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/06/2018] [Accepted: 11/07/2018] [Indexed: 01/22/2023] Open
Abstract
Prior talc pleurodesis does not result in worsened outcomes from subsequent indwelling pleural catheter use, and patients should not be dissuaded from choosing talc as a primary treatment for recurrent pleural effusion. http://ow.ly/qAAC30mYmr3.
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Affiliation(s)
- Rachelle Asciak
- Pleural Unit, Oxford Centre for Respiratory Medicine, Oxford University Hospitals NHS Trust, Oxford, UK
| | - Rachel M Mercer
- Pleural Unit, Oxford Centre for Respiratory Medicine, Oxford University Hospitals NHS Trust, Oxford, UK
| | - Robert J Hallifax
- Pleural Unit, Oxford Centre for Respiratory Medicine, Oxford University Hospitals NHS Trust, Oxford, UK
| | - Maged Hassan
- Pleural Unit, Oxford Centre for Respiratory Medicine, Oxford University Hospitals NHS Trust, Oxford, UK
| | - Eihab Bedawi
- Pleural Unit, Oxford Centre for Respiratory Medicine, Oxford University Hospitals NHS Trust, Oxford, UK
| | - David McCracken
- Pleural Unit, Oxford Centre for Respiratory Medicine, Oxford University Hospitals NHS Trust, Oxford, UK
| | - Nikolaos I Kanellakis
- Laboratory of Pleural and Lung Cancer Translational Research, Nuffield Dept of Medicine, University of Oxford, Oxford, UK
| | - John M Wrightson
- Pleural Unit, Oxford Centre for Respiratory Medicine, Oxford University Hospitals NHS Trust, Oxford, UK
| | - Ioannis Psallidas
- Pleural Unit, Oxford Centre for Respiratory Medicine, Oxford University Hospitals NHS Trust, Oxford, UK
| | - Najib M Rahman
- Pleural Unit, Oxford Centre for Respiratory Medicine, Oxford University Hospitals NHS Trust, Oxford, UK
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Asciak R, Hallifax RJ, Mercer RM, Hassan M, Wigston C, Wrightson JM, Psallidas I, Rahman NM. The Hospital and Patient Burden of Indwelling Pleural Catheters: A Retrospective Case Series of 210 Indwelling Pleural Catheter Insertions. Respiration 2018; 97:70-77. [PMID: 30227409 DOI: 10.1159/000491934] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/03/2018] [Accepted: 07/06/2018] [Indexed: 11/19/2022] Open
Abstract
BACKGROUND Indwelling pleural catheters (IPC) offer an alternative to talc pleurodesis in recurrent effusion, especially in patients wishing to avoid hospitalization. Two randomized trials have demonstrated reduced time in hospital using IPCs versus talc pleurodesis in malignant pleural effusion (MPE). However, the impact of IPCs on hospital services and patients has not been well studied. OBJECTIVES To analyze long-term outcomes of IPCs and understand the hospital burden in terms of requirement for hospital visits and contacts with healthcare, while the IPC was in situ. METHODS IPC insertions in a tertiary pleural center were analyzed retrospectively. Reviews of patients with IPCs in situ considered "additional" to routine clinical follow-up were defined pre-hoc. RESULTS A total of 202 cases were analyzed: 89.6% MPE group (n = 181) and 10.4% non-MPE group (n = 21). There were a median 3.0 (interquartile range [IQR] 3) and 2.0 (IQR 2) ipsilateral pleural procedures prior to each IPC insertion in non-MPE and MPE groups, respectively (p = 0.26), and a mean 1.3 (SD 1.7) planned IPC-related outpatient follow-up visits per patient. There were 2 (9.5%) and 14 (7.7%) IPC-related infections in non-MPE and MPE groups, respectively. Four (19.0%) and 44 (24.3%) patients required additional IPC-related reviews in non-MPE and MPE groups, respectively (p = 0.6), and these occurred within 250 days post IPC insertion. CONCLUSIONS Although IPCs decrease initial length of hospital stay compared to talc pleurodesis via chest drain, IPCs are associated with significant hospital-visit burden, in addition to planned visits and regular home IPC drainages. IPC-using services need to be prepared for this additional work to run an IPC service effectively.
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16
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Asciak R, Hallifax RJ, Mercer RM, Hassan M, Bradley C, Corcoran JP, Wrightson JM, Psallidas I, Rahman NM. Activity and Outcomes From a Dedicated Pleural On-Call Service. Chest 2018; 154:717-718. [PMID: 30195353 DOI: 10.1016/j.chest.2018.05.027] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/04/2018] [Revised: 05/07/2018] [Accepted: 05/08/2018] [Indexed: 10/28/2022] Open
Affiliation(s)
- Rachelle Asciak
- Oxford University Hospitals NHS Foundation Trust, Oxford, England.
| | | | - Rachel M Mercer
- Oxford University Hospitals NHS Foundation Trust, Oxford, England
| | - Maged Hassan
- Oxford University Hospitals NHS Foundation Trust, Oxford, England
| | - Clare Bradley
- Oxford University Hospitals NHS Foundation Trust, Oxford, England
| | - John P Corcoran
- Oxford University Hospitals NHS Foundation Trust, Oxford, England
| | - John M Wrightson
- Oxford University Hospitals NHS Foundation Trust, Oxford, England
| | | | - Najib M Rahman
- Oxford University Hospitals NHS Foundation Trust, Oxford, England
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17
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Ahmed M, Wrightson JM. Malignant Pleural Effusions—Personalised Management. Curr Geri Rep 2018. [DOI: 10.1007/s13670-018-0246-0] [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: 10/28/2022]
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Hallifax RJ, Talwar A, Wrightson JM, Edey A, Gleeson FV. State-of-the-art: Radiological investigation of pleural disease. Respir Med 2017; 124:88-99. [PMID: 28233652 DOI: 10.1016/j.rmed.2017.02.013] [Citation(s) in RCA: 54] [Impact Index Per Article: 7.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/02/2016] [Revised: 01/12/2017] [Accepted: 02/13/2017] [Indexed: 12/17/2022]
Abstract
Pleural disease is common. Radiological investigation of pleural effusion, thickening, masses, and pneumothorax is key in diagnosing and determining management. Conventional chest radiograph (CXR) remains as the initial investigation of choice for patients with suspected pleural disease. When abnormalities are detected, thoracic ultrasound (US), computed tomography (CT), magnetic resonance imaging (MRI) and positron emission tomography (PET) can each play important roles in further investigation, but appropriate modality selection is critical. US adds significant value in the identification of pleural fluid and pleural nodularity, guiding pleural procedures and, increasingly, as "point of care" assessment for pneumothorax, but is highly operator dependent. CT scan is the modality of choice for further assessment of pleural disease: Characterising pleural thickening, some pleural effusions and demonstration of homogeneity of pleural masses and areas of fatty attenuation or calcification. MRI has specific utility for soft tissue abnormalities and may have a role for younger patients requiring follow-up serial imaging. MRI and PET/CT may provide additional information in malignant pleural disease regarding prognosis and response to therapy. This article summarises existing techniques, highlighting the benefits and applications of these different imaging modalities and provides an up to date review of the evidence.
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Affiliation(s)
- R J Hallifax
- Oxford Centre for Respiratory Medicine, Oxford University Hospitals NHS Foundation Trust, Churchill Hospital, Old Road, Oxford, UK.
| | - A Talwar
- Oxford Centre for Respiratory Medicine, Oxford University Hospitals NHS Foundation Trust, Churchill Hospital, Old Road, Oxford, UK
| | - J M Wrightson
- Oxford Centre for Respiratory Medicine, Oxford University Hospitals NHS Foundation Trust, Churchill Hospital, Old Road, Oxford, UK
| | - A Edey
- Department of Radiology, North Bristol NHS Trust, Bristol, UK
| | - F V Gleeson
- Department of Radiology, Churchill Hospital, Old Road, Oxford, UK
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19
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Ratnakumar R, Corcoran JP, Talwar A, Hallifax RJ, Psallidas I, Wrightson JM, Gleeson FV, Rahman NM. P50 Changing use of CT pulmonary angiography in a uk tertiary hospital over a 6-year period. Thorax 2016. [DOI: 10.1136/thoraxjnl-2016-209333.193] [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: 11/03/2022]
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20
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Corcoran JP, Talwar A, Hallifax RJ, Psallidas I, Wrightson JM, Rahman NM. P2 Incorporation of an in-depth thoracic ultrasound assessment into routine pre-procedural evaluation of patients with pleural effusions. Thorax 2016. [DOI: 10.1136/thoraxjnl-2016-209333.145] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/04/2022]
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21
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Corcoran JP, Wrightson JM, Moore AJ, Gleeson FV, Sykes A. Large airways nodularity secondary to tracheobronchopathia osteochondroplastica. Thorax 2016; 72:288-289. [PMID: 27682329 DOI: 10.1136/thoraxjnl-2016-209164] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/11/2016] [Revised: 08/22/2016] [Accepted: 09/02/2016] [Indexed: 11/04/2022]
Affiliation(s)
- John P Corcoran
- Oxford Centre for Respiratory Medicine, Oxford University Hospitals NHS Foundation Trust, Oxford, UK.,University of Oxford Respiratory Trials Unit, Churchill Hospital, Oxford, UK
| | - John M Wrightson
- Oxford Centre for Respiratory Medicine, Oxford University Hospitals NHS Foundation Trust, Oxford, UK
| | - Alastair J Moore
- Oxford Centre for Respiratory Medicine, Oxford University Hospitals NHS Foundation Trust, Oxford, UK
| | - Fergus V Gleeson
- Department of Radiology, Oxford University Hospitals NHS Foundation Trust, Oxford, UK.,NIHR Oxford Biomedical Research Centre, University of Oxford, Oxford, UK
| | - Annemarie Sykes
- Oxford Centre for Respiratory Medicine, Oxford University Hospitals NHS Foundation Trust, Oxford, UK
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Corcoran JP, Wrightson JM, Belcher E, DeCamp MM, Feller-Kopman D, Rahman NM. Pleural infection: past, present, and future directions. Lancet Respir Med 2016; 3:563-77. [PMID: 26170076 DOI: 10.1016/s2213-2600(15)00185-x] [Citation(s) in RCA: 53] [Impact Index Per Article: 6.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Received: 02/10/2015] [Revised: 04/13/2015] [Accepted: 05/05/2015] [Indexed: 02/09/2023]
Abstract
Pleural space infections are increasing in incidence and continue to have high associated morbidity, mortality, and need for invasive treatments such as thoracic surgery. The mechanisms of progression from a non-infected, pneumonia-related effusion to a confirmed pleural infection have been well described in the scientific literature, but the route by which pathogenic organisms access the pleural space is poorly understood. Data suggests that not all pleural infections can be related to lung parenchymal infection. Studies examining the microbiological profile of pleural infection inform antibiotic choice and can help to delineate the source and pathogenesis of infection. The development of radiological methods and use of clinical indices to predict which patients with pleural infection will have a poor outcome, as well as inform patient selection for more invasive treatments, is particularly important. Randomised clinical trial and case series data have shown that the combination of an intrapleural tissue plasminogen activator and deoxyribonuclease therapy can potentially improve outcomes, but the use of this treatment as compared with surgical options has not been precisely defined, particularly in terms of when and in which patients it should be used.
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Affiliation(s)
- John P Corcoran
- Oxford Centre for Respiratory Medicine, Oxford University Hospitals NHS Trust, Oxford, UK; University of Oxford Respiratory Trials Unit, Churchill Hospital, Oxford, UK
| | - John M Wrightson
- Oxford Centre for Respiratory Medicine, Oxford University Hospitals NHS Trust, Oxford, UK; University of Oxford Respiratory Trials Unit, Churchill Hospital, Oxford, UK; NIHR Oxford Biomedical Research Centre, University of Oxford, Oxford, UK
| | - Elizabeth Belcher
- Department of Cardiothoracic Surgery, Oxford University Hospitals NHS Trust, Oxford, UK
| | - Malcolm M DeCamp
- Division of Thoracic Surgery, Northwestern Memorial Hospital, Northwestern University Feinberg School of Medicine, Chicago, IL, USA
| | - David Feller-Kopman
- Division of Pulmonary and Critical Care Medicine, Johns Hopkins Hospital, Baltimore, MD, USA
| | - Najib M Rahman
- Oxford Centre for Respiratory Medicine, Oxford University Hospitals NHS Trust, Oxford, UK; University of Oxford Respiratory Trials Unit, Churchill Hospital, Oxford, UK; NIHR Oxford Biomedical Research Centre, University of Oxford, Oxford, UK.
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Quan TP, Fawcett NJ, Wrightson JM, Finney J, Wyllie D, Jeffery K, Jones N, Shine B, Clarke L, Crook D, Walker AS, Peto TEA. Increasing burden of community-acquired pneumonia leading to hospitalisation, 1998-2014. Thorax 2016; 71:535-42. [PMID: 26888780 PMCID: PMC4893127 DOI: 10.1136/thoraxjnl-2015-207688] [Citation(s) in RCA: 70] [Impact Index Per Article: 8.8] [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] [Received: 08/11/2015] [Accepted: 12/23/2015] [Indexed: 11/03/2022]
Abstract
BACKGROUND Community-acquired pneumonia (CAP) is a major cause of mortality and morbidity in many countries but few recent large-scale studies have examined trends in its incidence. METHODS Incidence of CAP leading to hospitalisation in one UK region (Oxfordshire) was calculated over calendar time using routinely collected diagnostic codes, and modelled using piecewise-linear Poisson regression. Further models considered other related diagnoses, typical administrative outcomes, and blood and microbiology test results at admission to determine whether CAP trends could be explained by changes in case-mix, coding practices or admission procedures. RESULTS CAP increased by 4.2%/year (95% CI 3.6 to 4.8) from 1998 to 2008, and subsequently much faster at 8.8%/year (95% CI 7.8 to 9.7) from 2009 to 2014. Pneumonia-related conditions also increased significantly over this period. Length of stay and 30-day mortality decreased slightly in later years, but the proportions with abnormal neutrophils, urea and C reactive protein (CRP) did not change (p>0.2). The proportion with severely abnormal CRP (>100 mg/L) decreased slightly in later years. Trends were similar in all age groups. Streptococcus pneumoniae was the most common causative organism found; however other organisms, particularly Enterobacteriaceae, increased in incidence over the study period (p<0.001). CONCLUSIONS Hospitalisations for CAP have been increasing rapidly in Oxfordshire, particularly since 2008. There is little evidence that this is due only to changes in pneumonia coding, an ageing population or patients with substantially less severe disease being admitted more frequently. Healthcare planning to address potential further increases in admissions and consequent antibiotic prescribing should be a priority.
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Affiliation(s)
- T Phuong Quan
- NIHR Oxford Biomedical Research Centre, Oxford, UK Nuffield Department of Medicine, University of Oxford, Oxford, UK
| | - Nicola J Fawcett
- NIHR Oxford Biomedical Research Centre, Oxford, UK Nuffield Department of Medicine, University of Oxford, Oxford, UK
| | - John M Wrightson
- NIHR Oxford Biomedical Research Centre, Oxford, UK Oxford University Hospitals NHS Foundation Trust, Oxford, UK
| | - John Finney
- NIHR Oxford Biomedical Research Centre, Oxford, UK Nuffield Department of Medicine, University of Oxford, Oxford, UK
| | - David Wyllie
- NIHR Oxford Biomedical Research Centre, Oxford, UK Nuffield Department of Medicine, University of Oxford, Oxford, UK
| | - Katie Jeffery
- Oxford University Hospitals NHS Foundation Trust, Oxford, UK
| | - Nicola Jones
- Oxford University Hospitals NHS Foundation Trust, Oxford, UK
| | - Brian Shine
- Oxford University Hospitals NHS Foundation Trust, Oxford, UK
| | - Lorraine Clarke
- Oxford University Hospitals NHS Foundation Trust, Oxford, UK
| | - Derrick Crook
- NIHR Oxford Biomedical Research Centre, Oxford, UK Nuffield Department of Medicine, University of Oxford, Oxford, UK Oxford University Hospitals NHS Foundation Trust, Oxford, UK
| | - A Sarah Walker
- NIHR Oxford Biomedical Research Centre, Oxford, UK Nuffield Department of Medicine, University of Oxford, Oxford, UK
| | - Timothy E A Peto
- NIHR Oxford Biomedical Research Centre, Oxford, UK Nuffield Department of Medicine, University of Oxford, Oxford, UK Oxford University Hospitals NHS Foundation Trust, Oxford, UK
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Rahman NM, Pepperell J, Rehal S, Saba T, Tang A, Ali N, West A, Hettiarachchi G, Mukherjee D, Samuel J, Bentley A, Dowson L, Miles J, Ryan CF, Yoneda KY, Chauhan A, Corcoran JP, Psallidas I, Wrightson JM, Hallifax R, Davies HE, Lee YCG, Dobson M, Hedley EL, Seaton D, Russell N, Chapman M, McFadyen BM, Shaw RA, Davies RJO, Maskell NA, Nunn AJ, Miller RF. Effect of Opioids vs NSAIDs and Larger vs Smaller Chest Tube Size on Pain Control and Pleurodesis Efficacy Among Patients With Malignant Pleural Effusion: The TIME1 Randomized Clinical Trial. JAMA 2015; 314:2641-53. [PMID: 26720026 DOI: 10.1001/jama.2015.16840] [Citation(s) in RCA: 115] [Impact Index Per Article: 12.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/14/2022]
Abstract
IMPORTANCE For treatment of malignant pleural effusion, nonsteroidal anti-inflammatory drugs (NSAIDs) are avoided because they may reduce pleurodesis efficacy. Smaller chest tubes may be less painful than larger tubes, but efficacy in pleurodesis has not been proven. OBJECTIVE To assess the effect of chest tube size and analgesia (NSAIDs vs opiates) on pain and clinical efficacy related to pleurodesis in patients with malignant pleural effusion. DESIGN, SETTING, AND PARTICIPANTS A 2×2 factorial phase 3 randomized clinical trial among 320 patients requiring pleurodesis in 16 UK hospitals from 2007 to 2013. INTERVENTIONS Patients undergoing thoracoscopy (n = 206; clinical decision if biopsy was required) received a 24F chest tube and were randomized to receive opiates (n = 103) vs NSAIDs (n = 103), and those not undergoing thoracoscopy (n = 114) were randomized to 1 of 4 groups (24F chest tube and opioids [n = 28]; 24F chest tube and NSAIDs [n = 29]; 12F chest tube and opioids [n = 29]; or 12F chest tube and NSAIDs [n = 28]). MAIN OUTCOMES AND MEASURES Pain while chest tube was in place (0- to 100-mm visual analog scale [VAS] 4 times/d; superiority comparison) and pleurodesis efficacy at 3 months (failure defined as need for further pleural intervention; noninferiority comparison; margin, 15%). RESULTS Pain scores in the opiate group (n = 150) vs the NSAID group (n = 144) were not significantly different (mean VAS score, 23.8 mm vs 22.1 mm; adjusted difference, -1.5 mm; 95% CI, -5.0 to 2.0 mm; P = .40), but the NSAID group required more rescue analgesia (26.3% vs 38.1%; rate ratio, 2.1; 95% CI, 1.3-3.4; P = .003). Pleurodesis failure occurred in 30 patients (20%) in the opiate group and 33 (23%) in the NSAID group, meeting criteria for noninferiority (difference, -3%; 1-sided 95% CI, -10% to ∞; P = .004 for noninferiority). Pain scores were lower among patients in the 12F chest tube group (n = 54) vs the 24F group (n = 56) (mean VAS score, 22.0 mm vs 26.8 mm; adjusted difference, -6.0 mm; 95% CI, -11.7 to -0.2 mm; P = .04) and 12F chest tubes vs 24F chest tubes were associated with higher pleurodesis failure (30% vs 24%), failing to meet noninferiority criteria (difference, -6%; 1-sided 95% CI, -20% to ∞; P = .14 for noninferiority). Complications during chest tube insertion occurred more commonly with 12F tubes (14% vs 24%; odds ratio, 1.91; P = .20). CONCLUSIONS AND RELEVANCE Use of NSAIDs vs opiates resulted in no significant difference in pain scores but was associated with more rescue medication. NSAID use resulted in noninferior rates of pleurodesis efficacy at 3 months. Placement of 12F chest tubes vs 24F chest tubes was associated with a statistically significant but clinically modest reduction in pain but failed to meet noninferiority criteria for pleurodesis efficacy. TRIAL REGISTRATION isrctn.org Identifier: ISRCTN33288337.
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Affiliation(s)
- Najib M Rahman
- Oxford Respiratory Trials Unit and Oxford Pleural Diseases Unit, Churchill Hospital, Oxford, England2National Institute for Health Research Oxford Biomedical Research Centre, University of Oxford, Oxford, England
| | | | - Sunita Rehal
- Medical Research Council Clinical Trials Unit at University College London, London, England
| | - Tarek Saba
- Blackpool Teaching Hospitals NHS Foundation Trust, Blackpool, England
| | - Augustine Tang
- Blackpool Teaching Hospitals NHS Foundation Trust, Blackpool, England
| | - Nabeel Ali
- King's Mill Hospital, Mansfield, England
| | - Alex West
- Medway Maritime Hospital, Gillingham, England
| | | | | | | | - Andrew Bentley
- University Hospital of South Manchester NHS Foundation Trust, Manchester, England
| | - Lee Dowson
- Royal Wolverhampton Hospital NHS Trust, Wolverhampton, England
| | | | - C Frank Ryan
- Vancouver Coastal Health, Vancouver, British Columbia, Canada
| | - Ken Y Yoneda
- University of California, Davis, Medical Center, Sacramento
| | | | - John P Corcoran
- Oxford Respiratory Trials Unit and Oxford Pleural Diseases Unit, Churchill Hospital, Oxford, England
| | - Ioannis Psallidas
- Oxford Respiratory Trials Unit and Oxford Pleural Diseases Unit, Churchill Hospital, Oxford, England
| | - John M Wrightson
- Oxford Respiratory Trials Unit and Oxford Pleural Diseases Unit, Churchill Hospital, Oxford, England2National Institute for Health Research Oxford Biomedical Research Centre, University of Oxford, Oxford, England
| | - Rob Hallifax
- Oxford Respiratory Trials Unit and Oxford Pleural Diseases Unit, Churchill Hospital, Oxford, England
| | - Helen E Davies
- Cardiff and Vale University Health Board, Cardiff, Wales
| | - Y C Gary Lee
- School of Medicine and Centre for Asthma, Allergy, and Respiratory Research, University of Western Australia, Crawley, Australia
| | - Melissa Dobson
- Oxford Respiratory Trials Unit and Oxford Pleural Diseases Unit, Churchill Hospital, Oxford, England
| | - Emma L Hedley
- Oxford Respiratory Trials Unit and Oxford Pleural Diseases Unit, Churchill Hospital, Oxford, England
| | - Douglas Seaton
- Department of Respiratory Medicine, Ipswich Hospital, Ipswich, England
| | - Nicky Russell
- Oxford Respiratory Trials Unit and Oxford Pleural Diseases Unit, Churchill Hospital, Oxford, England
| | - Margaret Chapman
- Oxford Respiratory Trials Unit and Oxford Pleural Diseases Unit, Churchill Hospital, Oxford, England
| | - Bethan M McFadyen
- Oxford Respiratory Trials Unit and Oxford Pleural Diseases Unit, Churchill Hospital, Oxford, England
| | - Rachel A Shaw
- Oxford Respiratory Trials Unit and Oxford Pleural Diseases Unit, Churchill Hospital, Oxford, England
| | - Robert J O Davies
- Oxford Respiratory Trials Unit and Oxford Pleural Diseases Unit, Churchill Hospital, Oxford, England
| | - Nick A Maskell
- Academic Respiratory Unit, Department of Clinical Sciences, Southmead Hospital, University of Bristol, Bristol, England
| | - Andrew J Nunn
- Medical Research Council Clinical Trials Unit at University College London, London, England
| | - Robert F Miller
- Research Department of Infection and Population Health, Institute of Epidemiology and Healthcare, University College London, London, England
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Rahman NM, Pepperell J, Rehal S, Saba T, Tang A, Ali N, West A, Hettiarachchi G, Mukherjee D, Samuel J, Bentley A, Dowson L, Miles J, Ryan F, Yoneda K, Chauhan A, Corcoran J, Psallidas I, Wrightson JM, Hallifax R, Davies HE, Lee YCG, Hedley EL, Seaton D, Russell N, Chapman M, McFadyen BM, Shaw RA, Davies RJO, Maskell NA, Nunn AJ, Miller RF. S20 Primary Result of the 1st Therapeutic Interventions in Malignant Effusion (TIME1) Trial: A 2 × 2 factorial, randomised trial of chest tube size and analgesic strategy for pleurodesis in malignant pleural effusion. Thorax 2015. [DOI: 10.1136/thoraxjnl-2015-207770.26] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/04/2022]
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Wrightson JM, Wray JA, Street TL, Chapman SJ, Gleeson FV, Maskell NA, Peto TEA, Rahman NM, Crook DWM. Absence of Atypical Pathogens in Pleural Infection. Chest 2015; 148:e102-e103. [PMID: 26324137 DOI: 10.1378/chest.15-1130] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/01/2022] Open
Affiliation(s)
- John M Wrightson
- Oxford Pleural Unit, Churchill Hospital, Oxford, England; NIHR Oxford Biomedical Research Centre, University of Oxford, Oxford, England; Department of Microbiology and Infectious Diseases, John Radcliffe Hospital, Oxford, England.
| | - Jessica A Wray
- NIHR Oxford Biomedical Research Centre, University of Oxford, Oxford, England
| | - Teresa L Street
- NIHR Oxford Biomedical Research Centre, University of Oxford, Oxford, England
| | - Stephen J Chapman
- Oxford Pleural Unit, Churchill Hospital, Oxford, England; NIHR Oxford Biomedical Research Centre, University of Oxford, Oxford, England
| | - Fergus V Gleeson
- Oxford Pleural Unit, Churchill Hospital, Oxford, England; Oxford Centre for Respiratory Medicine, Department of Thoracic Radiology, Oxford, England; NIHR Oxford Biomedical Research Centre, University of Oxford, Oxford, England
| | - Nicholas A Maskell
- North Bristol Lung Centre, Southmead Hospital, Bristol, England; Academic Respiratory Unit, Department of Clinical Sciences, Bristol University, Bristol, England
| | - Timothy E A Peto
- NIHR Oxford Biomedical Research Centre, University of Oxford, Oxford, England; Department of Microbiology and Infectious Diseases, John Radcliffe Hospital, Oxford, England
| | - Najib M Rahman
- Oxford Pleural Unit, Churchill Hospital, Oxford, England; Oxford Respiratory Trials Unit, Churchill Hospital, Oxford, England; NIHR Oxford Biomedical Research Centre, University of Oxford, Oxford, England
| | - Derrick W M Crook
- NIHR Oxford Biomedical Research Centre, University of Oxford, Oxford, England; Department of Microbiology and Infectious Diseases, John Radcliffe Hospital, Oxford, England
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Corcoran JP, Acton L, Ahmed A, Hallifax RJ, Psallidas I, Wrightson JM, Rahman NM, Gleeson FV. Diagnostic value of radiological imaging pre‐ and post‐drainage of pleural effusions. Respirology 2015; 21:392-5. [DOI: 10.1111/resp.12675] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/21/2015] [Revised: 08/07/2015] [Accepted: 08/19/2015] [Indexed: 11/30/2022]
Affiliation(s)
- John P. Corcoran
- Oxford Centre for Respiratory MedicineOxford University Hospitals NHS Trust Oxford UK
- University of Oxford Respiratory Trials UnitChurchill Hospital Oxford UK
| | - Louise Acton
- Department of RadiologyOxford University Hospitals NHS Trust Oxford UK
| | - Asia Ahmed
- Department of RadiologyOxford University Hospitals NHS Trust Oxford UK
| | - Robert J. Hallifax
- Oxford Centre for Respiratory MedicineOxford University Hospitals NHS Trust Oxford UK
- University of Oxford Respiratory Trials UnitChurchill Hospital Oxford UK
| | - Ioannis Psallidas
- Oxford Centre for Respiratory MedicineOxford University Hospitals NHS Trust Oxford UK
- University of Oxford Respiratory Trials UnitChurchill Hospital Oxford UK
| | - John M. Wrightson
- Oxford Centre for Respiratory MedicineOxford University Hospitals NHS Trust Oxford UK
- University of Oxford Respiratory Trials UnitChurchill Hospital Oxford UK
- NIHR Oxford Biomedical Research CentreUniversity of Oxford Oxford UK
| | - Najib M. Rahman
- Oxford Centre for Respiratory MedicineOxford University Hospitals NHS Trust Oxford UK
- University of Oxford Respiratory Trials UnitChurchill Hospital Oxford UK
- NIHR Oxford Biomedical Research CentreUniversity of Oxford Oxford UK
| | - Fergus V. Gleeson
- Department of RadiologyOxford University Hospitals NHS Trust Oxford UK
- NIHR Oxford Biomedical Research CentreUniversity of Oxford Oxford UK
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Corcoran JP, Psallidas I, Wrightson JM, Hallifax RJ, Rahman NM. Pleural procedural complications: prevention and management. J Thorac Dis 2015; 7:1058-67. [PMID: 26150919 PMCID: PMC4466427 DOI: 10.3978/j.issn.2072-1439.2015.04.42] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Key Words] [Grants] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/10/2015] [Accepted: 04/08/2015] [Indexed: 12/11/2022]
Abstract
Pleural disease is common with a rising case frequency. Many of these patients will be symptomatic and require diagnostic and/or therapeutic procedures. Patients with pleural disease present to a number of different medical specialties, and an equally broad range of clinicians are therefore required to have practical knowledge of these procedures. There is often underestimation of the morbidity and mortality associated with pleural interventions, even those regarded as being relatively straightforward, with potentially significant implications for processes relating to patient safety and informed consent. The advent of thoracic ultrasound (TUS) has had a major influence on patient safety and the number of physicians with the necessary skill set to perform pleural procedures. As the variety and complexity of pleural interventions increases, there is increasing recognition that early specialist input can reduce the risk of complications and number of procedures a patient requires. This review looks at the means by which complications of pleural procedures arise, along with how they can be managed or ideally prevented.
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Du Rand IA, Blaikley J, Booton R, Chaudhuri N, Gupta V, Khalid S, Mandal S, Martin J, Mills J, Navani N, Rahman NM, Wrightson JM, Munavvar M. Summary of the British Thoracic Society guideline for diagnostic flexible bronchoscopy in adults. Thorax 2013; 68:786-7. [PMID: 23842821 DOI: 10.1136/thoraxjnl-2013-203629] [Citation(s) in RCA: 40] [Impact Index Per Article: 3.6] [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: 11/04/2022]
Abstract
Flexible bronchoscopy is an essential, established and expanding tool in respiratory medicine. Its practice, however, needs to be safe, effective and for the right indications to maximise clinical utility. This guideline is based on the best available evidence and is a revised update of the British Thoracic Society guideline on diagnostic flexible bronchoscopy.
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Affiliation(s)
- I A Du Rand
- Worcestershire Royal Hospital, Worcestershire Acute Hospitals NHS Trust, Worcester, UK.
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Du Rand IA, Blaikley J, Booton R, Chaudhuri N, Gupta V, Khalid S, Mandal S, Martin J, Mills J, Navani N, Rahman NM, Wrightson JM, Munavvar M. British Thoracic Society guideline for diagnostic flexible bronchoscopy in adults: accredited by NICE. Thorax 2013; 68 Suppl 1:i1-i44. [PMID: 23860341 DOI: 10.1136/thoraxjnl-2013-203618] [Citation(s) in RCA: 489] [Impact Index Per Article: 44.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/16/2022]
Affiliation(s)
- I A Du Rand
- Worcestershire Royal Hospital, Worcestershire Acute Hospitals NHS Trust, Worcester, UK.
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Wrightson JM, Bateman KM, Hooper C, Gleeson FV, Rahman NM, Maskell NA. Development and efficacy of a 1-d thoracic ultrasound training course. Chest 2013; 142:1359-1361. [PMID: 23131959 DOI: 10.1378/chest.12-1797] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/01/2022] Open
Affiliation(s)
- John M Wrightson
- Oxford Pleural Unit, Oxford Centre for Respiratory Medicine, Churchill Hospital, Oxford, England; National Institute for Health Research Biomedical Research Centre, Oxford, University of Oxford, Oxford, England.
| | - Kathryn M Bateman
- Department of Respiratory Medicine, University Hospitals Bristol National Health Service Foundation Trust, Bristol, England
| | - Clare Hooper
- Department of Respiratory Medicine, Worcestershire Royal Hospital, Worcestershire, England
| | - Fergus V Gleeson
- Oxford Pleural Unit, Oxford Centre for Respiratory Medicine, Churchill Hospital, Oxford, England; National Institute for Health Research Biomedical Research Centre, Oxford, University of Oxford, Oxford, England; Department of Thoracic Radiology, Churchill Hospital, Bristol, England
| | - Najib M Rahman
- Oxford Pleural Unit, Oxford Centre for Respiratory Medicine, Churchill Hospital, Oxford, England; National Institute for Health Research Biomedical Research Centre, Oxford, University of Oxford, Oxford, England
| | - Nicholas A Maskell
- Academic Respiratory Unit, Department of Clinical Sciences, University of Bristol, Bristol, England; North Bristol National Health Service Trust Lung Centre, Southmead Hospital, University of Bristol, Bristol, England
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Hallifax RJ, Nagendran M, Maruthappu M, Manuel A, Wrightson JM, Maskell NA, Davies HE, Rahman NM. P124 Effusion Size on the Chest Radiograph at Day 7 Post-Pleural Drainage is a Good Predictor of Size at 3 Months, Regardless of Initial Intrapleural Therapy. Thorax 2012. [DOI: 10.1136/thoraxjnl-2012-202678.407] [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: 11/03/2022]
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Corcoran JP, Lockey JW, Zheng SL, Wrightson JM, Rahman NM. S13 The bacteriology and epidemiology of pleural infection – a review of the literature and its relevance to clinical practise. Thorax 2012. [DOI: 10.1136/thoraxjnl-2012-202678.019] [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: 11/04/2022]
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Fysh ET, Wrightson JM, Lee YG, Rahman NM. Complications of Removal of Indwelling Pleural Catheters: Response. Chest 2012. [DOI: 10.1378/chest.12-1357] [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: 11/01/2022] Open
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Davies HE, Mishra EK, Kahan BC, Wrightson JM, Stanton AE, Guhan A, Davies CWH, Grayez J, Harrison R, Prasad A, Crosthwaite N, Lee YCG, Davies RJO, Miller RF, Rahman NM. Effect of an indwelling pleural catheter vs chest tube and talc pleurodesis for relieving dyspnea in patients with malignant pleural effusion: the TIME2 randomized controlled trial. JAMA 2012; 307:2383-9. [PMID: 22610520 DOI: 10.1001/jama.2012.5535] [Citation(s) in RCA: 392] [Impact Index Per Article: 32.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/27/2023]
Abstract
CONTEXT Malignant pleural effusion causes disabling dyspnea in patients with a short life expectancy. Palliation is achieved by fluid drainage, but the most effective first-line method has not been determined. OBJECTIVE To determine whether indwelling pleural catheters (IPCs) are more effective than chest tube and talc slurry pleurodesis (talc) at relieving dyspnea. DESIGN Unblinded randomized controlled trial (Second Therapeutic Intervention in Malignant Effusion Trial [TIME2]) comparing IPC and talc (1:1) for which 106 patients with malignant pleural effusion who had not previously undergone pleurodesis were recruited from 143 patients who were treated at 7 UK hospitals. Patients were screened from April 2007-February 2011 and were followed up for a year. INTERVENTION Indwelling pleural catheters were inserted on an outpatient basis, followed by initial large volume drainage, education, and subsequent home drainage. The talc group were admitted for chest tube insertion and talc for slurry pleurodesis. MAIN OUTCOME MEASURE Patients completed daily 100-mm line visual analog scale (VAS) of dyspnea over 42 days after undergoing the intervention (0 mm represents no dyspnea and 100 mm represents maximum dyspnea; 10 mm represents minimum clinically significant difference). Mean difference was analyzed using a mixed-effects linear regression model adjusted for minimization variables. RESULTS Dyspnea improved in both groups, with no significant difference in the first 42 days with a mean VAS dyspnea score of 24.7 in the IPC group (95% CI, 19.3-30.1 mm) and 24.4 mm (95% CI, 19.4-29.4 mm) in the talc group, with a difference of 0.16 mm (95% CI, −6.82 to 7.15; P = .96). There was a statistically significant improvement in dyspnea in the IPC group at 6 months, with a mean difference in VAS score between the IPC group and the talc group of −14.0 mm (95% CI, −25.2 to −2.8 mm; P = .01). Length of initial hospitalization was significantly shorter in the IPC group with a median of 0 days (interquartile range [IQR], 0-1 day) and 4 days (IQR, 2-6 days) for the talc group, with a difference of −3.5 days (95% CI, −4.8 to −1.5 days; P < .001). There was no significant difference in quality of life. Twelve patients (22%) in the talc group required further pleural procedures compared with 3 (6%) in the IPC group (odds ratio [OR], 0.21; 95% CI, 0.04-0.86; P = .03). Twenty-one of the 52 patients in the catheter group experienced adverse events vs 7 of 54 in the talc group (OR, 4.70; 95% CI, 1.75-12.60; P = .002). CONCLUSION Among patients with malignant pleural effusion and no previous pleurodesis, there was no significant difference between IPCs and talc pleurodesis at relieving patient-reported dyspnea. TRIAL REGISTRATION isrctn.org Identifier: ISRCTN87514420.
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Affiliation(s)
- Helen E Davies
- Department of Respiratory Medicine, University Hospital of Wales, Cardiff, Wales
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Abstract
Indwelling pleural catheters (IPCs) are increasingly used in the management of malignant pleural effusions. IPCs are designed to be secured in situ indefinitely; however, in selected patients, IPCs can be removed when drainage ceases. This case series reports complications of removal of IPCs that resulted in fractured catheters or necessitated deliberate severing of the catheters. From the combined data of two pleural centers, 61 of 170 IPCs inserted (35.9%) were removed. In six cases (9.8%), the removals were complicated, leading to fracture or iatrogenic severing of the IPC. Although four patients had catheter fragments retained within the pleural space, none developed any complications (eg, pain or infection) (median follow-up, 459 days; range, 113-1,119 days), despite two patients undergoing subsequent chemotherapy. Clinicians should be aware that IPC removal can be problematic, but retained fragments are safe, and aggressive retrieval is unnecessary.
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Affiliation(s)
- Edward T H Fysh
- Centre for Asthma, Allergy, and Respiratory Research, School of Medicine and Pharmacology, University of Western Australia, Australia; Department of Respiratory Medicine, Sir Charles Gairdner Hospital, Perth, WA, Australia
| | - John M Wrightson
- Oxford Centre for Respiratory Medicine, Churchill Hospital, University of Oxford, Oxford, England; Oxford NIHR Biomedical Research Centre, University of Oxford, Oxford, England
| | - Y C Gary Lee
- Centre for Asthma, Allergy, and Respiratory Research, School of Medicine and Pharmacology, University of Western Australia, Australia; Department of Respiratory Medicine, Sir Charles Gairdner Hospital, Perth, WA, Australia.
| | - Najib M Rahman
- Oxford Centre for Respiratory Medicine, Churchill Hospital, University of Oxford, Oxford, England; Oxford NIHR Biomedical Research Centre, University of Oxford, Oxford, England
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Affiliation(s)
- John M Wrightson
- Oxford Pleural Unit, Churchill Hospital, Oxford Centre for Respiratory Medicine.
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Rahman NM, Maskell NA, West A, Teoh R, Arnold A, Mackinlay C, Peckham D, Davies CWH, Ali N, Kinnear W, Bentley A, Kahan BC, Wrightson JM, Davies HE, Hooper CE, Lee YCG, Hedley EL, Crosthwaite N, Choo L, Helm EJ, Gleeson FV, Nunn AJ, Davies RJO. Intrapleural use of tissue plasminogen activator and DNase in pleural infection. N Engl J Med 2011; 365:518-26. [PMID: 21830966 DOI: 10.1056/nejmoa1012740] [Citation(s) in RCA: 465] [Impact Index Per Article: 35.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/19/2022]
Abstract
BACKGROUND More than 30% of patients with pleural infection either die or require surgery. Drainage of infected fluid is key to successful treatment, but intrapleural fibrinolytic therapy did not improve outcomes in an earlier, large, randomized trial. METHODS We conducted a blinded, 2-by-2 factorial trial in which 210 patients with pleural infection were randomly assigned to receive one of four study treatments for 3 days: double placebo, intrapleural tissue plasminogen activator (t-PA) and DNase, t-PA and placebo, or DNase and placebo. The primary outcome was the change in pleural opacity, measured as the percentage of the hemithorax occupied by effusion, on chest radiography on day 7 as compared with day 1. Secondary outcomes included referral for surgery, duration of hospital stay, and adverse events. RESULTS The mean (±SD) change in pleural opacity was greater in the t-PA-DNase group than in the placebo group (-29.5±23.3% vs. -17.2±19.6%; difference, -7.9%; 95% confidence interval [CI], -13.4 to -2.4; P=0.005); the change observed with t-PA alone and with DNase alone (-17.2±24.3 and -14.7±16.4%, respectively) was not significantly different from that observed with placebo. The frequency of surgical referral at 3 months was lower in the t-PA-DNase group than in the placebo group (2 of 48 patients [4%] vs. 8 of 51 patients [16%]; odds ratio for surgical referral, 0.17; 95% CI, 0.03 to 0.87; P=0.03) but was greater in the DNase group (18 of 46 patients [39%]) than in the placebo group (odds ratio, 3.56; 95% CI, 1.30 to 9.75; P=0.01). Combined t-PA-DNase therapy was associated with a reduction in the hospital stay, as compared with placebo (difference, -6.7 days; 95% CI, -12.0 to -1.9; P=0.006); the hospital stay with either agent alone was not significantly different from that with placebo. The frequency of adverse events did not differ significantly among the groups. CONCLUSIONS Intrapleural t-PA-DNase therapy improved fluid drainage in patients with pleural infection and reduced the frequency of surgical referral and the duration of the hospital stay. Treatment with DNase alone or t-PA alone was ineffective. (Funded by an unrestricted educational grant to the University of Oxford from Roche UK and by others; Current Controlled Trials number, ISRCTN57454527.).
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Affiliation(s)
- Najib M Rahman
- UKCRC Oxford Respiratory Trials Unit, Oxford Centre for Respiratory Medicine, Nuffield Department of Medicine, University of Oxford, Churchill Hospital Site, Headington, Oxford OX3 7LJ, United Kingdom.
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Affiliation(s)
- John M Wrightson
- NIHR Oxford Biomedical Research Centre, University of Oxford, Oxford, and Oxford Pleural Unit, Oxford Centre for Respiratory Medicine, Churchill Hospital, Oxford OX3 7LJ
| | - Nick A Maskell
- North Bristol Lung Centre, Southmead Hospital, Bristol University, Bristol
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Menzies SM, Rahman NM, Wrightson JM, Davies HE, Shorten R, Gillespie SH, Davies CWH, Maskell NA, Jeffrey AA, Lee YCG, Davies RJO. Blood culture bottle culture of pleural fluid in pleural infection. Thorax 2011; 66:658-62. [PMID: 21459855 DOI: 10.1136/thx.2010.157842] [Citation(s) in RCA: 89] [Impact Index Per Article: 6.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/03/2022]
Abstract
BACKGROUND Pleural infection is common, and has a >30% major morbidity and mortality-particularly when infection is caused by Gram-negative, Staphylococcus aureus or mixed aerobic pathogens. Standard pleural fluid culture is negative in ∼40% of cases. Culturing pleural fluid in blood culture bottles may increase microbial yield, and is cheap and easy to perform. OBJECTIVES To determine whether inoculating pleural fluid into blood culture bottles increases the culture positivity of pleural infection over standard laboratory culture, and to assess the optimum volume of inoculum to introduce. METHODS 62 patients with pleural infection were enrolled. Pairs of aerobic and anaerobic blood culture bottles were inoculated at the bedside with 2, 5 or 10 ml of pleural fluid, and two pleural fluid specimens were sent for standard culture. Pleural fluid from nine control patients was cultured to test for 'false-positive' results. RESULTS The addition of blood culture bottle culture to standard culture increased the proportion of patients with identifiable pathogens by 20.8% (20/53 (37.7%) to 31/53 (58.5%) (difference 20.8%, 95% CI difference 8.9% to 20.8%, p<0.001)). The second standard culture did not similarly improve the culture positivity (19/49 (38.8%) to 22/49 (44.9%) (difference 6.1%, 95% CI difference -2.5% to 6.1%, p=0.08)). The culture inoculum volume did not influence bacterial isolation frequency. The control fluids were culture negative. CONCLUSIONS Blood culture bottle culture of infected pleural fluid increases microbial yield when used in addition to standard culture. This technique should be part of routine care.
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Affiliation(s)
- Sarah M Menzies
- UKCRC Oxford Respiratory Trials Unit, Churchill Hospital, Oxford, UK.
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Abstract
Parapneumonic effusions are seen in up to 57% of patients with pneumonia. The majority of these effusions are noninfected and resolve with standard antibiotic treatment for the associated pneumonia. However, parapneumonic effusions in a minority of cases become infected and require prompt chest tube drainage and occasionally thoracic surgery. Patients may present in a variety of ways from florid sepsis to weight loss and anorexia; such diversity mandates a high index of suspicion among physicians. The role of the combination of intrapleural deoxyribonuclease (DNase) and tissue plasminogen activator (t-PA) to aid fluid drainage shows promise but needs further assessment in large trials with surgery and mortality as primary end points.
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Affiliation(s)
- John M Wrightson
- Oxford Pleural Unit, Oxford Centre for Respiratory Medicine, Churchill Hospital, Oxford, United Kingdom.
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Wrightson JM, Stanton AE, Maskell NA, Davies RJ, Lee YG. Could Decortication Become Necessary in Cases of Pseudochylothorax?: Response. Chest 2010. [DOI: 10.1378/chest.10-1350] [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: 11/01/2022] Open
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Wrightson JM, Rahman NM, Novak T, Huggett JF, Maskell NA, Zumla A, Miller RF, Davies RJO. Pneumocystis jirovecii in pleural infection: a nucleic acid amplification study. Thorax 2010; 66:450-1. [PMID: 20805155 DOI: 10.1136/thx.2009.129940] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [What about the content of this article? (0)] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/03/2022]
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Warren RM, Bashford JA, Wrightson JM. Detection of long interaural delays for broadband noise. J Acoust Soc Am 1981; 69:1510-1514. [PMID: 7240583 DOI: 10.1121/1.385790] [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] [Subscribe] [Scholar Register] [Indexed: 05/21/2023]
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