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Ching DKZ, Fysh ETH. Chronic haemothorax: an important cause of pleural effusion. Respirol Case Rep 2021; 9:e00758. [PMID: 33976887 PMCID: PMC8094057 DOI: 10.1002/rcr2.758] [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] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/28/2021] [Accepted: 04/09/2021] [Indexed: 11/10/2022] Open
Abstract
We describe a case of chronic exudative pleural effusion in a patient initially referred with anorexia, weight loss, and past history of breast cancer, following multiple presentations with chest pain and dyspnoea. Detailed history included past blunt thoracic trauma with pleural effusion drainage and anticoagulation for atrial fibrillation (AF). This case highlights several learning points for physicians around the management of thoracic trauma, anticoagulation for AF, and chronic haemothorax as an uncommon but important cause of exudative pleural effusion.
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Affiliation(s)
- David K. Z. Ching
- Department of Respiratory MedicineSt John of God Midland HospitalsMidlandWAAustralia
| | - Edward T. H. Fysh
- Department of Respiratory MedicineSt John of God Midland HospitalsMidlandWAAustralia
- Department of Intensive CareSt John of God Midland HospitalsMidlandWAAustralia
- Faculty of Health and Medical SciencesUniversity of Western AustraliaPerthWAAustralia
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Chan KP, Badiei A, Tan CPS, Fitzgerald DB, Stanley C, Fysh ETH, Shrestha R, Muruganandan S, Read CA, Thomas R, Lee YCG. Use of indwelling pleural/peritoneal catheter in the management of malignant ascites: a retrospective study of 48 patients. Intern Med J 2021; 50:705-711. [PMID: 31566871 DOI: 10.1111/imj.14642] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/21/2019] [Revised: 08/10/2019] [Accepted: 09/08/2019] [Indexed: 12/14/2022]
Abstract
BACKGROUND Patients suffering from malignant ascites usually require repeated large volume paracentesis (LVP) for symptomatic relief. This often requires hospital admission and has inherent risks. AIMS To report the first Australian experience of placing tunnelled indwelling peritoneal catheters (IPeC) for management of recurrent malignant ascites. METHODS A retrospective study was conducted of tunnelled IPeC use in patients with symptomatic malignant ascites in four hospitals in Western Australia (from 2010 to 2018). Procedure data, success rate and safety profile were collected from a database. RESULTS Forty-eight patients (median age 65 years; female 56%) underwent 51 peritoneal catheter insertion procedures that were performed mostly by pleural specialists. The majority of patients (96%) had prior LVP (median two drainages, interquartile range (IQR) 1-4) before IPeC insertion. The IPeC was inserted successfully under ultrasound guidance in all patients. The median length of hospital stay for IPeC insertion and initial ascites drainage was 2 days (IQR 2-3 days) and most patients (96%) did not require further paracentesis after IPeC placement. The majority (96%) of patients experienced relief from ascites symptoms after catheter insertion. Most IPeC-related adverse events were self-limiting, including pain (in 25% cases), transient hypotension after initial fluid drainage (10%), peritoneal fluid leakage (10%), bacterial peritonitis (8%), fluid loculation (2%) and catheter dislodgement (2%). Six (12%) patients had IPeC removed. All patients with bacterial peritonitis responded to antibiotics and one required catheter removal. CONCLUSIONS Use of tunnelled IPeC improves symptoms and can minimise further invasive drainage procedures in patients with symptomatic malignant ascites. Placement of IPeC was associated with a low rate of adverse events, most of which could be managed conservatively.
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Affiliation(s)
- Ka P Chan
- Department of Respiratory Medicine, Sir Charles Gairdner Hospital, Perth, Western Australia, Australia.,Department of Medicine and Therapeutics, Chinese University of Hong Kong, Hong Kong
| | - Arash Badiei
- Department of Respiratory Medicine, Sir Charles Gairdner Hospital, Perth, Western Australia, Australia
| | - Carmen P S Tan
- Department of Respiratory Medicine, Sir Charles Gairdner Hospital, Perth, Western Australia, Australia
| | - Deirdre B Fitzgerald
- Department of Respiratory Medicine, Sir Charles Gairdner Hospital, Perth, Western Australia, Australia.,School of Medicine and Pharmacology, University of Western Australia, Perth, Western Australia, Australia
| | - Christopher Stanley
- Department of Respiratory Medicine, Royal Perth Hospital, Perth, Western Australia, Australia
| | - Edward T H Fysh
- Department of Respiratory Medicine, St John of God Midland Public Hospital, Perth, Western Australia, Australia
| | - Ranjan Shrestha
- Department of Respiratory Medicine, Fiona Stanley Hospital, Perth, Western Australia, Australia
| | - Sanjeevan Muruganandan
- Department of Respiratory Medicine, Sir Charles Gairdner Hospital, Perth, Western Australia, Australia.,School of Medicine and Pharmacology, University of Western Australia, Perth, Western Australia, Australia
| | - Catherine A Read
- Department of Respiratory Medicine, Sir Charles Gairdner Hospital, Perth, Western Australia, Australia
| | - Rajesh Thomas
- Department of Respiratory Medicine, Sir Charles Gairdner Hospital, Perth, Western Australia, Australia.,School of Medicine and Pharmacology, University of Western Australia, Perth, Western Australia, Australia
| | - Yun Chor Gary Lee
- Department of Respiratory Medicine, Sir Charles Gairdner Hospital, Perth, Western Australia, Australia.,School of Medicine and Pharmacology, University of Western Australia, Perth, Western Australia, Australia
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Fysh ETH, Smallbone P, Mattock N, McCloskey C, Litton E, Wibrow B, Ho KM, Lee YCG. Clinically Significant Pleural Effusion in Intensive Care: A Prospective Multicenter Cohort Study. Crit Care Explor 2020; 2:e0070. [PMID: 32166290 PMCID: PMC7063904 DOI: 10.1097/cce.0000000000000070] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022] Open
Abstract
OBJECTIVES The prevalence and optimal management of clinically significant pleural effusion, confirmed by thoracic ultrasound, in the critically ill is unknown. This study aimed to determine: 1) the prevalence, characteristics, and outcomes of patients treated in intensive care with clinically significant effusion and 2) the comparative efficacy and safety of pleural drainage or expectant medical management. DESIGN A prospective multicenter cohort study. SETTING ICUs in four teaching hospitals in Western Australia. PATIENTS Consecutive patients with clinically significant pleural effusions (depth ≥ 2 cm on thoracic ultrasound with clinician-determined adverse effects on patient progress). INTERVENTIONS None. MEASUREMENTS AND MAIN RESULTS Primary outcome was the change in Pao2:Fio2 (mm Hg) ratio from baseline to 24 hours. Changes in diagnosis and treatment based on pleural fluid analysis and pleural effusion related serious adverse events between those who underwent either drainage within 24 hours or expectant management were compared. Of the 7,342 patients screened, 226 patients (3.1%) with 300 pleural effusions were enrolled. Early drainage of pleural effusion occurred in 76 patients (34%) and significantly improved oxygenation (Pao2:Fio2 ratio 203 at baseline vs 263 at 24 hr, +29.6% increment; p < 0.01). This was not observed in the other 150 patients who had expectant management (Pao2:Fio2 ratio 250 at baseline vs 268 at 24 hr, +7.2% increment; p = 0.44). The improvement in oxygenation after early drainage remained unchanged after adjustment for a propensity score on the decision to initiate early drainage. Pleural effusion related serious adverse events were not different between the two groups (early drainage 10.5% vs no early drainage 16.0%; p = 0.32). Improvements in diagnosis were noted in 91 initial (nonrepetitive) drainages (76.5% out of 119); treatment strategy was optimized after 80 drainage episodes (59.7% out of 134). CONCLUSIONS Early drainage of clinically significant pleural effusion was associated with improved oxygenation and diagnostic accuracy without increased complications.
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Affiliation(s)
- Edward T H Fysh
- Faculty of Medicine and Health Sciences, University of Western Australia, Perth, WA, Australia
- Pleural Diseases Unit, Department of General Medicine, Sir Charles Gairdner Hospital, Perth, WA, Australia
- Intensive Care Unit, St John of God Midland Public and Private Hospitals, Perth, WA, Australia
| | - Portia Smallbone
- Pleural Diseases Unit, Department of General Medicine, Sir Charles Gairdner Hospital, Perth, WA, Australia
| | - Nicholas Mattock
- Faculty of Medicine and Health Sciences, University of Western Australia, Perth, WA, Australia
| | | | - Edward Litton
- Faculty of Medicine and Health Sciences, University of Western Australia, Perth, WA, Australia
- Intensive Care Unit, Fiona Stanley Hospital, Perth, WA, Australia
| | - Bradley Wibrow
- Faculty of Medicine and Health Sciences, University of Western Australia, Perth, WA, Australia
- Intensive Care Unit, Sir Charles Gairdner Hospital, Perth, WA, Australia
| | - Kwok M Ho
- Intensive Care Unit, Royal Perth Hospital, Perth, WA, Australia
- School of Veterinary & Life Sciences, Murdoch, Perth, WA, Australia
| | - Y C Gary Lee
- Faculty of Medicine and Health Sciences, University of Western Australia, Perth, WA, Australia
- Pleural Diseases Unit, Department of General Medicine, Sir Charles Gairdner Hospital, Perth, WA, Australia
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Thomas R, Fysh ETH, Smith NA, Lee P, Kwan BCH, Yap E, Horwood FC, Piccolo F, Lam DCL, Garske LA, Shrestha R, Kosky C, Read CA, Murray K, Lee YCG. Effect of an Indwelling Pleural Catheter vs Talc Pleurodesis on Hospitalization Days in Patients With Malignant Pleural Effusion: The AMPLE Randomized Clinical Trial. JAMA 2017; 318:1903-1912. [PMID: 29164255 PMCID: PMC5820726 DOI: 10.1001/jama.2017.17426] [Citation(s) in RCA: 154] [Impact Index Per Article: 22.0] [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: 12/16/2022]
Abstract
IMPORTANCE Indwelling pleural catheter and talc pleurodesis are established treatments for malignant pleural effusions among patients with poor prognosis. OBJECTIVE To determine whether indwelling pleural catheters are more effective than talc pleurodesis in reducing total hospitalization days in the remaining lifespan of patients with malignant pleural effusion. DESIGN, SETTING, AND PARTICIPANTS This open-label, randomized clinical trial included participants recruited from 9 centers in Australia, New Zealand, Singapore, and Hong Kong between July 2012 and October 2014; they were followed up for 12 months (study end date: October 16, 2015). Patients (n = 146) with symptomatic malignant pleural effusion who had not undergone indwelling pleural catheter or pleurodesis treatment were included. INTERVENTIONS Participants were randomized (1:1) to indwelling pleural catheter (n = 74) or talc pleurodesis (n = 72), minimized by malignancy (mesothelioma vs others) and trapped lung (vs not), and stratified by region (Australia vs Asia). MAIN OUTCOMES AND MEASURES The primary end point was the total number of days spent in hospital from procedure to death or to 12 months. Secondary outcomes included further pleural interventions, patient-reported breathlessness, quality-of-life measures, and adverse events. RESULTS Among the 146 patients who were randomized (median age, 70.5 years; 56.2% male), 2 withdrew before receiving the randomized intervention and were excluded. The indwelling pleural catheter group spent significantly fewer days in hospital than the pleurodesis group (median, 10.0 [interquartile range [IQR], 3-17] vs 12.0 [IQR, 7-21] days; P = .03; Hodges-Lehmann estimate of difference, 2.92 days; 95% CI, 0.43-5.84). The reduction was mainly in effusion-related hospitalization days (median, 1.0 [IQR, 1-3] day with the indwelling pleural catheter vs 4.0 (IQR, 3-6) days with pleurodesis; P < .001; Hodges-Lehmann estimate, 2.06 days; 95% CI, 1.53-2.58). Fewer patients randomized to indwelling pleural catheter required further ipsilateral invasive pleural drainages (4.1% vs 22.5%; difference, 18.4%; 95% CI, 7.7%-29.2%). There were no significant differences in improvements in breathlessness or quality of life offered by indwelling pleural catheter or talc pleurodesis. Adverse events were seen in 22 patients in the indwelling pleural catheter group (30 events) and 13 patients in the pleurodesis group (18 events). CONCLUSIONS AND RELEVANCE Among patients with malignant pleural effusion, treatment with an indwelling pleural catheter vs talc pleurodesis resulted in fewer hospitalization days from treatment to death, but the magnitude of the difference is of uncertain clinical importance. These findings may help inform patient choice of management for pleural effusion. TRIAL REGISTRATION anzctr.org.au Identifier: ACTRN12611000567921.
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Affiliation(s)
- Rajesh Thomas
- Department of Respiratory Medicine, Sir Charles Gairdner Hospital, Perth, Western Australia, Australia
- School of Medicine and Pharmacology, University of Western Australia, Perth, Australia
- Institute for Respiratory Health, University of Western Australia, Perth, Australia
| | - Edward T. H. Fysh
- Department of Respiratory Medicine, Sir Charles Gairdner Hospital, Perth, Western Australia, Australia
- School of Medicine and Pharmacology, University of Western Australia, Perth, Australia
- Institute for Respiratory Health, University of Western Australia, Perth, Australia
| | - Nicola A. Smith
- Medical Research Institute of New Zealand, Wellington, New Zealand
| | - Pyng Lee
- Division of Respiratory and Critical Care Medicine, Department of Medicine, Yong Loo Lin Medical School, National University of Singapore, Singapore
| | - Benjamin C. H. Kwan
- Department of Respiratory Medicine, St George Hospital and Sutherland Hospital, Sydney, New South Wales, Australia
| | - Elaine Yap
- Department of Respiratory Medicine, Middlemore Hospital, Auckland, New Zealand
| | - Fiona C. Horwood
- Department of Respiratory Medicine, Middlemore Hospital, Auckland, New Zealand
| | - Francesco Piccolo
- Department of Internal Medicine, St John of God Midland Hospital, Perth, Western Australia, Australia
| | - David C. L. Lam
- Department of Medicine, University of Hong Kong, Hong Kong SAR, China
| | - Luke A. Garske
- Department of Respiratory and Sleep Medicine, Princess Alexandra Hospital, Brisbane, Queensland, Australia
| | - Ranjan Shrestha
- Department of Respiratory Medicine, Fiona Stanley Hospital, Perth, Western Australia, Australia
| | - Christopher Kosky
- School of Medicine and Pharmacology, University of Western Australia, Perth, Australia
- Departments of Pulmonary Physiology and General Medicine, Sir Charles Gairdner Hospital, Perth, Western Australia, Australia
| | - Catherine A. Read
- Institute for Respiratory Health, University of Western Australia, Perth, Australia
| | - Kevin Murray
- School of Population and Global Health, University of Western Australia, Perth, Australia
| | - Y. C. Gary Lee
- Department of Respiratory Medicine, Sir Charles Gairdner Hospital, Perth, Western Australia, Australia
- School of Medicine and Pharmacology, University of Western Australia, Perth, Australia
- Institute for Respiratory Health, University of Western Australia, Perth, Australia
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Azzopardi M, Fysh ETH, Lee YCG. Response. Chest 2015; 147:e233. [PMID: 26033143 DOI: 10.1378/chest.15-0558] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/01/2022] Open
Affiliation(s)
- Maree Azzopardi
- Perth, Australia From Respiratory Medicine, Sir Charles Gairdner Hospital, Western Australia; and Centre for Asthma, Allergy and Respiratory Research and School of Medicine and Pharmacology, The University of Western Australia
| | - Edward T H Fysh
- Perth, Australia From Respiratory Medicine, Sir Charles Gairdner Hospital, Western Australia; and Centre for Asthma, Allergy and Respiratory Research and School of Medicine and Pharmacology, The University of Western Australia
| | - Y C Gary Lee
- Perth, Australia From Respiratory Medicine, Sir Charles Gairdner Hospital, Western Australia; and Centre for Asthma, Allergy and Respiratory Research and School of Medicine and Pharmacology, The University of Western Australia.
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Fysh ETH, Bielsa S, Budgeon CA, Read CA, Porcel JM, Maskell NA, Lee YCG. Predictors of clinical use of pleurodesis and/or indwelling pleural catheter therapy for malignant pleural effusion. Chest 2015; 147:1629-1634. [PMID: 25474713 DOI: 10.1378/chest.14-1701] [Citation(s) in RCA: 29] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/01/2022] Open
Abstract
BACKGROUND The clinical course of patients with malignant pleural effusions (MPEs) varies. The decision to undertake "definitive therapy" (pleurodesis, indwelling pleural catheter [IPC], or both) for MPEs is decided on a case-by-case basis. Identifying factors that predict definitive therapy may help guide early initiation of treatment. The aim of the study was to identify clinical, laboratory, and radiologic predictors associated with clinicians' prescription of definitive therapy for patients with MPE. METHODS A multicenter, observational study was conducted over 55 months involving tertiary centers in Perth, Western Australia, Australia, and Lleida, Spain. Demographic, clinical, radiologic, biochemical, and histologic data and the treatments received were recorded. Logistic regression was performed to determine the variables useful for predicting definitive therapy. RESULTS Data of 540 patients (365 from Perth and 184 from Lleida) were analyzed; 537 fulfilled the criteria of an MPE. Definitive therapy was used in 288 patients (53.6%): 199 received a pleurodesis and 89 an IPC. Univariate analysis of the combined cohort revealed that definitive therapy was more likely if the effusion has low pH, either as a continuous variable (OR, 30.30; P < .01) or with a pH cutoff of < 7.2 (OR, 2.09; P = .03); was large (> 50% of hemithorax) (OR, 2.75; P < .01); or was associated with mesothelioma (OR, 1.83; P < .01). Following multivariate analysis, low pleural pH (OR, 37.04; P < .01), large effusions (OR, 3.31; P < .01), and increasing age (OR 1.02, P = .01) were associated with the use of definitive therapy. CONCLUSIONS Patients with MPE with an effusion of low pleural fluid pH and large size on radiographs at first presentation are more likely to be treated with pleurodesis and/or IPC.
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Affiliation(s)
- Edward T H Fysh
- Respiratory Medicine, Sir Charles Gairdner Hospital, Government of Western Australia, Perth, WA, Australia; Centre for Asthma, Allergy and Respiratory Research, The University of Western Australia, Perth, WA, Australia; School of Medicine and Pharmacology, The University of Western Australia, Perth, WA, Australia
| | - Silvia Bielsa
- Pleural Diseases Unit, University Hospital Arnau de Vilanova, Lleida, Spain
| | - Charley A Budgeon
- Centre for Applied Statistics, The University of Western Australia, Perth, WA, Australia; Department of Research, Sir Charles Gairdner Hospital, Government of Western Australia, Perth, WA, Australia
| | - Catherine A Read
- Centre for Asthma, Allergy and Respiratory Research, The University of Western Australia, Perth, WA, Australia
| | - Jose M Porcel
- Pleural Diseases Unit, University Hospital Arnau de Vilanova, Lleida, Spain
| | - Nick A Maskell
- North Bristol Lung Centre, Southmead Hospital, Bristol University, Bristol, England
| | - Y C Gary Lee
- Respiratory Medicine, Sir Charles Gairdner Hospital, Government of Western Australia, Perth, WA, Australia; Centre for Asthma, Allergy and Respiratory Research, The University of Western Australia, Perth, WA, Australia; School of Medicine and Pharmacology, The University of Western Australia, Perth, WA, Australia.
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Fysh ETH, Thomas R, Read CA. Correction. Protocol of the Australasian Malignant Pleural Effusion (AMPLE) trial: a multicentre randomised study comparing indwelling pleural catheter versus talc pleurodesis. BMJ Open 2015; 5:e006757corr1. [PMID: 25948403 PMCID: PMC4431144 DOI: 10.1136/bmjopen-2014-006757corr1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/20/2022] Open
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Azzopardi M, Porcel JM, Koegelenberg CFN, Lee YCG, Fysh ETH. Current controversies in the management of malignant pleural effusions. Semin Respir Crit Care Med 2014; 35:723-31. [PMID: 25463163 DOI: 10.1055/s-0034-1395795] [Citation(s) in RCA: 29] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/24/2022]
Abstract
Malignant pleural effusion (MPE) can complicate most malignancies and is a common clinical problem presenting to respiratory and cancer care physicians. Despite its frequent occurrence, current knowledge of MPE remains limited and controversy surrounds almost every aspect in its diagnosis and management. A lack of robust data has led to significant practice variations worldwide, inefficiencies in healthcare provision, and threats to patient safety. Recent studies have highlighted evolving concepts in MPE care that challenge traditional beliefs. Advancing laboratory techniques have improved the diagnostic yield from pleural fluid cytology, minimizing the need for invasive tissue biopsies, even in many cases of mesothelioma. Imaging-guided biopsy is comparable to thoracoscopy in suitable patients, if cytological examination was noncontributory. Cumulating evidence for the benefits of indwelling pleural catheters (IPCs) has led some centers to adopt this approach as first-line definitive management for MPE over conventional talc pleurodesis. The optimal technique of talc pleurodesis is still debated despite its use for many decades. Strategies combining pleurodesis and IPC are being studied. MPE consists of a heterogenous group of diseases and careful phenotyping of malignant effusion patients can provide important clinical information that will advance the field and allow better stratification of patients and planning of therapy accordingly. This review addresses the controversies in MPE diagnosis and management and exposes the deficits in knowledge of MPE that should be the focus of future research.
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Affiliation(s)
- Maree Azzopardi
- Thoracic Medicine Program, The Prince Charles Hospital, Brisbane, Australia
| | - José M Porcel
- Pleural Diseases Unit, Department of Internal Medicine, Arnau de Vilanova University Hospital, Biomedical Re search Institute of Lleida, Lleida, Spain
| | - Coenraad F N Koegelenberg
- Division of Pulmonology, Department of Medicine, Stellenbosch University and Tygerberg Academic Hospital, Cape Town, South Africa
| | - Y C Gary Lee
- Centre for Asthma, Allergy & Respiratory Research, School of Medicine & Pharmacology, University of Western Australia, Perth, Australia
| | - Edward T H Fysh
- Centre for Asthma, Allergy & Respiratory Research, School of Medicine & Pharmacology, University of Western Australia, Perth, Australia
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Clive AO, Kahan BC, Hooper CE, Bhatnagar R, Morley AJ, Zahan-Evans N, Bintcliffe OJ, Boshuizen RC, Fysh ETH, Tobin CL, Medford ARL, Harvey JE, van den Heuvel MM, Lee YCG, Maskell NA. Predicting survival in malignant pleural effusion: development and validation of the LENT prognostic score. Thorax 2014; 69:1098-104. [PMID: 25100651 PMCID: PMC4251306 DOI: 10.1136/thoraxjnl-2014-205285] [Citation(s) in RCA: 250] [Impact Index Per Article: 25.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
Abstract
BACKGROUND Malignant pleural effusion (MPE) causes debilitating breathlessness and predicting survival is challenging. This study aimed to obtain contemporary data on survival by underlying tumour type in patients with MPE, identify prognostic indicators of overall survival and develop and validate a prognostic scoring system. METHODS Three large international cohorts of patients with MPE were used to calculate survival by cell type (univariable Cox model). The prognostic value of 14 predefined variables was evaluated in the most complete data set (multivariable Cox model). A clinical prognostic scoring system was then developed and validated. RESULTS Based on the results of the international data and the multivariable survival analysis, the LENT prognostic score (pleural fluid lactate dehydrogenase, Eastern Cooperative Oncology Group (ECOG) performance score (PS), neutrophil-to-lymphocyte ratio and tumour type) was developed and subsequently validated using an independent data set. Risk stratifying patients into low-risk, moderate-risk and high-risk groups gave median (IQR) survivals of 319 days (228-549; n=43), 130 days (47-467; n=129) and 44 days (22-77; n=31), respectively. Only 65% (20/31) of patients with a high-risk LENT score survived 1 month from diagnosis and just 3% (1/31) survived 6 months. Analysis of the area under the receiver operating curve revealed the LENT score to be superior at predicting survival compared with ECOG PS at 1 month (0.77 vs 0.66, p<0.01), 3 months (0.84 vs 0.75, p<0.01) and 6 months (0.85 vs 0.76, p<0.01). CONCLUSIONS The LENT scoring system is the first validated prognostic score in MPE, which predicts survival with significantly better accuracy than ECOG PS alone. This may aid clinical decision making in this diverse patient population.
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Affiliation(s)
- Amelia O Clive
- Academic Respiratory Unit, University of Bristol, Bristol, UK
- North Bristol Lung Centre, Southmead Hospital, North Bristol NHS Trust, Bristol, UK
| | - Brennan C Kahan
- Pragmatic Clinical Trials Unit, Queen Mary University of London, London, UK
| | - Clare E Hooper
- Academic Respiratory Unit, University of Bristol, Bristol, UK
- North Bristol Lung Centre, Southmead Hospital, North Bristol NHS Trust, Bristol, UK
| | - Rahul Bhatnagar
- Academic Respiratory Unit, University of Bristol, Bristol, UK
- North Bristol Lung Centre, Southmead Hospital, North Bristol NHS Trust, Bristol, UK
| | - Anna J Morley
- North Bristol Lung Centre, Southmead Hospital, North Bristol NHS Trust, Bristol, UK
| | - Natalie Zahan-Evans
- North Bristol Lung Centre, Southmead Hospital, North Bristol NHS Trust, Bristol, UK
| | - Oliver J Bintcliffe
- North Bristol Lung Centre, Southmead Hospital, North Bristol NHS Trust, Bristol, UK
| | - Rogier C Boshuizen
- Thoracic Oncology, The Netherlands Cancer Institute, Antonie van Leeuwenhoek Hospital, Amsterdam, The Netherlands
| | - Edward T H Fysh
- Respiratory Department, Sir Charles Gairdner Hospital, Perth, Australia
- Centre for Asthma, Allergy & Respiratory Research, School of Medicine & Pharmacology, University of Western Australia, Perth, Australia
| | - Claire L Tobin
- Respiratory Department, Sir Charles Gairdner Hospital, Perth, Australia
| | - Andrew R L Medford
- North Bristol Lung Centre, Southmead Hospital, North Bristol NHS Trust, Bristol, UK
| | - John E Harvey
- North Bristol Lung Centre, Southmead Hospital, North Bristol NHS Trust, Bristol, UK
| | - Michel M van den Heuvel
- Thoracic Oncology, The Netherlands Cancer Institute, Antonie van Leeuwenhoek Hospital, Amsterdam, The Netherlands
| | - Y C Gary Lee
- Respiratory Department, Sir Charles Gairdner Hospital, Perth, Australia
- Centre for Asthma, Allergy & Respiratory Research, School of Medicine & Pharmacology, University of Western Australia, Perth, Australia
| | - Nick A Maskell
- Academic Respiratory Unit, University of Bristol, Bristol, UK
- North Bristol Lung Centre, Southmead Hospital, North Bristol NHS Trust, Bristol, UK
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Fysh ETH, Thomas R, Read CA, Lam BCH, Yap E, Horwood FC, Lee P, Piccolo F, Shrestha R, Garske LA, Lam DCL, Rosenstengel A, Bint M, Murray K, Smith NA, Lee YCG. Protocol of the Australasian Malignant Pleural Effusion (AMPLE) trial: a multicentre randomised study comparing indwelling pleural catheter versus talc pleurodesis. BMJ Open 2014; 4:e006757. [PMID: 25377015 PMCID: PMC4225240 DOI: 10.1136/bmjopen-2014-006757] [Citation(s) in RCA: 16] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/29/2014] [Accepted: 10/10/2014] [Indexed: 02/05/2023] Open
Abstract
INTRODUCTION Malignant pleural effusion can complicate most cancers. It causes breathlessness and requires hospitalisation for invasive pleural drainages. Malignant effusions often herald advanced cancers and limited prognosis. Minimising time spent in hospital is of high priority to patients and their families. Various treatment strategies exist for the management of malignant effusions, though there is no consensus governing the best choice. Talc pleurodesis is the conventional management but requires hospitalisation (and substantial healthcare resources), can cause significant side effects, and has a suboptimal success rate. Indwelling pleural catheters (IPCs) allow ambulatory fluid drainage without hospitalisation, and are increasingly employed for management of malignant effusions. Previous studies have only investigated the length of hospital care immediately related to IPC insertion. Whether IPC management reduces time spent in hospital in the patients' remaining lifespan is unknown. A strategy of malignant effusion management that reduces hospital admission days will allow patients to spend more time outside hospital, reduce costs and save healthcare resources. METHODS AND ANALYSIS The Australasian Malignant Pleural Effusion (AMPLE) trial is a multicentred, randomised trial designed to compare IPC with talc pleurodesis for the management of malignant pleural effusion. This study will randomise 146 adults with malignant pleural effusions (1:1) to IPC management or talc slurry pleurodesis. The primary end point is the total number of days spent in hospital (for any admissions) from treatment procedure to death or end of study follow-up. Secondary end points include hospital days specific to pleural effusion management, adverse events, self-reported symptom and quality-of-life scores. ETHICS AND DISSEMINATION The Sir Charles Gairdner Group Human Research Ethics Committee has approved the study as have the ethics boards of all the participating hospitals. The trial results will be published in peer-reviewed journals and presented at scientific conferences. TRIAL REGISTRATION NUMBERS Australia New Zealand Clinical Trials Registry-ACTRN12611000567921; National Institutes of Health-NCT02045121.
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Affiliation(s)
- Edward T H Fysh
- Department of Respiratory Medicine, Sir Charles Gairdner Hospital, Perth, Western Australia, Australia
- School of Medicine & Pharmacology, University of Western Australia, Perth, Western Australia, Australia
- Lung Institute of Western Australia, Perth, Western Australia, Australia
| | - Rajesh Thomas
- Department of Respiratory Medicine, Sir Charles Gairdner Hospital, Perth, Western Australia, Australia
- School of Medicine & Pharmacology, University of Western Australia, Perth, Western Australia, Australia
- Lung Institute of Western Australia, Perth, Western Australia, Australia
| | - Catherine A Read
- Lung Institute of Western Australia, Perth, Western Australia, Australia
| | - Ben C H Lam
- Department of Respiratory and Sleep Medicine, The Sutherland Hospital, Sydney, New South Wales, Australia
- Department of Respiratory Medicine, St George Hospital, Sydney, Australia
| | - Elaine Yap
- Department of Respiratory Medicine, Middlemore Hospital, Auckland, New Zealand
| | - Fiona C Horwood
- Department of Respiratory Medicine, Middlemore Hospital, Auckland, New Zealand
| | - Pyng Lee
- Division of Respiratory & Critical Care Medicine, Department of Medicine, Yong Loo Lin Medical School, National University Hospital, National University of Singapore, Singapore
| | - Francesco Piccolo
- Department of Internal Medicine, Swan District Hospital, Perth, Australia
| | - Ranjan Shrestha
- Department of Respiratory Medicine, Fremantle Hospital, Fremantle, Australia
| | - Luke A Garske
- Department of Respiratory and Sleep Medicine, Princess Alexandra Hospital, Brisbane, Queensland, Australia
| | - David C L Lam
- Department of Medicine, University of Hong Kong, Kong SAR, China
| | - Andrew Rosenstengel
- School of Medicine, University of Queensland, Brisbane, Queensland, Australia
- Holy Spirit Northside Hospital, Brisbane, Queensland, Australia
| | - Michael Bint
- Department of Respiratory Medicine, Nambour General Hospital, Sunshine Coast, Queensland, Australia
| | - Kevin Murray
- Centre for Applied Statistics, University of Western Australia, Perth, Western Australia, Australia
| | - Nicola A Smith
- Medical Research Institute of New Zealand, Wellington Hospital, Wellington, New Zealand
| | - Y C Gary Lee
- Department of Respiratory Medicine, Sir Charles Gairdner Hospital, Perth, Western Australia, Australia
- School of Medicine & Pharmacology, University of Western Australia, Perth, Western Australia, Australia
- Lung Institute of Western Australia, Perth, Western Australia, Australia
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11
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Fysh ETH, Tremblay A, Feller-Kopman D, Mishra EK, Slade M, Garske L, Clive AO, Lamb C, Boshuizen R, Ng BJ, Rosenstengel AW, Yarmus L, Rahman NM, Maskell NA, Lee YCG. Clinical outcomes of indwelling pleural catheter-related pleural infections: an international multicenter study. Chest 2014; 144:1597-1602. [PMID: 23828305 DOI: 10.1378/chest.12-3103] [Citation(s) in RCA: 120] [Impact Index Per Article: 12.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/27/2023] Open
Abstract
BACKGROUND Indwelling pleural catheters (IPCs) offer effective control of malignant pleural effusions (MPEs). IPC-related infection is uncommon but remains a major concern. Individual IPC centers see few infections, and previous reports lack sufficient numbers and detail. This study combined the experience of 11 centers from North America, Europe, and Australia to describe the incidence, microbiology, management, and clinical outcomes of IPC-related pleural infection. METHODS This was a multicenter retrospective review of 1,021 patients with IPCs. All had confirmed MPE. RESULTS Only 50 patients (4.9%) developed an IPC-related pleural infection; most (94%) were successfully controlled with antibiotics (62% IV). One death (2%) directly resulted from the infection, whereas two patients (4%) had ongoing infectious symptoms when they died of cancer progression. Staphylococcus aureus was the causative organism in 48% of cases. Infections from gram-negative organisms were associated with an increased need for continuous antibiotics or death (60% vs 15% in gram-positive and 25% mixed infections, P = .02). The infections in the majority (54%) of cases were managed successfully without removing the IPC. Postinfection pleurodesis developed in 31 patients (62%), especially those infected with staphylococci (79% vs 45% with nonstaphylococcal infections, P = .04). CONCLUSIONS The incidence of IPC-related pleural infection was low. The overall mortality risk from pleural infection in patients treated with IPC was only 0.29%. Antibiotics should cover S aureus and gram-negative organisms until microbiology is confirmed. Postinfection pleurodesis is common and often allows removal of IPC. Heterogeneity in management is common, and future studies to define the optimal treatment strategies are needed.
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Affiliation(s)
- Edward T H Fysh
- Pleural Diseases Unit, Sir Charles Gairdner Hospital, Perth, WA, Australia; Centre for Asthma, Allergy, and Respiratory Research, and the School of Medicine and Pharmacology, University of Western Australia, Perth, WA, Australia
| | - Alain Tremblay
- Division of Respiratory Medicine, University of Calgary, Calgary, AB, Canada
| | - David Feller-Kopman
- Division of Pulmonary and Critical Care Medicine, Johns Hopkins Hospital, Baltimore, MD
| | - Eleanor K Mishra
- Oxford Respiratory Trials Unit, Churchill Hospital, Oxford, England
| | - Mark Slade
- Department of Thoracic Oncology, Papworth Hospital, Cambridge, England
| | - Luke Garske
- Princess Alexandra Hospital, Brisbane, QLD, Australia
| | - Amelia O Clive
- Academic Respiratory Unit, School of Clinical Sciences, University of Bristol, Bristol, England
| | | | | | - Benjamin J Ng
- Nepean Hospital Lung Cancer Multidisciplinary Group, Sydney, NSW, Australia
| | | | - Lonny Yarmus
- Division of Pulmonary and Critical Care Medicine, Johns Hopkins Hospital, Baltimore, MD
| | - Najib M Rahman
- Oxford Respiratory Trials Unit, Churchill Hospital, Oxford, England
| | - Nick A Maskell
- Academic Respiratory Unit, School of Clinical Sciences, University of Bristol, Bristol, England
| | - Y C Gary Lee
- Pleural Diseases Unit, Sir Charles Gairdner Hospital, Perth, WA, Australia; Centre for Asthma, Allergy, and Respiratory Research, and the School of Medicine and Pharmacology, University of Western Australia, Perth, WA, Australia.
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12
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Clive AO, Hooper CE, Fysh ETH, Tobin C, Morley AJ, Zahan N, Sellar C, Bhatnagar R, Medford AR, Lee YCG, Maskell NA. S16 A Large, Prospective, Multicentre Study Evaluating the Survival of Patients with Malignant Pleural Effusion According to the Underlying Cell Type. Thorax 2012. [DOI: 10.1136/thoraxjnl-2012-202678.022] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [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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13
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Fysh ETH, Waterer GW, Kendall PA, Bremner PR, Dina S, Geelhoed E, McCarney K, Morey S, Millward M, Musk AWB, Lee YCG. Indwelling pleural catheters reduce inpatient days over pleurodesis for malignant pleural effusion. Chest 2012; 142:394-400. [PMID: 22406960 DOI: 10.1378/chest.11-2657] [Citation(s) in RCA: 116] [Impact Index Per Article: 9.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/01/2022] Open
Abstract
BACKGROUND Patients with malignant pleural effusion (MPE) have limited prognoses. They require long-lasting symptom relief with minimal hospitalization. Indwelling pleural catheters (IPCs) and talc pleurodesis are approved treatments for MPE. Establishing the implications of IPC and talc pleurodesis on subsequent hospital stay will influence patient choice of treatment. Therefore, our objective was to compare patients with MPE treated with IPC vs pleurodesis in terms of hospital bed days (from procedure to death or end of follow-up) and safety. METHODS In this prospective, 12-month, multicenter study, patients with MPE were treated with IPC or talc pleurodesis, based on patient choice. Key end points were hospital bed days from procedure to death (total and effusion-related). Complications, including infection and protein depletion, were monitored longitudinally. RESULTS One hundred sixty patients with MPE were recruited, and 65 required definitive fluid control; 34 chose IPCs and 31 pleurodesis. Total hospital bed days (from any causes) were significantly fewer in patients with IPCs (median, 6.5 days; interquartile range [IQR] = 3.75-13.0 vs pleurodesis, mean, 18.0; IQR, 8.0-26.0; P = .002). Effusion-related hospital bed days were significantly fewer with IPCs (median, 3.0 days; IQR, 1.8-8.3 vs pleurodesis, median, 10.0 days; IQR, 6.0-18.0; P < .001). Patients with IPCs spent significantly fewer of their remaining days of life in hospital (8.0% vs 11.2%, P < .001, χ(2) = 28.25). Fewer patients with IPCs required further pleural procedures (13.5% vs 32.3% in pleurodesis group). There was no difference in rates of pleural infection (P = .68) and protein (P = .65) or albumin loss (P = .22). More patients treated with IPC reported immediate (within 7 days) improvements in quality of life and dyspnea. CONCLUSIONS Patients treated with IPCs required significantly fewer days in hospital and fewer additional pleural procedures than those who received pleurodesis. Safety profiles and symptom control were comparable.
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Affiliation(s)
- Edward T H Fysh
- Department of Respiratory Medicine, Sir Charles Gairdner Hospital, Perth; Centre for Asthma, Allergy, and Respiratory Research, University of Western Australia, Perth; School of Medicine and Pharmacology, University of Western Australia, Perth
| | - Grant W Waterer
- School of Medicine and Pharmacology, University of Western Australia, Perth; Department of Respiratory Medicine, Royal Perth Hospital, Perth
| | - Peter A Kendall
- School of Medicine and Pharmacology, University of Western Australia, Perth; Department of Respiratory Medicine, Fremantle Hospital, Fremantle, WA, Australia
| | - Peter R Bremner
- Department of Respiratory Medicine, Fremantle Hospital, Fremantle, WA, Australia
| | - Sharifa Dina
- Department of Respiratory Medicine, Fremantle Hospital, Fremantle, WA, Australia
| | | | - Kate McCarney
- Department of Respiratory Medicine, Sir Charles Gairdner Hospital, Perth
| | - Sue Morey
- Department of Respiratory Medicine, Sir Charles Gairdner Hospital, Perth
| | - Michael Millward
- Department of Medical Oncology, Sir Charles Gairdner Hospital, Perth; School of Medicine and Pharmacology, University of Western Australia, Perth
| | - A W Bill Musk
- Department of Respiratory Medicine, Sir Charles Gairdner Hospital, Perth; School of Population Health, University of Western Australia, Perth
| | - Y C Gary Lee
- Department of Respiratory Medicine, Sir Charles Gairdner Hospital, Perth; Centre for Asthma, Allergy, and Respiratory Research, University of Western Australia, Perth; School of Medicine and Pharmacology, University of Western Australia, Perth.
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14
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Abstract
Multiple medical disorders can lead to the development of pleural effusions. Most effusions are given a single diagnosis in clinical practice. However, the cause of the effusion can change during the disease course, and concomitant yet distinct causes are often underrecognized. We highlight this point by reporting a complex case of recurrent pleural effusions with different predominant causes during the disease course. Five causes for the pleural effusion were diagnosed, namely malignant pleural effusion, empyema, chylothorax, transudative pleural effusion secondary to hypoalbuminemia, and esophagopleural fistula. This case serves as a reminder to clinicians that recurrent pleural effusion, even within the same pleural space, can arise from different causes and, whenever clinically appropriate, reinvestigation of the pleural effusion may be needed.
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Affiliation(s)
- Edward T H Fysh
- School of Medicine and Pharmacology and Centre for Asthma, Allergy and Respiratory Research, University of Western Australia, Australia; Department of Respiratory Medicine, Sir Charles Gairdner Hospital, Perth, WA, Australia
| | - Ranjan L Shrestha
- Department of Respiratory Medicine, Sir Charles Gairdner Hospital, Perth, WA, Australia
| | - Benjamin A Wood
- Department of Pathology and Laboratory Medicine, University of Western Australia, Australia
| | - Y C Gary Lee
- School of Medicine and Pharmacology and Centre for Asthma, Allergy and Respiratory Research, University of Western Australia, Australia; Department of Respiratory Medicine, Sir Charles Gairdner Hospital, Perth, WA, Australia.
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15
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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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