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Carneiro DC, Duarte D'Ambrosio P, Mariani AW, Fonini JS, Aguirre GKZ, Carneiro Leão JP, Schmidt Júnior AF, Bedawi EO, Rahman NM, Manuel Pêgo-Fernandes P. Evaluation of the RAPID score as a predictor of postoperative morbidity and mortality in patients undergoing pulmonary decortication for stage III pleural empyema. Clinics (Sao Paulo) 2024; 79:100356. [PMID: 38608555 PMCID: PMC11019092 DOI: 10.1016/j.clinsp.2024.100356] [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] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/28/2023] [Revised: 02/22/2024] [Accepted: 03/24/2024] [Indexed: 04/14/2024] Open
Abstract
OBJECTIVE This study aims to correlate the RAPID score with the 3-month survival and surgical results of patients undergoing lung decortication with stage III pleural empyema. METHODS This was a retrospective study with the population of patients with pleural empyema who underwent pulmonary decortication between January 2019 and June 2022. Data were collected from the institution's database, and patients were classified as low, medium, and high risk according to the RAPID score. The primary outcome was 3-month mortality. Secondary outcomes were the length of hospital stay, readmission rate, and the need for pleural re-intervention. RESULTS Of the 34 patients with pleural empyema, according to the RAPID score, patients were stratified into low risk (23.5 %), medium risk (47.1 %), and high risk (29.4 %). The high-risk group had a 3-month mortality of 40 %, while the moderate-risk group had a 6.25 % and the low-risk group had no deaths within 90 days, confirming a good correlation with the RAPID score (p < 0.05). Sensitivity and specificity for the primary outcome in the high-risk score were 80.0 % and 79.3 %, respectively. The secondary outcomes did not reach statistical significance. CONCLUSIONS In this retrospective series, the RAPID score had a good correlation with 3-month mortality in patients undergoing lung decortication. The morbidity indicators did not reach statistical significance. The present data justifies further studies to explore the capacity of the RAPID score to be used as a selection tool for treatment modality in patients with stage III pleural empyema.
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Affiliation(s)
- Danilo Caribé Carneiro
- Thoracic Surgery Resident, Instituto do Coração, Hospital das Clínicas, Faculdade de Medicina, Universidade de São Paulo (HCFMUSP), São Paulo, SP, Brazil
| | - Paula Duarte D'Ambrosio
- Thoracic Surgery Departament, Instituto do Coração, Hospital das Clínicas, Faculdade de Medicina, Universidade de São Paulo (HCFMUSP), São Paulo, SP, Brazil.
| | - Alessandro Wasum Mariani
- Thoracic Surgery Departament, Instituto do Coração, Hospital das Clínicas, Faculdade de Medicina, Universidade de São Paulo (HCFMUSP), São Paulo, SP, Brazil
| | - Jaqueline Schaparini Fonini
- Thoracic Surgery Resident, Instituto do Coração, Hospital das Clínicas, Faculdade de Medicina, Universidade de São Paulo (HCFMUSP), São Paulo, SP, Brazil
| | - Gabriela Ketherine Zurita Aguirre
- Thoracic Surgery Resident, Instituto do Coração, Hospital das Clínicas, Faculdade de Medicina, Universidade de São Paulo (HCFMUSP), São Paulo, SP, Brazil
| | - João Pedro Carneiro Leão
- Thoracic Surgery Resident, Instituto do Coração, Hospital das Clínicas, Faculdade de Medicina, Universidade de São Paulo (HCFMUSP), São Paulo, SP, Brazil
| | - Aurelino Fernandes Schmidt Júnior
- Thoracic Surgery Departament, Instituto do Coração, Hospital das Clínicas, Faculdade de Medicina, Universidade de São Paulo (HCFMUSP), São Paulo, SP, Brazil
| | - Eihab O Bedawi
- Department of Infection, Immunity and Cardiovascular Disease (IICD), University of Sheffield, Sheffield, United Kingdom of Great Britain and Northern Ireland United Kingdom; Department of Respiratory Medicine, Sheffield Teaching Hospitals NHS Foundation Trust, Sheffield, United Kingdom of Great Britain and Northern Ireland United Kingdom
| | - Najib M Rahman
- Oxford Respiratory Trials Unit, Nuffield Department of Medicine, University of Oxford, NIHR Oxford Biomedical Research Centre, University of Oxford, Oxford, United Kingdom of Great Britain and Northern Ireland United Kingdom; Oxford Centre for Respiratory Medicine, Oxford University Hospitals NHS Foundation Trust, Oxford, United Kingdom of Great Britain and Northern Ireland United Kingdom
| | - Paulo Manuel Pêgo-Fernandes
- Thoracic Surgery Departament, Instituto do Coração, Hospital das Clínicas, Faculdade de Medicina, Universidade de São Paulo (HCFMUSP), São Paulo, SP, Brazil
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Bedawi EO, Rahman NM. Reply to: Insights on the ERS/ESTS statement on the management of pleural infection in adults. Eur Respir J 2024; 63:2400244. [PMID: 38485182 DOI: 10.1183/13993003.00244-2024] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/03/2024] [Accepted: 02/06/2024] [Indexed: 03/19/2024]
Affiliation(s)
- Eihab O Bedawi
- Department of Respiratory Medicine, Brearley Wing, Northern General Hospital, Sheffield Teaching Hospitals NHS Foundation Trust, Sheffield, UK
- Department of Infection, Immunity and Cardiovascular Disease, University of Sheffield, Sheffield, UK
| | - Najib M Rahman
- Oxford Pleural Unit, Churchill Hospital, Oxford University Hospitals NHS Foundation Trust, Oxford, UK
- NIHR Oxford Biomedical Research Centre, University of Oxford, Oxford, UK
- China Academy of Medical Sciences Oxford Institute, University of Oxford, Oxford, UK
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Gonnelli F, Hassan W, Bonifazi M, Pinelli V, Bedawi EO, Porcel JM, Rahman NM, Mei F. Malignant pleural effusion: current understanding and therapeutic approach. Respir Res 2024; 25:47. [PMID: 38243259 PMCID: PMC10797757 DOI: 10.1186/s12931-024-02684-7] [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] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/10/2023] [Accepted: 01/05/2024] [Indexed: 01/21/2024] Open
Abstract
Malignant pleural effusion (MPE) is a common complication of thoracic and extrathoracic malignancies and is associated with high mortality and elevated costs to healthcare systems. Over the last decades the understanding of pathophysiology mechanisms, diagnostic techniques and optimal treatment intervention in MPE have been greatly advanced by recent high-quality research, leading to an ever less invasive diagnostic approach and more personalized management. Despite a number of management options, including talc pleurodesis, indwelling pleural catheters and combinations of the two, treatment for MPE remains symptom directed and centered around drainage strategy. In the next future, because of a better understanding of underlying tumor biology together with more sensitive molecular diagnostic techniques, it is likely that combined diagnostic and therapeutic procedures allowing near total outpatient management of MPE will become popular. This article provides a review of the current advances, new discoveries and future directions in the pathophysiology, diagnosis and management of MPE.
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Affiliation(s)
- Francesca Gonnelli
- Department of Biomedical Sciences and Public Health, Università Politecnica delle Marche, Ancona Via Conca 71, Ancona, 60126, Italy
| | - Wafa Hassan
- Department of Respiratory Medicine, Sheffield Teaching Hospitals, University of Sheffield, Sheffield, UK
| | - Martina Bonifazi
- Department of Biomedical Sciences and Public Health, Università Politecnica delle Marche, Ancona Via Conca 71, Ancona, 60126, Italy
| | | | - Eihab O Bedawi
- Department of Respiratory Medicine, Sheffield Teaching Hospitals, University of Sheffield, Sheffield, UK
| | - José M Porcel
- Research Group of Cancer Biomarkers, Lleida Institute for Biomedical Research Dr. Pifarré Foundation (IRBLleida), Lleida, Spain
- Pleural Medicine and Clinical Ultrasound Unit, Department of Internal Medicine, Arnau de Vilanova, University Hospital, Lleida, Spain
| | - Najib M Rahman
- Oxford Pleural Unit, Oxford University Hospitals NHS Foundation Trust, Churchill Hospital, Oxford, UK
- Oxford NIHR Biomedical Research Unit, Oxford, UK
- Chinese Academy of Medicine Oxford Institute, Oxford, UK
| | - Federico Mei
- Department of Biomedical Sciences and Public Health, Università Politecnica delle Marche, Ancona Via Conca 71, Ancona, 60126, Italy.
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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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Asciak R, Bedawi EO, Bhatnagar R, Clive AO, Hassan M, Lloyd H, Reddy R, Roberts H, Rahman NM. British Thoracic Society Clinical Statement on pleural procedures. Thorax 2023; 78:s43-s68. [PMID: 37433579 DOI: 10.1136/thorax-2022-219371] [Citation(s) in RCA: 5] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 07/13/2023]
Affiliation(s)
- Rachelle Asciak
- Respiratory Medicine, Portsmouth Hospitals University NHS Trust, Portsmouth, UK
| | - Eihab O Bedawi
- Sheffield Teaching Hospitals NHS Foundation Trust, Sheffield, UK
| | | | | | - Maged Hassan
- Chest Diseases Department, Alexandria University Faculty of Medicine, Alexandria, Egypt
| | - Heather Lloyd
- Worcestershire Acute Hospitals NHS Trust, Worcester, UK
| | - Raja Reddy
- Kettering General Hospital NHS Foundation Trust, Kettering, UK
| | - Helen Roberts
- Sherwood Forest Hospitals NHS Foundation Trust, Sutton-In-Ashfield, UK
| | - Najib M Rahman
- Oxford University Hospitals NHS Foundation Trust, Oxford, UK
- Oxford NIHR Biomedical Research Centre, Oxford, UK
- Oxford Respiratory Trials Unit, University of Oxford, Oxford, UK
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Bedawi EO, Kanellakis NI, Corcoran JP, Zhao Y, Hassan M, Asciak R, Mercer RM, Sundaralingam A, Addala DN, Miller RF, Dong T, Condliffe AM, Rahman NM. The Biological Role of Pleural Fluid PAI-1 and Sonographic Septations in Pleural Infection: Analysis of a Prospectively Collected Clinical Outcome Study. Am J Respir Crit Care Med 2023; 207:731-739. [PMID: 36191254 PMCID: PMC10037470 DOI: 10.1164/rccm.202206-1084oc] [Citation(s) in RCA: 6] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/08/2022] [Accepted: 10/03/2022] [Indexed: 11/16/2022] Open
Abstract
Rationale: Sonographic septations are assumed to be important clinical predictors of outcome in pleural infection, but the evidence for this is sparse. The inflammatory and fibrinolysis-associated intrapleural pathway(s) leading to septation formation have not been studied in a large cohort of pleural fluid (PF) samples with confirmed pleural infection matched with ultrasound and clinical outcome data. Objectives: To assess the presence and severity of septations against baseline PF PAI-1 (Plasminogen-Activator Inhibitor-1) and other inflammatory and fibrinolysis-associated proteins as well as to correlate these with clinically important outcomes. Methods: We analyzed 214 pleural fluid samples from PILOT (Pleural Infection Longitudinal Outcome Study), a prospective observational pleural infection study, for inflammatory and fibrinolysis-associated proteins using the Luminex platform. Multivariate regression analyses were used to assess the association of pleural biological markers with septation presence and severity (on ultrasound) and clinical outcomes. Measurements and Main Results: PF PAI-1 was the only protein independently associated with septation presence (P < 0.001) and septation severity (P = 0.003). PF PAI-1 concentrations were associated with increased length of stay (P = 0.048) and increased 12-month mortality (P = 0.003). Sonographic septations alone had no relation to clinical outcomes. Conclusions: In a large and well-characterized cohort, this is the first study to associate pleural biological parameters with a validated sonographic septation outcome in pleural infection. PF PAI-1 is the first biomarker to demonstrate an independent association with mortality. Although PF PAI-1 plays an integral role in driving septation formation, septations themselves are not associated with clinically important outcomes. These novel findings now require prospective validation.
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Affiliation(s)
- Eihab O. Bedawi
- Oxford Pleural Unit, Oxford Centre for Respiratory Medicine, Oxford University Hospitals NHS Foundation Trust, Oxford, United Kingdom
- Oxford Respiratory Trials Unit
- National Institute for Health Research Oxford Biomedical Research Centre
- Department of Infection, Immunity, and Cardiovascular Disease, University of Sheffield, Sheffield, United Kingdom
| | - Nikolaos I. Kanellakis
- Oxford Pleural Unit, Oxford Centre for Respiratory Medicine, Oxford University Hospitals NHS Foundation Trust, Oxford, United Kingdom
- Oxford Respiratory Trials Unit
- National Institute for Health Research Oxford Biomedical Research Centre
- Laboratory of Pleural and Lung Cancer Translational Research, Nuffield Department of Medicine
- Chinese Academy of Medical Sciences Oxford Institute, Nuffield Department of Medicine, and
| | - John P. Corcoran
- Department of Respiratory Medicine, Derriford Hospital, University Hospitals Plymouth NHS Trust, Plymouth, United Kingdom
| | - Yu Zhao
- Laboratory of Pleural and Lung Cancer Translational Research, Nuffield Department of Medicine
| | - Maged Hassan
- Oxford Pleural Unit, Oxford Centre for Respiratory Medicine, Oxford University Hospitals NHS Foundation Trust, Oxford, United Kingdom
- Chest Diseases Department, Alexandria University Faculty of Medicine, Alexandria, Egypt
| | - Rachelle Asciak
- Queen Alexandra Hospital, Portsmouth Hospitals NHS Trust, Portsmouth, United Kingdom; and
| | - Rachel M. Mercer
- Queen Alexandra Hospital, Portsmouth Hospitals NHS Trust, Portsmouth, United Kingdom; and
| | - Anand Sundaralingam
- Oxford Pleural Unit, Oxford Centre for Respiratory Medicine, Oxford University Hospitals NHS Foundation Trust, Oxford, United Kingdom
- Oxford Respiratory Trials Unit
| | - Dinesh N. Addala
- Oxford Pleural Unit, Oxford Centre for Respiratory Medicine, Oxford University Hospitals NHS Foundation Trust, Oxford, United Kingdom
- Oxford Respiratory Trials Unit
| | - Robert F. Miller
- Institute for Global Health, University College London, London, United Kingdom
| | - Tao Dong
- Chinese Academy of Medical Sciences Oxford Institute, Nuffield Department of Medicine, and
- Medical Research Council Human Immunology Unit, Medical Research Council Weatherall Institute of Molecular Medicine, University of Oxford, Oxford, United Kingdom
| | - Alison M. Condliffe
- Department of Infection, Immunity, and Cardiovascular Disease, University of Sheffield, Sheffield, United Kingdom
| | - Najib M. Rahman
- Oxford Pleural Unit, Oxford Centre for Respiratory Medicine, Oxford University Hospitals NHS Foundation Trust, Oxford, United Kingdom
- Oxford Respiratory Trials Unit
- National Institute for Health Research Oxford Biomedical Research Centre
- Laboratory of Pleural and Lung Cancer Translational Research, Nuffield Department of Medicine
- Chinese Academy of Medical Sciences Oxford Institute, Nuffield Department of Medicine, and
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7
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Bedawi EO, Ricciardi S, Hassan M, Gooseman MR, Asciak R, Castro-Añón O, Armbruster K, Bonifazi M, Poole S, Harris EK, Elia S, Krenke R, Mariani A, Maskell NA, Polverino E, Porcel JM, Yarmus L, Belcher EP, Opitz I, Rahman NM. ERS/ESTS statement on the management of pleural infection in adults. Eur Respir J 2023; 61:2201062. [PMID: 36229045 DOI: 10.1183/13993003.01062-2022] [Citation(s) in RCA: 19] [Impact Index Per Article: 19.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/14/2022] [Accepted: 08/22/2022] [Indexed: 02/07/2023]
Abstract
Pleural infection is a common condition encountered by respiratory physicians and thoracic surgeons alike. The European Respiratory Society (ERS) and European Society of Thoracic Surgeons (ESTS) established a multidisciplinary collaboration of clinicians with expertise in managing pleural infection with the aim of producing a comprehensive review of the scientific literature. Six areas of interest were identified: 1) epidemiology of pleural infection, 2) optimal antibiotic strategy, 3) diagnostic parameters for chest tube drainage, 4) status of intrapleural therapies, 5) role of surgery and 6) current place of outcome prediction in management. The literature revealed that recently updated epidemiological data continue to show an overall upwards trend in incidence, but there is an urgent need for a more comprehensive characterisation of the burden of pleural infection in specific populations such as immunocompromised hosts. There is a sparsity of regular analyses and documentation of microbiological patterns at a local level to inform geographical variation, and ongoing research efforts are needed to improve antibiotic stewardship. The evidence remains in favour of a small-bore chest tube optimally placed under image guidance as an appropriate initial intervention for most cases of pleural infection. With a growing body of data suggesting delays to treatment are key contributors to poor outcomes, this suggests that earlier consideration of combination intrapleural enzyme therapy (IET) with concurrent surgical consultation should remain a priority. Since publication of the MIST-2 study, there has been considerable data supporting safety and efficacy of IET, but further studies are needed to optimise dosing using individualised biomarkers of treatment failure. Pending further prospective evaluation, the MIST-2 regimen remains the most evidence based. Several studies have externally validated the RAPID score, but it requires incorporating into prospective intervention studies prior to adopting into clinical practice.
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Affiliation(s)
- Eihab O Bedawi
- Oxford Pleural Unit, Oxford Centre for Respiratory Medicine, Oxford University Hospitals NHS Foundation Trust, Oxford, UK
- Oxford Respiratory Trials Unit, University of Oxford, Oxford, UK
- NIHR Oxford Biomedical Research Centre, University of Oxford, Oxford, UK
- Department of Infection, Immunity and Cardiovascular Disease, University of Sheffield, Sheffield, UK
| | - Sara Ricciardi
- Unit of Thoracic Surgery, San Camillo Forlanini Hospital, Rome, Italy
- PhD Program Alma Mater Studiorum, University of Bologna, Bologna, Italy
| | - Maged Hassan
- Chest Diseases Department, Faculty of Medicine, Alexandria University, Alexandria, Egypt
| | - Michael R Gooseman
- Department of Thoracic Surgery, Hull University Teaching Hospitals NHS Trust, Hull York Medical School, University of Hull, Hull, UK
| | - Rachelle Asciak
- Department of Respiratory Medicine, Queen Alexandra Hospital, Portsmouth, UK
- Department of Respiratory Medicine, Mater Dei Hospital, Msida, Malta
| | - Olalla Castro-Añón
- Department of Respiratory Medicine, Lucus Augusti University Hospital, EOXI Lugo, Cervo y Monforte de Lemos, Lugo, Spain
- C039 Biodiscovery Research Group HULA-USC, Health Research Institute of Santiago de Compostela (IDIS), Santiago de Compostela, Spain
| | - Karin Armbruster
- Department of Medicine, Section of Pulmonary Medicine, Herlev-Gentofte Hospital, University of Copenhagen, Copenhagen, Denmark
| | - Martina Bonifazi
- Department of Biomedical Sciences and Public Health, Marche Polytechnic University, Ancona, Italy
- Respiratory Diseases Unit, Azienda Ospedaliero-Universitaria "Ospedali Riuniti", Ancona, Italy
| | - Sarah Poole
- Department of Pharmacy and Medicines Management, Oxford University Hospitals NHS Foundation Trust, Oxford, UK
| | - Elinor K Harris
- Bodleian Health Care Libraries, University of Oxford, Oxford, UK
| | - Stefano Elia
- Department of Medicine and Health Sciences "V. Tiberio", University of Molise, Campobasso, Italy
- Thoracic Surgical Oncology Programme, Policlinico Tor Vergata, Rome, Italy
| | - Rafal Krenke
- Department of Internal Medicine, Pulmonary Diseases and Allergy, Medical University of Warsaw, Warsaw, Poland
| | - Alessandro Mariani
- Thoracic Surgery Department, Heart Institute (InCor) do Hospital das Clnicas da Faculdade de Medicina da Universidade de São Paulo, São Paulo, Brazil
| | - Nick A Maskell
- Academic Respiratory Unit, University of Bristol, Bristol, UK
| | - Eva Polverino
- Pneumology Department, Hospital Universitari Vall d'Hebron, Institut de Recerca Vall d'Hebron, Barcelona, Spain
| | - Jose M Porcel
- Pleural Medicine Unit, Department of Internal Medicine, Arnau de Vilanova University Hospital, IRBLleida, Lleida, Spain
| | - Lonny Yarmus
- Division of Pulmonary and Critical Care, Johns Hopkins University School of Medicine, Baltimore, MD, USA
| | - Elizabeth P Belcher
- Department of Thoracic Surgery, Oxford University Hospitals NHS Foundation Trust, Oxford, UK
| | - Isabelle Opitz
- Department of Thoracic Surgery, University Hospital Zurich, Zurich, Switzerland
| | - Najib M Rahman
- Oxford Pleural Unit, Oxford Centre for Respiratory Medicine, Oxford University Hospitals NHS Foundation Trust, Oxford, UK
- Oxford Respiratory Trials Unit, University of Oxford, Oxford, UK
- NIHR Oxford Biomedical Research Centre, University of Oxford, Oxford, UK
- Chinese Academy of Medical Health Sciences, University of Oxford, Oxford, UK
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Mei F, Rota M, Bonifazi M, Zuccatosta L, Porcarelli FM, Sediari M, Bedawi EO, Sundaralingam A, Addala D, Gasparini S, Rahman NM. Efficacy of Small versus Large-Bore Chest Drain in Pleural Infection: A Systematic Review and Meta-Analysis. Respiration 2023; 102:247-256. [PMID: 36693327 DOI: 10.1159/000529027] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/17/2022] [Accepted: 01/04/2023] [Indexed: 01/25/2023] Open
Abstract
BACKGROUND Pleural infection represents a significant clinical challenge worldwide. Although prompt drainage of pleural fluid is thought to play a key role in pleural infection management, the optimal size of intrapleural catheter has yet to be defined. OBJECTIVES The aim of this systematic review and meta-analysis was to summarize data on efficacy and complications of small-bore drain (SBD), defined as ≤14F, in comparison to large-bore drain (LBD) in patients with pleural infection. METHOD We searched MEDLINE and Embase for all studies reporting outcomes of interest published up to October 2021. Two authors reviewed selected full text to identify studies according to predefined eligibility criteria. Summary estimates were derived using the random-effects model. RESULTS Twelve original studies were included for qualitative analysis and 7 of these for quantitative analysis. The surgical referral rate of SBD and LBD were, respectively, 0.16 (95% confidence interval [CI], 0.12-0.21) and 0.20 (95% CI, 0.10-0.32), the pooled mortality were 0.12 (95% CI, 0.05-0.21) and 0.20 (95% CI, 0.10-0.32), and the length of hospital stay was 24 days in both groups. Data on complications suggest similar proportions of tube dislodgement. Intensity of pain was evaluated in one study only, reporting higher scores for LBD. CONCLUSIONS This systematic review and meta-analysis provide the first synthesis of data on performance of SBD and LBD in management of pleural infection, and, overall, clinical outcomes and complications did not substantially differ, although the limited number of studies and the absence of dedicated randomized trials does limit the reliability of results.
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Affiliation(s)
- Federico Mei
- Respiratory Diseases Unit, Department of Internal Medicine, Azienda Ospedaliero-Universitaria Ospedali Riuniti, Ancona, Italy
- Department of Biomedical Sciences and Public Health, Università Politecnica delle Marche, Ancona, Italy
| | - Matteo Rota
- Department of Molecular and Translational Medicine, Università degli Studi di Brescia, Brescia, Italy
| | - Martina Bonifazi
- Respiratory Diseases Unit, Department of Internal Medicine, Azienda Ospedaliero-Universitaria Ospedali Riuniti, Ancona, Italy
- Department of Biomedical Sciences and Public Health, Università Politecnica delle Marche, Ancona, Italy
| | - Lina Zuccatosta
- Respiratory Diseases Unit, Department of Internal Medicine, Azienda Ospedaliero-Universitaria Ospedali Riuniti, Ancona, Italy
| | - Francesco M Porcarelli
- Respiratory Diseases Unit, Department of Internal Medicine, Azienda Ospedaliero-Universitaria Ospedali Riuniti, Ancona, Italy
- Department of Biomedical Sciences and Public Health, Università Politecnica delle Marche, Ancona, Italy
| | - Michele Sediari
- Respiratory Diseases Unit, Department of Internal Medicine, Azienda Ospedaliero-Universitaria Ospedali Riuniti, Ancona, Italy
| | - Eihab O Bedawi
- Oxford Pleural Unit, Oxford University Hospitals NHS Foundation Trust, Churchill Hospital, Oxford, UK
| | - Anand Sundaralingam
- Oxford Pleural Unit, Oxford University Hospitals NHS Foundation Trust, Churchill Hospital, Oxford, UK
| | - Dinesh Addala
- Oxford Pleural Unit, Oxford University Hospitals NHS Foundation Trust, Churchill Hospital, Oxford, UK
| | - Stefano Gasparini
- Respiratory Diseases Unit, Department of Internal Medicine, Azienda Ospedaliero-Universitaria Ospedali Riuniti, Ancona, Italy
- Department of Biomedical Sciences and Public Health, Università Politecnica delle Marche, Ancona, Italy
| | - Najib M Rahman
- Oxford Pleural Unit, Oxford University Hospitals NHS Foundation Trust, Churchill Hospital, Oxford, UK
- Oxford NIHR Biomedical Research Unit, Oxford, UK
- Chinese Academy of Medicine Oxford Institute, Oxford, UK
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9
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Klausen MB, Laursen C, Bendixen M, Naidu B, Bedawi EO, Rahman NM, Christensen TD. Does the time to diagnosis and treatment influence outcome in adults with pleural infections. Eur Clin Respir J 2023; 10:2174645. [PMID: 36743828 PMCID: PMC9897775 DOI: 10.1080/20018525.2023.2174645] [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] [Indexed: 02/04/2023] Open
Abstract
Objective To investigate the effect of early diagnosis and intervention in adult patients with complicated parapneumonic pleural effusion or pleural empyema and the impact on outcomes. Methods A systematic review based on a literature search of the PubMed database was performed. Results Eleven eligible studies were included; nine observational studies and two randomised controlled trials totalling a study population of 10,717 patients. The studies were conducted from 1992 to 2018, all in Europe and Northern America except one. Results varied between studies, but a trend towards better outcome in patients with shorter duration of symptoms and quicker initiation of treatment was found. We found that duration of symptoms before treatment may affect length of hospital stay, rate of conversion to open surgery, and frequency of complications. Conclusion We found that an earlier intervention in adults suffering from complicated parapneumonic pleural effusion and pleural empyema may potentially improve the outcome of patients in terms of length of stay, conversion to open surgery, and general complications following treatment, but not regarding mortality. Further studies are required to specify the timing of each intervention, and direct comparison in early management of interventions.
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Affiliation(s)
- Mads Brögger Klausen
- Department of Cardiothoracic and Vascular Surgery, Aarhus University Hospital, Aarhus, Denmark
| | - Christian 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
| | - Morten Bendixen
- Department of Cardiothoracic and Vascular Surgery, Aarhus University Hospital, Aarhus, Denmark
| | - Babu Naidu
- Department of Thoracic Surgery, Queen Elizabeth Hospital Birmingham, UK & Institute of Inflammation and Ageing, University of Birmingham, Birmingham, UK
| | - Eihab O Bedawi
- NIHR Oxford Biomedical Research Centre, University of Oxford, Oxford, UK
| | - Najib M Rahman
- NIHR Oxford Biomedical Research Centre, University of Oxford, Oxford, UK
| | - Thomas Decker Christensen
- Department of Cardiothoracic and Vascular Surgery, Aarhus University Hospital, Aarhus, Denmark.,Department of Clinical Medicine, Aarhus University Hospital, Aarhus, Denmark
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10
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Akulian J, Bedawi EO, Abbas H, Argento C, Arnold DT, Balwan A, Batra H, Uribe Becerra JP, Belanger A, Berger K, Burks AC, Chang J, Chrissian AA, DiBardino DM, Fuentes XF, Gesthalter YB, Gilbert CR, Glisinski K, Godfrey M, Gorden JA, Grosu H, Gupta M, Kheir F, Ma KC, Majid A, Maldonado F, Maskell NA, Mehta H, Mercer J, Mullon J, Nelson D, Nguyen E, Pickering EM, Puchalski J, Reddy C, Revelo AE, Roller L, Sachdeva A, Sanchez T, Sathyanarayan P, Semaan R, Senitko M, Shojaee S, Story R, Thiboutot J, Wahidi M, Wilshire CL, Yu D, Zouk A, Rahman NM, Yarmus L. Bleeding Risk With Combination Intrapleural Fibrinolytic and Enzyme Therapy in Pleural Infection: An International, Multicenter, Retrospective Cohort Study. Chest 2022; 162:1384-1392. [PMID: 35716828 PMCID: PMC9773231 DOI: 10.1016/j.chest.2022.06.008] [Citation(s) in RCA: 12] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/02/2022] [Revised: 06/01/2022] [Accepted: 06/01/2022] [Indexed: 01/05/2023] Open
Abstract
BACKGROUND Combination intrapleural fibrinolytic and enzyme therapy (IET) has been established as a therapeutic option in pleural infection. Despite demonstrated efficacy, studies specifically designed and adequately powered to address complications are sparse. The safety profile, the effects of concurrent therapeutic anticoagulation, and the nature and extent of nonbleeding complications remain poorly defined. RESEARCH QUESTION What is the bleeding complication risk associated with IET use in pleural infection? STUDY DESIGN AND METHODS This was a multicenter, retrospective observational study conducted in 24 centers across the United States and the United Kingdom. Protocolized data collection for 1,851 patients treated with at least one dose of combination IET for pleural infection between January 2012 and May 2019 was undertaken. The primary outcome was the overall incidence of pleural bleeding defined using pre hoc criteria. RESULTS Overall, pleural bleeding occurred in 76 of 1,833 patients (4.1%; 95% CI, 3.0%-5.0%). Using a half-dose regimen (tissue plasminogen activator, 5 mg) did not change this risk significantly (6/172 [3.5%]; P = .68). Therapeutic anticoagulation alongside IET was associated with increased bleeding rates (19/197 [9.6%]) compared with temporarily withholding anticoagulation before administration of IET (3/118 [2.6%]; P = .017). As well as systemic anticoagulation, increasing RAPID score, elevated serum urea, and platelets of < 100 × 109/L were associated with a significant increase in bleeding risk. However, only RAPID score and use of systemic anticoagulation were independently predictive. Apart from pain, non-bleeding complications were rare. INTERPRETATION IET use in pleural infection confers a low overall bleeding risk. Increased rates of pleural bleeding are associated with concurrent use of anticoagulation but can be mitigated by withholding anticoagulation before IET. Concomitant administration of IET and therapeutic anticoagulation should be avoided. Parameters related to higher IET-related bleeding have been identified that may lead to altered risk thresholds for treatment.
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Affiliation(s)
- Jason Akulian
- Division of Pulmonary and Critical Care, University of North Carolina at Chapel Hill School of Medicine, Chapel Hill, NC; Carolina Center for Pleural Diseases, University of North Carolina at Chapel Hill School of Medicine, Chapel Hill, NC
| | - Eihab O Bedawi
- Oxford Pleural Unit, Oxford University Hospitals NHS Foundation Trust, Oxford, England; NIHR Oxford Biomedical Research Centre, University of Oxford, Oxford, England.
| | - Hawazin Abbas
- Division of Pulmonary, Critical Care and Sleep Medicine, University of Florida, Gainesville, FL
| | - Christine Argento
- Division of Pulmonary and Critical Care, Johns Hopkins University School of Medicine, Baltimore, MD
| | - David T Arnold
- Division of Pulmonary and Critical Care, Duke University, Durham, NC
| | - Akshu Balwan
- Division of Pulmonary, Critical Care and Sleep Medicine, University of New Mexico School of Medicine, Albuquerque, NM
| | - Hitesh Batra
- Division of Pulmonary, Allergy, and Critical Care Medicine, The University of Alabama at Birmingham, Birmingham, AL
| | - Juan Pablo Uribe Becerra
- Division of Thoracic Surgery and Interventional Pulmonology, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, MA
| | - Adam Belanger
- Division of Pulmonary and Critical Care, University of North Carolina at Chapel Hill School of Medicine, Chapel Hill, NC
| | - Kristin Berger
- Division of Pulmonary and Critical Care Medicine, Weill Cornell Medicine, New York, NY
| | - Allen Cole Burks
- Division of Pulmonary and Critical Care, University of North Carolina at Chapel Hill School of Medicine, Chapel Hill, NC; Carolina Center for Pleural Diseases, University of North Carolina at Chapel Hill School of Medicine, Chapel Hill, NC
| | - Jiwoon Chang
- Division of Pulmonary, Allergy, and Critical Care Medicine, Stanford University School of Medicine, Palo Alto, CA
| | - Ara A Chrissian
- Division of Pulmonary, Critical Care, Hyperbaric, Allergy, and Sleep Medicine, Loma Linda University, Loma Linda, CA
| | - David M DiBardino
- Section of Interventional Pulmonology, Division of Pulmonary, Allergy, and Critical Care Medicine, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA
| | | | - Yaron B Gesthalter
- Division of Pulmonary, Critical Care, Allergy and Sleep, The University of California San Francisco, San Francisco, CA
| | - Christopher R Gilbert
- Division of Thoracic Surgery and Interventional Pulmonology, Swedish Cancer Institute and Center for Lung Cancer Research in Honor of Wayne Gittinger, Seattle, WA
| | - Kristen Glisinski
- Division of Pulmonary and Critical Care, National Jewish Health, Denver, CO
| | - Mark Godfrey
- Division of Pulmonary and Critical Care, Yale University School of Medicine, New Haven, CT
| | - Jed A Gorden
- Division of Thoracic Surgery and Interventional Pulmonology, Swedish Cancer Institute and Center for Lung Cancer Research in Honor of Wayne Gittinger, Seattle, WA
| | - Horiana Grosu
- Division of Pulmonary and Critical Care, The University Texas MD Anderson Cancer Center, Houston, TX
| | - Mridul Gupta
- Division of Pulmonary, Critical Care, and Sleep Medicine, University of Mississippi Medical Center, Jackson, MS
| | - Fayez Kheir
- Division of Thoracic Surgery and Interventional Pulmonology, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, MA
| | - Kevin C Ma
- Section of Interventional Pulmonology, Division of Pulmonary, Allergy, and Critical Care Medicine, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA
| | - Adnan Majid
- Division of Thoracic Surgery and Interventional Pulmonology, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, MA
| | - Fabien Maldonado
- Division of Allergy, Pulmonary and Critical Care Medicine, Vanderbilt University Medical Center, Nashville, TN
| | - Nick A Maskell
- Academic Respiratory Unit, Bristol Medical School, University of Bristol, Bristol, England
| | - Hiren Mehta
- Division of Pulmonary, Critical Care and Sleep Medicine, University of Florida, Gainesville, FL
| | - Joshua Mercer
- Division of Pulmonary and Critical Care, Johns Hopkins University School of Medicine, Baltimore, MD
| | - John Mullon
- Division of Pulmonary and Critical Care Medicine, Mayo Clinic, Rochester, MN
| | - Darlene Nelson
- Division of Pulmonary and Critical Care Medicine, Mayo Clinic, Rochester, MN
| | - Elaine Nguyen
- Division of Pulmonary, Critical Care, Hyperbaric, Allergy, and Sleep Medicine, Loma Linda University, Loma Linda, CA
| | - Edward M Pickering
- Division of Pulmonary and Critical Care, University of Maryland School of Medicine, Baltimore, MD
| | - Jonathan Puchalski
- Division of Pulmonary and Critical Care, Yale University School of Medicine, New Haven, CT
| | - Chakravarthy Reddy
- Division of Pulmonary and Critical Care, University of Utah, Salt Lake City, UT
| | - Alberto E Revelo
- Interventional Pulmonology Section, Division of Pulmonary, Critical Care and Sleep Medicine, The Ohio State University Wexner Medical Center, Columbus, OH
| | - Lance Roller
- Division of Allergy, Pulmonary and Critical Care Medicine, Vanderbilt University Medical Center, Nashville, TN
| | - Ashutosh Sachdeva
- Division of Pulmonary and Critical Care, University of Maryland School of Medicine, Baltimore, MD
| | - Trinidad Sanchez
- Division of Pulmonary and Critical Care, Virginia Commonwealth University, Richmond, VA
| | - Priya Sathyanarayan
- Division of Pulmonary and Critical Care, Johns Hopkins University School of Medicine, Baltimore, MD
| | - Roy Semaan
- Division of Pulmonary, Allergy and Critical Care Medicine, University of Pittsburgh School of Medicine, Pittsburgh, PA
| | - Michal Senitko
- Division of Pulmonary, Critical Care, and Sleep Medicine, University of Mississippi Medical Center, Jackson, MS
| | - Samira Shojaee
- Division of Pulmonary and Critical Care, Virginia Commonwealth University, Richmond, VA
| | - Ryan Story
- Interventional Pulmonology Section, Division of Pulmonary, Critical Care and Sleep Medicine, The Ohio State University Wexner Medical Center, Columbus, OH
| | - Jeffrey Thiboutot
- Division of Pulmonary and Critical Care, Johns Hopkins University School of Medicine, Baltimore, MD
| | - Momen Wahidi
- Division of Pulmonary and Critical Care, Duke University, Durham, NC
| | - Candice L Wilshire
- Division of Thoracic Surgery and Interventional Pulmonology, Swedish Cancer Institute and Center for Lung Cancer Research in Honor of Wayne Gittinger, Seattle, WA
| | - Diana Yu
- Division of Pulmonary, Critical Care and Sleep Medicine, Keck School of Medicine, University of Southern California, Los Angeles, CA
| | - Aline Zouk
- Division of Pulmonary, Allergy, and Critical Care Medicine, The University of Alabama at Birmingham, Birmingham, AL
| | - Najib M Rahman
- Oxford Pleural Unit, Oxford University Hospitals NHS Foundation Trust, Oxford, England; NIHR Oxford Biomedical Research Centre, University of Oxford, Oxford, England
| | - Lonny Yarmus
- Division of Pulmonary and Critical Care, Johns Hopkins University School of Medicine, Baltimore, MD
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11
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Bedawi EO, Kanellakis NI, Rahman NM. Reply to: Is the uPA/PAI-1 Ratio a Marker of Sonographic Septations in Pleural Infection? Am J Respir Crit Care Med 2022; 207:950. [PMID: 36413773 PMCID: PMC10111988 DOI: 10.1164/rccm.202211-2110le] [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] [Indexed: 11/23/2022] Open
Affiliation(s)
- Eihab O Bedawi
- University of Oxford, 6396, Oxford Respiratory Trials Unit, Oxford, Oxfordshire, United Kingdom of Great Britain and Northern Ireland.,University of Oxford, 6396, NIHR Oxford Biomedical Research Centre, Oxford, United Kingdom of Great Britain and Northern Ireland.,The University of Sheffield, 7315, Department of Infection, Immunity and Cardiovascular Disease, Sheffield, South Yorkshire, United Kingdom of Great Britain and Northern Ireland;
| | - Nikolaos I Kanellakis
- University of Oxford, 6396, Oxford Respiratory Trials Unit, Oxford, United Kingdom of Great Britain and Northern Ireland.,University of Oxford, 6396, NIHR Oxford Biomedical Research Centre, Oxford, Oxfordshire, United Kingdom of Great Britain and Northern Ireland.,University of Oxford, 6396, Chinese Academy of Medical Sciences Oxford Institute, Nuffield Department of Medicine, Oxford, Oxfordshire, United Kingdom of Great Britain and Northern Ireland
| | - Najib M Rahman
- University of Oxford, 6396, Oxford Respiratory Trials Unit, Oxford, Oxfordshire, United Kingdom of Great Britain and Northern Ireland.,University of Oxford, 6396, NIHR Oxford Biomedical Research Centre, Oxford, Oxfordshire, United Kingdom of Great Britain and Northern Ireland.,University of Oxford, 6396, Chinese Academy of Medical Sciences Oxford Institute, Nuffield Department of Medicine, Oxford, Oxfordshire, United Kingdom of Great Britain and Northern Ireland
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12
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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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13
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McCracken DJ, Bedawi EO, Stevenson M, Cullen KM, Stanton AE, Rahman NM. Thoracic ultrasound competence for ultrasound guided pleural procedures: The creation and validation of an assessment tool for use in the certification of basic thoracic ultrasound competence. J Clin Ultrasound 2022; 50:781-788. [PMID: 35034353 DOI: 10.1002/jcu.23137] [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] [Track Full Text] [Subscribe] [Scholar Register] [Received: 10/11/2021] [Accepted: 11/02/2021] [Indexed: 06/14/2023]
Abstract
OBJECTIVES Focused thoracic ultrasound (TUS) provides an increased safety profile when undertaking invasive pleural procedures. This has led to the requirement for defined curricula, high quality teaching and robust, validated assessment tools among physicians to ensure patient safety and clinical excellence. Current UK practice is based almost exclusively on expert consensus, but assessment methods employed have been shown to have low reliability and validity and are potentially open to bias. As a result, several assessment tools have been developed, although each has its own limitations. METHODS This study aimed to develop and validate an assessment tool corresponding to those skills associated with the most basic level of practice, defined recently as an emergency level operator in the British Thoracic Society Training Standards for Thoracic Ultrasound. RESULTS A total of 27 candidates were enrolled by two examiners based in Belfast and Oxford over a 10-month period between February and November 2019. Mean score of the inexperienced group was 44.3 (95% CI 39.2-49.4, range 28-54) compared with 74.9 (95% CI 72.8-77, range 64-80) in the experienced group providing an estimated mean difference of 30.7 between the two groups (95% CI 24.7-36.7; p < .001). CONCLUSIONS This tool appears to discriminate between trainees with limited experience of TUS performance and those with no experience. It has the potential to form part of the assessment strategy for trainees in the United Kingdom and beyond, alongside well established assessment tools in postgraduate training.
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Affiliation(s)
- David J McCracken
- Oxford Centre for Respiratory Medicine, Churchill Hospital, Oxford, UK
- Belfast Health and Social Care Trust, Royal Victoria Hospital, Belfast, UK
- Queen's University Belfast, Centre for Medical Education, Mulhouse Building, Royal Victoria Hospital, Belfast, UK
| | - Eihab O Bedawi
- Oxford Centre for Respiratory Medicine, Churchill Hospital, Oxford, UK
- Oxford Respiratory Trials Unit, Oxford, UK
| | - Michael Stevenson
- Queen's University Belfast, Centre for Medical Education, Mulhouse Building, Royal Victoria Hospital, Belfast, UK
| | - Kathy M Cullen
- Belfast Health and Social Care Trust, Royal Victoria Hospital, Belfast, UK
- Queen's University Belfast, Centre for Medical Education, Mulhouse Building, Royal Victoria Hospital, Belfast, UK
| | - Andrew E Stanton
- Department of Respiratory Medicine, Freeman Hospital, Newcastle upon Tyne, UK
| | - Najib M Rahman
- Oxford Centre for Respiratory Medicine, Churchill Hospital, Oxford, UK
- Oxford Respiratory Trials Unit, Oxford, UK
- NIHR Biomedical Research Centre, University of Oxford, Oxford, UK
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14
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Bedawi EO, Ur Rehman K, Sivakumar DP, Ferguson K, Ajmal S, Graham E, Panchal RK, Corcoran JP, Blyth KG, Rahman NM, West A. The Impact of the COVID-19 Pandemic on Pleural Infection incidence: a UK multicentre retrospective analysis. ERJ Open Res 2022; 8:00206-2022. [PMID: 35919861 PMCID: PMC9235054 DOI: 10.1183/23120541.00206-2022] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/03/2022] [Accepted: 06/15/2022] [Indexed: 12/05/2022] Open
Abstract
The fall in non-coronavirus disease 2019 (non-COVID-19) respiratory viruses, including seasonal influenza, during the pandemic is well reported [1–4]. It is thought to be a result of a combination of social distancing, lockdowns, improved hand hygiene and potentially virus–virus interactions and cross-protection affecting population dynamics. However, as vaccines weaken the transmission of severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2), clinicians remain vigilant for a potential resurgence of other respiratory pathogens and the implications of an ongoing rise in new SARS-CoV-2 variants. There was a significant reduction in pleural infection incidence, by almost a third, in the year following the start of the #COVID19 pandemic. Public health measures enforced during this period are likely to have played a significant role.https://bit.ly/3QAPPR9
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15
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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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16
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Christensen TD, Bendixen M, Skaarup SH, Jensen JU, Petersen RH, Christensen M, Licht P, Neckelmann K, Bibby BM, Møller LB, Bodtger U, Borg MH, Saghir Z, Langfeldt S, Harders SMW, Bedawi EO, Naidu B, Rahman N, Laursen CB. Intrapleural fibrinolysis and DNase versus video-assisted thoracic surgery (VATS) for the treatment of pleural empyema (FIVERVATS): protocol for a randomised, controlled trial - surgery as first-line treatment. BMJ Open 2022; 12:e054236. [PMID: 35264347 PMCID: PMC8915266 DOI: 10.1136/bmjopen-2021-054236] [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] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/03/2022] Open
Abstract
INTRODUCTION Pleural empyema is a frequent disease with a high morbidity and mortality. Current standard treatment includes antibiotics and thoracic ultrasound (TUS)-guided pigtail drainage. Simultaneously with drainage, an intrapleural fibrinolyticum can be given. A potential better alternative is surgery in terms of video-assisted thoracoscopic surgery (VATS) as first-line treatment. The aim of this study is to determine the difference in outcome in patients diagnosed with complex parapneumonic effusion (stage II) and pleural empyema (stage III) who are treated with either VATS surgery or TUS-guided drainage and intrapleural therapy (fibrinolytic (Alteplase) with DNase (Pulmozyme)) as first-line treatment. METHODS AND ANALYSIS A national, multicentre randomised, controlled study. Totally, 184 patients with a newly diagnosed community acquired complicated parapneumonic effusion or pleural empyema are randomised to either (1) VATS procedure with drainage or (2) TUS-guided pigtail catheter placement and intrapleural therapy with Actilyse and DNase. The total follow-up period is 12 months. The primary endpoint is length of hospital stay and secondary endpoints include for example, mortality, need for additional interventions, consumption of analgesia and quality of life. ETHICS AND DISSEMINATION All patients provide informed consent before randomisation. The research project is carried out in accordance with the Helsinki II Declaration, European regulations and Good Clinical Practice Guidelines. The Scientific Ethics Committees for Denmark and the Danish Data Protection Agency have provided permission. Information about the subjects is protected under the Personal Data Processing Act and the Health Act. The trial is registered at www. CLINICALTRIALS gov, and monitored by the regional Good clinical practice monitoring unit. The results of this study will be published in peer-reviewed journals and presented at various national and international conferences. TRIAL REGISTRATION NUMBER NCT04095676.
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Affiliation(s)
- Thomas Decker Christensen
- Department of Cardiothoracic and Vascular Surgery & Department of Clinical Medicine, Aarhus University Hospital, Aarhus, Denmark
| | - Morten Bendixen
- Department of Cardiothoracic and Vascular Surgery, Aarhus University Hospital, Aarhus, Denmark
| | - Søren Helbo Skaarup
- Department of Respiratory Diseases and Allergy, Aarhus University Hospital, Aarhus, Denmark
| | - Jens-Ulrik Jensen
- Department of Internal Medicine, Respiratory Medicine Section, Herlev and Gentofte Hospital, Copenhagen, Denmark
- Institute for Clinical Medicine, Faculty of Health Sciences, University of Copenhagen, Copenhagen, Denmark
| | - Rene Horsleben Petersen
- Institute for Clinical Medicine, Faculty of Health Sciences, University of Copenhagen, Copenhagen, Denmark
- Department of Cardiothoracic Surgery, Copenhagen University Hospital, Rigshospitalet, Copenhagen, Denmark
| | - Merete Christensen
- Department of Cardiothoracic Surgery, Copenhagen University Hospital, Rigshospitalet, Copenhagen, Denmark
| | - Peter Licht
- Department of Cardiothoracic Surgery, Odense University Hospital, Odense, Denmark
| | - Kirsten Neckelmann
- Department of Cardiothoracic Surgery, Odense University Hospital, Odense, Denmark
| | - Bo Martin Bibby
- Department of Public Health, Section for Biostatistics, Aarhus University, Aarhus, Denmark
| | - Lars B Møller
- Department of Cardiothoracic Surgery, Aalborg University Hospital, Aalborg, Denmark
| | - Uffe Bodtger
- Department of Internal Medicine & Department of Respiratory Medicine, Zealand University Hospital, Naestved-Slagelse Hospital, Naestved, Denmark
- Institute of Regional Health Research, University of Southern Denmark, Odense, Denmark
| | - Morten Hornemann Borg
- Department of Respiratory Medicine & Clinical Institute, Aalborg University Hospital, Aalborg, Denmark
| | - Zaigham Saghir
- Department of Internal Medicine, Respiratory Medicine Section, Herlev and Gentofte Hospital, Copenhagen, Denmark
- Institute for Clinical Medicine, Faculty of Health Sciences, University of Copenhagen, Copenhagen, Denmark
| | - Sten Langfeldt
- Department of Radiology, Aarhus University Hospital, Aarhus, Denmark
| | | | - Eihab O Bedawi
- NIHR Oxford Biomedical Research Centre, University of Oxford, Oxford, UK
| | - Babu Naidu
- Department of Thoracic Surgery, Queen Elizabeth Hospital, Birmingham, UK
- Institute of Inflammation and Ageing, University of Birmingham, Birmingham, UK
| | - Najib Rahman
- NIHR Oxford Biomedical Research Centre, University of Oxford, Oxford, UK
| | - 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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17
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Addala DN, Kanellakis NI, Bedawi EO, Dong T, Rahman NM. Malignant pleural effusion: Updates in diagnosis, management and current challenges. Front Oncol 2022; 12:1053574. [PMID: 36465336 PMCID: PMC9712949 DOI: 10.3389/fonc.2022.1053574] [Citation(s) in RCA: 4] [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: 09/25/2022] [Accepted: 10/27/2022] [Indexed: 11/19/2022] Open
Abstract
Malignant pleural effusion (MPE) is a common condition which often causes significant symptoms to patients and costs to healthcare systems. Over the past decade, the management of MPE has progressed enormously with large scale, randomised trials answering key questions regarding optimal diagnostic strategies and effective management strategies. Despite a number of management options, including talc pleurodesis, indwelling pleural catheters and combinations of the two, treatment for MPE remains symptom directed and centered around drainage strategy. The future goals for providing improved care for patients lies in changing the treatment paradigm from a generic pathway to personalised care, based on probability of malignancy type and survival. This article reviews the current evidence base, new discoveries and future directions in the diagnosis and management of MPE.
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Affiliation(s)
- Dinesh Narayan Addala
- Oxford Centre for Respiratory Medicine, Churchill Hospital, Oxford University Hospitals NHS Foundation Trust, Oxford, United Kingdom.,Oxford Pleural Unit, Oxford University Hospitals, Oxford, United Kingdom
| | - Nikolaos I Kanellakis
- Oxford Centre for Respiratory Medicine, Churchill Hospital, Oxford University Hospitals NHS Foundation Trust, Oxford, United Kingdom.,Oxford Biomedical Research Centre, National Institute for Health Research, Oxford, United Kingdom.,Nuffield Department of Medicine, Medical Sciences Division, Chinese Academy of Medical Science Oxford Institute, University of Oxford, Oxford, United Kingdom
| | - Eihab O Bedawi
- Oxford Pleural Unit, Oxford University Hospitals, Oxford, United Kingdom.,Department of Infection, Immunity and Cardiovascular Disease, University of Sheffield, Sheffield, United Kingdom
| | - Tao Dong
- Nuffield Department of Medicine, Medical Sciences Division, Chinese Academy of Medical Science Oxford Institute, University of Oxford, Oxford, United Kingdom.,Medical Research Council (MRC) Human Immunology Unit, Radcliffe Department of Medicine, Medical Research Council (MRC) Weatherall Institute of Molecular Medicine, University of Oxford, Oxford, United Kingdom
| | - Najib M Rahman
- Oxford Centre for Respiratory Medicine, Churchill Hospital, Oxford University Hospitals NHS Foundation Trust, Oxford, United Kingdom.,Oxford Pleural Unit, Oxford University Hospitals, Oxford, United Kingdom.,Oxford Biomedical Research Centre, National Institute for Health Research, Oxford, United Kingdom.,Nuffield Department of Medicine, Medical Sciences Division, Chinese Academy of Medical Science Oxford Institute, University of Oxford, Oxford, United Kingdom
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18
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Sundaralingam A, Bedawi EO, Harriss EK, Munnavar M, Rahman NM. The Frequency, Risk Factors and Management of Complications from Pleural Procedures. Chest 2021; 161:1407-1425. [PMID: 34896096 DOI: 10.1016/j.chest.2021.11.031] [Citation(s) in RCA: 11] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/19/2021] [Revised: 11/11/2021] [Accepted: 11/14/2021] [Indexed: 10/19/2022] Open
Abstract
Pleural disease is a common presentation and spans a heterogenous population across broad disease entities but a common feature is the requirement for interventional procedures. Despite the frequency of such procedures, there is little consensus on rates of complications and risk factors associated with such complications. Here follows a narrative review based on a structured search of the literature. Searches were limited to 2010 onwards, in recognition of the sea-change in procedural complications following the mainstream use of thoracic ultrasound (US). Procedures of interest were limited to thoracocentesis, intercostal drains (ICD), indwelling pleural catheters (IPC) and local anaesthetic thoracoscopy (LAT). 4308 studies were screened, to identify 48 studies for inclusion. Iatrogenic pneumothorax (PTX) remains the commonest complication following thoracocentesis: 3.3% (95% CI, 3.2-3.4), though PTX requiring intervention was rare: 0.3% (95% CI, 0.2-0.4) when the procedure was US guided. Drain blockage and displacement are the commonest complications following ICD insertion (6.3%, and 6.8%, respectively). IPC related infections can be a significant problem: 5.8% (95% CI, 5.1-6.7), however most cases can be managed without removal of the IPC. LAT has an overall mortality of 0.1% (95% CI, 0.03-0.3). Data on safety and complication rates in procedural interventions are limited by methodological problems and novel methods to study this topic bears consideration. Whilst complications remain rare events, once encountered, they have the potential to rapidly escalate. It is of paramount importance for operators to prepare and have in place plans for such events, to ensure high quality and above all, safe care.
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Affiliation(s)
- Anand Sundaralingam
- Oxford Pleural Unit, Oxford Centre for Respiratory Medicine, Churchill Hospital.
| | - Eihab O Bedawi
- Oxford Pleural Unit, Oxford Centre for Respiratory Medicine, Churchill Hospital
| | | | | | - Najib M Rahman
- Oxford Pleural Unit, Oxford Centre for Respiratory Medicine, Churchill Hospital; University of Oxford, NIHR Oxford Biomedical Research Centre
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19
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Abstract
The rising incidence and high morbidity of pleural infection remain a significant challenge to health care systems worldwide. With distinct microbiology and treatment paradigms from pneumonia, pleural infection is an area in which the evidence base has been rapidly evolving. Progress in recent years has revolved around characterizing the microbiome of pleural infection and the addition of new strategies such as intrapleural enzyme therapy to the established treatment pathway of drainage and antibiotics. The future of improving outcomes lies with personalizing treatment, establishing optimal timing of intrapleural agents and surgery, alongside wider use of risk stratification to guide treatment.
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Affiliation(s)
- Dinesh N Addala
- Oxford University Hospitals NHS Foundation Trust; Department of Respiratory Medicine, Churchill Hospital, Old Road, Headington, Oxford OX3 7LE, UK.
| | - Eihab O Bedawi
- Oxford University Hospitals NHS Foundation Trust; Department of Respiratory Medicine, Churchill Hospital, Old Road, Headington, Oxford OX3 7LE, UK
| | - Najib M Rahman
- Oxford University Hospitals NHS Foundation Trust; Oxford NIHR Biomedical Research Centre, John Radcliffe Hospital, Headington OX3 9DU, UK
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20
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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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21
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Psallidas I, Hassan M, Yousuf A, Duncan T, Khan SL, Blyth KG, Evison M, Corcoran JP, Barnes S, Reddy R, Bonta PI, Bhatnagar R, Kagithala G, Dobson M, Knight R, Dutton SJ, Luengo-Fernandez R, Hedley E, Piotrowska H, Brown L, Asa'ari KAM, Mercer RM, Asciak R, Bedawi EO, Hallifax RJ, Slade M, Benamore R, Edey A, Miller RF, Maskell NA, Rahman NM. Role of thoracic ultrasonography in pleurodesis pathways for malignant pleural effusions (SIMPLE): an open-label, randomised controlled trial. Lancet Respir Med 2021; 10:139-148. [PMID: 34634246 DOI: 10.1016/s2213-2600(21)00353-2] [Citation(s) in RCA: 16] [Impact Index Per Article: 5.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Received: 04/08/2021] [Revised: 06/30/2021] [Accepted: 07/13/2021] [Indexed: 01/24/2023]
Abstract
BACKGROUND Pleurodesis is done as an in-patient procedure to control symptomatic recurrent malignant pleural effusion (MPE) and has a success rate of 75-80%. Thoracic ultrasonography has been shown in a small study to predict pleurodesis success early by demonstrating cessation of lung sliding (a normal sign seen in healthy patients, lung sliding indicates normal movement of the lung inside the thorax). We aimed to investigate whether the use of thoracic ultrasonography in pleurodesis pathways could shorten hospital stay in patients with MPE undergoing pleurodesis. METHODS The Efficacy of Sonographic and Biological Pleurodesis Indicators of Malignant Pleural Effusion (SIMPLE) trial was an open-label, randomised controlled trial done in ten respiratory centres in the UK and one respiratory centre in the Netherlands. Adult patients (aged ≥18 years) with confirmed MPE who required talc pleurodesis via either a chest tube or as poudrage during medical thorascopy were eligible. Patients were randomly assigned (1:1) to thoracic ultrasonography-guided care or standard care via an online platform using a minimisation algorithm. In the intervention group, daily thoracic ultrasonography examination for lung sliding in nine regions was done to derive an adherence score: present (1 point), questionable (2 points), or absent (3 points), with a lowest possible score of 9 (preserved sliding) and a highest possible score of 27 (complete absence of sliding); the chest tube was removed if the score was more than 20. In the standard care group, tube removal was based on daily output volume (per British Thoracic Society Guidelines). The primary outcome was length of hospital stay, and secondary outcomes were pleurodesis failure at 3 months, time to tube removal, all-cause mortality, symptoms and quality-of-life scores, and cost-effectiveness of thoracic ultrasonography-guided care. All outcomes were assessed in the modified intention-to-treat population (patients with missing data excluded), and a non-inferiority analysis of pleurodesis failure was done in the per-protocol population. This trial was registered with ISRCTN, ISRCTN16441661. FINDINGS Between Dec 31, 2015, and Dec 17, 2019, 778 patients were assessed for eligibility and 313 participants (165 [53%] male) were recruited and randomly assigned to thoracic ultrasonography-guided care (n=159) or standard care (n=154). In the modified intention-to-treat population, the median length of hospital stay was significantly shorter in the intervention group (2 days [IQR 2-4]) than in the standard care group (3 days [2-5]; difference 1 day [95% CI 1-1]; p<0·0001). In the per-protocol analysis, thoracic ultrasonography-guided care was non-inferior to standard care in terms of pleurodesis failure at 3 months, which occurred in 27 (29·7%) of 91 patients in the intervention group versus 34 (31·2%) of 109 patients in the standard care group (risk difference -1·5% [95% CI -10·2% to 7·2%]; non-inferiority margin 15%). Mean time to chest tube removal in the intervention group was 2·4 days (SD 2·5) versus 3·1 days (2·0) in the standard care group (mean difference -0·72 days [95% CI -1·22 to -0·21]; p=0·0057). There were no significant between-group differences in all-cause mortality, symptom scores, or quality-of-life scores, except on the EQ-5D visual analogue scale, which was significantly lower in the standard care group at 3 months. Although costs were similar between the groups, thoracic ultrasonography-guided care was cost-effective compared with standard care. INTERPRETATION Thoracic ultrasonography-guided care for pleurodesis in patients with MPE results in shorter hospital stay (compared with the British Thoracic Society recommendation for pleurodesis) without reducing the success rate of the procedure at 3 months. The data support consideration of standard use of thoracic ultrasonography in patients undergoing MPE-related pleurodesis. FUNDING Marie Curie Cancer Care Committee.
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Affiliation(s)
- Ioannis Psallidas
- Oxford Centre for Respiratory Medicine, Oxford University Hospitals NHS Foundation Trust, Oxford, UK; Oxford Respiratory Trials Unit, University of Oxford, 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 Department, Alexandria University Faculty of Medicine, Alexandria, Egypt.
| | - Ahmed Yousuf
- Oxford Centre for Respiratory Medicine, Oxford University Hospitals NHS Foundation Trust, Oxford, UK; Oxford Respiratory Trials Unit, University of Oxford, Oxford, UK
| | - Tracy Duncan
- Department of Respiratory Medicine, North Manchester General Hospital, Manchester, UK
| | - Shahul Leyakathali Khan
- Department of Respiratory Medicine, University Hospitals of North Midlands NHS Trust, Stoke-on-Trent, UK
| | - Kevin G Blyth
- Institute of Cancer Sciences, University of Glasgow and Glasgow Pleural Disease Unit, Queen Elizabeth University Hospital, Glasgow, UK
| | - Matthew Evison
- North West Lung Centre, University Hospital of South Manchester NHS Foundation Trust, Manchester, UK
| | - John P Corcoran
- Interventional Pulmonology Unit, Chest Clinic, University Hospitals Plymouth NHS Trust, Plymouth, UK
| | - Simon Barnes
- Department of Respiratory Medicine, Somerset NHS Foundation Trust, Taunton, UK
| | - Raja Reddy
- Department of Respiratory Medicine, Kettering General Hospital, Kettering, UK
| | - Peter I Bonta
- Amsterdam University Medical Centre, University of Amsterdam, Amsterdam, Netherlands
| | - Rahul Bhatnagar
- Academic Respiratory Unit, University of Bristol, Bristol, UK
| | | | - Melissa Dobson
- Oxford Respiratory Trials Unit, University of Oxford, Oxford, UK
| | - Ruth Knight
- Oxford Clinical Trials Research Unit, Centre for Statistics in Medicine, University of Oxford, Oxford, UK
| | - Susan J Dutton
- Oxford Clinical Trials Research Unit, Centre for Statistics in Medicine, University of Oxford, Oxford, UK
| | - Ramon Luengo-Fernandez
- Health Economics Research Centre, Nuffield Department of Population Health, University of Oxford, Oxford, UK
| | - Emma Hedley
- Oxford Respiratory Trials Unit, University of Oxford, Oxford, UK
| | - Hania Piotrowska
- Oxford Respiratory Trials Unit, University of Oxford, Oxford, UK
| | - Louise Brown
- Department of Respiratory Medicine, North Manchester General Hospital, Manchester, UK
| | - Kamal Abi Musa Asa'ari
- Department of Respiratory Medicine, University Hospitals of North Midlands NHS Trust, Stoke-on-Trent, 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
| | - Rachelle Asciak
- Oxford Centre for Respiratory Medicine, Oxford University Hospitals NHS Foundation Trust, Oxford, UK; Oxford Respiratory Trials Unit, University of Oxford, Oxford, UK
| | - 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
| | - 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
| | - Mark Slade
- Department of Respiratory Medicine, Gloucestershire Hospitals NHS Foundation Trust, Gloucester, UK
| | - Rachel Benamore
- Department of Thoracic Imaging, Oxford University Hospitals NHS Foundation Trust, Oxford, UK
| | - Anthony Edey
- Department of Imaging, North Bristol NHS Trust, Bristol, UK
| | - Robert F Miller
- Institute for Global Health, University College London, London, UK
| | - Nick A Maskell
- Academic Respiratory Unit, University of Bristol, Bristol, UK
| | - Najib M Rahman
- Oxford Centre for Respiratory Medicine, Oxford University Hospitals NHS Foundation Trust, Oxford, UK; Oxford Respiratory Trials Unit, University of Oxford, Oxford, UK; Oxford NIHR Biomedical Research Centre, Oxford, UK
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22
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Hassan M, Banka R, Castro-Añón O, Mercer RM, Bedawi EO, Asciak R, Stradling J, Rahman NM. Physical Activity and Sedentary Behaviour in Patients With Malignant Pleural Effusion Undergoing Therapeutic Pleural Interventions (The ASPIRE Study). Arch Bronconeumol 2021; 57:656-658. [PMID: 35699052 DOI: 10.1016/j.arbr.2020.09.013] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/15/2020] [Accepted: 09/30/2020] [Indexed: 06/15/2023]
Affiliation(s)
- Maged Hassan
- Oxford Centre for Respiratory Medicine, Oxford University Hospitals NHS Trust, Oxford, UK; Chest Diseases Department, Alexandria University Faculty of Medicine, Alexandria, Egypt.
| | - Radhika Banka
- Oxford Centre for Respiratory Medicine, Oxford University Hospitals NHS Trust, Oxford, UK
| | - Olalla Castro-Añón
- Oxford Centre for Respiratory Medicine, Oxford University Hospitals NHS Trust, Oxford, UK; Pneumology Service, Lucus Augusti University Hospital, Lugo, Spain
| | - Rachel M Mercer
- Oxford Centre for Respiratory Medicine, Oxford University Hospitals NHS Trust, Oxford, UK
| | - Eihab O Bedawi
- Oxford Centre for Respiratory Medicine, Oxford University Hospitals NHS Trust, Oxford, UK
| | - Rachelle Asciak
- Oxford Centre for Respiratory Medicine, Oxford University Hospitals NHS Trust, Oxford, UK
| | - John Stradling
- Oxford Centre for Respiratory Medicine, Oxford University Hospitals NHS Trust, Oxford, UK; Oxford NIHR Biomedical Research Centre, Oxford, UK
| | - Najib M Rahman
- Oxford Centre for Respiratory Medicine, Oxford University Hospitals NHS Trust, Oxford, UK; Oxford NIHR Biomedical Research Centre, Oxford, UK
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23
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Mercer RM, Varatharajah R, Shepherd G, Lu Q, Castro-Añón O, McCracken DJ, Dudina A, Addala D, Tsikrika S, George V, Banka R, Asciak R, Hassan M, Hallifax R, Bedawi EO, Shute JK, Rahman NM. Critical analysis of the utility of initial pleural aspiration in the diagnosis and management of suspected malignant pleural effusion. BMJ Open Respir Res 2021; 7:7/1/e000701. [PMID: 32963027 PMCID: PMC7509958 DOI: 10.1136/bmjresp-2020-000701] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/30/2020] [Revised: 08/04/2020] [Accepted: 08/10/2020] [Indexed: 01/19/2023] Open
Abstract
INTRODUCTION Current guidelines recommend an initial pleural aspiration in the investigation and management of suspected malignant pleural effusions (MPEs) with the aim of establishing a diagnosis, identifying non-expansile lung (NEL) and, at times, providing a therapeutic procedure. A wealth of research has been published since the guidelines suggesting that results and outcomes from an aspiration may not always provide sufficient information to guide management. It is important to establish the validity of these findings in a 'real world' population. METHODS A retrospective analysis was conducted of all patients who underwent pleural fluid (PF) sampling, in a single centre, over 3 years to determine the utility of the initial aspiration. RESULTS A diagnosis of MPE was confirmed in 230/998 (23%) cases, a further 95/998 (9.5%) were presumed to represent MPE. Transudative biochemistry was found in 3% of cases of confirmed MPE. Positive PF cytology was only sufficient to guide management in 45/140 (32%) cases. Evidence of pleural thickening on CT was associated with both negative cytology (χ2 1df=26.27, p<0.001) and insufficient samples (χ2 1df=10.39, p=0.001). In NEL 44.4% of patients did not require further procedures after pleurodesis compared with 72.7% of those with expansile lung (χ2 1df=5.49, p=0.019). In patients who required a combined diagnostic and therapeutic aspiration 106/113 (93.8%) required further pleural procedures. CONCLUSIONS An initial pleural aspiration does not achieve either definitive diagnosis or therapy in the majority of patients. A new pathway prioritising symptom management while reducing procedures should be considered.
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Affiliation(s)
- Rachel Mary Mercer
- Oxford Centre for Respiratory Medicine, Churchill Hospital, Oxford, United Kingdom .,School of Pharmacy and Biomedical Sciences, University of Portsmouth, Portsmouth, UK.,Oxford Respiratory Trials Unit, Churchill Hospital, Oxford, United Kingdom
| | - Rebecca Varatharajah
- Oxford Centre for Respiratory Medicine, Churchill Hospital, Oxford, United Kingdom
| | - Gillian Shepherd
- Oxford Centre for Respiratory Medicine, Churchill Hospital, Oxford, United Kingdom
| | - Qiang Lu
- Oxford Centre for Respiratory Medicine, Churchill Hospital, Oxford, United Kingdom
| | - Olalla Castro-Añón
- Oxford Centre for Respiratory Medicine, Churchill Hospital, Oxford, United Kingdom.,Respiratory Division and Sleep Disorders Unit, Lucus Augusti University Hospital, Lugo, Spain
| | - David J McCracken
- Oxford Centre for Respiratory Medicine, Churchill Hospital, Oxford, United Kingdom
| | - Alexandra Dudina
- Oxford Centre for Respiratory Medicine, Churchill Hospital, Oxford, United Kingdom
| | - Dinesh Addala
- Oxford Centre for Respiratory Medicine, Churchill Hospital, Oxford, United Kingdom
| | - Stamatoula Tsikrika
- Oxford Centre for Respiratory Medicine, Churchill Hospital, Oxford, United Kingdom.,Pulmonary Division, Department of Critical Care, Medical School, National and Kapodistrian, University of Athens, Evangelismos General Hospital, Athens, Greece
| | - Vineeth George
- Oxford Centre for Respiratory Medicine, Churchill Hospital, Oxford, United Kingdom
| | - Radhika Banka
- Oxford Centre for Respiratory Medicine, Churchill Hospital, Oxford, United Kingdom
| | - Rachelle Asciak
- Oxford Centre for Respiratory Medicine, Churchill Hospital, Oxford, United Kingdom
| | - Maged Hassan
- Oxford Centre for Respiratory Medicine, Churchill Hospital, Oxford, United Kingdom.,Chest Diseases Department, Faculty of Medicine, Alexandria University, Alexandria, Egypt
| | - Robert Hallifax
- Oxford Centre for Respiratory Medicine, Churchill Hospital, Oxford, United Kingdom
| | - Eihab O Bedawi
- Oxford Centre for Respiratory Medicine, Churchill Hospital, Oxford, United Kingdom
| | - Janis Kay Shute
- School of Pharmacy and Biomedical Sciences, University of Portsmouth, Portsmouth, UK
| | - Najib M Rahman
- Oxford Centre for Respiratory Medicine, Churchill Hospital, Oxford, United Kingdom.,Oxford Respiratory Trials Unit, Churchill Hospital, Oxford, United Kingdom.,Oxford NIHR Biomedical Research Centre, University of Oxford and Oxford University Hospitals, Oxford, UK
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24
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Hassan M, Patel S, Sadaka AS, Bedawi EO, Corcoran JP, Porcel JM. Recent Insights into the Management of Pleural Infection. Int J Gen Med 2021; 14:3415-3429. [PMID: 34290522 PMCID: PMC8286963 DOI: 10.2147/ijgm.s292705] [Citation(s) in RCA: 16] [Impact Index Per Article: 5.3] [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] [Received: 05/27/2021] [Accepted: 06/29/2021] [Indexed: 01/15/2023] Open
Abstract
Pleural infection in adults has considerable morbidity and continues to be a life-threatening condition. The term “pleural infection” encompasses complicated parapneumonic effusions and primary pleural infections, and includes but is not limited to empyema, which refers to collection of pus in the pleural cavity. The incidence of pleural infection in adults has been continuously increasing over the past two decades, particularly in older adults, and most of such patients have comorbidities. Management of pleural infection requires prolonged duration of hospitalization (average 14 days). There are recognized differences in microbial etiology of pleural infection depending on whether the infection was acquired in the community or in a health-care setting. Anaerobic bacteria are acknowledged as a major cause of pleural infection, and thus anaerobic coverage in antibiotic regimens for pleural infection is mandatory. The key components of managing pleural infection are appropriate antimicrobial therapy and chest-tube drainage. In patients who fail medical therapy by manifesting persistent sepsis despite standard measures, surgical intervention to clear the infected space or intrapleural fibrinolytic therapy (in poor surgical candidates) are recommended. Recent studies have explored the role of early intrapleural fibrinolytics or first-line surgery, but due to considerable costs of such interventions and the lack of convincing evidence of improved outcomes with early use, early intervention cannot be recommended, and further evidence is awaited from ongoing studies. Other areas of research include the role of routine molecular testing of infected pleural fluid in improving the rate of identification of causative organisms. Other research topics include the benefit of such interventions as medical thoracoscopy, high-volume pleural irrigation with saline/antiseptic solution, and repeated thoracentesis (as opposed to chest-tube drainage) in reducing morbidity and improving outcomes of pleural infection. This review summarizes current knowledge and practice in managing pleural infection and future research directions.
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Affiliation(s)
- Maged Hassan
- Chest Diseases Department, Alexandria University Faculty of Medicine, Alexandria, Egypt
| | - Shefaly Patel
- Oxford Centre for Respiratory Medicine, Oxford University Hospitals, Oxford, UK
| | - Ahmed S Sadaka
- Chest Diseases Department, Alexandria University Faculty of Medicine, Alexandria, Egypt
| | - Eihab O Bedawi
- Oxford Centre for Respiratory Medicine, Oxford University Hospitals, Oxford, UK
| | - John P Corcoran
- Department of Respiratory Medicine, University Hospitals Plymouth NHS Trust, Plymouth, UK
| | - José M Porcel
- Department of Internal Medicine, Arnau de Vilanova University Hospital, Lleida, Spain
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25
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Bedawi EO, Moore T, Turner GD, McCole M, Gleeson FV, Rahman NM. Female patient with recurrent chest infections and non-resolving consolidation. Thorax 2021; 76:522-524. [PMID: 33268454 PMCID: PMC7712926 DOI: 10.1136/thoraxjnl-2020-216168] [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] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/08/2020] [Revised: 10/23/2020] [Accepted: 10/26/2020] [Indexed: 11/03/2022]
Affiliation(s)
- Eihab O Bedawi
- Oxford Centre for Respiratory Medicine, Oxford University Hospitals NHS Foundation Trust, Oxford, Oxfordshire, UK
- Oxford Respiratory Trials Unit, University of Oxford, Oxford, Oxfordshire, UK
| | - Thomas Moore
- Oxford Centre for Respiratory Medicine, Oxford University Hospitals NHS Foundation Trust, Oxford, Oxfordshire, UK
| | - Gareth D Turner
- Department of Cellular Pathology, Oxford University Hospitals NHS Trust, Oxford, Oxfordshire, UK
- Nuffield Division of Clinical Laboratory Sciences, Radcliffe Department of Medicine, University of Oxford, Oxford, Oxfordshire, UK
| | - Mark McCole
- Department of Cellular Pathology, Oxford University Hospitals NHS Trust, Oxford, Oxfordshire, UK
| | - Fergus V Gleeson
- Departments of Radiology and Nuclear Medicine, Oxford University Hospitals NHS Trust, Oxford, Oxfordshire, UK
| | - Najib M Rahman
- Oxford Centre for Respiratory Medicine, Oxford University Hospitals NHS Foundation Trust, Oxford, Oxfordshire, UK
- Oxford Respiratory Trials Unit, University of Oxford, Oxford, Oxfordshire, UK
- NIHR Oxford Biomedical Research Centre, University of Oxford, Oxford, Oxfordshire, UK
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26
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Asciak R, Kanellakis NI, Yao X, Abd Hamid M, Mercer RM, Hassan M, Bedawi EO, Dobson M, Fsadni P, Montefort S, Dong T, Rahman NM, Psallidas I. Pleural Fluid Has Pro-Growth Biological Properties Which Enable Cancer Cell Proliferation. Front Oncol 2021; 11:658395. [PMID: 33996582 PMCID: PMC8115017 DOI: 10.3389/fonc.2021.658395] [Citation(s) in RCA: 9] [Impact Index Per Article: 3.0] [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: 01/25/2021] [Accepted: 03/15/2021] [Indexed: 12/14/2022] Open
Abstract
Objectives Patients with malignant pleural mesothelioma (MPM) or pleural metastases often present with malignant pleural effusion (MPE). This study aimed to analyze the effect of pleural fluid on cancer cells. Materials and Methods Established patient-derived cancer cell cultures derived from MPE (MPM, breast carcinoma, lung adenocarcinoma) were seeded in 100% pleural fluid (exudate MPM MPE, transudate MPE, non-MPE transudate fluid) and proliferation was monitored. In addition, the establishment of new MPM cell cultures, derived from MPE specimens, was attempted by seeding the cells in 100% MPE fluid. Results All established cancer cell cultures proliferated with similar growth rates in the different types of pleural fluid. Primary MPM cell culture success was similar with MPE fluid as with full culture medium. Conclusions Pleural fluid alone is adequate for cancer cell proliferation in vitro, regardless of the source of pleural fluid. These results support the hypothesis that pleural fluid has important pro-growth biological properties, but the mechanisms for this effect are unclear and likely not malignant effusion specific.
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Affiliation(s)
- Rachelle Asciak
- Oxford Centre for Respiratory Medicine, Churchill Hospital, Oxford University Hospitals NHS Foundation Trust, Oxford, United Kingdom.,Laboratory of Pleural and Lung Cancer Translational Research, Nuffield Department of Medicine, University of Oxford, Oxford, United Kingdom.,Mater Dei Hospital, Msida, Malta
| | - Nikolaos I Kanellakis
- Oxford Centre for Respiratory Medicine, Churchill Hospital, Oxford University Hospitals NHS Foundation Trust, Oxford, United Kingdom.,Laboratory of Pleural and Lung Cancer Translational Research, Nuffield Department of Medicine, University of Oxford, Oxford, United Kingdom.,National Institute for Health Research Oxford Biomedical Research Centre, University of Oxford, Oxford, United Kingdom.,Chinese Academy of Medical Sciences Oxford Institute, Nuffield Department of Medicine, University of Oxford, Oxford, United Kingdom
| | - Xuan Yao
- Chinese Academy of Medical Sciences Oxford Institute, Nuffield Department of Medicine, University of Oxford, Oxford, United Kingdom.,MRC Human Immunology Unit, MRC Weatherall Institute of Molecular Medicine, University of Oxford, Oxford, United Kingdom
| | - Megat Abd Hamid
- Chinese Academy of Medical Sciences Oxford Institute, Nuffield Department of Medicine, University of Oxford, Oxford, United Kingdom.,MRC Human Immunology Unit, MRC Weatherall Institute of Molecular Medicine, University of Oxford, Oxford, United Kingdom
| | - Rachel M Mercer
- Oxford Centre for Respiratory Medicine, Churchill Hospital, Oxford University Hospitals NHS Foundation Trust, Oxford, United Kingdom
| | - Maged Hassan
- Oxford Centre for Respiratory Medicine, Churchill Hospital, Oxford University Hospitals NHS Foundation Trust, Oxford, United Kingdom
| | - Eihab O Bedawi
- Oxford Centre for Respiratory Medicine, Churchill Hospital, Oxford University Hospitals NHS Foundation Trust, Oxford, United Kingdom
| | - Melissa Dobson
- Oxford Respiratory Trials Unit, Nuffield Department of Medicine, University of Oxford, Oxford, United Kingdom
| | | | | | - Tao Dong
- Chinese Academy of Medical Sciences Oxford Institute, Nuffield Department of Medicine, University of Oxford, Oxford, United Kingdom.,MRC Human Immunology Unit, MRC Weatherall Institute of Molecular Medicine, University of Oxford, Oxford, United Kingdom
| | - Najib M Rahman
- Oxford Centre for Respiratory Medicine, Churchill Hospital, Oxford University Hospitals NHS Foundation Trust, Oxford, United Kingdom.,Laboratory of Pleural and Lung Cancer Translational Research, Nuffield Department of Medicine, University of Oxford, Oxford, United Kingdom.,National Institute for Health Research Oxford Biomedical Research Centre, University of Oxford, Oxford, United Kingdom.,Oxford Respiratory Trials Unit, Nuffield Department of Medicine, University of Oxford, Oxford, United Kingdom
| | - Ioannis Psallidas
- Oxford Centre for Respiratory Medicine, Churchill Hospital, Oxford University Hospitals NHS Foundation Trust, Oxford, United Kingdom.,Laboratory of Pleural and Lung Cancer Translational Research, Nuffield Department of Medicine, University of Oxford, Oxford, United Kingdom.,Research and Early Development, Respiratory & Immunology, AstraZeneca, Cambridge, United Kingdom
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27
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Abstract
Pleural infection and malignancy are among the most common causes of pleural disease and form the mainstay of pleural practice. There has been significant research and increase in scientific understanding in these areas in the past decade. With regard to pleural infection, the rising incidence remains worrying. An increased awareness allowing earlier diagnosis, earlier escalation of therapy and the use of validated risk stratification measures may improve outcomes. In pleural malignancy, research has enabled clinicians to streamline patient pathways with focus on reducing time to diagnosis, definitive management of malignant pleural effusion and achieving these with the minimum number of pleural interventions. Trials comparing treatment modalities of malignant pleural effusion continue to highlight the importance of patient choice in clinical decision-making. This article aims to summarise some of the most recent literature informing current practice in these two areas.
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Affiliation(s)
- Eihab O Bedawi
- Oxford Pleural Unit, Oxford Centre for Respiratory Medicine, Oxford University Hospitals, Oxford, UK
| | - Julien Guinde
- Dept of Thoracic Oncology, Pleural Diseases and Interventional Pulmonology, North University Hospital, Marseille, France
| | - Najiib M Rahman
- Oxford Pleural Unit, Oxford Centre for Respiratory Medicine, Oxford University Hospitals, Oxford, UK
- NIHR Biomedical Research Centre, University of Oxford, Oxford, UK
| | - Philippe Astoul
- Dept of Thoracic Oncology, Pleural Diseases and Interventional Pulmonology, North University Hospital, Marseille, France
- Aix-Marseille University, Marseille, France
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28
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Laursen CB, Clive A, Hallifax R, Pietersen PI, Asciak R, Davidsen JR, Bhatnagar R, Bedawi EO, Jacobsen N, Coleman C, Edey A, Via G, Volpicelli G, Massard G, Raimondi F, Evison M, Konge L, Annema J, Rahman NM, Maskell N. European Respiratory Society statement on thoracic ultrasound. Eur Respir J 2021; 57:13993003.01519-2020. [PMID: 33033148 DOI: 10.1183/13993003.01519-2020] [Citation(s) in RCA: 58] [Impact Index Per Article: 19.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/01/2020] [Accepted: 08/20/2020] [Indexed: 12/19/2022]
Abstract
Thoracic ultrasound is increasingly considered to be an essential tool for the pulmonologist. It is used in diverse clinical scenarios, including as an adjunct to clinical decision making for diagnosis, a real-time guide to procedures and a predictor or measurement of treatment response. The aim of this European Respiratory Society task force was to produce a statement on thoracic ultrasound for pulmonologists using thoracic ultrasound within the field of respiratory medicine. The multidisciplinary panel performed a review of the literature, addressing major areas of thoracic ultrasound practice and application. The selected major areas include equipment and technique, assessment of the chest wall, parietal pleura, pleural effusion, pneumothorax, interstitial syndrome, lung consolidation, diaphragm assessment, intervention guidance, training and the patient perspective. Despite the growing evidence supporting the use of thoracic ultrasound, the published literature still contains a paucity of data in some important fields. Key research questions for each of the major areas were identified, which serve to facilitate future multicentre collaborations and research to further consolidate an evidence-based use of thoracic ultrasound, for the benefit of the many patients being exposed to clinicians using thoracic ultrasound.
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Affiliation(s)
- Christian B Laursen
- Dept of Respiratory Medicine, Odense University Hospital, Odense, Denmark .,Dept of Clinical Research, Faculty of Health Sciences, University of Southern Denmark, Odense, Denmark
| | - Amelia Clive
- Academic Respiratory Unit, University of Bristol, Bristol, UK.,Southmead Hospital, North Bristol NHS Trust, Bristol, UK
| | - Rob Hallifax
- Oxford Centre for Respiratory Medicine, Churchill Hospital, Oxford University Hospitals NHS Foundation Trust, Oxford, UK.,Oxford Respiratory Trials Unit, Nuffield Dept of Medicine, University of Oxford, Oxford, UK
| | - Pia Iben Pietersen
- Dept of Respiratory Medicine, Odense University Hospital, Odense, Denmark.,Dept of Clinical Research, Faculty of Health Sciences, University of Southern Denmark, Odense, Denmark.,Regional Center for Technical Simulation, Odense University Hospital, Odense, Denmark
| | - Rachelle Asciak
- Oxford Centre for Respiratory Medicine, Churchill Hospital, Oxford University Hospitals NHS Foundation Trust, Oxford, UK.,Oxford Respiratory Trials Unit, Nuffield Dept of Medicine, University of Oxford, Oxford, UK
| | - Jesper Rømhild Davidsen
- Dept of Respiratory Medicine, Odense University Hospital, Odense, Denmark.,Dept of Clinical Research, Faculty of Health Sciences, University of Southern Denmark, Odense, Denmark.,South Danish Center for Interstitial Lung Diseases (SCILS), Odense University Hospital, Odense, Denmark
| | - Rahul Bhatnagar
- Academic Respiratory Unit, University of Bristol, Bristol, UK.,Southmead Hospital, North Bristol NHS Trust, Bristol, UK
| | - Eihab O Bedawi
- Oxford Centre for Respiratory Medicine, Churchill Hospital, Oxford University Hospitals NHS Foundation Trust, Oxford, UK.,Oxford Respiratory Trials Unit, Nuffield Dept of Medicine, University of Oxford, Oxford, UK
| | - Niels Jacobsen
- Dept of Respiratory Medicine, Odense University Hospital, Odense, Denmark.,Dept of Clinical Research, Faculty of Health Sciences, University of Southern Denmark, Odense, Denmark.,Regional Center for Technical Simulation, Odense University Hospital, Odense, Denmark
| | | | - Anthony Edey
- Dept of Radiology, Southmead Hospital, North Bristol NHS Trust, Bristol, UK
| | - Gabriele Via
- Cardiac Anesthesia and Intensive Care, Cardiocentro Ticino, Lugano, Switzerland
| | | | - Gilbert Massard
- Faculty of Science, Technology and Medicine, University of Luxembourg, Grand-Duchy of Luxembourg
| | - Francesco Raimondi
- Division of Neonatology, Section of Pediatrics, Dept of Translational Medical Sciences, Università "Federico II" di Napoli, Naples, Italy
| | - Matthew Evison
- Wythenshawe Hospital, Manchester University NHS Foundation Trust, Manchester, UK
| | - Lars Konge
- Copenhagen Academy for Medical Education and Simulation, The Capital Region of Denmark, Centre for HR, University of Copenhagen, Copenhagen, Denmark
| | - Jouke Annema
- Dept of Respiratory Medicine, Amsterdam UMC, University of Amsterdam, Amsterdam, The Netherlands
| | - Najib M Rahman
- Oxford Centre for Respiratory Medicine, Churchill Hospital, Oxford University Hospitals NHS Foundation Trust, Oxford, UK.,Oxford Respiratory Trials Unit, Nuffield Dept of Medicine, University of Oxford, Oxford, UK.,Laboratory of Pleural and Lung Cancer Translational Research, Nuffield Dept of Medicine, University of Oxford, Oxford, UK.,National Institute for Health Research, Oxford Biomedical Research Centre, University of Oxford, Oxford, UK.,Joint last authors
| | - Nick Maskell
- Academic Respiratory Unit, University of Bristol, Bristol, UK.,Southmead Hospital, North Bristol NHS Trust, Bristol, UK.,Joint last authors
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29
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Chaddha U, Agrawal A, Feller-Kopman D, Kaul V, Shojaee S, Maldonado F, Ferguson MK, Blyth KG, Grosu HB, Corcoran JP, Sachdeva A, West A, Bedawi EO, Majid A, Mehta RM, Folch E, Liberman M, Wahidi MM, Gangadharan SP, Roberts ME, DeCamp MM, Rahman NM. Use of fibrinolytics and deoxyribonuclease in adult patients with pleural empyema: a consensus statement. Lancet Respir Med 2021; 9:1050-1064. [PMID: 33545086 DOI: 10.1016/s2213-2600(20)30533-6] [Citation(s) in RCA: 20] [Impact Index Per Article: 6.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Received: 09/15/2020] [Revised: 11/09/2020] [Accepted: 11/10/2020] [Indexed: 02/06/2023]
Abstract
Although our understanding of the pathogenesis of empyema has grown tremendously over the past few decades, questions still remain on how to optimally manage this condition. It has been almost a decade since the publication of the MIST2 trial, but there is still an extensive debate on the appropriate use of intrapleural fibrinolytic and deoxyribonuclease therapy in patients with empyema. Given the scarcity of overall guidance on this subject, we convened an international group of 22 experts from 20 institutions across five countries with experience and expertise in managing adult patients with empyema. We did a literature and internet search for reports addressing 11 clinically relevant questions pertaining to the use of intrapleural fibrinolytic and deoxyribonuclease therapy in adult patients with bacterial empyema. This Position Paper, consisting of seven graded and four ungraded recommendations, was formulated by a systematic and rigorous process involving the evaluation of published evidence, augmented with provider experience when necessary. Panel members participated in the development of the final recommendations using the modified Delphi technique. Our Position Paper aims to address the existing gap in knowledge and to provide consensus-based recommendations to offer guidance in clinical decision making when considering the use of intrapleural therapy in adult patients with bacterial empyema.
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Affiliation(s)
- Udit Chaddha
- Division of Pulmonary, Critical Care and Sleep Medicine, Icahn School of Medicine at Mount Sinai, New York, NY, USA.
| | - Abhinav Agrawal
- Division of Pulmonary, Critical Care and Sleep Medicine, Donald and Barbara Zucker School of Medicine at Hofstra-Northwell, New Hyde Park, NY, USA
| | - David Feller-Kopman
- Department of Otolaryngology-Head and Neck Surgery, Johns Hopkins University, Baltimore, MD, USA
| | - Viren Kaul
- Department of Pulmonary and Critical Care Medicine, Crouse Health-SUNY Upstate Medical University, Syracuse, NY, USA
| | - Samira Shojaee
- Department of Medicine, Division of Pulmonary and Critical Care Medicine, Virginia Commonwealth University, Richmond, VA, USA
| | - Fabien Maldonado
- Division of Allergy, Pulmonary and Critical Care Medicine, Vanderbilt University Medical Center, Nashville, TN, USA
| | - Mark K Ferguson
- Section of Thoracic Surgery, University of Chicago Medical Center, Chicago, IL, USA
| | - Kevin G Blyth
- Institute of Cancer Sciences and Glasgow Pleural Disease Unit, University of Glasgow, Glasgow, UK
| | - Horiana B Grosu
- The University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | - John P Corcoran
- Interventional Pulmonology Service, University Hospitals Plymouth NHS Trust, Plymouth, UK
| | - Ashutosh Sachdeva
- Division of Pulmonary and Critical Care Medicine, University of Maryland, Baltimore, MD, USA
| | - Alex West
- Guy's and St Thomas' NHS Foundation Trust, London, UK
| | - Eihab O Bedawi
- Oxford Centre for Respiratory Medicine, Oxford University Hospitals NHS Trust, Oxford, UK; Oxford Respiratory Trials Unit, University of Oxford, Oxford, UK
| | - Adnan Majid
- Department of Surgery, Division of Thoracic Surgery and Interventional Pulmonology, Beth Israel Deaconess Medical Center, Massachusetts General Hospital Harvard Medical School, Boston, MA, USA
| | - Ravindra M Mehta
- Department of Pulmonary and Critical Care, Apollo Hospitals, Bangalore, India
| | - Erik Folch
- Complex Chest Disease Center, Beth Israel Deaconess Medical Center, Massachusetts General Hospital Harvard Medical School, Boston, MA, USA
| | - Moishe Liberman
- Division of Thoracic Surgery, University of Montreal, Montreal, QC, Canada
| | - Momen M Wahidi
- Department of Medicine, Division of Pulmonary, Allergy and Critical Care, Duke University Medical Center, Durham, NC, USA
| | - Sidhu P Gangadharan
- Department of Surgery, Division of Thoracic Surgery and Interventional Pulmonology, Beth Israel Deaconess Medical Center, Massachusetts General Hospital Harvard Medical School, Boston, MA, USA
| | - Mark E Roberts
- Sherwood Forest Hospitals NHS Foundation Trust, Sutton-in-Ashfield, UK
| | - Malcolm M DeCamp
- Division of Cardiothoracic Surgery, University of Wisconsin, Madison, WI, USA
| | - Najib M Rahman
- Oxford Respiratory Trials Unit, University of Oxford, Oxford, UK
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30
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Mei F, Bonifazi M, Rota M, Cirilli L, Grilli M, Duranti C, Zuccatosta L, Bedawi EO, McCracken D, Gasparini S, Rahman NM. Diagnostic Yield and Safety of Image-Guided Pleural Biopsy: A Systematic Review and Meta-Analysis. Respiration 2020; 100:77-87. [PMID: 33373985 DOI: 10.1159/000511626] [Citation(s) in RCA: 20] [Impact Index Per Article: 5.0] [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: 07/07/2020] [Accepted: 09/15/2020] [Indexed: 11/19/2022] Open
Abstract
BACKGROUND Diagnostic yield (DY) and safety of computed tomography (CT)- and thoracic ultrasound (TUS)-guided biopsies in the diagnosis of pleural lesions have been investigated in a number of studies, but no synthesis of data from the literature has ever been performed. OBJECTIVES We aimed to provide the first systematic review and meta-analysis on the DY and safety of CT- versus TUS-guided biopsy in the diagnosis of pleural lesions. METHOD We searched MEDLINE and EMBASE for all studies reporting outcomes of interest published up to April 2018. Two authors reviewed all titles/abstracts and retrieved selected full text to identify studies according to predefined selection criteria. Summary estimates were derived using the random-effects model. Cumulative meta-analysis assessed the influence of increasing adoption of the procedures over time. RESULTS Thirty original studies were included in the present review; the number of studies on TUS-guided biopsy was almost three-fold higher than those on CT-guided biopsy. The pooled DYs of the 2 procedures were overall excellent and differed <10%, being 84% for TUS-guided biopsy and 93% for CT-guided biopsy. Safety profiles were reassuring for both the techniques, being 7 and 3% for CT- and TUS-guided biopsy, respectively. DY of ultrasound technique significantly improved over time, while no time effect was observed for CT-guided biopsy. CONCLUSIONS Data show that CT- and TUS-guided biopsies in the diagnosis of pleural lesions are both excellent procedures, without meaningful differences in DYs and safety. Considering that TUS is non-ionizing and easily performed at the bedside, it should be the preferred approach in presence of adequate skills.
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Affiliation(s)
- Federico Mei
- Respiratory Diseases Unit, Department of Internal Medicine, Azienda Ospedaliero-Universitaria, Ospedali Riuniti, Ancona, Italy,
| | - Martina Bonifazi
- Respiratory Diseases Unit, Department of Internal Medicine, Azienda Ospedaliero-Universitaria, Ospedali Riuniti, Ancona, Italy.,Department of Biomedical Sciences and Public Health, Università Politecnica delle Marche, Ancona, Italy
| | - Matteo Rota
- Department of Molecular and Translational Medicine, Università degli Studi di Brescia, Brescia, Italy
| | - Laura Cirilli
- Department of Biomedical Sciences and Public Health, Università Politecnica delle Marche, Ancona, Italy
| | - Martina Grilli
- Respiratory Diseases Unit, Department of Internal Medicine, Azienda Ospedaliero-Universitaria, Ospedali Riuniti, Ancona, Italy
| | - Claudia Duranti
- Respiratory Diseases Unit, Department of Internal Medicine, Azienda Ospedaliero-Universitaria, Ospedali Riuniti, Ancona, Italy
| | - Lina Zuccatosta
- Respiratory Diseases Unit, Department of Internal Medicine, Azienda Ospedaliero-Universitaria, Ospedali Riuniti, Ancona, Italy
| | - Eihab O Bedawi
- Oxford Pleural Unit, Oxford University Hospitals NHS Foundation Trust, Churchill Hospital, Oxford, United Kingdom
| | - David McCracken
- Oxford Pleural Unit, Oxford University Hospitals NHS Foundation Trust, Churchill Hospital, Oxford, United Kingdom
| | - Stefano Gasparini
- Respiratory Diseases Unit, Department of Internal Medicine, Azienda Ospedaliero-Universitaria, Ospedali Riuniti, Ancona, Italy.,Department of Biomedical Sciences and Public Health, Università Politecnica delle Marche, Ancona, Italy
| | - Najib M Rahman
- Oxford Pleural Unit, Oxford University Hospitals NHS Foundation Trust, Churchill Hospital, Oxford, United Kingdom.,Oxford NIHR Biomedical Research Unit, Oxford, United Kingdom
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31
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Hassan M, Banka R, Castro-Añón O, Mercer RM, Bedawi EO, Asciak R, Stradling J, Rahman NM. Physical Activity and Sedentary Behaviour in Patients With Malignant Pleural Effusion Undergoing Therapeutic Pleural Interventions (The ASPIRE Study). Arch Bronconeumol 2020; 57:S0300-2896(20)30382-3. [PMID: 33189419 DOI: 10.1016/j.arbres.2020.09.018] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/15/2020] [Revised: 09/20/2020] [Accepted: 09/30/2020] [Indexed: 10/23/2022]
Affiliation(s)
- Maged Hassan
- Oxford Centre for Respiratory Medicine, Oxford University Hospitals NHS Trust, Oxford, UK; Chest Diseases Department, Alexandria University Faculty of Medicine, Alexandria, Egypt.
| | - Radhika Banka
- Oxford Centre for Respiratory Medicine, Oxford University Hospitals NHS Trust, Oxford, UK
| | - Olalla Castro-Añón
- Oxford Centre for Respiratory Medicine, Oxford University Hospitals NHS Trust, Oxford, UK; Pneumology Service, Lucus Augusti University Hospital, Lugo, Spain
| | - Rachel M Mercer
- Oxford Centre for Respiratory Medicine, Oxford University Hospitals NHS Trust, Oxford, UK
| | - Eihab O Bedawi
- Oxford Centre for Respiratory Medicine, Oxford University Hospitals NHS Trust, Oxford, UK
| | - Rachelle Asciak
- Oxford Centre for Respiratory Medicine, Oxford University Hospitals NHS Trust, Oxford, UK
| | - John Stradling
- Oxford Centre for Respiratory Medicine, Oxford University Hospitals NHS Trust, Oxford, UK; Oxford NIHR Biomedical Research Centre, Oxford, UK
| | - Najib M Rahman
- Oxford Centre for Respiratory Medicine, Oxford University Hospitals NHS Trust, Oxford, UK; Oxford NIHR Biomedical Research Centre, Oxford, UK
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Kanellakis NI, Asciak R, Hamid MA, Yao X, McCole M, McGowan S, Seraia E, Hatch S, Hallifax RJ, Mercer RM, Bedawi EO, Jones S, Verrill C, Dobson M, George V, Stathopoulos GT, Peng Y, Ebner D, Dong T, Rahman NM, Psallidas I. Patient-derived malignant pleural mesothelioma cell cultures: a tool to advance biomarker-driven treatments. Thorax 2020; 75:1004-1008. [PMID: 32943495 PMCID: PMC7569377 DOI: 10.1136/thoraxjnl-2020-215027] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/13/2020] [Revised: 07/03/2020] [Accepted: 07/14/2020] [Indexed: 12/17/2022]
Abstract
Malignant pleural mesothelioma (MPM) is an aggressive cancer, associated with poor prognosis. We assessed the feasibility of patient-derived cell cultures to serve as an ex vivo model of MPM. Patient-derived MPM cell cultures (n=16) exhibited stemness features and reflected intratumour and interpatient heterogeneity. A subset of the cells were subjected to high-throughput drug screening and coculture assays with cancer-specific cytotoxic T cells and showed diverse responses. Some of the biphasic MPM cells were capable of processing and presenting the neoantigen SSX-2 endogenously. In conclusion, patient-derived MPM cell cultures are a promising and faithful ex vivo model of MPM.
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Affiliation(s)
- Nikolaos I Kanellakis
- Oxford Centre for Respiratory Medicine, Churchill Hospital, Oxford University Hospitals NHS Foundation Trust, Oxford, United Kingdom .,Laboratory of Pleural and Lung Cancer Translational Research, Nuffield Department of Medicine, University of Oxford, Oxford, United Kingdom.,National Institute for Health Research Oxford Biomedical Research Centre, University of Oxford, Oxford, United Kingdom.,Oxford Respiratory Trials Unit, Nuffield Department of Medicine, University of Oxford, Oxford, United Kingdom
| | - Rachelle Asciak
- Oxford Centre for Respiratory Medicine, Churchill Hospital, Oxford University Hospitals NHS Foundation Trust, Oxford, United Kingdom.,Laboratory of Pleural and Lung Cancer Translational Research, Nuffield Department of Medicine, University of Oxford, Oxford, United Kingdom.,Oxford Respiratory Trials Unit, Nuffield Department of Medicine, University of Oxford, Oxford, United Kingdom
| | - Megat Abd Hamid
- Chinese Academy of Medical Sciences Oxford Institute, Nuffield Department of Medicine, University of Oxford, Oxford, United Kingdom.,MRC Human Immunology Unit, MRC Weatherall Institute of Molecular Medicine, University of Oxford, Oxford, United Kingdom
| | - Xuan Yao
- Chinese Academy of Medical Sciences Oxford Institute, Nuffield Department of Medicine, University of Oxford, Oxford, United Kingdom.,MRC Human Immunology Unit, MRC Weatherall Institute of Molecular Medicine, University of Oxford, Oxford, United Kingdom
| | - Mark McCole
- Cellular Pathology Department, John Radcliffe Hospital, Oxford University Hospitals NHS Foundation Trust, Oxford, United Kingdom
| | - Simon McGowan
- Computational Biology Research Group, MRC Weatherall Institute of Molecular Medicine, University of Oxford, Oxford, United Kingdom
| | - Elena Seraia
- Cellular High Throughput Screening Facility, Target Discovery Institute, Nuffield Department of Medicine, University of Oxford, Oxford, Oxfordshire, United Kingdom
| | - Stephanie Hatch
- Cellular High Throughput Screening Facility, Target Discovery Institute, Nuffield Department of Medicine, University of Oxford, Oxford, Oxfordshire, United Kingdom
| | - Rob J Hallifax
- Oxford Centre for Respiratory Medicine, Churchill Hospital, Oxford University Hospitals NHS Foundation Trust, Oxford, United Kingdom.,Oxford Respiratory Trials Unit, Nuffield Department of Medicine, University of Oxford, Oxford, United Kingdom
| | - Rachel M Mercer
- Oxford Centre for Respiratory Medicine, Churchill Hospital, Oxford University Hospitals NHS Foundation Trust, Oxford, United Kingdom.,Oxford Respiratory Trials Unit, Nuffield Department of Medicine, University of Oxford, Oxford, United Kingdom
| | - Eihab O Bedawi
- Oxford Centre for Respiratory Medicine, Churchill Hospital, Oxford University Hospitals NHS Foundation Trust, Oxford, United Kingdom.,Oxford Respiratory Trials Unit, Nuffield Department of Medicine, University of Oxford, Oxford, United Kingdom
| | - Stephanie Jones
- Oxford Radcliffe Biobank, Nuffield Department of Surgical Sciences, University of Oxford, Oxford, United Kingdom
| | - Clare Verrill
- Oxford Radcliffe Biobank, Nuffield Department of Surgical Sciences, University of Oxford, Oxford, United Kingdom
| | - Melissa Dobson
- Oxford Respiratory Trials Unit, Nuffield Department of Medicine, University of Oxford, Oxford, United Kingdom
| | - Vineeth George
- Oxford Centre for Respiratory Medicine, Churchill Hospital, Oxford University Hospitals NHS Foundation Trust, Oxford, United Kingdom.,Oxford Respiratory Trials Unit, Nuffield Department of Medicine, University of Oxford, Oxford, United Kingdom
| | - Georgios T Stathopoulos
- Molecular Lung Carcinogenesis Group, Comprehensive Pneumology Center and Institute for Lung Biology and Disease, Ludwig-Maximilians University and Helmholtz Center, Munich, Germany.,Laboratory for Molecular Respiratory Carcinogenesis, Department of Physiology, Faculty of Medicine, University of Patras, Patras, Greece
| | - Yanchun Peng
- Chinese Academy of Medical Sciences Oxford Institute, Nuffield Department of Medicine, University of Oxford, Oxford, United Kingdom.,MRC Human Immunology Unit, MRC Weatherall Institute of Molecular Medicine, University of Oxford, Oxford, United Kingdom
| | - Daniel Ebner
- Cellular High Throughput Screening Facility, Target Discovery Institute, Nuffield Department of Medicine, University of Oxford, Oxford, Oxfordshire, United Kingdom
| | - Tao Dong
- Chinese Academy of Medical Sciences Oxford Institute, Nuffield Department of Medicine, University of Oxford, Oxford, United Kingdom.,MRC Human Immunology Unit, MRC Weatherall Institute of Molecular Medicine, University of Oxford, Oxford, United Kingdom
| | - Najib M Rahman
- Oxford Centre for Respiratory Medicine, Churchill Hospital, Oxford University Hospitals NHS Foundation Trust, Oxford, United Kingdom.,Laboratory of Pleural and Lung Cancer Translational Research, Nuffield Department of Medicine, University of Oxford, Oxford, United Kingdom.,National Institute for Health Research Oxford Biomedical Research Centre, University of Oxford, Oxford, United Kingdom.,Oxford Respiratory Trials Unit, Nuffield Department of Medicine, University of Oxford, Oxford, United Kingdom
| | - Ioannis Psallidas
- Oxford Centre for Respiratory Medicine, Churchill Hospital, Oxford University Hospitals NHS Foundation Trust, Oxford, United Kingdom.,Laboratory of Pleural and Lung Cancer Translational Research, Nuffield Department of Medicine, University of Oxford, Oxford, United Kingdom.,Oxford Respiratory Trials Unit, Nuffield Department of Medicine, University of Oxford, Oxford, United Kingdom
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Mercer RM, Wigston C, Banka R, Cardillo G, Benamore R, Nicholson AG, Asciak R, Hassan M, Hallifax RJ, Wing L, Bedawi EO, Maskell NA, Harriss EK, Miller RF, Rahman NM. Management of solitary fibrous tumours of the pleura: a systematic review and meta-analysis. ERJ Open Res 2020; 6:00055-2020. [PMID: 32832532 PMCID: PMC7430150 DOI: 10.1183/23120541.00055-2020] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/04/2020] [Accepted: 05/26/2020] [Indexed: 12/24/2022] Open
Abstract
Background Solitary fibrous tumours of the pleura (SFTP), or pleural fibromas, are rare tumours that generally, but not universally, follow a benign course. Surgical resection is the standard treatment, but there are no evidence-based guidelines regarding the management of these tumours. Methods Five databases were searched from inception to April 1, 2019 for studies reporting on SFTP management. Results Twenty-seven studies met the inclusion criteria (1542 patients, all non-comparative case series); 98% of these patients underwent resection and all SFTP included were pathologically diagnosed. 394 out of 1299 cases (30.5%, 95% CI 27.8–32.8%) were malignant with recurrence rates of between 0% and 42.9%. A pleural effusion was always associated with a negative outcome, but no other features were consistently reported to have negative associations. Preoperative biopsies incorrectly reported malignant histology in two studies. Over 25% of cases of recurrence occurred when a complete (R0) resection had been achieved. The first recurrence occurred >5 years after the initial resection in at least 23% of cases. Conclusions There is strong evidence to support long-term surveillance after surgical resection of SFTP, even where a complete (R0) resection has been achieved; however, there is no clear evidence to inform clinicians regarding the selection of patients who should undergo resection. The rates of malignant SFTP and SFTP recurrence are higher than previously reported. Only those that were pathologically diagnosed or resected were included, which may bias the data towards more aggressive tumours. Data collection on radiologically diagnosed SFTP is required to draw conclusions regarding the timing and need for intervention. Long-term surveillance should be undertaken after a resection of solitary fibrous tumours of the pleura but further work is needed to determine which patients are likely to follow a malignant clinical course to decide timing and necessity of a resectionhttps://bit.ly/2U10SaA
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Affiliation(s)
- Rachel M Mercer
- University of Oxford Respiratory Trials Unit, Churchill Hospital, Oxford, UK.,Oxford Centre for Respiratory Medicine, Oxford University Hospitals NHS Trust, Oxford, UK
| | - Charlotte Wigston
- University of Oxford Respiratory Trials Unit, Churchill Hospital, Oxford, UK
| | - Radhika Banka
- University of Oxford Respiratory Trials Unit, Churchill Hospital, Oxford, UK
| | | | - Rachel Benamore
- University of Oxford Respiratory Trials Unit, Churchill Hospital, Oxford, UK
| | - Andrew G Nicholson
- Dept of Histopathology, Royal Brompton and Harefield NHS Foundation Trust, and National Heart and Lung Institute, Imperial College, London, UK
| | - Rachelle Asciak
- University of Oxford Respiratory Trials Unit, Churchill Hospital, Oxford, UK.,Oxford Centre for Respiratory Medicine, Oxford University Hospitals NHS Trust, Oxford, UK
| | - Maged Hassan
- University of Oxford Respiratory Trials Unit, Churchill Hospital, Oxford, UK.,Oxford Centre for Respiratory Medicine, Oxford University Hospitals NHS Trust, Oxford, UK.,Chest Diseases Department, Faculty of Medicine, Alexandria University, Alexandria, Egypt
| | - Robert J Hallifax
- University of Oxford Respiratory Trials Unit, Churchill Hospital, Oxford, UK.,Oxford Centre for Respiratory Medicine, Oxford University Hospitals NHS Trust, Oxford, UK
| | - Louise Wing
- University of Oxford Respiratory Trials Unit, Churchill Hospital, Oxford, UK
| | - Eihab O Bedawi
- University of Oxford Respiratory Trials Unit, Churchill Hospital, Oxford, UK.,Oxford Centre for Respiratory Medicine, Oxford University Hospitals NHS Trust, Oxford, UK
| | - Nick A Maskell
- Academic Respiratory Unit, Bristol Medical School, Southmead Hospital, University of Bristol, Bristol, UK
| | - Elinor K Harriss
- Bodleian Health Care Libraries, University of Oxford, Oxford, UK
| | - Robert F Miller
- Institute for Global Health, University College London, London, UK
| | - Najib M Rahman
- University of Oxford Respiratory Trials Unit, Churchill Hospital, Oxford, UK.,Oxford Centre for Respiratory Medicine, Oxford University Hospitals NHS Trust, Oxford, UK.,NIHR Oxford Biomedical Research Centre, University of Oxford, Oxford, UK
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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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Bedawi EO, Rahman NM. Shining Light on Pleural Biopsy in Mesothelioma: Is It Time to Get "Smart"? Chest 2019; 156:643-644. [PMID: 31590705 DOI: 10.1016/j.chest.2019.06.030] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/30/2019] [Revised: 06/27/2019] [Accepted: 06/30/2019] [Indexed: 11/26/2022] Open
Affiliation(s)
- Eihab O Bedawi
- Oxford Respiratory Trials Unit, Oxford Pleural Unit, University of Oxford, Oxford, England.
| | - Najib M Rahman
- Oxford Respiratory Trials Unit, Oxford Pleural Unit, University of Oxford, Oxford, England; NIHR Biomedical Research Centre, University of Oxford, Oxford, England
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36
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Hassan M, Cargill T, Harriss E, Asciak R, Mercer RM, Bedawi EO, McCracken DJ, Psallidas I, Corcoran JP, Rahman NM. The microbiology of pleural infection in adults: a systematic review. Eur Respir J 2019; 54:13993003.00542-2019. [PMID: 31248959 DOI: 10.1183/13993003.00542-2019] [Citation(s) in RCA: 51] [Impact Index Per Article: 10.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/16/2019] [Accepted: 06/14/2019] [Indexed: 01/24/2023]
Abstract
BACKGROUND AND OBJECTIVES Pleural infection is a major cause of morbidity and mortality among adults. Identification of the offending organism is key to appropriate antimicrobial therapy. It is not known whether the microbiological pattern of pleural infection is variable temporally or geographically. This systematic review aimed to investigate available literature to understand the worldwide pattern of microbiology and the factors that might affect such pattern. DATA SOURCES AND ELIGIBILITY CRITERIA Ovid MEDLINE and Embase were searched between 2000 and 2018 for publications that reported on the microbiology of pleural infection in adults. Both observational and interventional studies were included. Studies were excluded if the main focus of the report was paediatric population, tuberculous empyema or post-operative empyema. STUDY APPRAISAL AND SYNTHESIS METHODS Studies of ≥20 patients with clear reporting of microbial isolates were included. The numbers of isolates of each specific organism/group were collated from the included studies. Besides the overall presentation of data, subgroup analyses by geographical distribution, infection setting (community versus hospital) and time of the report were performed. RESULTS From 20 980 reports returned by the initial search, 75 articles reporting on 10 241 patients were included in the data synthesis. The most common organism reported worldwide was Staphylococcus aureus. Geographically, pneumococci and viridans streptococci were the most commonly reported isolates from tropical and temperate regions, respectively. The microbiological pattern was considerably different between community- and hospital-acquired infections, where more Gram-negative and drug-resistant isolates were reported in the hospital-acquired infections. The main limitations of this systematic review were the heterogeneity in the method of reporting of certain bacteria and the predominance of reports from Europe and South East Asia. CONCLUSIONS In pleural infection, the geographical location and the setting of infection have considerable bearing on the expected causative organisms. This should be reflected in the choice of empirical antimicrobial treatment.
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Affiliation(s)
- Maged Hassan
- Oxford Pleural Unit, Oxford University Hospitals, Oxford, UK .,Oxford Respiratory Trial Unit, University of Oxford, Oxford, UK.,Chest Diseases Dept, Alexandria Faculty of Medicine, Alexandria, Egypt
| | - Tamsin Cargill
- Oxford Pleural Unit, Oxford University Hospitals, Oxford, UK
| | - Elinor Harriss
- Bodleian Healthcare Libraries, University of Oxford, Oxford, UK
| | - Rachelle Asciak
- Oxford Pleural Unit, Oxford University Hospitals, Oxford, UK.,Oxford Respiratory Trial Unit, University of Oxford, Oxford, UK
| | - Rachel M Mercer
- Oxford Pleural Unit, Oxford University Hospitals, Oxford, UK.,Oxford Respiratory Trial Unit, University of Oxford, Oxford, UK
| | - Eihab O Bedawi
- Oxford Pleural Unit, Oxford University Hospitals, Oxford, UK.,Oxford Respiratory Trial Unit, University of Oxford, Oxford, UK
| | - David J McCracken
- Oxford Pleural Unit, Oxford University Hospitals, Oxford, UK.,Oxford Respiratory Trial Unit, University of Oxford, Oxford, UK
| | - Ioannis Psallidas
- Oxford Pleural Unit, Oxford University Hospitals, Oxford, UK.,Oxford Respiratory Trial Unit, University of Oxford, Oxford, UK
| | - John P Corcoran
- Interventional Pulmonology Service, Dept of Respiratory Medicine, University Hospitals Plymouth NHS Trust, Plymouth, UK
| | - Najib M Rahman
- Oxford Pleural Unit, Oxford University Hospitals, Oxford, UK.,Oxford Respiratory Trial Unit, University of Oxford, Oxford, UK.,Oxford NIHR Biomedical Research Centre, Oxford, UK
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37
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Cargill TN, Hassan M, Corcoran JP, Harriss E, Asciak R, Mercer RM, McCracken DJ, Bedawi EO, Rahman NM. A systematic review of comorbidities and outcomes of adult patients with pleural infection. Eur Respir J 2019; 54:13993003.00541-2019. [PMID: 31391221 PMCID: PMC6860993 DOI: 10.1183/13993003.00541-2019] [Citation(s) in RCA: 35] [Impact Index Per Article: 7.0] [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: 03/18/2019] [Accepted: 07/19/2019] [Indexed: 11/09/2022]
Abstract
Background Pleural infection remains an important cause of mortality. This study aimed to investigate worldwide patterns of pre-existing comorbidities and clinical outcomes of patients with pleural infection. Methods Studies reporting on adults with pleural infection between 2000 and 2017 were identified from a search of Embase and MEDLINE. Articles reporting exclusively on tuberculous, fungal or post-pneumonectomy infection were excluded. Two reviewers assessed 20 980 records for eligibility. Results 211 studies met the inclusion criteria. 134 articles (227 898 patients, mean age 52.8 years) reported comorbidity and/or outcome data. The majority of studies were retrospective observational cohorts (n=104, 78%) and the most common region of reporting was East Asia (n=33, 24%) followed by North America (n=27, 20%). 85 articles (50 756 patients) reported comorbidity. The median (interquartile range (IQR)) percentage prevalence of any comorbidity was 72% (58–83%), with respiratory illness (20%, 16–32%) and cardiac illness (19%, 15–27%) most commonly reported. 125 papers (192 298 patients) reported outcome data. The median (IQR) length of stay was 19 days (13–27 days) and median in-hospital or 30-day mortality was 4% (IQR 1–11%). In regions with high-income economies (n=100, 74%) patients were older (mean 56.5 versus 42.5 years, p<0.0001), but there were no significant differences in prevalence of pre-existing comorbidity nor in length of hospital stay or mortality. Conclusion Patients with pleural infection have high levels of comorbidity and long hospital stays. Most reported data are from high-income economy settings. Data from lower-income regions is needed to better understand regional trends and enable optimal resource provision going forward. In pleural infection, patients from higher-income countries tend to be older with more comorbidities and are more likely to be referred for fibrinolytic treatment in comparison to patients from lower-income countrieshttp://bit.ly/2K2M5HL
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Affiliation(s)
- Tamsin N Cargill
- Oxford Centre for Respiratory Medicine, Oxford University Hospitals NHS Trust, Oxford, UK.,Joint first authors
| | - Maged Hassan
- Oxford Centre for Respiratory Medicine, Oxford University Hospitals NHS Trust, Oxford, UK .,Joint first authors
| | - John P Corcoran
- Interventional Pulmonology Service, Respiratory Medicine Dept, University Hospitals Plymouth, Plymouth, UK
| | - Elinor Harriss
- Bodleian Health Care Libraries, University of Oxford, Oxford, UK
| | - Rachelle Asciak
- Oxford Centre for Respiratory Medicine, Oxford University Hospitals NHS Trust, Oxford, UK
| | - Rachel M Mercer
- Oxford Centre for Respiratory Medicine, Oxford University Hospitals NHS Trust, Oxford, UK
| | - David J McCracken
- Oxford Centre for Respiratory Medicine, Oxford University Hospitals NHS Trust, Oxford, UK
| | - Eihab O Bedawi
- Oxford Centre for Respiratory Medicine, Oxford University Hospitals NHS Trust, Oxford, UK
| | - Najib M Rahman
- Oxford Centre for Respiratory Medicine, Oxford University Hospitals NHS Trust, Oxford, UK
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38
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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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39
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Hassan M, Mercer RM, Maskell NA, Asciak R, McCracken DJ, Bedawi EO, Shaarawy H, El-Ganady A, Psallidas I, Miller RF, Rahman NM. Survival in patients with malignant pleural effusion undergoing talc pleurodesis. Lung Cancer 2019; 137:14-18. [PMID: 31521977 DOI: 10.1016/j.lungcan.2019.09.003] [Citation(s) in RCA: 22] [Impact Index Per Article: 4.4] [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: 04/01/2019] [Revised: 07/11/2019] [Accepted: 09/04/2019] [Indexed: 12/15/2022]
Abstract
OBJECTIVES Recent observations indicate a potential survival benefit in patients with malignant pleural effusion (MPE) who achieve successful pleurodesis in comparison to patients who experience effusion recurrence post pleurodesis. This study aimed to explore this observation using two datasets of patients with MPE undergoing talc pleurodesis. MATERIALS AND METHODS Dataset 1 comprised patients who underwent talc pleurodesis at Oxford Pleural Unit for MPE. Dataset 2 comprised patients enrolled in the TIME1 clinical trial. Pleurodesis success was defined as absence of need for further therapeutic procedures for MPE in the three months following pleurodesis. Data on various clinical, laboratory and radiological parameters were collected and survival was compared according to pleurodesis outcome (success vs. failure) after adjusting for the aforementioned parameters. RESULTS Dataset 1 comprised 60 patients with mean age 74.1±10.3 years. The most common primary malignancies were mesothelioma, breast and lung cancer. 29 patients (48.3%) achieved pleurodesis. The adjusted odds ratio (aOR) for poor survival with pleurodesis failure was 2.85 (95% CI 1.08-7.50, =p 0.034). Dataset 2 comprised 259 patients from the TIME1 trial. The mean age was 70.8±10.3 and the most common primary malignancies were mesothelioma, lung and breast cancer. Pleurodesis was successful in 205 patients (79%). aOR for poor survival was 1.62 (95% CI 1.09-2.39, p = 0.015). CONCLUSION Achieving pleurodesis seems to impart a survival benefit in patients with MPE. Further studies are required to explore factors that may contribute to this phenomenon and to address the difference in survival between pleurodesis and indwelling pleural catheter interventions.
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Affiliation(s)
- Maged Hassan
- Oxford Pleural Unit, Oxford University Hospitals NHS Foundation Trust, UK; Chest Diseases Department, Faculty of Medicine, Alexandria University, Egypt.
| | - Rachel M Mercer
- Oxford Pleural Unit, Oxford University Hospitals NHS Foundation Trust, UK
| | - Nick A Maskell
- Academic Respiratory Unit, Bristol Medical School, Southmead Hospital, University of Bristol, Bristol, UK
| | - Rachelle Asciak
- Oxford Pleural Unit, Oxford University Hospitals NHS Foundation Trust, UK
| | - David J McCracken
- Oxford Pleural Unit, Oxford University Hospitals NHS Foundation Trust, UK
| | - Eihab O Bedawi
- Oxford Pleural Unit, Oxford University Hospitals NHS Foundation Trust, UK
| | - Hany Shaarawy
- Chest Diseases Department, Faculty of Medicine, Alexandria University, Egypt
| | - Anwar El-Ganady
- Chest Diseases Department, Faculty of Medicine, Alexandria University, Egypt
| | - Ioannis Psallidas
- Oxford Pleural Unit, Oxford University Hospitals NHS Foundation Trust, UK
| | - Robert F Miller
- Institute for Global Health, University College London, London, 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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Bedawi EO, Hassan M, McCracken D, Rahman NM. Pleural infection: a closer look at the etiopathogenesis, microbiology and role of antibiotics. Expert Rev Respir Med 2019; 13:337-347. [PMID: 30707629 DOI: 10.1080/17476348.2019.1578212] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.8] [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: 12/22/2022]
Abstract
INTRODUCTION Pleural infection is a condition that continues to pose a significant challenge to respiratory physicians. We hypothesize that the main barriers to progress include limited understanding of the etiopathogenesis, microbiology,and role of antibiotics in the pleural space. Areas covered: PubMed was searched for articles related to adult pleural infection using the terms 'pleural infection', 'empyema' and 'parapneumonic'. The search focused on relevant literature within the last 10 years, with any older citations used only to display context or lack of progress. Tuberculous pleural infection was excluded. We chose to give specific attention to the etiopathogenesis of pleural infection, including recent advances in diagnostics and biomarkers. We discuss our understanding of the pleural microbiome and rationalize the current use of antibiotics in treating this condition. Expert commentary: Understanding of key events in the development of this condition remains limited. The microbiology is unique compared to the lung, and highly variable. Higher culture yields from pleural biopsy may add new insights into the etiopathogenesis. There is little evidence into achievable effective antibiotic concentration within the pleura. Research into issues including the relevance of biofilm formation and significance of pleural thickening is necessary for treatment progress.
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Affiliation(s)
- Eihab O Bedawi
- a Oxford Pleural Unit , Oxford University Hospitals , Oxford , UK.,b Oxford Respiratory Trials Unit , University of Oxford , Oxford , UK
| | - Maged Hassan
- a Oxford Pleural Unit , Oxford University Hospitals , Oxford , UK.,b Oxford Respiratory Trials Unit , University of Oxford , Oxford , UK.,c Chest Diseases Department, Faculty of Medicine , Alexandria University , Alexandria , Egypt
| | - David McCracken
- a Oxford Pleural Unit , Oxford University Hospitals , Oxford , UK.,b Oxford Respiratory Trials Unit , University of Oxford , Oxford , UK
| | - Najib M Rahman
- a Oxford Pleural Unit , Oxford University Hospitals , Oxford , UK.,b Oxford Respiratory Trials Unit , University of Oxford , Oxford , UK.,d Oxford NIHR Biomedical Research Centre , Oxford , UK
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McCracken DJ, Bedawi EO, Hassan M, Stavroulias D, Rahman NM. Secondary pneumothorax in end-stage lung disease complicated by noninvasive ventilation and a persistent air leak. Breathe (Sheff) 2019; 14:e119-e122. [PMID: 30820251 PMCID: PMC6388652 DOI: 10.1183/20734735.027318] [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] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022] Open
Abstract
Pneumothorax is a well-recognised complication of end-stage COPD, but the management is often complex and may be complicated by other sequelae of advanced respiratory disease including the requirement for NIV http://ow.ly/vkoJ30mB4nZ.
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Affiliation(s)
- David J McCracken
- Oxford Pleural Unit, Churchill Hospital, Oxford, UK.,Oxford Respiratory Trials Unit, Churchill Hospital, Oxford, UK
| | - Eihab O Bedawi
- Oxford Pleural Unit, Churchill Hospital, Oxford, UK.,Oxford Respiratory Trials Unit, Churchill Hospital, Oxford, UK
| | - Maged Hassan
- Oxford Pleural Unit, Churchill Hospital, Oxford, UK.,Oxford Respiratory Trials Unit, Churchill Hospital, Oxford, UK
| | | | - Najib M Rahman
- Oxford Pleural Unit, Churchill Hospital, Oxford, UK.,Oxford Respiratory Trials Unit, Churchill Hospital, Oxford, UK
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Bedawi EO, Hassan M, Rahman NM. Recent developments in the management of pleural infection: A comprehensive review. Clin Respir J 2018; 12:2309-2320. [PMID: 30005142 DOI: 10.1111/crj.12941] [Citation(s) in RCA: 32] [Impact Index Per Article: 5.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 03/06/2018] [Revised: 06/25/2018] [Accepted: 06/27/2018] [Indexed: 11/29/2022]
Abstract
OBJECTIVES Pleural infection is a condition commonly encountered by the respiratory physician. This review aims to provide the reader with an update on the most recent data regarding the epidemiology, microbiology, and the management of pleural infection. DATA SOURCE Medline was searched for articles related to pleural infection using the terms "pleural infection," "empyema," and "parapneumonic." The search was limited to the years 1997-2017. Only human studies and reports in English were included. RESULTS A rise in the incidence of pleural infection is seen worldwide. Despite the improvement in healthcare practices, the mortality from pleural infection remains high. The role of oral microflora in the etiology of pleural infection is firmly established. A concise review of the recent insights on the pathogenesis of pleural infections is presented. A particular focus is made on the role of tPA, DNAse and similar substances and their interaction with inflammatory cells and how this affects the pathogenesis and treatment of pleural infection. CONCLUSION Pleural infection is a common disease with significant morbidity and mortality, as well as a considerable economic burden. The role of medical management is expanding thanks to the widespread use of newer treatments.
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Affiliation(s)
- Eihab O Bedawi
- Oxford Centre for Respiratory Medicine, Oxford University Hospitals, Oxford, United Kingdom.,Oxford Respiratory Trials Unit, University of Oxford, Oxford, United Kingdom
| | - Maged Hassan
- Oxford Centre for Respiratory Medicine, Oxford University Hospitals, Oxford, United Kingdom.,Oxford Respiratory Trials Unit, University of Oxford, Oxford, United Kingdom.,Chest Diseases Department, Faculty of Medicine, Alexandria University, Alexandria, Egypt
| | - Najib M Rahman
- Oxford Centre for Respiratory Medicine, Oxford University Hospitals, Oxford, United Kingdom.,Oxford Respiratory Trials Unit, University of Oxford, Oxford, United Kingdom.,NIHR Oxford Biomedical Research Centre, University of Oxford, Oxford, United Kingdom
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Affiliation(s)
- Eihab O Bedawi
- Oxford Centre for Respiratory Medicine, Oxford University Hospitals, Oxford, UK.,Oxford Respiratory Trials Unit, University of Oxford, Oxford, UK
| | - Lonny Yarmus
- Division of Pulmonary and Critical Care, Johns Hopkins University, Baltimore, MD, USA
| | - Najib M Rahman
- Oxford Centre for Respiratory Medicine, Oxford University Hospitals, Oxford, UK.,Oxford Respiratory Trials Unit, University of Oxford, Oxford, UK.,NIHR Oxford Biomedical Research Centre, University of Oxford, Oxford, UK
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