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Barton EC, Maskell NA, Walker SP. Expert Review on Spontaneous Pneumothorax: Advances, Controversies, and New Directions. Semin Respir Crit Care Med 2023. [PMID: 37321247 DOI: 10.1055/s-0043-1769615] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/17/2023]
Abstract
For decades, there has been scanty evidence, most of which is of poor quality, to guide clinicians in the assessment and management of pneumothorax. A recent surge in pneumothorax research has begun to address controversies surrounding the topic and change the face of pneumothorax management. In this article, we review controversies concerning the etiology, pathogenesis, and classification of pneumothorax, and discuss recent advances in its management, including conservative and ambulatory management. We review the evidence base for the challenges of managing pneumothorax, including persistent air leak, and suggest new directions for future research that can help provide patient-centered, evidence-based management for this challenging cohort of patients.
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Hallifax RJ, Iqbal B, Walker SP, Maskell NA, Rahman NM. Aspirating Pneumothorax: Clearing the Air or Muddying the Water? Am J Respir Crit Care Med 2023; 207:1647-1648. [PMID: 37084396 PMCID: PMC10273119 DOI: 10.1164/rccm.202303-0593le] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 04/23/2023] Open
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Hallifax RJ, Walker SP, Maskell NA, Rahman NM. Reply to Albert and Dhooria et al.. Am J Respir Crit Care Med 2023; 207:226-227. [PMID: 36070598 PMCID: PMC9893321 DOI: 10.1164/rccm.202209-1642le] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/18/2023] Open
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Arnold DT, Tucker E, Morley A, Milne A, Stadon L, Patole S, Nava GW, Walker SP, Maskell NA. A feasibility randomised trial comparing therapeutic thoracentesis to chest tube insertion for the management of pleural infection: results from the ACTion trial. BMC Pulm Med 2022; 22:330. [PMID: 36042460 PMCID: PMC9425800 DOI: 10.1186/s12890-022-02126-4] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/13/2022] [Accepted: 08/02/2022] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND Pleural infection is a complex condition with a considerable healthcare burden. The average hospital stay for pleural infection is 14 days. Current standard of care defaults to chest tube insertion and intravenous antibiotics. There have been no randomised trials on the use of therapeutic thoracentesis (TT) for pleural fluid drainage in pleural infection. AIMS AND OBJECTIVES To assess the feasibility of a full-scale trial of chest tube vs TT for pleural infection in a single UK centre. The primary outcome was defined as the acceptability of randomisation to patients. METHODS Adult patients admitted with a pleural effusion felt to be related to infection and meeting criteria for drainage (based on international guidelines) were eligible for randomisation. Participants were randomised (1:1) to chest tube insertion or TT with daily review assessing need for further drainages or other therapies. Neither participant nor clinician were blinded to treatment allocation. Patients were followed up at 90 days post-randomisation. RESULTS From September 2019 to June 2021, 51 patients were diagnosed with pleural infection (complex parapneumonic effusion/empyema). Eleven patients met the inclusion criteria for trial and 10 patients were randomised (91%). The COVID-19 pandemic had a substantial impact on recruitment. Data completeness was high in both groups with no protocol deviations. Patients randomised to TT had a significantly shorter overall mean hospital stay (5.4 days, SD 5.1) compared to the chest tube control group (13 days, SD 6.0), p = 0.04. Total number of pleural procedures required per patient were similar, 1.2 in chest tube group and 1.4 in TT group. No patient required a surgical referral. Adverse events were similar between the groups with no readmissions related to pleural infection. CONCLUSIONS The ACTion trial met its pre-specified feasibility criteria for patient acceptability but other issues around feasibility of a full-scale trial remain. From the results available the hypothesis that TT can reduce length of stay in pleural infection should be explored further. TRIAL REGISTRATION ISRCTN: 84674413.
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Walker SP, Hallifax R, Rahman NM, Maskell NA. Challenging the Paradigm of Persistent Air Leak: Are We Prolonging the Problem? Am J Respir Crit Care Med 2022; 206:145-149. [PMID: 35353640 DOI: 10.1164/rccm.202109-2149pp] [Citation(s) in RCA: 14] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/02/2023] Open
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Walker SP. Self-compassion mediates the relationship between dispositional mindfulness and athlete burnout among adolescent squash players in South Africa. SOUTH AFRICAN JOURNAL OF SPORTS MEDICINE 2021; 33:v33i1a11877. [PMID: 36816900 PMCID: PMC9924516 DOI: 10.17159/2078-516x/2021/v33i1a11877] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022] Open
Abstract
Background Dispositional mindfulness has been found to positively impact athlete burnout. Furthermore, self-compassion has been identified as a potential mechanism of action through which mindfulness is related to lower rates of athlete burnout. However, this interaction has yet to be investigated among adolescents. Objectives To determine whether self-compassion mediates the relationship between dispositional mindfulness and athlete burnout among adolescent squash players in South Africa. Methods Competitive adolescent squash players (n=158) from two provinces in South Africa completed measures of dispositional mindfulness, self-compassion and athlete burnout. Intercorrelations were calculated between the three variables. An ordinary least squares regression analysis was performed to test the indirect effect of self-compassion on the relationship between dispositional mindfulness and the three components of athlete burnout. Results Both dispositional mindfulness and self-compassion were negatively related to athlete burnout, while displaying positive correlations with each other. Self-compassion was found to partially mediate the relationship between dispositional mindfulness and a sense of reduced accomplishment (b = -0.075; 95% CI [-0.037; -0.012]), as well as the association between dispositional mindfulness and sport devaluation (b = -0.056; 95% CI [-0.099; -0.022]). The relationship between dispositional mindfulness and exhaustion was, however, not mediated by self-compassion (b = -0.002; 95% CI [-0.052; 0.049]). Conclusion The effect of dispositional mindfulness on certain components of athlete burnout is partially mediated by self-compassion among adolescent athletes. Based on the current findings, interventions aimed at increasing mindfulness among adolescent athletes appear to be a potential avenue by which to reduce certain aspects of burnout, partially through increasing self-compassion.
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Flenady V, Gardener G, Ellwood D, Coory M, Weller M, Warrilow KA, Middleton PF, Wojcieszek AM, Groom KM, Boyle FM, East C, Lawford H, Callander E, Said JM, Walker SP, Mahomed K, Andrews C, Gordon A, Norman JE, Crowther C. My Baby's Movements: a stepped-wedge cluster-randomised controlled trial of a fetal movement awareness intervention to reduce stillbirths. BJOG 2021; 129:29-41. [PMID: 34555257 DOI: 10.1111/1471-0528.16944] [Citation(s) in RCA: 14] [Impact Index Per Article: 4.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 08/20/2021] [Indexed: 10/20/2022]
Abstract
OBJECTIVE The My Baby's Movements (MBM) trial aimed to evaluate the impact on stillbirth rates of a multifaceted awareness package (the MBM intervention). DESIGN Stepped-wedge cluster-randomised controlled trial. SETTING Twenty-seven maternity hospitals in Australia and New Zealand. POPULATION Women with a singleton pregnancy without major fetal anomaly at ≥28 weeks of gestation from August 2016 to May 2019. METHODS The MBM intervention was implemented at randomly assigned time points, with the sequential introduction of eight groups of between three and five hospitals at 4-monthly intervals. Using generalised linear mixed models, the stillbirth rate was compared in the control and the intervention periods, adjusting for calendar time, study population characteristics and hospital effects. MAIN OUTCOME MEASURES Stillbirth at ≥28 weeks of gestation. RESULTS There were 304 850 births with 290 105 births meeting the inclusion criteria: 150 053 in the control and 140 052 in the intervention periods. The stillbirth rate was lower (although not statistically significantly so) during the intervention compared with the control period (2.2/1000 versus 2.4/1000 births; aOR 1.18, 95% CI 0.93-1.50; P = 0.18). The decrease in stillbirth rate was greater across calendar time: 2.7/1000 in the first versus 2.0/1000 in the last 18 months. No increase in secondary outcomes, including obstetric intervention or adverse neonatal outcome, was evident. CONCLUSIONS The MBM intervention did not reduce stillbirths beyond the downward trend over time. As a result of low uptake, the role of the intervention remains unclear, although the downward trend across time suggests some benefit in lowering the stillbirth rate. In this study setting, an awareness of the importance of fetal movements may have reached pregnant women and clinicians prior to the implementation of the intervention. TWEETABLE ABSTRACT The My Baby's Movements intervention to raise awareness of decreased fetal movement did not significantly reduce stillbirth rates.
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Walker SP, Bintcliffe O, Keenan E, Stadon L, Evison M, Haris M, Nagarajan T, West A, Ionescu A, Prudon B, Guhan A, Mustafa R, Herre J, Arnold D, Bhatnagar R, Kahan B, Miller RF, Rahman NM, Maskell NA. Randomised trial of indwelling pleural catheters for refractory transudative pleural effusions. Eur Respir J 2021; 59:13993003.01362-2021. [PMID: 34413152 DOI: 10.1183/13993003.01362-2021] [Citation(s) in RCA: 15] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/26/2021] [Accepted: 06/27/2021] [Indexed: 11/05/2022]
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Walker SP, Keenan E, Bintcliffe O, Stanton AE, Roberts M, Pepperell J, Fairbairn I, McKeown E, Goldring J, Maddekar N, Walters J, West A, Bhatta A, Knight M, Mercer R, Hallifax R, White P, Miller RF, Rahman NM, Maskell NA. Ambulatory management of secondary spontaneous pneumothorax: a randomised controlled trial. Eur Respir J 2021; 57:13993003.03375-2020. [PMID: 33334938 DOI: 10.1183/13993003.03375-2020] [Citation(s) in RCA: 15] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/16/2020] [Accepted: 11/30/2020] [Indexed: 11/05/2022]
Abstract
Secondary spontaneous pneumothorax (SSP) is traditionally managed with an intercostal chest tube attached to an underwater seal. We investigated whether use of a one-way flutter valve shortened patients' length of stay (LoS).This open-label randomised controlled trial enrolled patients presenting with SSP and randomised to either a chest tube and underwater seal (standard care: SC) or ambulatory care (AC) with a flutter valve. The type of flutter valve used depended on whether at randomisation the patient already had a chest tube in place: in those without a chest tube a pleural vent (PV) was used; in those with a chest tube in situ, an Atrium Pneumostat (AP) valve was attached. The primary end-point was LoS.Between March 2017 and March 2020, 41 patients underwent randomisation: 20 to SC and 21 to AC (13=PV, 8=AP). There was no difference in LoS in the first 30 days following treatment intervention: AC (median=6 days, IQR 14.5) and SC (median=6 days, IQR 13.3). In patients treated with PV there was a high rate of early treatment failure (6/13; 46%), compared to patients receiving SC (3/20; 15%) (p=0.11) Patients treated with AP had no (0/8 0%) early treatment failures and a median LoS of 1.5 days (IQR 23.8).There was no difference in LoS between ambulatory and standard care. Pleural Vents had high rates of treatment failure and should not be used in SSP. Atrium Pneumostats are a safer alternative, with a trend towards lower LoS.
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Lovett BA, Firth EC, Tuck ID, Symonds JE, Walker SP, Perrott MR, Davie PS, Munday JS, Preece MA, Herbert NA. Radiographic characterisation of spinal curvature development in farmed New Zealand Chinook salmon Oncorhynchus tshawytscha throughout seawater production. Sci Rep 2020; 10:20039. [PMID: 33208797 PMCID: PMC7674505 DOI: 10.1038/s41598-020-77121-y] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/10/2019] [Accepted: 11/03/2020] [Indexed: 01/07/2023] Open
Abstract
Spinal anomalies are a recognised source of downgrading in finfish aquaculture, but identifying their cause(s) is difficult and often requires extensive knowledge of the underlying pathology. Late-onset spinal curvatures (lordosis, kyphosis, scoliosis) can affect up to 40% of farmed New Zealand Chinook (king) salmon (Oncorhynchus tshawytscha) at harvest, but little is known about their pathogenesis. Curvature development was radiographically documented in two related cohorts of commercially-farmed Chinook salmon throughout seawater production to determine (1) the timing of radiographic onset and relationships between (2) the curvature types, (3) the spinal regions in which they develop and (4) their associations with co-existing vertebral body anomalies (vertebral compression, fusion and vertical shift). Onset of curvature varied between individuals, but initially occurred eight months post-seawater transfer. There were strong associations between the three curvature types and the four recognised spinal regions: lordosis was predominantly observed in regions (R)1 and R3, kyphosis in R2 and R4, manifesting as a distinct pattern of alternating lordosis and kyphosis from head to tail. This was subsequently accompanied by scoliosis, which primarily manifested in spinal regions R2 and R3, where most of the anaerobic musculature is concentrated. Co-existing vertebral body anomalies, of which vertebral compression and vertical shift were most common, appeared to arise either independent of curvature development or as secondary effects. Our results suggest that spinal curvature in farmed New Zealand Chinook salmon constitutes a late-onset, rapidly-developing lordosis-kyphosis-scoliosis (LKS) curvature complex with a possible neuromuscular origin.
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Bhatnagar R, Piotrowska HEG, Laskawiec-Szkonter M, Kahan BC, Luengo-Fernandez R, Pepperell JCT, Evison MD, Holme J, Al-Aloul M, Psallidas I, Lim WS, Blyth KG, Roberts ME, Cox G, Downer NJ, Herre J, Sivasothy P, Menzies D, Munavvar M, Kyi MM, Ahmed L, West AG, Harrison RN, Prudon B, Hettiarachchi G, Chakrabarti B, Kavidasan A, Sutton BP, Zahan-Evans NJ, Quaddy JL, Edey AJ, Clive AO, Walker SP, Little MHR, Mei XW, Harvey JE, Hooper CE, Davies HE, Slade M, Sivier M, Miller RF, Rahman NM, Maskell NA. Effect of Thoracoscopic Talc Poudrage vs Talc Slurry via Chest Tube on Pleurodesis Failure Rate Among Patients With Malignant Pleural Effusions: A Randomized Clinical Trial. JAMA 2020; 323:60-69. [PMID: 31804680 PMCID: PMC6990658 DOI: 10.1001/jama.2019.19997] [Citation(s) in RCA: 69] [Impact Index Per Article: 17.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/05/2023]
Abstract
IMPORTANCE Malignant pleural effusion (MPE) is challenging to manage. Talc pleurodesis is a common and effective treatment. There are no reliable data, however, regarding the optimal method for talc delivery, leading to differences in practice and recommendations. OBJECTIVE To test the hypothesis that administration of talc poudrage during thoracoscopy with local anesthesia is more effective than talc slurry delivered via chest tube in successfully inducing pleurodesis. DESIGN, SETTING, AND PARTICIPANTS Open-label, randomized clinical trial conducted at 17 UK hospitals. A total of 330 participants were enrolled from August 2012 to April 2018 and followed up until October 2018. Patients were eligible if they were older than 18 years, had a confirmed diagnosis of MPE, and could undergo thoracoscopy with local anesthesia. Patients were excluded if they required a thoracoscopy for diagnostic purposes or had evidence of nonexpandable lung. INTERVENTIONS Patients randomized to the talc poudrage group (n = 166) received 4 g of talc poudrage during thoracoscopy while under moderate sedation, while patients randomized to the control group (n = 164) underwent bedside chest tube insertion with local anesthesia followed by administration of 4 g of sterile talc slurry. MAIN OUTCOMES AND MEASURES The primary outcome was pleurodesis failure up to 90 days after randomization. Secondary outcomes included pleurodesis failure at 30 and 180 days; time to pleurodesis failure; number of nights spent in the hospital over 90 days; patient-reported thoracic pain and dyspnea at 7, 30, 90, and 180 days; health-related quality of life at 30, 90, and 180 days; all-cause mortality; and percentage of opacification on chest radiograph at drain removal and at 30, 90, and 180 days. RESULTS Among 330 patients who were randomized (mean age, 68 years; 181 [55%] women), 320 (97%) were included in the primary outcome analysis. At 90 days, the pleurodesis failure rate was 36 of 161 patients (22%) in the talc poudrage group and 38 of 159 (24%) in the talc slurry group (adjusted odds ratio, 0.91 [95% CI, 0.54-1.55]; P = .74; difference, -1.8% [95% CI, -10.7% to 7.2%]). No statistically significant differences were noted in any of the 24 prespecified secondary outcomes. CONCLUSIONS AND RELEVANCE Among patients with malignant pleural effusion, thoracoscopic talc poudrage, compared with talc slurry delivered via chest tube, resulted in no significant difference in the rate of pleurodesis failure at 90 days. However, the study may have been underpowered to detect small but potentially important differences. TRIAL REGISTRATION ISRCTN Identifier: ISRCTN47845793.
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Walker SP, Dasgupta A. Phenomenological modelling of film-dryout ‘critical heat flux’. NUCLEAR ENGINEERING AND DESIGN 2019. [DOI: 10.1016/j.nucengdes.2019.110178] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 10/26/2022]
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MacDonald TM, Hui L, Robinson AJ, Dane KM, Middleton AL, Tong S, Walker SP. Cerebral-placental-uterine ratio as novel predictor of late fetal growth restriction: prospective cohort study. ULTRASOUND IN OBSTETRICS & GYNECOLOGY : THE OFFICIAL JOURNAL OF THE INTERNATIONAL SOCIETY OF ULTRASOUND IN OBSTETRICS AND GYNECOLOGY 2019; 54:367-375. [PMID: 30338593 DOI: 10.1002/uog.20150] [Citation(s) in RCA: 18] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 06/02/2018] [Revised: 08/26/2018] [Accepted: 10/08/2018] [Indexed: 06/08/2023]
Abstract
OBJECTIVE Fetal growth restriction (FGR) is a major risk factor for stillbirth and most commonly arises from uteroplacental insufficiency. Despite clinical examination and third-trimester fetal biometry, cases of FGR often remain undetected antenatally. Placental insufficiency is known to be associated with altered blood flow resistance in maternal, placental and fetal vessels. The aim of this study was to evaluate the performance of individual and combined Doppler blood flow resistance measurements in the prediction of term small-for-gestational age and FGR. METHODS This was a prospective study of 347 nulliparous women with a singleton pregnancy at 36 weeks' gestation in which fetal growth and Doppler measurements were obtained. Pulsatility indices (PI) of the uterine arteries (UtA), umbilical artery (UA) and fetal vessels were analyzed, individually and in combination, for prediction of birth weight < 10th , < 5th and < 3rd centiles. Doppler values were converted into centiles or multiples of the median (MoM) for gestational age. The sensitivities, positive and negative predictive values and odds ratios (OR) of the Doppler parameters for these birth weights at ∼ 90% specificity were assessed. Additionally, the correlations between Doppler measurements and other measures of placental insufficiency, namely fetal growth velocity and neonatal body fat measures, were analyzed. RESULTS The Doppler combination most strongly associated with placental insufficiency was a newly generated parameter, which we have named the cerebral-placental-uterine ratio (CPUR). CPUR is the cerebroplacental ratio (CPR) (middle cerebral artery PI/UA-PI) divided by mean UtA-PI. CPUR MoM detected FGR better than did mean UtA-PI MoM or CPR MoM alone. At ∼ 90% specificity, low CPUR MoM had sensitivities of 50% for birth weight < 10th centile, 68% for < 5th centile and 89% for < 3rd centile. The respective sensitivities of low CPR MoM were 26%, 37% and 44% and those of high UtA-PI MoM were 34%, 47% and 67%. Low CPUR MoM was associated with birth weight < 10th centile with an OR of 9.1, < 5th centile with an OR of 17.3 and < 3rd centile with an OR of 57.0 (P < 0.0001 for all). CPUR MoM was also correlated most strongly with fetal growth velocity and neonatal body fat measures, as compared with CPR MoM or UtA-PI MoM alone. CONCLUSIONS In this cohort, a novel Doppler variable combination, the CPUR (CPR/UtA-PI), had the strongest association with indicators of placental insufficiency. CPUR detected more cases of FGR than did any other Doppler parameter measured. If these results are replicated independently, this new parameter may lead to better identification of fetuses at increased risk of stillbirth that may benefit from obstetric intervention. Copyright © 2018 ISUOG. Published by John Wiley & Sons Ltd.
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Groom KM, McCowan LM, Mackay LK, Lee AC, Gardener G, Unterscheider J, Sekar R, Dickinson JE, Muller P, Reid RA, Watson D, Welsh A, Marlow J, Walker SP, Hyett J, Morris J, Stone PR, Baker PN. STRIDER NZAus: a multicentre randomised controlled trial of sildenafil therapy in early-onset fetal growth restriction. BJOG 2019; 126:997-1006. [PMID: 30779295 DOI: 10.1111/1471-0528.15658] [Citation(s) in RCA: 39] [Impact Index Per Article: 7.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 01/31/2019] [Indexed: 12/20/2022]
Abstract
OBJECTIVE To assess the effect of maternal sildenafil therapy on fetal growth in pregnancies with early-onset fetal growth restriction. DESIGN A randomised placebo-controlled trial. SETTING Thirteen maternal-fetal medicine units across New Zealand and Australia. POPULATION Women with singleton pregnancies affected by fetal growth restriction at 22+0 to 29+6 weeks. METHODS Women were randomised to oral administration of 25 mg sildenafil citrate or visually matching placebo three times daily until 32+0 weeks, birth or fetal death (whichever occurred first). MAIN OUTCOME MEASURES The primary outcome was the proportion of pregnancies with an increase in fetal growth velocity. Secondary outcomes included live birth, survival to hospital discharge free of major neonatal morbidity and pre-eclampsia. RESULTS Sildenafil did not affect the proportion of pregnancies with an increase in fetal growth velocity; 32/61 (52.5%) sildenafil-treated, 39/57 (68.4%) placebo-treated [adjusted odds ratio (OR) 0.49, 95% CI 0.23-1.05] and had no effect on abdominal circumference Z-scores (P = 0.61). Sildenafil use was associated with a lower mean uterine artery pulsatility index after 48 hours of treatment (1.56 versus 1.81; P = 0.02). The live birth rate was 56/63 (88.9%) for sildenafil-treated and 47/59 (79.7%) for placebo-treated (adjusted OR 2.50, 95% CI 0.80-7.79); survival to hospital discharge free of major neonatal morbidity was 42/63 (66.7%) for sildenafil-treated and 33/59 (55.9%) for placebo-treated (adjusted OR 1.93, 95% CI 0.84-4.45); and new-onset pre-eclampsia was 9/51 (17.7%) for sildenafil-treated and 14/55 (25.5%) for placebo-treated (OR 0.67, 95% CI 0.26-1.75). CONCLUSIONS Maternal sildenafil use had no effect on fetal growth velocity. Prospectively planned meta-analyses will determine whether sildenafil exerts other effects on maternal and fetal/neonatal wellbeing. TWEETABLE ABSTRACT Maternal sildenafil use has no beneficial effect on growth in early-onset FGR, but also no evidence of harm.
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Walker SP, Bibby AC, Halford P, Stadon L, White P, Maskell NA. Recurrence rates in primary spontaneous pneumothorax: a systematic review and meta-analysis. Eur Respir J 2018; 52:13993003.00864-2018. [DOI: 10.1183/13993003.00864-2018] [Citation(s) in RCA: 51] [Impact Index Per Article: 8.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/09/2018] [Accepted: 07/01/2018] [Indexed: 11/05/2022]
Abstract
Primary spontaneous pneumothorax (PSP) recurrence rates vary widely in the published literature, with limited data describing the factors that influence recurrence. The aims of this systematic review were to determine an estimation of PSP recurrence rates and describe risk factors for recurrence.A systematic review was conducted of all studies reporting PSP recurrence. Electronic searches were performed to identify English language publications of randomised trials and observational studies. The population was adults with PSP, who underwent conservative management, pleural aspiration or chest drainage. The outcome of interest was recurrence. Articles were screened and data extracted from eligible studies by two reviewers.Of 3607 identified studies, 29 were eligible for inclusion, comprising 13 548 patients. Pooled 1-year and overall recurrence rates were 29.0% (95% CI 20.9–37.0%) and 32.1% (95% CI 27.0–37.2%), respectively. Female sex was associated with increased recurrence (OR 3.03, 95% CI 1.24–7.41), while smoking cessation was associated with a four-fold decrease in risk (OR 0.26, 95% CI 0.10–0.63). I2 for random effects meta-analysis was 94% (p<0.0001), reflecting high heterogeneity between studies.This systematic review demonstrates a 32% PSP recurrence rate, with greatest risk in the first year. Female sex was associated with higher risk, suggesting possible sex-specific pathophysiology.
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Munday JS, Perrott MR, Symonds JE, Walker SP, Preece MA, Davie PS. Prevalence of spinal abnormalities in Chinook salmon smolt and influence of early rearing temperature and growth rates. JOURNAL OF FISH DISEASES 2018; 41:1111-1116. [PMID: 29600512 DOI: 10.1111/jfd.12804] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 01/16/2018] [Revised: 02/19/2018] [Accepted: 02/20/2018] [Indexed: 06/08/2023]
Abstract
Spinal abnormalities can be detected at harvest in around 40% of farmed Chinook salmon in New Zealand. However, whether these abnormalities are present in smolt is unknown. Radiographs of 3,736 smolt were taken immediately prior to transfer to sea water and evaluated for fusions, compressions, vertical shifts, and lordosis, kyphosis and/or scoliosis (LKS). The survey included smolt from two different chilling strategies that had been graded into slow- or fast-growing fish. Overall, 4.34% of Chinook salmon smolt had at least one spinal abnormality, similar to the rates of reported in Atlantic salmon smolt. The rate of abnormality was significantly higher in faster-growing fish. Fusions were most common with 2.68% of smolt affected. Smolt subjected to longer chilling times had lower rates of fusions. Compressions and vertical shifts were both observed in 1.31% of smolt. Although LKS is the most common abnormality of harvested fish, LKS was detected in just five smolt. The results suggest that some fusions in harvest fish have developed at the time of seawater transfer while LKS develops late in the production cycle. Overall, spinal abnormalities are uncommon in Chinook salmon smolt and may be influenced by chilling times and growth rates.
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Bhatnagar R, Keenan EK, Morley AJ, Kahan BC, Stanton AE, Haris M, Harrison RN, Mustafa RA, Bishop LJ, Ahmed L, West A, Holme J, Evison M, Munavvar M, Sivasothy P, Herre J, Cooper D, Roberts M, Guhan A, Hooper C, Walters J, Saba TS, Chakrabarti B, Gunatilake S, Psallidas I, Walker SP, Bibby AC, Smith S, Stadon LJ, Zahan-Evans NJ, Lee YCG, Harvey JE, Rahman NM, Miller RF, Maskell NA. Outpatient Talc Administration by Indwelling Pleural Catheter for Malignant Effusion. N Engl J Med 2018; 378:1313-1322. [PMID: 29617585 DOI: 10.1056/nejmoa1716883] [Citation(s) in RCA: 149] [Impact Index Per Article: 24.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/19/2022]
Abstract
BACKGROUND Malignant pleural effusion affects more than 750,000 persons each year across Europe and the United States. Pleurodesis with the administration of talc in hospitalized patients is the most common treatment, but indwelling pleural catheters placed for drainage offer an ambulatory alternative. We examined whether talc administered through an indwelling pleural catheter was more effective at inducing pleurodesis than the use of an indwelling pleural catheter alone. METHODS Over a period of 4 years, we recruited patients with malignant pleural effusion at 18 centers in the United Kingdom. After the insertion of an indwelling pleural catheter, patients underwent drainage regularly on an outpatient basis. If there was no evidence of substantial lung entrapment (nonexpandable lung, in which lung expansion and pleural apposition are not possible because of visceral fibrosis or bronchial obstruction) at 10 days, patients were randomly assigned to receive either 4 g of talc slurry or placebo through the indwelling pleural catheter on an outpatient basis. Talc or placebo was administered on a single-blind basis. Follow-up lasted for 70 days. The primary outcome was successful pleurodesis at day 35 after randomization. RESULTS The target of 154 patients undergoing randomization was reached after 584 patients were approached. At day 35, a total of 30 of 69 patients (43%) in the talc group had successful pleurodesis, as compared with 16 of 70 (23%) in the placebo group (hazard ratio, 2.20; 95% confidence interval, 1.23 to 3.92; P=0.008). No significant between-group differences in effusion size and complexity, number of inpatient days, mortality, or number of adverse events were identified. No significant excess of blockages of the indwelling pleural catheter was noted in the talc group. CONCLUSIONS Among patients without substantial lung entrapment, the outpatient administration of talc through an indwelling pleural catheter for the treatment of malignant pleural effusion resulted in a significantly higher chance of pleurodesis at 35 days than an indwelling catheter alone, with no deleterious effects. (Funded by Becton Dickinson; EudraCT number, 2012-000599-40 .).
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Walker SP, Barratt SL, Thompson J, Maskell NA. Conservative Management in Traumatic Pneumothoraces: An Observational Study. Chest 2017; 153:946-953. [PMID: 29080710 DOI: 10.1016/j.chest.2017.10.015] [Citation(s) in RCA: 20] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/07/2017] [Revised: 09/29/2017] [Accepted: 10/13/2017] [Indexed: 11/26/2022] Open
Abstract
BACKGROUND Traumatic pneumothoraces are a common consequence of major trauma. Despite this, there is a paucity of literature regarding their optimal management, including the role of conservative treatment. The aim of this study was to assess the treatment, complications, and outcomes of traumatic pneumothoraces in patients presenting to a major trauma center. METHODS The prospectively collected Trauma Audit and Research Network (TARN) database was used to identify all patients presenting with traumatic pneumothoraces to a UK major trauma center from April 2012 to December 2016. Demographics, mechanism of injury, injury severity score (ISS), management, and outcomes were analyzed. RESULTS Six hundred two patients were included during the study period. Mean age was 48 years (SD, 22 years), and 73% were men. Mean ISS was 26 and inpatient mortality was 9%. Of the 602 traumatic pneumothoraces, 277 of 602 (46%) were initially treated conservatively. Two hundred fifty-two of 277 patients in this cohort (90%) did not require subsequent chest tube insertion, including the majority of patients (56 of 62 [90%]) who were receiving positive pressure ventilation (PPV) on admission. The hazard ratio (HR) for failure of conservative management showed no difference between the ventilated and nonventilated patients (HR, 1.1; P = .84). Only the presence of a large hemothorax was associated with an increased likelihood of failure of conservative management. CONCLUSIONS In the largest observational study of traumatic pneumothoraces published to date, > 90% of patients whose pneumothorax was managed conservatively never required subsequent tube drainage. Importantly, this also applies to patients requiring PPV, with no significant increased risk of failure of expectant management. These data support a role for conservative management in traumatic pneumothoraces.
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Lockie E, McCarthy EA, Hui L, Churilov L, Walker SP. Feasibility of using self-reported ethnicity in pregnancy according to the gestation-related optimal weight classification: a cross-sectional study. BJOG 2017; 125:704-709. [DOI: 10.1111/1471-0528.14825] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 06/11/2017] [Indexed: 12/28/2022]
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Walker SP, Morley AJ, Stadon L, De Fonseka D, Arnold DT, Medford ARL, Maskell NA. Nonmalignant Pleural Effusions: A Prospective Study of 356 Consecutive Unselected Patients. Chest 2017; 151:1099-1105. [PMID: 28025056 DOI: 10.1016/j.chest.2016.12.014] [Citation(s) in RCA: 51] [Impact Index Per Article: 7.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/26/2016] [Revised: 12/12/2016] [Accepted: 12/14/2016] [Indexed: 02/07/2023] Open
Abstract
BACKGROUND Pleural effusion secondary to a nonmalignant cause can represent significant morbidity and mortality. Nonmalignant pleural effusion (NMPE) is common, with congestive heart failure representing the leading cause. Despite this, there are limited data on mortality risk and associated prognostic factors. METHODS We recruited 782 consecutive patients presenting to a pleural service between March 2008 and March 2015 with an undiagnosed pleural effusion. Further analysis was conducted in 356 patients with NMPE. Pleural biochemical analysis, cytologic analysis, thoracic ultrasonography, and chest radiography were performed. Echocardiography, CT imaging, radiologically guided biopsy, and medical thoracoscopy were undertaken as clinically indicated. Patients were followed for a minimum duration of 12 months, with the final diagnosis decided through independent review by two respiratory consultants. RESULTS Of the 782 patients, 356 were diagnosed with NMPE (46%). These patients had a mean age of 68 years (SD, 17 years) with 69% of them being men. Patients with cardiac, renal, and hepatic failure had 1-year mortality rates of 50%, 46%, and 25%, respectively. Bilateral effusions (hazard ratio [HR], 3.55; 95% CI, 2.22-5.68) and transudative effusions (HR, 2.78; 95% CI, 1.81-4.28) were associated with a worse prognosis in patients with NMPE, with a 57% and 43% 1-year mortality rate, respectively. CONCLUSIONS This is the largest prospectively collected series in patients with NMPE, demonstrating that cases secondary to organ dysfunction have extremely high 1-year mortality. In addition, the presence of bilateral and transudative effusions is an indicator of increased mortality. Clinicians should be aware of these poor prognostic features and guide management accordingly.
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McCarthy EA, Walker SP, Ugoni A, Lappas M, Leong O, Shub A. Self-weighing and simple dietary advice for overweight and obese pregnant women to reduce obstetric complications without impact on quality of life: a randomised controlled trial. BJOG 2016; 123:965-73. [DOI: 10.1111/1471-0528.13919] [Citation(s) in RCA: 35] [Impact Index Per Article: 4.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 12/16/2015] [Indexed: 11/26/2022]
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Walker SP. Mindfulness and mental toughness among provincial adolescent female hockey players. SOUTH AFRICAN JOURNAL OF SPORTS MEDICINE 2016. [DOI: 10.17159/2078-516x/2016/v28i2a1110] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022] Open
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Hui L, Tabor A, Walker SP, Kilby MD. How to safeguard competency and training in invasive prenatal diagnosis: 'the elephant in the room'. ULTRASOUND IN OBSTETRICS & GYNECOLOGY : THE OFFICIAL JOURNAL OF THE INTERNATIONAL SOCIETY OF ULTRASOUND IN OBSTETRICS AND GYNECOLOGY 2016; 47:8-13. [PMID: 26643796 DOI: 10.1002/uog.15806] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 09/28/2015] [Revised: 10/21/2015] [Accepted: 10/27/2015] [Indexed: 06/05/2023]
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Brownfoot FC, Cluver CA, Walker SP. Persistent reversed end diastolic flow in the fetal middle cerebral artery: an ominous finding. ULTRASOUND (LEEDS, ENGLAND) 2015; 23:186-9. [PMID: 27433256 PMCID: PMC4760589 DOI: 10.1177/1742271x15587600] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
Fetal persistent middle cerebral artery reversed end diastolic flow is a rare and ominous finding. Previous cases have been associated with intracranial hemorrhage, growth restriction, anaemia, and hepatic anomaly. Intrauterine demise or early neonatal death is a common outcome. We report the case of persistent middle cerebral artery reversed end diastolic flow in a well-grown fetus at 32 weeks' gestation resulting from acute, severe anaemia due to a large feto-maternal hemorrhage. An emergency cesarean section was performed and the neonate required advanced resuscitation and immediate blood transfusion. Postnatal magnetic resonance imaging confirmed a hemorrhagic parietal infarct and bilateral ischaemic changes in the basal ganglia. This provides further evidence that persistent middle cerebral artery reversed end diastolic flow in any fetus is an ominous finding warranting urgent diagnostic evaluation and/or delivery.
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Vorster AC, Walker SP, Esterhuyse KGF. Coping responses as predictors of psychosocial functioning amongst individuals suffering from chronic pain. SOUTHERN AFRICAN JOURNAL OF ANAESTHESIA AND ANALGESIA 2014. [DOI: 10.1080/22201173.2009.10872613] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/24/2022]
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