Effect of Opioids vs NSAIDs and Larger vs Smaller Chest Tube Size on Pain Control and Pleurodesis Efficacy Among Patients With Malignant Pleural Effusion: The TIME1 Randomized Clinical Trial

IMPORTANCE

For treatment of malignant pleural effusion, nonsteroidal anti-inflammatory drugs (NSAIDs) are avoided because they may reduce pleurodesis efficacy. Smaller chest tubes may be less painful than larger tubes, but efficacy in pleurodesis has not been proven.

OBJECTIVE

To assess the effect of chest tube size and analgesia (NSAIDs vs opiates) on pain and clinical efficacy related to pleurodesis in patients with malignant pleural effusion.

DESIGN, SETTING, AND PARTICIPANTS

A 2×2 factorial phase 3 randomized clinical trial among 320 patients requiring pleurodesis in 16 UK hospitals from 2007 to 2013.

INTERVENTIONS

Patients undergoing thoracoscopy (n = 206; clinical decision if biopsy was required) received a 24F chest tube and were randomized to receive opiates (n = 103) vs NSAIDs (n = 103), and those not undergoing thoracoscopy (n = 114) were randomized to 1 of 4 groups (24F chest tube and opioids [n = 28]; 24F chest tube and NSAIDs [n = 29]; 12F chest tube and opioids [n = 29]; or 12F chest tube and NSAIDs [n = 28]).

MAIN OUTCOMES AND MEASURES

Pain while chest tube was in place (0- to 100-mm visual analog scale [VAS] 4 times/d; superiority comparison) and pleurodesis efficacy at 3 months (failure defined as need for further pleural intervention; noninferiority comparison; margin, 15%).

RESULTS

Pain scores in the opiate group (n = 150) vs the NSAID group (n = 144) were not significantly different (mean VAS score, 23.8 mm vs 22.1 mm; adjusted difference, -1.5 mm; 95% CI, -5.0 to 2.0 mm; P = .40), but the NSAID group required more rescue analgesia (26.3% vs 38.1%; rate ratio, 2.1; 95% CI, 1.3-3.4; P = .003). Pleurodesis failure occurred in 30 patients (20%) in the opiate group and 33 (23%) in the NSAID group, meeting criteria for noninferiority (difference, -3%; 1-sided 95% CI, -10% to ∞; P = .004 for noninferiority). Pain scores were lower among patients in the 12F chest tube group (n = 54) vs the 24F group (n = 56) (mean VAS score, 22.0 mm vs 26.8 mm; adjusted difference, -6.0 mm; 95% CI, -11.7 to -0.2 mm; P = .04) and 12F chest tubes vs 24F chest tubes were associated with higher pleurodesis failure (30% vs 24%), failing to meet noninferiority criteria (difference, -6%; 1-sided 95% CI, -20% to ∞; P = .14 for noninferiority). Complications during chest tube insertion occurred more commonly with 12F tubes (14% vs 24%; odds ratio, 1.91; P = .20).

CONCLUSIONS AND RELEVANCE

Use of NSAIDs vs opiates resulted in no significant difference in pain scores but was associated with more rescue medication. NSAID use resulted in noninferior rates of pleurodesis efficacy at 3 months. Placement of 12F chest tubes vs 24F chest tubes was associated with a statistically significant but clinically modest reduction in pain but failed to meet noninferiority criteria for pleurodesis efficacy.

TRIAL REGISTRATION

isrctn.org Identifier: ISRCTN33288337.

A prospective randomized, controlled trial of intravenous versus oral iron for moderate iron deficiency anaemia of pregnancy

BACKGROUND

Iron deficiency anaemia is the most common deficiency disorder in the world, affecting more than one billion people, with pregnant women at particular risk.

OBJECTIVES AND DESIGN

We conducted a single site, prospective, nonblinded randomized-controlled trial to compare the efficacy, safety, tolerability and compliance of standard oral daily iron versus intravenous iron.

SUBJECTS

We prospectively screened 2654 pregnant women between March 2007 and January 2009 with a full blood count and iron studies, of which 461 (18%) had moderate IDA. Two hundred women matched for haemoglobin concentration and serum ferritin level were recruited.

INTERVENTIONS

Patients were randomized to daily oral ferrous sulphate 250 mg (elemental iron 80 mg) with or without a single intravenous iron polymaltose infusion.

RESULTS

Prior to delivery, the intravenous plus oral iron arm was superior to the oral iron only arm as measured by the increase in haemoglobin level (mean of 19.5 g/L vs. 12 g/L; P < 0.001); the increase in mean serum ferritin level (222 microg/L vs. 18 ug/L; P < 0.001); and the percentage of mothers with ferritin levels below 30 microg/L (4.5% vs. 79%; P < 0.001). A single dose of intravenous iron polymaltose was well tolerated without significant side effects.

CONCLUSIONS

Our data indicate that intravenous iron polymaltose is safe and leads to improved efficacy and iron stores compared to oral iron alone in pregnancy-related IDA.

Bedside tracer gas technique accurately predicts outcome in aspiration of spontaneous pneumothorax

BACKGROUND

There is no technique in general use that reliably predicts the outcome of manual aspiration of spontaneous pneumothorax. We have hypothesised that the absence of a pleural leak at the time of aspiration will identify a group of patients in whom immediate discharge is unlikely to be complicated by early lung re-collapse and have tested this hypothesis by using a simple bedside tracer gas technique.

METHODS

Eighty four episodes of primary spontaneous pneumothorax and 35 episodes of secondary spontaneous pneumothorax were studied prospectively. Patients breathed air containing a tracer (propellant gas from a pressurised metered dose inhaler) while the pneumothorax was aspirated percutaneously. Tracer gas in the aspirate was detected at the bedside using a portable flame ioniser and episodes were categorised as tracer gas positive (>1 part per million of tracer gas) or negative. The presence of tracer gas was taken to imply a persistent pleural leak. Failure of manual aspiration and the need for a further intervention was based on chest radiographic appearances showing either failure of the lung to re-expand or re-collapse following initial re-expansion.

RESULTS

A negative tracer gas test alone implied that manual aspiration would be successful in the treatment of 93% of episodes of primary spontaneous pneumothorax (p<0.001) and in 86% of episodes of secondary spontaneous pneumothorax (p=0.01). A positive test implied that manual aspiration would either fail to re-expand the lung or that early re-collapse would occur despite initial re-expansion in 66% of episodes of primary spontaneous pneumothorax and 71% of episodes of secondary spontaneous pneumothorax. Lung re-inflation on the chest radiograph taken immediately after aspiration was a poor predictor of successful aspiration, with lung re-collapse occurring in 34% of episodes by the following day such that a further intervention was required.

CONCLUSIONS

National guidelines currently recommend immediate discharge of patients with primary spontaneous pneumothorax based primarily on the outcome of the post-aspiration chest radiograph which we have shown to be a poor predictor of early lung re-collapse. Using a simple bedside test in combination with the post-aspiration chest radiograph, we can predict with high accuracy the success of aspiration in achieving sustained lung re-inflation, thereby identifying patients with primary spontaneous pneumothorax who can be safely and immediately discharged home and those who should be observed overnight because of a significant risk of re-collapse, with an estimated re-admission rate of 1%.

Bedside tracer gas technique accurately predicts outcome in aspiration of spontaneous pneumothorax

BACKGROUND

There is no technique in general use that reliably predicts the outcome of manual aspiration of spontaneous pneumothorax. We have hypothesised that the absence of a pleural leak at the time of aspiration will identify a group of patients in whom immediate discharge is unlikely to be complicated by early lung re-collapse and have tested this hypothesis by using a simple bedside tracer gas technique.

METHODS

Eighty four episodes of primary spontaneous pneumothorax and 35 episodes of secondary spontaneous pneumothorax were studied prospectively. Patients breathed air containing a tracer (propellant gas from a pressurised metered dose inhaler) while the pneumothorax was aspirated percutaneously. Tracer gas in the aspirate was detected at the bedside using a portable flame ioniser and episodes were categorised as tracer gas positive (>1 part per million of tracer gas) or negative. The presence of tracer gas was taken to imply a persistent pleural leak. Failure of manual aspiration and the need for a further intervention was based on chest radiographic appearances showing either failure of the lung to re-expand or re-collapse following initial re-expansion.

RESULTS

A negative tracer gas test alone implied that manual aspiration would be successful in the treatment of 93% of episodes of primary spontaneous pneumothorax (p<0.001) and in 86% of episodes of secondary spontaneous pneumothorax (p=0.01). A positive test implied that manual aspiration would either fail to re-expand the lung or that early re-collapse would occur despite initial re-expansion in 66% of episodes of primary spontaneous pneumothorax and 71% of episodes of secondary spontaneous pneumothorax. Lung re-inflation on the chest radiograph taken immediately after aspiration was a poor predictor of successful aspiration, with lung re-collapse occurring in 34% of episodes by the following day such that a further intervention was required.

CONCLUSIONS

National guidelines currently recommend immediate discharge of patients with primary spontaneous pneumothorax based primarily on the outcome of the post-aspiration chest radiograph which we have shown to be a poor predictor of early lung re-collapse. Using a simple bedside test in combination with the post-aspiration chest radiograph, we can predict with high accuracy the success of aspiration in achieving sustained lung re-inflation, thereby identifying patients with primary spontaneous pneumothorax who can be safely and immediately discharged home and those who should be observed overnight because of a significant risk of re-collapse, with an estimated re-admission rate of 1%.

Iatrogenic pneumothorax: marker gas technique for predicting outcome of manual aspiration

BACKGROUND

Although manual aspiration is used for treating pneumothorax, the post-aspiration radiograph may not be a reliable indicator of whether the pleural leak remains. We have previously shown that marker gas can identify an air leak in patients with spontaneous pneumothoraces.

OBJECTIVE

This study examines whether a marker gas technique can be safely used to manage patients with iatrogenic pneumothoraces.

METHODS

10 patients with iatrogenic pneumothorax were identified among a cohort referred for manual aspiration of pneumothorax, using a marker gas technique, in which inspired metered-dose inhaler propellant gas is detectable in pneumothorax aspirate using a portable flame ioniser. The presence of marker gas was taken to imply a persistent air leak.

RESULTS

Marker gas was detected in the aspirate from 3 out of 10 pneumothoraces. 2 required intercostal tube drainage because of lung collapse following initial aspiration and 1 was treated conservatively. Marker gas was not detected in 7 cases (2 post-pacemaker insertion, 5 pleural aspiration +/- biopsy), and in all these cases, manual aspiration resulted in sustained re-expansion of the lung. There was a trend towards a significant relationship between the presence or absence of marker gas and the need for a further intervention (p = 0.055).

CONCLUSION

The presence or absence of a pleural leak during manual aspiration of iatrogenic pneumothorax can be demonstrated by this technique. The absence of marker gas in the aspirate implies that manual aspiration will be successful, whereas its presence, in most cases, predicts either failure of manual aspiration to expand the lung or early re-collapse of the lung.

Determination of right ventricular ejection fraction from reprojected gated blood pool SPET: comparison with first-pass ventriculography

Gated blood pool (GBP) studies are widely available and relatively inexpensive. We have previously published a simple and convenient method for measuring left ventricle ejection fraction (EF) with increased accuracy from single-photon emission tomography (SPET) GBP scans. This paper describes an extension of this method by which right ventricular EF may also be measured. Gated SPET images of the blood pool are acquired and re-oriented in short-axis slices. Counts from the left ventricle are excluded from the short-axis slices, which are then reprojected to give horizontal long-axis images. Time-activity curves are generated from each pixel around the right ventricle, and an image is created with non-ventricular pixels "greyed out". This image is used as a guide in drawing regions of interest around the right ventricle on the end-diastolic and end-systolic long-axis images. In 28 patients, first-pass ventriculography studies were acquired followed by SPET GBP scans. The first-pass images were analysed a total of four times by two observers and the SPET images were analysed three times each by two observers. The agreement between the two techniques was good, with a correlation coefficient of 0.72 and a mean absolute difference between first-pass and reprojected SPET EFs of 4.8 EF units. Only four of the 28 patients had a difference of greater than 8 EF units. Variability was also excellent for SPET right ventricular EF values. Intra-observer variability was significantly lower for SPET than for first-pass EFs: standard error of the estimate (SEE)=5.1 and 7.3 EF units, respectively (P<0.05). Inter-observer variability was comparable in the two techniques (SEE=5.2 and 6.9 EF units for SPET and first-pass ventriculography, respectively).

Investigative modalities of mandibular invasion by squamous cell carcinoma

OBJECTIVES/HYPOTHESIS

To compare preoperative investigations with histological findings in squamous cell carcinoma (SCC) of the oral mucosa that abuts the mandible. Both clinical and radiological examinations fail to predict accurately invasion of the mandible by intraoral SCC.

STUDY DESIGN

This two-part, prospective study is of a consecutive series of patients whose first malignancy of the upper aerodigestive tract abutted the lingual surface of the mandible.

METHODS

AR patients presented to the Queensland Radium Institute Head and Neck Clinic between 1993 and 1997 with a biopsy-proven SCC that abutted the mandible. These tumors were investigated clinically, radiologically, and histologically. Sensitivity, specificity, and predictive values were calculated for various approaches. In the second part of the study, single photon emission computed tomography (SPECT) bone scans were included. Quantification ratios of bone scans compared the average counting statistics in visually identified mandibular abnormal uptake with normal cervical spine and jaw.

RESULTS

Sixty-seven patients were followed for 55 months and assessed with orthopantomogram (OPG), computed tomography (CT) scans, and, in the second part of the study, SPECT bone scans. Thirty-six tumors showed histological evidence of bony invasion. Bony involvement was suggested by OPG in 36 and confirmed histologically in 27 patients. CT scans showed evidence of bone invasion in 22 cases, with 18 of these histologically confirmed. Technetium 99m methylene diphosphonate (MDP) bone scans with planar imaging and SPECT were performed in 24 patients, and histological appearance was suitable for analysis in 14. Three patients with tumor (cervical spine ratios greater than 1.5 predicting malignant involvement) had this confirmed histologically.

CONCLUSIONS

The first part of the study confirms our hypothesis that currently used investigations, as well as clinical assessment, fail to predict accurately invasion of the mandible by intraoral SCC. The second part suggests that SPECT scanning with high quantification ratios is promising in the prediction of tumor involvement.

Spontaneous pneumothorax: marker gas technique for predicting outcome of manual aspiration

OBJECTIVE

To determine whether in a patient with spontaneous pneumothorax the presence or absence of a pleural leak can be shown at the time of manual aspiration by use of a marker gas. Also, to find out if the technique can predict whether manual aspiration will be successful, hence avoiding the need for intercostal tube drainage.

DESIGN

Prospective study of 25 episodes of pneumothorax during which patients breathed air from a Douglas bag that contained chlorofluorocarbon gases from a metered dose inhaler while the pneumothorax was aspirated.

SETTING

Medical unit of a district general hospital.

PATIENTS

22 patients who presented over nine months with acute pneumothorax.

MAIN OUTCOME MEASURES

Presence or absence of chlorofluorocarbon marker gases in the aspirate. Presence or absence of sustained re-expansion of the affected lung in the chest radiograph.

RESULTS

Marker gas was detected in the aspirate from 16 out of 25 pneumothoraces. Of these, 13 required intercostal tube drainage because of failure of the lung to re-expand. Marker gas was not detected in nine cases, and in all of these cases manual aspiration resulted in sustained re-expansion of the lung.

CONCLUSIONS

The presence or absence of a pleural leak during manual aspiration of spontaneous pneumothorax can be shown by using this technique. The absence of marker gas in the aspirate implies that manual aspiration will be successful, whereas its presence predicts, in most cases, either failure of manual aspiration to expand the lung or early re-collapse of the lung.

The relationship between nasal airway size and nasal-oral breathing

Most clinicians agree that impaired nasal breathing results in obligatory mouth breathing. Some believe that mouth breathing influences dentofacial growth; others disagree. The term mouth breathing is confusing because total mouth breathing rarely occurs. A combination of nasal and oral breathing is more usual. The purpose of the present study involving 116 adult subjects was to (1) assess the relationship between nasal impairment and nasal-oral breathing, (2) determine the switching range from nasal to nasal-oral breathing, and (3) quantify the term mouth breathing. The pressure-flow technique was used to estimate nasal airway size; inductive plethysmography was used to assess nasal-oral breathing in normal and impaired breathers. Analysis of the date showed a Pearson rank correlation of 0.545 (P less than 0.001) between nasal area and nasal-oral respiration. Ninety-seven percent of subjects with a nasal size less than 0.4 cm2 were mouth breathers to some extent. About 12% of subjects with an adequate airway were assumed to be habitual mouth breathers. The findings indicate that the switching range from nasal to nasal-oral breathing is very narrow (0.4-0.45 cm2). These results also confirm our contention that in adults an airway less than 0.4 cm2 is impaired.

The relationship between nasal cross-sectional area and nasal air volume in normal and nasally impaired adults

The controversy concerning the effects of nasal airway impairment on facial growth has stimulated renewed interest in upper airway respiratory function. The subjective manner in which airway impairment and mouth breathing have been assessed is, in our opinion, responsible for the differences observed among investigators and for their conclusions. We have been involved in a series of studies dealing with airway impairment and have report modifications of two techniques for objectively assessing respiration. The purpose of the present study was to examine a large population of adults, with and without nasal airway impairment, and assess the relationship between nasal cross-sectional area and nasal air volume to determine at what point airway size controls the passage of air during breathing. Statistical analysis of the data demonstrates that airway size alters air volume when nasal cross-sectional area is less than 0.4 cm2. The relationship between area and volume is very linear below 0.4 cm2, with air volume decreasing with decreased size. Although the data do indicate some influence over volume at sizes greater than 0.4 cm2, the effect is very slight. These findings support the prediction that upper airway impairment is present at nasal airways less than 0.4 cm2 in adults.

Tuberculous empyema--a case history extending over 30 years

A patient with chronic tuberculous empyema is described. The condition had been present for 30 years, following treatment by outpatient pneumothorax. A broncho-pleural fistula developed, the symptoms of which were aggravated during air-flight.

Papilloedema and respiratory failure

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Tracheal compression relieved by cardiomyotomy

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Respiratory disability in coal miners

It has been suggested that the assessment of ventilatory capacity alone is inadequate for the determination of disabling occupational respiratory impairment in coal miners. The Department of Labor has accepted this view and now routinely requests blood gas analyses in those claimants not meeting the ventilatory criteria. We tested the validity of this contention by selecting two groups of coal miners claiming total disability. The first consisted of 150 claimants who were referred for spirometry, while the second consisted of 50 claimants who had been referred for blood gas studies. Of those in group 1, eight met the extent criteria for disability, while only two of those in group 2 satisfied the criteria, and, in both, cardiac disease was responsible. We conclude that blood gas analyses are unnecessary in the determination of pulmonary disability in coal miners.

Late sequelae of paralytic poliomyelitis: a clinical and electromyographic study

A prospective study was carried out on 24 volunteers who had suffered from paralytic poliomyelitis up to 51 years earlier. A quantitative EMG was carried out in each subject. Grossly raised mean amplitudes of the interference patterns were found in many strong muscles as well as in weak muscles. Such muscles frequently showed "contraction fasciculation", a manifestation of loss of normal small motor units. In many subjects the clinical and EMG evidence of chronic partial denervation were more widespread than the subjects had realised. It is suggested that if, with advancing age, minor damage occurs to the peripheral nervous system and the complement of motor neurones is already depleted by poliomyelitis, there will be an exaggerated response with increase in the lower motor neurone signs.

Regional lung function in asymptomatic cigarette smokers

Regional pulmonary ventilation and perfusion were studied in the supine posture using xenon-133 in 10 asymptomatic cigarette smokers with normal chest radiographs and no evidence of large airway obstruction. The results were compared with those obtained in age-matched control subjects who were lifelong nonsmokers. The ventilation of the upper zones of the lungs was significantly less than that of the lower zones in smokers but not in control subjects, and perfusion of the upper zones of the lungs was significantly greater than that of the mid-zones in control subjects but not in smokers. It is suggested that the upper zone abnormalities found in the group of smokers were consistent with the development of early emphysema.

Regional lung function in asbestos workers

Regional lung function was measured using radioactive xenon-133 in a group of normal subjects and in two groups of asbestos workers. When compared with the normal group, patients with pulmonary asbestosis showed impaired ventilation of the lower zones. Subjects with calcified pleural plaques without radiological evidence of lung parenchymal fibrosis did not show this abnormality.

Primary diaphragmatic haemangiopericytoma

Seaton, D. (1974).Thorax,29, 595-598. Primary diaphragmatic haemangiopericytoma. Haemangiopericytomas are tumours consisting of vascular spaces surrounded by proliferating pericytes. Since this neoplasm was first described (Stout and Murray, 1942) over 300 cases have been reported. All tumours of the diaphragm are rare, and a primary diaphragmatic haemangiopericytoma has not been previously recorded in the English literature. Such a case is described and the features of haemangiopericytomas are discussed.