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Lau EPM, Ing M, Vekaria S, Tan AL, Charlesworth C, Fysh E, Shrestha R, Yap ELC, Smith NA, Kwan BCH, Saghaie T, Roy B, Goddard J, Muruganandan S, Badiei A, Nguyen P, Hamid MFA, George V, Fitzgerald D, Maskell N, Feller-Kopman D, Murray K, Chakera A, Lee YCG. Australasian Malignant PLeural Effusion (AMPLE)-4 trial: study protocol for a multi-centre randomised trial of topical antibiotics prophylaxis for infections of indwelling pleural catheters. Trials 2024; 25:249. [PMID: 38594766 PMCID: PMC11005276 DOI: 10.1186/s13063-024-08065-1] [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: 12/20/2023] [Accepted: 03/18/2024] [Indexed: 04/11/2024] Open
Abstract
BACKGROUND Malignant pleural effusion (MPE) is a debilitating condition as it commonly causes disabling breathlessness and impairs quality of life (QoL). Indwelling pleural catheter (IPC) offers an effective alternative for the management of MPE. However, IPC-related infections remain a significant concern and there are currently no long-term strategies for their prevention. The Australasian Malignant PLeural Effusion (AMPLE)-4 trial is a multicentre randomised trial that evaluates the use of topical mupirocin prophylaxis (vs no mupirocin) to reduce catheter-related infections in patients with MPE treated with an IPC. METHODS A pragmatic, multi-centre, open-labelled, randomised trial. Eligible patients with MPE and an IPC will be randomised 1:1 to either regular topical mupirocin prophylaxis or no mupirocin (standard care). For the interventional arm, topical mupirocin will be applied around the IPC exit-site after each drainage, at least twice weekly. Weekly follow-up via phone calls or in person will be conducted for up to 6 months. The primary outcome is the percentage of patients who develop an IPC-related (pleural, skin, or tract) infection between the time of catheter insertion and end of follow-up period. Secondary outcomes include analyses of infection (types and episodes), hospitalisation days, health economics, adverse events, and survival. Subject to interim analyses, the trial will recruit up to 418 participants. DISCUSSION Results from this trial will determine the efficacy of mupirocin prophylaxis in patients who require IPC for MPE. It will provide data on infection rates, microbiology, and potentially infection pathways associated with IPC-related infections. ETHICS AND DISSEMINATION Sir Charles Gairdner and Osborne Park Health Care Group Human Research Ethics Committee has approved the study (RGS0000005920). Results will be published in peer-reviewed journals and presented at scientific conferences. TRIAL REGISTRATION Australia New Zealand Clinical Trial Registry ACTRN12623000253606. Registered on 9 March 2023.
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Affiliation(s)
- Estee P M Lau
- Pleural Medicine Unit, Institute for Respiratory Health, Perth, Australia
- School of Medical and Health Sciences, Edith Cowan University, Perth, Australia
| | - Matthew Ing
- Pleural Medicine Unit, Institute for Respiratory Health, Perth, Australia
- Medical School, Faculty of Health & Medical Sciences, University of Western Australia, Perth, Australia
- Department of Respiratory Medicine, Sir Charles Gairdner Hospital, Perth, Australia
| | - Sona Vekaria
- Department of Respiratory Medicine, Sir Charles Gairdner Hospital, Perth, Australia
- Department of Pharmacy, Sir Charles Gairdner Hospital, Perth, Australia
| | - Ai Ling Tan
- Pleural Medicine Unit, Institute for Respiratory Health, Perth, Australia
| | - Chloe Charlesworth
- Department of Respiratory Medicine, Sir Charles Gairdner Hospital, Perth, Australia
| | - Edward Fysh
- Medical School, Faculty of Health & Medical Sciences, University of Western Australia, Perth, Australia
- Department of Respiratory Medicine, St John of God Hospital Midland, Perth, Australia
- Curtin University Medical School, Perth, Australia
| | - Ranjan Shrestha
- Department of Respiratory Medicine, Fiona Stanley Hospital, Perth, Australia
| | - Elaine L C Yap
- Department of Respiratory Medicine, Middlemore Hospital, Auckland, New Zealand
| | - Nicola A Smith
- Department of Respiratory Medicine, Wellington Regional Hospital, Wellington, New Zealand
| | - Benjamin C H Kwan
- Department of Respiratory and Sleep Medicine, The Sutherland Hospital, Sydney, Australia
- University of New South Wales, Sydney, Australia
| | - Tajalli Saghaie
- Department of Respiratory Medicine, Concord Repatriation General Hospital, Concord, NSW, Australia
- Faculty of Medicine and Health Sciences, Macquarie University, Sydney, Australia
| | - Bapti Roy
- Department of Respiratory and Sleep Medicine, Westmead Hospital, Sydney, Australia
| | - John Goddard
- Department of Respiratory Medicine, Sunshine Coast University Hospital, Birtinya, QLD, Australia
- Griffith University, Brisbane, QLD, Australia
| | | | - Arash Badiei
- Thoracic Medicine, Royal Adelaide Hospital, Adelaide, SA, Australia
- Adelaide Medical School, Faculty of Health and Medical Science, University of Adelaide, Adelaide, SA, Australia
| | - Phan Nguyen
- Thoracic Medicine, Royal Adelaide Hospital, Adelaide, SA, Australia
- Adelaide Medical School, Faculty of Health and Medical Science, University of Adelaide, Adelaide, SA, Australia
| | | | - Vineeth George
- Department of Respiratory and Sleep Medicine, John Hunter Hospital, New Lambton Heights, NSW, Australia
- Hunter Medical Research Institute, Newcastle, Australia
| | - Deirdre Fitzgerald
- Department of Respiratory Medicine, Tallaght University Hospital, Dublin, Ireland
| | - Nick Maskell
- Academic Respiratory Unit, Bristol Medical School, University of Bristol, Bristol, UK
| | - David Feller-Kopman
- Department of Medicine, Section of Pulmonary and Critical Care Medicine, Dartmouth-Hitchcock Medical Center, Lebanon, NH, USA
| | - Kevin Murray
- School of Population and Global Health, University of Western Australia, Perth, Australia
| | - Aron Chakera
- Medical School, Faculty of Health & Medical Sciences, University of Western Australia, Perth, Australia
- Renal Unit, Sir Charles Gairdner Hospital, Perth, Australia
| | - Y C Gary Lee
- Pleural Medicine Unit, Institute for Respiratory Health, Perth, Australia.
- Medical School, Faculty of Health & Medical Sciences, University of Western Australia, Perth, Australia.
- Department of Respiratory Medicine, Sir Charles Gairdner Hospital, Perth, Australia.
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Lau EPM, Faber S, Charlesworth C, Morey S, Vekaria S, Filion P, Chakera A, Lee YCG. Topical antibiotics prophylaxis for infections of indwelling pleural/peritoneal catheters (TAP-IPC): A pilot study. Respirology 2024; 29:176-182. [PMID: 37696757 DOI: 10.1111/resp.14595] [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: 05/29/2023] [Accepted: 08/28/2023] [Indexed: 09/13/2023]
Abstract
BACKGROUND AND OBJECTIVE Indwelling pleural catheter (IPC) and indwelling peritoneal catheter (IPeC) have established roles in the management of malignant pleural and peritoneal effusions but catheter-related infections remain a major concern. Topical mupirocin prophylaxis has been shown to reduce peritoneal dialysis catheter infections. This study aimed to assess the (i) compatibility of IPC with mupirocin and (ii) feasibility, tolerability and compliance of topical mupirocin prophylaxis in patients with an IPC or IPeC. METHODS (i) Three preparations of mupirocin were applied onto segments of IPC thrice weekly and examined with scanning electron microscope (SEM) at different time intervals. (ii) Consecutive patients fitted with IPC or IPeC were given topical mupirocin prophylaxis to apply to the catheter exit-site following every drainage/dressing change (at least twice weekly) and followed up for 6 months. RESULTS (i) No detectable structural catheter damage was found with mupirocin applied for up to 6 months. (ii) Fifty indwelling catheters were inserted in 48 patients for malignant pleural (n = 41) and peritoneal (n = 9) effusions. Median follow-up was 121 [median, IQR 19-181] days. All patients tolerated mupirocin well; one patient reported short-term local tenderness. Compliance was excellent with 95.8% of the 989 scheduled doses delivered. Six patients developed catheter-related pleural (n = 3), concurrent peritoneal/local (n = 1) and skin/tract (n = 2) infections from Streptococcus mitis (with Bacillus species or anaerobes), Staphylococcus aureus, Klebsiella pneumoniae and Pseudomonas aeruginosa. CONCLUSION This first study of long-term prevention of IPC- or IPeC-related infections found topical mupirocin prophylaxis feasible and well tolerated. Its efficacy warrants future randomized studies.
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Affiliation(s)
- Estee P M Lau
- Pleural Medicine Unit, Institute for Respiratory Health, Perth, Western Australia, Australia
- School of Medical and Health Sciences, Edith Cowan University, Perth, Western Australia, Australia
| | - Sam Faber
- Department of Respiratory Medicine, Sir Charles Gairdner Hospital, Perth, Western Australia, Australia
| | - Chloe Charlesworth
- Department of Respiratory Medicine, Sir Charles Gairdner Hospital, Perth, Western Australia, Australia
| | - Sue Morey
- Department of Respiratory Medicine, Sir Charles Gairdner Hospital, Perth, Western Australia, Australia
| | - Sona Vekaria
- Department of Respiratory Medicine, Sir Charles Gairdner Hospital, Perth, Western Australia, Australia
- Department of Pharmacy, Sir Charles Gairdner Hospital, Perth, Western Australia, Australia
| | - Pierre Filion
- PathWest Laboratory Medicine, QEII Medical Centre, Perth, Western Australia, Australia
| | - Aron Chakera
- Renal Unit, Sir Charles Gairdner Hospital, Perth, Western Australia, Australia
- School of Medicine, University of Western Australia, Perth, Western Australia, Australia
| | - Y C Gary Lee
- Pleural Medicine Unit, Institute for Respiratory Health, Perth, Western Australia, Australia
- Department of Respiratory Medicine, Sir Charles Gairdner Hospital, Perth, Western Australia, Australia
- School of Medicine, University of Western Australia, Perth, Western Australia, Australia
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Sivakumar P, Fitzgerald DB, Ip H, Rao D, West A, Noorzad F, Wallace D, Haris M, Prudon B, Hettiarachchi G, Jayaram D, Goldring J, Maskell N, Holme J, Sharma N, Ismail I, Kadwani O, Simpson S, Read CA, Sun X, Douiri A, Lee YCG, Ahmed L. The impact of outpatient versus inpatient management on health-related quality of life outcomes for patients with malignant pleural effusion: the OPTIMUM randomised clinical trial. Eur Respir J 2024; 63:2201215. [PMID: 37996243 DOI: 10.1183/13993003.01215-2022] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/14/2022] [Accepted: 10/22/2023] [Indexed: 11/25/2023]
Abstract
BACKGROUND The principal aim of malignant pleural effusion (MPE) management is to improve health-related quality of life (HRQoL) and symptoms. METHODS In this open-label randomised controlled trial, patients with symptomatic MPE were randomly assigned to either indwelling pleural catheter (IPC) insertion with the option of talc pleurodesis or chest drain and talc pleurodesis. The primary end-point was global health status, measured with the 30-item European Organisation for Research and Treatment of Cancer Quality of Life Core Questionnaire (EORTC QLQ-C30) at 30 days post-intervention. 142 participants were enrolled from July 2015 to December 2019. RESULTS Of participants randomly assigned to the IPC (n=70) and chest drain (n=72) groups, primary outcome data were available in 58 and 56 patients, respectively. Global health status improved in both groups at day 30 compared with baseline: IPC (mean difference 13.11; p=0.001) and chest drain (mean difference 10.11; p=0.001). However, there was no significant between-group difference at day 30 (mean intergroup difference in baseline-adjusted global health status 2.06, 95% CI -5.86-9.99; p=0.61), day 60 or day 90. No significant differences were identified between groups in breathlessness and chest pain scores. All chest drain arm patients were admitted (median length of stay 4 days); seven patients in the IPC arm required intervention-related hospitalisation. CONCLUSIONS While HRQoL significantly improved in both groups, there were no differences in patient-reported global health status at 30 days. The outpatient pathway using an IPC was not superior to inpatient treatment with a chest drain.
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Affiliation(s)
- Parthipan Sivakumar
- Department of Thoracic Medicine, Guy's and St Thomas' NHS Trust, London, UK
- Western Sydney University, Sydney, Australia
- P. Sivakumar and L. Ahmed are joint first authors
| | - Deirdre B Fitzgerald
- Institute for Respiratory Health, University of Western Australia, Nedlands, Australia
- Respiratory Department, Sir Charles Gairdner Hospital, Nedlands, Australia
| | - Hugh Ip
- Centre for Respiratory Medicine, Royal Free Hospital, London, UK
| | - Deepak Rao
- Department of Thoracic Medicine, Princess Royal University Hospital, King's College Hospital NHS Foundation Trust, Orpington, UK
| | - Alex West
- Department of Thoracic Medicine, Guy's and St Thomas' NHS Trust, London, UK
| | | | - Deirdre Wallace
- Department of Thoracic Medicine, Guy's and St Thomas' NHS Trust, London, UK
| | - Mohamed Haris
- University Hospital of North Midlands NHS Trust, Stoke-on-Trent, UK
| | - Benjamin Prudon
- Department of Respiratory Medicine, North Tees and Hartlepool NHS Foundation Trust, Stockton-on-Tees, UK
| | | | | | - James Goldring
- Centre for Respiratory Medicine, Royal Free Hospital, London, UK
| | - Nick Maskell
- Academic Respiratory Unit, University of Bristol, Bristol, UK
| | - Jayne Holme
- North West Lung Centre, Manchester University NHS Foundation Trust, Manchester, UK
| | - Neel Sharma
- Respiratory Medicine, East Sussex NHS Trust, Eastbourne, UK
| | - Iyad Ismail
- University Hospitals Birmingham NHS Foundation Trust, Birmingham, UK
| | - Owais Kadwani
- Department of Thoracic Medicine, Guy's and St Thomas' NHS Trust, London, UK
| | - Sanchez Simpson
- Department of Thoracic Medicine, Guy's and St Thomas' NHS Trust, London, UK
| | - Catherine A Read
- Institute for Respiratory Health, University of Western Australia, Nedlands, Australia
| | - Xiaohui Sun
- School of Population Health and Environmental Sciences, King's College London, London, UK
| | - Abdel Douiri
- Institute for Respiratory Health, University of Western Australia, Nedlands, Australia
| | - Y C Gary Lee
- Institute for Respiratory Health, University of Western Australia, Nedlands, Australia
- Respiratory Department, Sir Charles Gairdner Hospital, Nedlands, Australia
| | - Liju Ahmed
- Department of Thoracic Medicine, Guy's and St Thomas' NHS Trust, London, UK
- Department of Thoracic Medicine, King Faisal Specialist Hospital and Research Centre, Madinah, Kingdom of Saudi Arabia
- P. Sivakumar and L. Ahmed are joint first authors
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Lee YCG. Pembrolizumab plus chemotherapy for pleural mesothelioma. Lancet 2023; 402:2266-2267. [PMID: 37931626 DOI: 10.1016/s0140-6736(23)01883-4] [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] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/17/2023] [Accepted: 09/04/2023] [Indexed: 11/08/2023]
Affiliation(s)
- Y C Gary Lee
- Pleural Medicine Unit, Institute for Respiratory Health, Perth, WA 6009, Australia; School of Medicine, University of Western Australia, Perth, WA, Australia; Department of Respiratory Medicine, Sir Charles Gairdner Hospital, Perth, WA, Australia.
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Lee YCG, Fitzgerald DB. Preface: Pleural Diseases Series. Semin Respir Crit Care Med 2023; 44:415-416. [PMID: 37429294 DOI: 10.1055/s-0043-1769613] [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] [Indexed: 07/12/2023]
Affiliation(s)
- Y C Gary Lee
- Medical School, University of Western Australia and Respiratory Medicine, Sir Charles Gairdner Hospital, Perth, Australia
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Lee YCG. Primary Spontaneous Pneumothorax: Treat the Patient, Not the X-Ray. Am J Respir Crit Care Med 2023; 207:1416-1417. [PMID: 36892609 PMCID: PMC10263137 DOI: 10.1164/rccm.202302-0273ed] [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] [Indexed: 03/10/2023] Open
Affiliation(s)
- Y C Gary Lee
- Respiratory Medicine Sir Charles Gairdner Hospital Perth, Western Australia, Australia
- Faculty of Health & Medical Sciences University of Western Australia Perth, Western Australia, Australia and Pleural Medicine Unit Institute for Respiratory Health Perth, Western Australia, Australia
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Faber S, McLean‐Tooke A, Kuok YJ, Lee YCG. Intrapleural therapy for pleural infection from bronchopleural fistula in an adult with hyper-IgE syndrome. Respirol Case Rep 2023; 11:e01156. [PMID: 37151367 PMCID: PMC10160851 DOI: 10.1002/rcr2.1156] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/23/2023] [Accepted: 04/24/2023] [Indexed: 05/09/2023] Open
Abstract
We presented the case of an adult patient with hyper-IgE syndrome (HIES) who was admitted acutely with a large hydropneumothorax from lung consolidation, a bronchopleural fistula and pleural infection. He has had recurrent pulmonary and skin infections since childhood and longstanding pneumatoceles. He was treated with systemic antibiotics and chest tube drainage. Administration of two doses of low-dose intrapleural therapy (1 mg tissue plasminogen activator and 5 mg deoxyribonuclease) allowed complete evacuation of his residual loculated pleural fluid, aided resolution of his infection without provoking a significant air leak and avoided the need for surgery.
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Affiliation(s)
- Sam Faber
- Respiratory DepartmentSir Charles Gairdner HospitalNedlandsWestern AustraliaAustralia
| | - Andrew McLean‐Tooke
- Department of Clinical ImmunologySir Charles Gairdner HospitalNedlandsWestern AustraliaAustralia
| | - Yi Jin Kuok
- Department of RadiologySir Charles Gairdner HospitalNedlandsWestern AustraliaAustralia
| | - Y. C. Gary Lee
- Respiratory DepartmentSir Charles Gairdner HospitalNedlandsWestern AustraliaAustralia
- Pleural Medicine UnitInstitute for Respiratory HealthNedlandsWestern AustraliaAustralia
- Medical SchoolUniversity of Western AustraliaPerthWestern AustraliaAustralia
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Sidhu C, Davies HE, Muruganandan S, Lui MMS, Lau EPM, Lee YCG. Indwelling Pleural Catheter: Management of Complications. Semin Respir Crit Care Med 2023. [PMID: 37257836 DOI: 10.1055/s-0043-1769093] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/02/2023]
Abstract
Multiple randomized clinical trials have established the advantages of indwelling pleural catheter (IPC) in the management of malignant pleural effusions, resulting in its widespread adoption in clinical practice. Complications can occur with IPC use and must be recognized and managed effectively. This review provides a comprehensive overview of IPC complications and their best care. Pain postinsertion or during drainage of IPC is easily manageable and must be distinguished from tumor-related chest wall pain. IPC-related infections require systemic antibiotics and often intrapleural fibrinolytic/deoxyribonuclease therapy. The removal of IPC for infection is usually unnecessary. Symptomatic loculation usually responds to fibrinolytics but may recur. Catheter tract metastases are common in mesothelioma patients and usually respond to radiotherapy without inducing damages to the IPC. Less common complications include dislodgement, irreversible blockage, and fractures (upon removal) of the catheter. Recommendations on the management of IPC complications by recent consensus statement/guideline are discussed. Expert opinions on management approaches are included in areas where evidence is lacking to guide care.
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Affiliation(s)
- Calvin Sidhu
- Pleural Medicine Unit, Institute for Respiratory Health, Perth, Australia
- School of Medical and Health Sciences, Edith Cowan University, Perth, Australia
- Department of Respiratory Medicine, Sir Charles Gairdner Hospital, Perth, Australia
| | - Helen E Davies
- Department of Respiratory Medicine, University Hospital of Wales, Cardiff, United Kingdom
| | - Sanjeevan Muruganandan
- Department of Respiratory Medicine, Northern Health, Melbourne, Australia
- Faculty of Medicine, Dentistry and Health Sciences, University of Melbourne, Parkville, Victoria, Australia
| | - Macy M S Lui
- Division of Respiratory Medicine, Queen Mary Hospital, The University of Hong Kong, Hong Kong
| | - Estee P M Lau
- Pleural Medicine Unit, Institute for Respiratory Health, Perth, Australia
- School of Medical and Health Sciences, Edith Cowan University, Perth, Australia
| | - Y C Gary Lee
- Pleural Medicine Unit, Institute for Respiratory Health, Perth, Australia
- Department of Respiratory Medicine, Sir Charles Gairdner Hospital, Perth, Australia
- School of Medicine, University of Western Australia, Perth, Australia
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Lee YCG, Singh B. Reply to Albert and Dhooria et al.. Am J Respir Crit Care Med 2023; 207:225-226. [PMID: 36070599 PMCID: PMC9893335 DOI: 10.1164/rccm.202207-1450le] [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] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/18/2023] Open
Affiliation(s)
- Y. C. Gary Lee
- Sir Charles Gairdner HospitalNedlands, Western Australia, Australia,University of Western AustraliaPerth, Western Australia, Australia,Institute for Respiratory HealthPerth, Western Australia, Australia,Corresponding author (e-mail: )
| | - Bhajan Singh
- Sir Charles Gairdner HospitalNedlands, Western Australia, Australia,University of Western AustraliaPerth, Western Australia, Australia,QE II Medical CentreNedlands, Western Australia, Australia
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Orozco Morales ML, Rinaldi CA, de Jong E, Lansley SM, Lee YCG, Zemek RM, Bosco A, Lake RA, Lesterhuis WJ. Geldanamycin treatment does not result in anti-cancer activity in a preclinical model of orthotopic mesothelioma. PLoS One 2023; 18:e0274364. [PMID: 37146029 PMCID: PMC10162533 DOI: 10.1371/journal.pone.0274364] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/11/2022] [Accepted: 03/26/2023] [Indexed: 05/07/2023] Open
Abstract
Mesothelioma is characterised by its aggressive invasive behaviour, affecting the surrounding tissues of the pleura or peritoneum. We compared an invasive pleural model with a non-invasive subcutaneous model of mesothelioma and performed transcriptomic analyses on the tumour samples. Invasive pleural tumours were characterised by a transcriptomic signature enriched for genes associated with MEF2C and MYOCD signaling, muscle differentiation and myogenesis. Further analysis using the CMap and LINCS databases identified geldanamycin as a potential antagonist of this signature, so we evaluated its potential in vitro and in vivo. Nanomolar concentrations of geldanamycin significantly reduced cell growth, invasion, and migration in vitro. However, administration of geldanamycin in vivo did not result in significant anti-cancer activity. Our findings show that myogenesis and muscle differentiation pathways are upregulated in pleural mesothelioma which may be related to the invasive behaviour. However, geldanamycin as a single agent does not appear to be a viable treatment for mesothelioma.
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Affiliation(s)
- M Lizeth Orozco Morales
- School of Biomedical Sciences, University of Western Australia, Crawley, Western Australia, Australia
- National Centre for Asbestos Related Diseases, Nedlands, Western Australia, Australia
- Institute for Respiratory Health, Nedlands, Western Australia, Australia
| | - Catherine A Rinaldi
- School of Biomedical Sciences, University of Western Australia, Crawley, Western Australia, Australia
- National Centre for Asbestos Related Diseases, Nedlands, Western Australia, Australia
- Centre for Microscopy Characterisation and Analysis, Nedlands, Western Australia, Australia
| | - Emma de Jong
- Telethon Kids Institute, The University of Western Australia, Nedlands, Western Australia, Australia
| | - Sally M Lansley
- Institute for Respiratory Health, Nedlands, Western Australia, Australia
| | - Y C Gary Lee
- Institute for Respiratory Health, Nedlands, Western Australia, Australia
| | - Rachael M Zemek
- Telethon Kids Institute, The University of Western Australia, Nedlands, Western Australia, Australia
| | - Anthony Bosco
- Telethon Kids Institute, The University of Western Australia, Nedlands, Western Australia, Australia
| | - Richard A Lake
- School of Biomedical Sciences, University of Western Australia, Crawley, Western Australia, Australia
- National Centre for Asbestos Related Diseases, Nedlands, Western Australia, Australia
- Institute for Respiratory Health, Nedlands, Western Australia, Australia
| | - W Joost Lesterhuis
- School of Biomedical Sciences, University of Western Australia, Crawley, Western Australia, Australia
- National Centre for Asbestos Related Diseases, Nedlands, Western Australia, Australia
- Institute for Respiratory Health, Nedlands, Western Australia, Australia
- Telethon Kids Institute, The University of Western Australia, Nedlands, Western Australia, Australia
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Lau EPM, Sidhu C, Popowicz ND, Lee YCG. Pharmacokinetics of antibiotics for pleural infection. Expert Rev Respir Med 2022; 16:1057-1066. [DOI: 10.1080/17476348.2022.2147508] [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] [Indexed: 11/16/2022]
Affiliation(s)
- E P M Lau
- Pleural Medicine Unit, Institute for Respiratory Health, Perth, Australia
- School of Medical and Health Sciences, Edith Cowan University, Perth, Australia
| | - Calvinjit Sidhu
- Pleural Medicine Unit, Institute for Respiratory Health, Perth, Australia
- School of Medical and Health Sciences, Edith Cowan University, Perth, Australia
- Department of Respiratory Medicine, Sir Charles Gairdner Hospital, Perth, Australia
| | - Natalia D Popowicz
- Pleural Medicine Unit, Institute for Respiratory Health, Perth, Australia
- School of Allied Health, Division of Pharmacy, University of Western Australia, Perth, Australia
- Department of Respiratory Medicine, Sir Charles Gairdner Hospital, Perth, Australia
| | - Y C Gary Lee
- Pleural Medicine Unit, Institute for Respiratory Health, Perth, Australia
- Department of Respiratory Medicine, Sir Charles Gairdner Hospital, Perth, Australia
- Centre for Respiratory Health, School of Medicine, University of Western Australia, Perth, Australia
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12
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Jayawardena T, Vekaria S, Krivinskas S, Sidhu C, Chakera A, Lee YCG. Antibiotic administration via indwelling peritoneal catheter to treat infected malignant ascites. Respirol Case Rep 2022; 10:e01055. [PMID: 36258693 PMCID: PMC9574600 DOI: 10.1002/rcr2.1055] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/01/2022] [Accepted: 10/05/2022] [Indexed: 11/10/2022] Open
Abstract
Indwelling pleural catheter is an established management for malignant pleural effusions. Extending its use to patients with malignant ascites by insertion of a catheter intraperitoneally enables regular outpatient drainage and improves quality-of-life. However, indwelling pleural/peritoneal catheter (IPC/IPeC) is associated with catheter-related infections, traditionally managed with systemic antibiotics and occasionally requires catheter removal. Direct administration of antibiotics intra-abdominally via peritoneal dialysis (PD) catheters is a well-established, efficacious practice in PD-related peritonitis and minimizes systemic adverse effects. We applied the same principles to a patient with peritoneal mesothelioma who developed peritonitis 3 weeks after insertion of IPeC. Intraperitoneal vancomycin was administered via, and compatible with, the IPeC. The patient tolerated the treatment without adverse effects and made a full recovery without requiring catheter removal.
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Affiliation(s)
- Thisuri Jayawardena
- Department of Respiratory MedicineSir Charles Gairdner HospitalPerthWestern AustraliaAustralia
| | - Sona Vekaria
- Department of Respiratory MedicineSir Charles Gairdner HospitalPerthWestern AustraliaAustralia,Department of PharmacySir Charles Gairdner HospitalPerthWestern AustraliaAustralia
| | - Sophie Krivinskas
- Department of Respiratory MedicineSir Charles Gairdner HospitalPerthWestern AustraliaAustralia
| | - Calvinjit Sidhu
- Department of Respiratory MedicineSir Charles Gairdner HospitalPerthWestern AustraliaAustralia
| | - Aron Chakera
- Department of Renal MedicineSir Charles Gairdner HospitalPerthWestern AustraliaAustralia
| | - Y. C. Gary Lee
- Department of Respiratory MedicineSir Charles Gairdner HospitalPerthWestern AustraliaAustralia,Centre for Respiratory Health, School of MedicineUniversity of Western AustraliaPerthWestern AustraliaAustralia
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Fitzgerald DB, Muruganandan S, Peddle-McIntyre CJ, Lee YCG, Singh B. Ipsilateral and contralateral hemidiaphragm dynamics in symptomatic pleural effusion: The 2nd PLeural Effusion And Symptom Evaluation (PLEASE-2) Study. Respirology 2022; 27:882-889. [PMID: 35672271 DOI: 10.1111/resp.14307] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/10/2022] [Accepted: 05/05/2022] [Indexed: 02/03/2023]
Abstract
BACKGROUND AND OBJECTIVE The pathophysiology of breathlessness in pleural effusion is unclear. In the PLEASE-1 study, abnormal ipsilateral hemidiaphragm shape and movement, assessed qualitatively, were independently associated with breathlessness relief after pleural drainage. Effects of pleural effusion on contralateral hemidiaphragm function are unknown. PLEASE-2, a prospective exploratory pilot study, assessed the effects of unilateral effusion and drainage on both hemidiaphragms using advanced quantitative bedside ultrasonography. METHODS Individuals with symptomatic unilateral pleural effusion undergoing therapeutic drainage were included. Measurements pre- and post-drainage included severity of breathlessness (visual analogue scale) and ultrasound measurements of diaphragm excursion and thickness, in addition to shape and movement. Diaphragm measurements were compared to published reference values. RESULTS Twenty participants were recruited (mean age 68.9 [SD 12.8] years, 12 females). During tidal breathing, contralateral hemidiaphragm excursion exceeded ipsilateral excursion and reference values (all p ≤ 0.001). Contralateral excursion was greatest in participants with abnormal ipsilateral hemidiaphragm movement and was inversely correlated with ipsilateral tidal excursion (r = -0.676, p = 0.001). Following drainage (mean volume 2121 [SD = 1206] ml), abnormal shape (n = 12) and paradoxical movement (n = 9) of the ipsilateral hemidiaphragm resolved in all participants, and tidal excursion of the contralateral hemidiaphragm normalized. Relief of breathlessness post-drainage correlated with improvement in ipsilateral hemidiaphragm excursion (r = 0.556, p = 0.031). CONCLUSION This pilot study suggests, for the first time, that unilateral pleural effusion not only impairs ipsilateral hemidiaphragm function but also causes compensatory hyperactivity of the contralateral hemidiaphragm, which resolves post-drainage. These findings provide a basis for detailed studies of diaphragmatic function and ventilatory drive in patients with symptomatic pleural effusion.
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Affiliation(s)
- Deirdre B Fitzgerald
- Department of Respiratory Medicine, Sir Charles Gairdner Hospital, Perth, Western Australia, Australia.,Pleural Medicine Unit, Institute for Respiratory Health, Perth, Western Australia, Australia.,Medical School, University of Western Australia, Perth, Western Australia, Australia
| | | | - Carolyn J Peddle-McIntyre
- Pleural Medicine Unit, Institute for Respiratory Health, Perth, Western Australia, Australia.,Exercise Medicine Research Institute, Edith Cowan University, Perth, Western Australia, Australia.,School of Medical and Health Sciences, Edith Cowan University, Joondalup, Western Australia, Australia
| | - Y C Gary Lee
- Department of Respiratory Medicine, Sir Charles Gairdner Hospital, Perth, Western Australia, Australia.,Pleural Medicine Unit, Institute for Respiratory Health, Perth, Western Australia, Australia.,Medical School, University of Western Australia, Perth, Western Australia, Australia
| | - Bhajan Singh
- Department of Pulmonary Physiology & Sleep Medicine, Sir Charles Gairdner Hospital, Perth, Western Australia, Australia.,School of Human Sciences, University of Western Australia, Perth, Western Australia, Australia.,West Australian Sleep Disorders Research Institute, Perth, Western Australia, Australia
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14
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Affiliation(s)
- Y C Gary Lee
- Respiratory Medicine Sir Charles Gairdner Hospital Western Australia, Australia.,Medical School University of Western Australia, Western Australia, Australia.,Pleural Medicine Unit Institute for Respiratory Health Perth, Western Australia, Australia
| | - Bhajan Singh
- Pulmonary Physiology and Sleep Medicine Sir Charles Gairdner Hospital Western Australia, Australia.,West Australian Sleep Disorders Research Institute Queen Elizabeth II Medical Centre Western Australia, Australia.,Faculty of Human Sciences University of Western Australia Western Australia, Australia
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15
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Breen LJ, Huseini T, Same A, Peddle-McIntyre CJ, Lee YCG. Living with mesothelioma: A systematic review of patient and caregiver psychosocial support needs. Patient Educ Couns 2022; 105:1904-1916. [PMID: 35260259 DOI: 10.1016/j.pec.2022.02.017] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [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: 05/18/2021] [Revised: 02/24/2022] [Accepted: 02/26/2022] [Indexed: 05/10/2023]
Abstract
OBJECTIVE Practice guidelines emphasize the importance of investigating psychosocial distress in mesothelioma patients and family caregivers. We aimed to synthesize research on the psychosocial support needs of mesothelioma patients and their family caregivers. METHODS We conducted a systematic review with a narrative synthesis and quality assessment. The review process adhered to the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines. RESULTS MEDLINE, EMBASE, Scopus, PsychArticles, and PsycINFO were searched until December 2020 and 37 studies in English met inclusion criteria. Most (n = 24) included mesothelioma patients as a very small proportion of their cancer samples. A narrative synthesis was conducted on the 13 studies including only mesothelioma patients (n = 297) and/or caregivers (n = 82). Patients and caregivers want improvements in the diagnosis delivery and access to palliative care. Patients want emotional support, patient-centered treatment, improved information about illness progression and death, and to meet others with mesothelioma. Caregivers want one-on-one practical and emotional support. Study quality varied. CONCLUSIONS Few studies focus on the psychosocial support needs relevant to mesothelioma. Mesothelioma patients and family caregivers highlight targeted psychosocial care as an unmet need. PRACTICE IMPLICATIONS Efforts are required to design and test psychosocial interventions for this vulnerable and overlooked group. PROTOCOL REGISTRATION PROSPERO (registration number CRD42020167852).
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Affiliation(s)
- Lauren J Breen
- Curtin School of Population Health, Curtin University, Perth, Western Australia, Australia; Curtin enAble Institute, Faculty of Health Sciences, Curtin University, Perth, Western Australia, Australia.
| | - Taha Huseini
- Curtin School of Population Health, Curtin University, Perth, Western Australia, Australia; Department of Respiratory Medicine, Sir Charles Gairdner Hospital, Perth, Western Australia, Australia
| | - Anne Same
- Curtin School of Population Health, Curtin University, Perth, Western Australia, Australia
| | - Carolyn J Peddle-McIntyre
- Exercise Medicine Research Institute, Edith Cowan University, Perth, Western Australia, Australia; School of Medical and Health Sciences, Edith Cowan University, Perth, Western Australia, Australia
| | - Y C Gary Lee
- Department of Respiratory Medicine, Sir Charles Gairdner Hospital, Perth, Western Australia, Australia; Centre for Respiratory Health, University of Western Australia, Perth, Western Australia, Australia
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16
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Fitzgerald DB, Sidhu C, Budgeon C, Tan AL, Read CA, Kwan BCH, Smith NA, Fysh ET, Muruganandan S, Saghaie T, Shrestha R, Badiei A, Nguyen P, Burke A, Goddard J, Windsor M, McDonald J, Wright G, Czarnecka K, Sivakumar P, Yasufuku K, Feller-Kopman DJ, Maskell NA, Murray K, Lee YCG. Australasian Malignant PLeural Effusion (AMPLE)-3 trial: study protocol for a multi-centre randomised study comparing indwelling pleural catheter (±talc pleurodesis) versus video-assisted thoracoscopic surgery for management of malignant pleural effusion. Trials 2022; 23:530. [PMID: 35761341 PMCID: PMC9235203 DOI: 10.1186/s13063-022-06405-7] [Citation(s) in RCA: 3] [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: 01/06/2022] [Accepted: 05/16/2022] [Indexed: 11/10/2022] Open
Abstract
Introduction Malignant pleural effusions (MPEs) are common. MPE causes significant breathlessness and impairs quality of life. Indwelling pleural catheters (IPC) allow ambulatory drainage and reduce hospital days and re-intervention rates when compared to standard talc slurry pleurodesis. Daily drainage accelerates pleurodesis, and talc instillation via the IPC has been proven feasible and safe. Surgical pleurodesis via video-assisted thoracoscopic surgery (VATS) is considered a one-off intervention for MPE and is often recommended to patients who are fit for surgery. The AMPLE-3 trial is the first randomised trial to compare IPC (±talc pleurodesis) and VATS pleurodesis in those who are fit for surgery. Methods and analysis A multi-centre, open-labelled randomised trial of patients with symptomatic MPE, expected survival of ≥ 6 months and good performance status randomised 1:1 to either IPC or VATS pleurodesis. Participant randomisation will be minimised for (i) cancer type (mesothelioma vs non-mesothelioma); (ii) previous pleurodesis (vs not); and (iii) trapped lung, if known (vs not). Primary outcome is the need for further ipsilateral pleural interventions over 12 months or until death, if sooner. Secondary outcomes include days in hospital, quality of life (QoL) measures, physical activity levels, safety profile, health economics, adverse events, and survival. The trial will recruit 158 participants who will be followed up for 12 months. Ethics and dissemination Sir Charles Gairdner and Osborne Park Health Care Group (HREC) has approved the study (reference: RGS356). Results will be published in peer-reviewed journals and presented at scientific meetings. Discussion Both IPC and VATS are commonly used procedures for MPE. The AMPLE-3 trial will provide data to help define the merits and shortcomings of these procedures and inform future clinical care algorithms. Trial registration Australia New Zealand Clinical Trial Registry ACTRN12618001013257. Registered on 18 June 2018. Protocol version: Version 3.00/4.02.19 Supplementary Information The online version contains supplementary material available at 10.1186/s13063-022-06405-7.
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Affiliation(s)
- Deirdre B Fitzgerald
- Respiratory Medicine, Sir Charles Gairdner Hospital, Nedlands, WA, Australia.,Medical School, Faculty of Health & Medical Sciences, University of Western Australia, Perth, WA, Australia.,Pleural Medicine Unit, Institute for Respiratory Health, Perth, WA, Australia
| | - Calvin Sidhu
- Respiratory Medicine, Sir Charles Gairdner Hospital, Nedlands, WA, Australia.,Pleural Medicine Unit, Institute for Respiratory Health, Perth, WA, Australia.,School of Medical and Health Sciences, Edith Cowan University, Joondalup, WA, Australia
| | - Charley Budgeon
- School of Population and Global Health, University of Western Australia, Perth, WA, Australia
| | - Ai Ling Tan
- Pleural Medicine Unit, Institute for Respiratory Health, Perth, WA, Australia
| | - Catherine A Read
- Pleural Medicine Unit, Institute for Respiratory Health, Perth, WA, Australia
| | - Benjamin C H Kwan
- Department of Respiratory and Sleep Medicine, The Sutherland Hospital, Sydney, NSW, Australia.,University of New South Wales, Sydney, NSW, Australia
| | - Nicola Ann Smith
- Respiratory Department, Wellington Regional Hospital, Wellington, New Zealand
| | - Edward T Fysh
- Medical School, Faculty of Health & Medical Sciences, University of Western Australia, Perth, WA, Australia.,Respiratory Medicine, St John of God Hospital Midland, Midland, WA, Australia
| | | | - Tajalli Saghaie
- Respiratory Medicine, Concord Repatriation General Hospital, Concord West, NSW, Australia.,Faculty of Medicine and Health Sciences, Macquarie University, Sydney, NSW, Australia
| | - Ranjan Shrestha
- Respiratory Medicine, Fiona Stanley Hospital, Murdoch, WA, Australia
| | - Arash Badiei
- Thoracic Medicine, Royal Adelaide Hospital, Adelaide, SA, Australia.,Adelaide Medical School, Faculty of Health and Medical Science, University of Adelaide, Adelaide, SA, Australia
| | - Phan Nguyen
- Thoracic Medicine, Royal Adelaide Hospital, Adelaide, SA, Australia.,Adelaide Medical School, Faculty of Health and Medical Science, University of Adelaide, Adelaide, SA, Australia
| | - Andrew Burke
- Thoracic Medicine, The Prince Charles Hospital, Brisbane, QLD, Australia.,School of Medicine, The University of Queensland School of Medicine, Brisbane, QLD, Australia
| | - John Goddard
- Respiratory Department, Sunshine Coast University Hospital, Birtinya, QLD, Australia.,Griffith University, Brisbane, QLD, Australia
| | - Morgan Windsor
- Thoracic Surgery, The Prince Charles Hospital, Brisbane, QLD, Australia
| | - Julie McDonald
- Respiratory and Sleep Medicine Department, St Vincent's Hospital, Melbourne, VIC, Australia
| | - Gavin Wright
- Department of Cardiothoracic Surgery & University of Melbourne Department of Surgery, St Vincent's Hospital, Melbourne, VIC, Australia
| | - Kasia Czarnecka
- Division of Thoracic Surgery, Toronto General Hospital University Health Network, University of Toronto, Toronto, Ontario, Canada
| | | | - Kazuhiro Yasufuku
- Division of Thoracic Surgery, Toronto General Hospital University Health Network, University of Toronto, Toronto, Ontario, Canada
| | | | - Nick A Maskell
- Academic Respiratory Unit, Bristol Medical School, University of Bristol, Bristol, UK
| | - Kevin Murray
- School of Population and Global Health, University of Western Australia, Perth, WA, Australia
| | - Y C Gary Lee
- Respiratory Medicine, Sir Charles Gairdner Hospital, Nedlands, WA, Australia. .,Medical School, Faculty of Health & Medical Sciences, University of Western Australia, Perth, WA, Australia. .,Pleural Medicine Unit, Institute for Respiratory Health, Perth, WA, Australia.
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17
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Creaney J, Patch AM, Addala V, Sneddon SA, Nones K, Dick IM, Lee YCG, Newell F, Rouse EJ, Naeini MM, Kondrashova O, Lakis V, Nakas A, Waller D, Sharkey A, Mukhopadhyay P, Kazakoff SH, Koufariotis LT, Davidson AL, Ramarao-Milne P, Holmes O, Xu Q, Leonard C, Wood S, Grimmond SM, Bueno R, Fennell DA, Pearson JV, Robinson BW, Waddell N. Comprehensive genomic and tumour immune profiling reveals potential therapeutic targets in malignant pleural mesothelioma. Genome Med 2022; 14:58. [PMID: 35637530 PMCID: PMC9150319 DOI: 10.1186/s13073-022-01060-8] [Citation(s) in RCA: 23] [Impact Index Per Article: 11.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/18/2021] [Accepted: 05/15/2022] [Indexed: 12/14/2022] Open
Abstract
Background Malignant pleural mesothelioma (MPM) has a poor overall survival with few treatment options. Whole genome sequencing (WGS) combined with the immune features of MPM offers the prospect of identifying changes that could inform future clinical trials. Methods We analysed somatic mutations from 229 MPM samples, including previously published data and 58 samples that had undergone WGS within this study. This was combined with RNA-seq analysis to characterize the tumour immune environment. Results The comprehensive genome analysis identified 12 driver genes, including new candidate genes. Whole genome doubling was a frequent event that correlated with shorter survival. Mutational signature analysis revealed SBS5/40 were dominant in 93% of samples, and defects in homologous recombination repair were infrequent in our cohort. The tumour immune environment contained high M2 macrophage infiltrate linked with MMP2, MMP14, TGFB1 and CCL2 expression, representing an immune suppressive environment. The expression of TGFB1 was associated with overall survival. A small subset of samples (less than 10%) had a higher proportion of CD8 T cells and a high cytolytic score, suggesting a ‘hot’ immune environment independent of the somatic mutations. Conclusions We propose accounting for genomic and immune microenvironment status may influence therapeutic planning in the future. Supplementary Information The online version contains supplementary material available at 10.1186/s13073-022-01060-8.
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18
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Fitzgerald DB, Waterer GW, Budgeon C, Shrestha R, Fysh ET, Muruganandan S, Stanley C, Saghaie T, Badiei A, Sidhu C, Harryanto H, Duong V, Azzopardi M, Manners D, Lan NSH, Popowicz ND, Peddle-McIntyre CJ, Rahman NM, Read CA, Tan AL, Gan SK, Murray K, Lee YCG. Steroid Therapy and Outcome of Parapneumonic Pleural Effusions (STOPPE): A Pilot Randomized Clinical Trial. Am J Respir Crit Care Med 2022; 205:1093-1101. [PMID: 35081010 DOI: 10.1164/rccm.202107-1600oc] [Citation(s) in RCA: 8] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/15/2022] Open
Abstract
Rationale: Pleural effusion commonly complicates community-acquired pneumonia and is associated with intense pleural inflammation. Whether antiinflammatory treatment with corticosteroids improves outcomes is unknown. Objectives: To assess the effects of corticosteroids in an adult population with pneumonia-related pleural effusion. Methods: The STOPPE (Steroid Therapy and Outcome of Parapneumonic Pleural Effusions) trial was a pilot, multicenter, double-blinded, placebo-controlled, randomized trial involving six Australian centers. Patients with community-acquired pneumonia and pleural effusion were randomized (2:1) to intravenous dexamethasone (4 mg twice daily for 48 h) or placebo and followed for 30 days. Given the diverse effects of corticosteroids, a comprehensive range of clinical, serological, and imaging outcomes were assessed in this pilot trial (ACTRN12618000947202). Measurements and Main Results: Eighty patients were randomized (one withdrawn before treatment) and received dexamethasone (n = 51) or placebo (n = 28). This pilot trial found no preliminary evidence of benefits of dexamethasone in improving time to sustained (>12 h) normalization of vital signs (temperature, oxygen saturations, blood pressure, heart, and respiratory rates): median, 41.0 (95% confidence interval, 32.3-54.5) versus 27.8 (15.4-49.5) hours in the placebo arm (hazard ratio, 0.729 [95% confidence interval, 0.453-1.173]; P = 0.193). Similarly, no differences in C-reactive protein or leukocyte counts were observed, except for a higher leukocyte count in the dexamethasone group at Day 3. Pleural drainage procedures were performed in 49.0% of dexamethasone-treated and 42.9% of placebo-treated patients (P = 0.60). Radiographic pleural opacification decreased over time with no consistent intergroup differences. Mean duration of antibiotic therapy (22.4 [SD, 15.4] vs. 20.4 [SD, 13.8] d) and median hospitalization (6.0 [interquartile range, 5.0-10.0] vs. 5.5 [interquartile range, 5.0-8.0] d) were similar between the dexamethasone and placebo groups. Serious adverse events occurred in 25.5% of dexamethasone-treated and 21.4% of placebo-treated patients. Transient hyperglycemia more commonly affected the dexamethasone group (15.6% vs. 7.1%). Conclusions: Systemic corticosteroids showed no preliminary benefits in adults with parapneumonic effusions. Clinical trial registered with www.anzctr.org.au (ACTRN12618000947202).
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Affiliation(s)
- Deirdre B Fitzgerald
- Respiratory Medicine, Sir Charles Gairdner Hospital, Nedlands, Western Australia, Australia.,Medical School, Faculty of Health and Medical Sciences.,Pleural Medicine Unit, Institute for Respiratory Health, Perth, Western Australia, Australia
| | - Grant W Waterer
- Medical School, Faculty of Health and Medical Sciences.,Department of Respiratory Medicine and
| | | | - Ranjan Shrestha
- Department of Respiratory Medicine, Fiona Stanley Hospital, Murdoch, Western Australia, Australia
| | - Edward T Fysh
- Medical School, Faculty of Health and Medical Sciences.,Department of Respiratory Medicine, St. John of God Midland Public and Private Hospitals, Midland, Western Australia, Australia
| | | | | | - Tajalli Saghaie
- Department of Respiratory Medicine, Concord Repatriation General Hospital, Concord, New South Wales, Australia.,Faculty of Medicine and Health Sciences, Macquarie University, Sydney, New South Wales, Australia
| | - Arash Badiei
- Department of Thoracic Medicine, Royal Adelaide Hospital, Adelaide, South Australia, Australia
| | - Calvin Sidhu
- Respiratory Medicine, Sir Charles Gairdner Hospital, Nedlands, Western Australia, Australia.,Pleural Medicine Unit, Institute for Respiratory Health, Perth, Western Australia, Australia.,School of Medical and Health Sciences and
| | - Hilman Harryanto
- Department of Respiratory Medicine, Fiona Stanley Hospital, Murdoch, Western Australia, Australia
| | - Victor Duong
- Department of Respiratory Medicine, Northern Health, Epping, Victoria, Australia
| | - Maree Azzopardi
- Respiratory Medicine, Sir Charles Gairdner Hospital, Nedlands, Western Australia, Australia
| | - David Manners
- Department of Respiratory Medicine, St. John of God Midland Public and Private Hospitals, Midland, Western Australia, Australia
| | - Norris S H Lan
- Respiratory Medicine, Sir Charles Gairdner Hospital, Nedlands, Western Australia, Australia
| | - Natalia D Popowicz
- Respiratory Medicine, Sir Charles Gairdner Hospital, Nedlands, Western Australia, Australia.,School of Allied Health, University of Western Australia, Crawley, Western Australia, Australia
| | - Carolyn J Peddle-McIntyre
- Pleural Medicine Unit, Institute for Respiratory Health, Perth, Western Australia, Australia.,School of Medical and Health Sciences and.,Exercise Medicine Research Institute, Edith Cowan University, Joondalup, Western Australia, Australia
| | - Najib M Rahman
- Oxford Respiratory Trials Unit and.,National Institute for Health Research Oxford Biomedical Research Centre, University of Oxford, Oxford, United Kingdom; and
| | - Catherine A Read
- Pleural Medicine Unit, Institute for Respiratory Health, Perth, Western Australia, Australia.,North Metropolitan Health Service, Perth, Western Australia, Australia
| | - Ai Ling Tan
- Pleural Medicine Unit, Institute for Respiratory Health, Perth, Western Australia, Australia
| | - Seng Khee Gan
- Medical School, Faculty of Health and Medical Sciences.,Department of Endocrinology and Diabetes, Royal Perth Hospital, Perth, Western Australia, Australia
| | | | - Y C Gary Lee
- Respiratory Medicine, Sir Charles Gairdner Hospital, Nedlands, Western Australia, Australia.,Medical School, Faculty of Health and Medical Sciences.,Pleural Medicine Unit, Institute for Respiratory Health, Perth, Western Australia, Australia
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19
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Popowicz N, Ip H, Lau EPM, Piccolo F, Dootson K, Yeoh C, Phu WY, Brown R, West A, Ahmed L, Lee YCG. Alteplase Dose Assessment for Pleural infection Therapy (ADAPT) Study-2: Use of 2.5 mg alteplase as a starting intrapleural dose. Respirology 2022; 27:510-516. [PMID: 35441458 DOI: 10.1111/resp.14261] [Citation(s) in RCA: 9] [Impact Index Per Article: 4.5] [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: 12/22/2021] [Revised: 02/09/2022] [Accepted: 03/28/2022] [Indexed: 11/27/2022]
Abstract
BACKGROUND AND OBJECTIVE Intrapleural tissue plasminogen activator/deoxyribonuclease (tPA/DNase) therapy is increasingly used in pleural infection. Bleeding risks and costs associated with tPA remain the clinical concerns. Our dose de-escalation series aims to establish the lowest effective dosing regimen for tPA/DNase. This study assesses the intrapleural use of 2.5 mg tPA/5 mg DNase for pleural infection. METHODS Consecutive patients with pleural infection treated with a starting regime of 2.5 mg tPA/5 mg DNase were included from two centres in Australia and UK. Escalation of tPA dose was permitted if clinical response was inadequate. RESULTS Sixty-nine patients (mean age 61.0 years) received intrapleural 2.5 mg tPA/5 mg DNase. Most (88.4%) were treated successfully and discharged from hospital without surgery by 90 days. Patients received a median of 5 [interquartile range [IQR] = 3-6] doses of tPA/DNase. Total amount of tPA used per patient was 12.5 mg [median, IQR = 7.5-15.0]. Seventeen patients required dose escalation of tPA; most (n = 12) for attempted drainage of distant non-communicating locule(s). Treatment success was corroborated by clearance of pleural opacities on radiographs (from median 27.0% [IQR = 17.1-44.5] to 11.0% [IQR = 6.4-23.3] of hemithorax, p < 0.0001), increased pleural fluid drainage (1.98 L [median, IQR = 1.38-2.68] over 72 h following commencement of tPA/DNase) and reduction of serum C-reactive protein level (by 45.0% [IQR = 39.3-77.0] from baseline at day 5, p < 0.0001). Two patients required surgery. Six patients with significant comorbidities (e.g., advanced cancer) had ongoing infection when palliated and died. Two patients experienced self-limiting pleural bleeding and received blood transfusion. CONCLUSION A starting intrapleural regime of 2.5 mg tPA/5 mg DNase, with up-titration if needed, can be effective and deserves further exploration.
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Affiliation(s)
- Natalia Popowicz
- School of Allied Health, Division of Pharmacy, University of Western Australia, Perth, Western Australia, Australia.,Pleural Medicine Unit, Institute for Respiratory Health, Perth, Western Australia, Australia.,Pharmacy Department, Sir Charles Gairdner Hospital, Perth, Western Australia, Australia
| | - Hugh Ip
- Respiratory Medicine, Royal Free Hospital, London, UK
| | - Estee P M Lau
- Pleural Medicine Unit, Institute for Respiratory Health, Perth, Western Australia, Australia.,School of Medical and Health Sciences, Edith Cowan University, Perth, Western Australia, Australia
| | - Francesco Piccolo
- Respiratory Medicine, St John of God Midland, Perth, Western Australia, Australia
| | - Kirstie Dootson
- School of Allied Health, Division of Pharmacy, University of Western Australia, Perth, Western Australia, Australia
| | - Cindy Yeoh
- School of Allied Health, Division of Pharmacy, University of Western Australia, Perth, Western Australia, Australia
| | - Wint Ywe Phu
- School of Allied Health, Division of Pharmacy, University of Western Australia, Perth, Western Australia, Australia
| | - Rebecca Brown
- Pharmacy Department, Sir Charles Gairdner Hospital, Perth, Western Australia, Australia
| | - Alex West
- Respiratory Medicine, Guy's and St Thomas' NHS Foundation Trust, St Thomas' Hospital, London, UK
| | - Liju Ahmed
- Respiratory Medicine, King Faisal Specialist Hospital and Research Centre Madinah, Riyadh, Saudi Arabia
| | - Y C Gary Lee
- Pleural Medicine Unit, Institute for Respiratory Health, Perth, Western Australia, Australia.,Respiratory Medicine, Sir Charles Gairdner Hospital, Perth, Western Australia, Australia.,Centre for Respiratory Health, School of Medicine, University of Western Australia, Perth, Western Australia, Australia
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20
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Louw A, van Vliet C, Peverall J, Colkers S, Acott N, Creaney J, Lee YCG, Chai SM. Analysis of early pleural fluid samples in patients with mesothelioma: A case series exploration of morphology, BAP1, and CDKN2A status with implications for the concept of mesothelioma in situ in cytology. Cancer Cytopathol 2022; 130:352-362. [PMID: 35143119 DOI: 10.1002/cncy.22548] [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: 09/10/2021] [Revised: 11/11/2021] [Accepted: 11/29/2021] [Indexed: 11/09/2022]
Abstract
BACKGROUND The concept of mesothelioma in situ has been revisited and is a new World Health Organization diagnostic entity. The definition centers on ancillary techniques used in pleural mesothelioma (PM) assessment. At the authors' institution, most PM diagnoses are made on cytologic specimens. Effusion samples obtained before definitive PM diagnosis were interrogated using BRCA1-associated protein 1 gene (BAP1), cyclin-dependent kinase inhibitor 2A gene (CDKN2A) and cytologic evaluation to assess whether early or possible in situ disease could be characterized. METHODS All cases of PM diagnosed between January 2008 and December 2019 were identified at a tertiary referral center. Patients who had a pleural fluid sample collected 24 months before the diagnosis were selected, numbering 8 in total. The cytomorphology of each sample was reviewed; and, retrospectively, BAP1 immunohistochemistry (IHC) and CDKN2A fluorescence in situ hybridization (FISH) were performed on initial and diagnostic samples. RESULTS The initial samples were deemed benign in 5 cases and atypical mesothelial proliferations in 3 cases. A spectrum of apparently normal to atypical cytomorphologic changes was identified. BAP1 loss was present in 6 of 8 initial cases, whereas CDKN2A homozygous deletion was identified in 1 of 7 initial cases. Either abnormality was identified in 7 of 8 initial samples. CONCLUSIONS Detectable abnormalities of BAP1 IHC and CDKN2A FISH were present in pleural fluid specimens before the development of cytomorphologic features diagnostic of PM. This is the largest series to date describing cytology samples early in the course of PM development, thereby highlighting a possible cytological equivalent for mesothelioma in situ.
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Affiliation(s)
- Amber Louw
- Department of Anatomical Pathology, PathWest Laboratory Medicine, Queen Elizabeth II Medical Center, Nedlands, Western Australia, Australia.,School of Medical and Health Sciences, Edith Cowan University, Perth, Western Australia, Australia.,Institute for Respiratory Health, Nedlands, Western Australia, Australia.,National Center for Asbestos Related Diseases, University of Western Australia, Nedlands, Western Australia, Australia
| | - Chris van Vliet
- Department of Anatomical Pathology, PathWest Laboratory Medicine, Queen Elizabeth II Medical Center, Nedlands, Western Australia, Australia
| | - Joanne Peverall
- Department of Diagnostic Genomics, PathWest Laboratory Medicine, Queen Elizabeth II Medical Center, Nedlands, Western Australia, Australia
| | - Shane Colkers
- Department of Anatomical Pathology, PathWest Laboratory Medicine, Queen Elizabeth II Medical Center, Nedlands, Western Australia, Australia
| | - Nathan Acott
- Department of Anatomical Pathology, PathWest Laboratory Medicine, Queen Elizabeth II Medical Center, Nedlands, Western Australia, Australia
| | - Jenette Creaney
- Institute for Respiratory Health, Nedlands, Western Australia, Australia.,National Center for Asbestos Related Diseases, University of Western Australia, Nedlands, Western Australia, Australia.,Department of Respiratory Medicine, Sir Charles Gairdner Hospital, Nedlands, Western Australia, Australia
| | - Y C Gary Lee
- Institute for Respiratory Health, Nedlands, Western Australia, Australia.,Department of Respiratory Medicine, Sir Charles Gairdner Hospital, Nedlands, Western Australia, Australia.,School of Medicine, University of Western Australia, Nedlands, Western Australia, Australia
| | - Siaw Ming Chai
- Department of Anatomical Pathology, PathWest Laboratory Medicine, Queen Elizabeth II Medical Center, Nedlands, Western Australia, Australia
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21
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Orozco Morales ML, Rinaldi CA, de Jong E, Lansley SM, Gummer JP, Olasz B, Nambiar S, Hope DE, Casey TH, Lee YCG, Leslie C, Nealon G, Shackleford DM, Powell AK, Grimaldi M, Balaguer P, Zemek RM, Bosco A, Piggott MJ, Vrielink A, Lake RA, Lesterhuis WJ. PPARα and PPARγ activation is associated with pleural mesothelioma invasion but therapeutic inhibition is ineffective. iScience 2022; 25:103571. [PMID: 34984327 PMCID: PMC8692993 DOI: 10.1016/j.isci.2021.103571] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [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: 07/23/2021] [Revised: 10/16/2021] [Accepted: 12/01/2021] [Indexed: 12/15/2022] Open
Abstract
Mesothelioma is a cancer that typically originates in the pleura of the lungs. It rapidly invades the surrounding tissues, causing pain and shortness of breath. We compared cell lines injected either subcutaneously or intrapleurally and found that only the latter resulted in invasive and rapid growth. Pleural tumors displayed a transcriptional signature consistent with increased activity of nuclear receptors PPARα and PPARγ and with an increased abundance of endogenous PPAR-activating ligands. We found that chemical probe GW6471 is a potent, dual PPARα/γ antagonist with anti-invasive and anti-proliferative activity in vitro. However, administration of GW6471 at doses that provided sustained plasma exposure levels sufficient for inhibition of PPARα/γ transcriptional activity did not result in significant anti-mesothelioma activity in mice. Lastly, we demonstrate that the in vitro anti-tumor effect of GW6471 is off-target. We conclude that dual PPARα/γ antagonism alone is not a viable treatment modality for mesothelioma.
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Affiliation(s)
- M. Lizeth Orozco Morales
- School of Biomedical Sciences, University of Western Australia, Crawley, WA 6009, Australia
- National Centre for Asbestos Related Diseases, Nedlands, WA 6009, Australia
| | - Catherine A. Rinaldi
- School of Biomedical Sciences, University of Western Australia, Crawley, WA 6009, Australia
- National Centre for Asbestos Related Diseases, Nedlands, WA 6009, Australia
- Centre for Microscopy Characterisation and Analysis, Nedlands, WA 6009, Australia
| | - Emma de Jong
- Telethon Kids Institute, University of Western Australia, West Perth, WA 6872, Australia
| | | | - Joel P.A. Gummer
- School of Science, Department of Science, Edith Cowan University, Joondalup, WA 6027, Australia
- UWA Medical School, The University of Western Australia, Crawley, WA 6009, Australia
| | - Bence Olasz
- School of Molecular Sciences, University of Western Australia, Crawley, WA 6009, Australia
| | - Shabarinath Nambiar
- School of Veterinary and Life Science, Murdoch University, Murdoch, WA 6150, Australia
| | - Danika E. Hope
- School of Biomedical Sciences, University of Western Australia, Crawley, WA 6009, Australia
- National Centre for Asbestos Related Diseases, Nedlands, WA 6009, Australia
| | - Thomas H. Casey
- School of Biomedical Sciences, University of Western Australia, Crawley, WA 6009, Australia
- National Centre for Asbestos Related Diseases, Nedlands, WA 6009, Australia
| | - Y. C. Gary Lee
- Institute for Respiratory Health, Nedlands, WA 6009, Australia
| | - Connull Leslie
- Department of Anatomical Pathology, PathWest Laboratory Medicine, QEII Medical Centre, Nedlands, WA 6009, Australia
| | - Gareth Nealon
- School of Molecular Sciences, University of Western Australia, Crawley, WA 6009, Australia
| | - David M. Shackleford
- Centre for Drug Candidate Optimisation, Monash Institute of Pharmaceutical Sciences, Monash University, Parkville, VIC 3052, Australia
| | - Andrew K. Powell
- Centre for Drug Candidate Optimisation, Monash Institute of Pharmaceutical Sciences, Monash University, Parkville, VIC 3052, Australia
| | - Marina Grimaldi
- IRCM, Institut de Recherche en Cancérologie de Montpellier, Montpellier 34090, France
| | - Patrick Balaguer
- IRCM, Institut de Recherche en Cancérologie de Montpellier, Montpellier 34090, France
| | - Rachael M. Zemek
- Telethon Kids Institute, University of Western Australia, West Perth, WA 6872, Australia
| | - Anthony Bosco
- Telethon Kids Institute, University of Western Australia, West Perth, WA 6872, Australia
| | - Matthew J. Piggott
- School of Molecular Sciences, University of Western Australia, Crawley, WA 6009, Australia
| | - Alice Vrielink
- School of Molecular Sciences, University of Western Australia, Crawley, WA 6009, Australia
| | - Richard A. Lake
- School of Biomedical Sciences, University of Western Australia, Crawley, WA 6009, Australia
- National Centre for Asbestos Related Diseases, Nedlands, WA 6009, Australia
| | - W. Joost Lesterhuis
- School of Biomedical Sciences, University of Western Australia, Crawley, WA 6009, Australia
- National Centre for Asbestos Related Diseases, Nedlands, WA 6009, Australia
- Telethon Kids Institute, University of Western Australia, West Perth, WA 6872, Australia
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22
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Jeffery E, Lee YCG, Newton RU, Lyons-Wall P, McVeigh J, Fitzgerald DB, Straker L, Peddle-McIntyre CJ. Changes in body composition in patients with malignant pleural mesothelioma and the relationship with activity levels and dietary intake. Eur J Clin Nutr 2022; 76:979-986. [PMID: 35039629 PMCID: PMC9270221 DOI: 10.1038/s41430-021-01062-6] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [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: 02/04/2021] [Revised: 11/14/2021] [Accepted: 12/16/2021] [Indexed: 12/28/2022]
Abstract
Background Skeletal muscle loss is common in advanced cancer and is associated with negative outcomes. In malignant pleural mesothelioma (MPM), no study has reported body composition changes or factors associated with these changes. This study aimed to describe changes in body composition over time and its relationship with activity levels, dietary intake and survival. Methods The study was a secondary analysis of data collected from a longitudinal observational study of patients with MPM. Participants completed 3-month assessments for up to 18 months. Participants with two dual-energy x-ray absorptiometry (DXA) scans were included. Changes in appendicular skeletal muscle mass (ASM) and total fat mass were used to categorise participants into phenotypes. Activity levels were measured with an ActiGraph GT3X+ accelerometer and energy and protein intake was measured with a 3-day food record and 24-h recall. Results Eighteen participants were included (89% men, mean age 68.9 ± 7.1 years). Median time between DXA was 91 [IQR 84–118] days. Compared to participants with ASM maintenance (n = 9), fewer participants with ASM loss (n = 9) survived ≥12 months from follow-up (p = 0.002). Participants with ASM loss increased sedentary time (p = 0.028) and decreased light activity (p = 0.028) and step count (p = 0.008). Activity levels did not change in participants with ASM maintenance (p > 0.05). Energy and protein intake did not change in either group (p > 0.05). Conclusions Muscle loss was associated with poorer survival and decreased activity levels. Interventions that improve physical activity or muscle mass could benefit patients with MPM.
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Affiliation(s)
- Emily Jeffery
- Exercise Medicine Research Institute, Edith Cowan University, Joondalup, WA, Australia. .,School of Medical and Health Sciences, Edith Cowan University, Joondalup, WA, Australia. .,School of Population Health, Curtin University, Perth, WA, Australia.
| | - Y C Gary Lee
- Respiratory Department, Sir Charles Gairdner Hospital, Nedlands, WA, Australia.,Institute for Respiratory Health, Nedlands, WA, Australia.,Medical School, University of Western Australia, Crawley, WA, Australia
| | - Robert U Newton
- Exercise Medicine Research Institute, Edith Cowan University, Joondalup, WA, Australia.,School of Medical and Health Sciences, Edith Cowan University, Joondalup, WA, Australia
| | - Philippa Lyons-Wall
- School of Medical and Health Sciences, Edith Cowan University, Joondalup, WA, Australia
| | - Joanne McVeigh
- School of Allied Health, Curtin University, Perth, WA, Australia.,Movement Physiology Laboratory, School of Physiology, University of Witwatersrand, Johannesburg, South Africa
| | | | - Leon Straker
- School of Allied Health, Curtin University, Perth, WA, Australia
| | - Carolyn J Peddle-McIntyre
- Exercise Medicine Research Institute, Edith Cowan University, Joondalup, WA, Australia.,School of Medical and Health Sciences, Edith Cowan University, Joondalup, WA, Australia
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23
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Fitzgerald DB, Blakey JD, Joshi P, Kuok YJ, Lee YCG, Thomas R. Ultrasound Clues in Lobar Pneumonia. Chest 2022; 161:e59-e62. [DOI: 10.1016/j.chest.2021.04.077] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/02/2021] [Accepted: 04/15/2021] [Indexed: 11/29/2022] Open
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24
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Brown S, Ball E, Lee YCG, Beasley R, Simpson G. Management of primary spontaneous pneumothorax: less is more. Lancet 2021; 396:1973. [PMID: 33341134 DOI: 10.1016/s0140-6736(20)32674-x] [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] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/09/2020] [Accepted: 08/18/2020] [Indexed: 10/22/2022]
Affiliation(s)
- Simon Brown
- Centre for Clinical Research in Emergency Medicine, Royal Perth Hospital, Perth, WA 6847, Australia.
| | - Emma Ball
- Centre for Clinical Research in Emergency Medicine, Royal Perth Hospital, Perth, WA 6847, Australia
| | - Y C Gary Lee
- Centre for Respiratory Health, School of Medicine and Pharmacology, University of Western Australia, Perth, WA, Australia
| | - Richard Beasley
- Medical Research Institute of New Zealand, Wellington, New Zealand
| | - Graham Simpson
- Department of Respiratory Medicine, Cairns Hospital, Cairns, QLD, Australia
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25
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Affiliation(s)
- Calvin Sidhu
- Respiratory Medicine, Sir Charles Gairdner Hospital, Perth, Western Australia; Pleural Medicine Unit, Institute for Respiratory Health, Perth, Western Australia; School of Medical & Health Sciences, Edith Cowan University, Perth, Western Australia
| | - Amber Louw
- Pleural Medicine Unit, Institute for Respiratory Health, Perth, Western Australia; School of Medical & Health Sciences, Edith Cowan University, Perth, Western Australia; National Centre for Asbestos Related Diseases, University of Western Australia
| | - Y C Gary Lee
- Respiratory Medicine, Sir Charles Gairdner Hospital, Perth, Western Australia; Pleural Medicine Unit, Institute for Respiratory Health, Perth, Western Australia; School of Medical & Health Sciences, Edith Cowan University, Perth, Western Australia; School of Medicine, University of Western Australia, Perth, Western Australia.
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26
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Lee YCG, Creaney J. P3‐6: A clinical analysis of PAP (pulmonary alveolar proteinosis) s diagnosed with difficulty in the COVID‐19 pandemic. Respirology 2021. [PMID: 33251664 PMCID: PMC9011559 DOI: 10.1111/resp.14150_162] [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] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Affiliation(s)
- Y C Gary Lee
- Department of Respiratory Medicine, Sir Charles Gairdner Hospital, Perth, WA, Australia
- Centre for Respiratory Health, School of Medicine, University of Western Australia, Perth, WA, Australia
- Pleural Medicine Unit, Institute for Respiratory Health, Perth, WA, Australia
- Department of Medicine, University of Hong Kong, Hong Kong
| | - Jenette Creaney
- Centre for Respiratory Health, School of Medicine, University of Western Australia, Perth, WA, Australia
- National Centre for Asbestos Related Diseases, University of Western Australia, Perth, WA, Australia
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27
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Lee YCG. Bedside ultrasonography to determine pleurodesis success: SIMPLE but how sound? Lancet Respir Med 2021; 10:122-123. [PMID: 34634247 DOI: 10.1016/s2213-2600(21)00441-0] [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] [Subscribe] [Scholar Register] [Received: 09/15/2021] [Accepted: 09/15/2021] [Indexed: 10/20/2022]
Affiliation(s)
- Y C Gary Lee
- School of Medicine and Pharmacology, University of Western Australia, Perth, WA 6009, Australia; Institute for Respiratory Health, Nedlands, WA, Australia; Respiratory Medicine, Sir Charles Gairdner Hospital, Perth, WA, Australia.
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28
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Jayawardena T, Krivinskas S, Lee YCG. Conservative management of a complete primary spontaneous pneumothorax. Respirol Case Rep 2021; 9:e0837. [PMID: 34471541 PMCID: PMC8390567 DOI: 10.1002/rcr2.837] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/01/2021] [Revised: 07/29/2021] [Accepted: 08/11/2021] [Indexed: 11/08/2022] Open
Abstract
Large primary spontaneous pneumothorax (PSP) has traditionally been managed with needle aspiration, chest tube drainage and, in refractory cases, thoracic surgery. A recent randomized trial, however, provided evidence that a conservative observational approach was safe and 85% of patients recovered without requiring pleural drainage interventions. A conservative approach provided similar re-expansion rates at 8 weeks compared with chest tube drainage and offered the advantages of early hospital discharge, fewer days off work and avoidance of procedural risks. Nonetheless, clinicians are understandably anxious with conservative (non-drainage) management for patients with very large pneumothorax. Here, we report a patient with a right-sided PSP and total lung collapse that was managed successfully without intervention with minimal time in hospital or off work.
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Affiliation(s)
- Thisuri Jayawardena
- Department of Respiratory MedicineSir Charles Gairdner HospitalPerthWestern AustraliaAustralia
| | - Sophie Krivinskas
- Department of Respiratory MedicineSir Charles Gairdner HospitalPerthWestern AustraliaAustralia
| | - Y. C. Gary Lee
- Department of Respiratory MedicineSir Charles Gairdner HospitalPerthWestern AustraliaAustralia
- Centre for Respiratory Health, School of MedicineUniversity of Western AustraliaPerthWestern AustraliaAustralia
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29
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Dick IM, Lee YCG, Cheah HM, Miranda A, Robinson BWS, Creaney J. Profile of soluble factors in pleural effusions predict prognosis in mesothelioma. Cancer Biomark 2021; 33:159-169. [PMID: 34487023 PMCID: PMC8925107 DOI: 10.3233/cbm-210280] [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: 11/17/2022]
Abstract
BACKGROUND: Pleural mesothelioma is a deadly asbestos induced cancer. Less than 10% of mesothelioma patients survive 5 years post diagnosis. However survival can range from a few months to a number of years. Accurate prediction of survival is important for patients to plan for their remaining life, and for clinicians to determine appropriate therapy. One unusual feature of mesothelioma is that patients frequently present with tumor-associated pleural effusions early in the course of the disease. OBJECTIVE: To study whether cells and molecules present in pleural effusions provide prognostic information for mesothelioma. METHODS: We profiled the cellular constituents and concentrations of 40 cytokines, chemokines and cellular factors (collectively “soluble factors”) involved in inflammatory and immune signalling pathways in pleural effusion samples from 50 mesothelioma patients. Associations with survival were evaluated by Cox proportional hazards regression methods. Results for the two soluble factors most significantly and independently associated with survival were validated in an independent set of samples (n= 51) using a separate assay system. RESULTS: Survival analysis revealed that IL8, IL2Ra (CD25) and PF4 were independent determinants of a more negative prognosis in mesothelioma patients, independent of other known prognostic factors. Lipocalin2 and IL4 were associated with better prognosis. CONCLUSIONS: This study demonstrates that pleural effusions rich in a range of soluble factors are associated with poor prognosis. These findings will enhance our ability to prognosticate outcomes in mesothelioma patients.
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Affiliation(s)
- I M Dick
- National Centre for Asbestos Related Disease, University of Western Australia, Nedlands, WA, Australia.,Faculty of Health and Medical Science, University of Western Australia, Nedlands, WA, Australia.,Institute of Respiratory Health, University of Western Australia, Nedlands, WA, Australia
| | - Y C G Lee
- Faculty of Health and Medical Science, University of Western Australia, Nedlands, WA, Australia.,Institute of Respiratory Health, University of Western Australia, Nedlands, WA, Australia.,Department of Respiratory Medicine, Sir Charles Gairdner Hospital, Nedlands, WA, Australia
| | - H M Cheah
- Institute of Respiratory Health, University of Western Australia, Nedlands, WA, Australia
| | - A Miranda
- National Centre for Asbestos Related Disease, University of Western Australia, Nedlands, WA, Australia
| | - B W S Robinson
- National Centre for Asbestos Related Disease, University of Western Australia, Nedlands, WA, Australia.,Faculty of Health and Medical Science, University of Western Australia, Nedlands, WA, Australia.,Department of Respiratory Medicine, Sir Charles Gairdner Hospital, Nedlands, WA, Australia
| | - J Creaney
- National Centre for Asbestos Related Disease, University of Western Australia, Nedlands, WA, Australia.,Faculty of Health and Medical Science, University of Western Australia, Nedlands, WA, Australia.,Institute of Respiratory Health, University of Western Australia, Nedlands, WA, Australia
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30
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Fitzgerald DB, Popowicz ND, Joseph J, Butcher SC, Westcott M, Lim EM, Creaney J, Lee YCG. Trace element levels in pleural effusions. Health Sci Rep 2021; 4:e262. [PMID: 33977154 PMCID: PMC8093853 DOI: 10.1002/hsr2.262] [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] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/07/2020] [Revised: 12/27/2020] [Accepted: 01/14/2021] [Indexed: 11/30/2022] Open
Affiliation(s)
- Deirdre B. Fitzgerald
- Medical SchoolUniversity of Western AustraliaPerthWestern AustraliaAustralia
- Pleural Medicine UnitInstitute for Respiratory HealthNedlandsWestern AustraliaAustralia
- Respiratory MedicineSir Charles Gairdner HospitalNedlandsWestern AustraliaAustralia
| | - Natalia D. Popowicz
- School of Allied HealthUniversity of Western AustraliaPerthWestern AustraliaAustralia
| | - John Joseph
- Department of Clinical Biochemistry, PathWest Laboratory MedicineQueen Elizabeth II Medical CentreNedlandsWestern AustraliaAustralia
| | - Steele C. Butcher
- Department of MedicineRoyal Perth HospitalPerthWestern AustraliaAustralia
| | - Marie Westcott
- Department of Clinical Biochemistry, PathWest Laboratory MedicineQueen Elizabeth II Medical CentreNedlandsWestern AustraliaAustralia
| | - Ee Mun Lim
- Department of Clinical Biochemistry, PathWest Laboratory MedicineQueen Elizabeth II Medical CentreNedlandsWestern AustraliaAustralia
| | - Jenette Creaney
- Pleural Medicine UnitInstitute for Respiratory HealthNedlandsWestern AustraliaAustralia
- Respiratory MedicineSir Charles Gairdner HospitalNedlandsWestern AustraliaAustralia
- National Centre for Asbestos Related Disease, Faculty of Health and Medical ScienceUniversity of Western AustraliaNedlandsWestern AustraliaAustralia
| | - Y. C. Gary Lee
- Medical SchoolUniversity of Western AustraliaPerthWestern AustraliaAustralia
- Pleural Medicine UnitInstitute for Respiratory HealthNedlandsWestern AustraliaAustralia
- Respiratory MedicineSir Charles Gairdner HospitalNedlandsWestern AustraliaAustralia
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31
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Charng J, Attia MS, Arunachalam S, Lam WS, Creaney J, Muruganandan S, Read C, Millward M, Spiro J, Chakera A, Lee YCG, Nowak AK, Chen FK. Increased interdigitation zone visibility on optical coherence tomography following systemic fibroblast growth factor receptor 1-3 tyrosine kinase inhibitor anticancer therapy. Clin Exp Ophthalmol 2021; 49:579-590. [PMID: 33934469 DOI: 10.1111/ceo.13940] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [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: 01/24/2021] [Revised: 04/06/2021] [Accepted: 04/28/2021] [Indexed: 12/12/2022]
Abstract
BACKGROUND To describe ocular adverse events and retinal changes during fibroblast growth factor receptor (FGFR) inhibitor (AZD4547) anticancer therapy. METHODS This is a sub-study examining ocular adverse effects from AZD4547 therapy (single-centre, open-label, single arm phase II clinical trial). Comprehensive ocular examinations were performed 3 weekly in 24 patients. Macular optical coherence tomography (OCT) scan (300 × 250 ) was obtained at each visit and OCT parameters [central 1 mm retinal thickness (CRT) and total macular volume in central 6 mm] extracted. OCT scans were subdivided into outer (ELM to RPE) and inner (ELM to ILM) layers to compare outer and inner retinal changes. RESULTS In 24 patients, AZD4547 was associated with eyelash elongation (n = 5, 21%) and punctate corneal erosion (n = 2, 8%). One patient developed clinically significant posterior capsular opacification during the study. OCT data were available in 23 patients, retinal changes ranged from an asymptomatic increased visibility of the interdigitation zone (IDZ) (n = 10, 43%) to multilobular subretinal fluid pockets (n = 5, 22%), which was associated with mild visual acuity loss. In a subset of patients (n = 9) with pre-AZD4547 dosing OCT baseline, CRT increased by mean (SD) of 9 (4) μm in those with IDZ change only compared with 64 (38) μm in those with other retinal changes. Retinal changes tended to be bilateral, self-limiting and improved over time without medical intervention. CONCLUSIONS The ocular signs and symptoms did not result in dose cessation. Posteriorly, FGFR inhibition leads to outer retinal changes ranging from increased visibility of IDZ to distinct, multiple fluid pockets.
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Affiliation(s)
- Jason Charng
- Centre for Ophthalmology and Visual Science (Incorporating Lions Eye Institute), The University of Western Australia, Nedlands, Western Australia, Australia
| | - Mary S Attia
- Centre for Ophthalmology and Visual Science (Incorporating Lions Eye Institute), The University of Western Australia, Nedlands, Western Australia, Australia
| | - Sukanya Arunachalam
- Centre for Ophthalmology and Visual Science (Incorporating Lions Eye Institute), The University of Western Australia, Nedlands, Western Australia, Australia
| | - Wei-Sen Lam
- Department of Medical Oncology, Fiona Stanley Hospital, Murdoch, Western Australia, Australia
| | - Jenette Creaney
- National Centre for Asbestos Related Diseases, University of Western Australia, QEII Medical Centre, Western Australia, Australia.,Institute for Respiratory Health, Harry Perkins Building, Nedlands, Western Australia, Australia.,Department of Respiratory Medicine, Sir Charles Gairdner Hospital, Nedlands, Western Australia, Australia
| | - Sanjeevan Muruganandan
- Department of Respiratory Medicine, Northern Health, Epping, Victoria, Australia.,School of Medicine and Pharmacology, University of Western Australia, Crawley, Western Australia, Australia
| | - Catherine Read
- Institute for Respiratory Health, Harry Perkins Building, Nedlands, Western Australia, Australia
| | - Michael Millward
- Department of Medical Oncology, Sir Charles Gairdner Hospital, Nedlands, Western Australia, Australia.,Medical School, University of Western Australia, Crawley, Western Australia, Australia
| | - Jon Spiro
- Department of Cardiology, Royal Perth Hospital, Perth, Western Australia, Australia
| | - Aron Chakera
- Medical School, University of Western Australia, Crawley, Western Australia, Australia.,Renal Unit, Sir Charles Gairdner Hospital, Nedlands, Western Australia, Australia
| | - Y C Gary Lee
- Institute for Respiratory Health, Harry Perkins Building, Nedlands, Western Australia, Australia.,Department of Respiratory Medicine, Sir Charles Gairdner Hospital, Nedlands, Western Australia, Australia.,Medical School, University of Western Australia, Crawley, Western Australia, Australia
| | - Anna K Nowak
- National Centre for Asbestos Related Diseases, University of Western Australia, QEII Medical Centre, Western Australia, Australia.,Institute for Respiratory Health, Harry Perkins Building, Nedlands, Western Australia, Australia.,Department of Medical Oncology, Sir Charles Gairdner Hospital, Nedlands, Western Australia, Australia.,Medical School, University of Western Australia, Crawley, Western Australia, Australia
| | - Fred K Chen
- Centre for Ophthalmology and Visual Science (Incorporating Lions Eye Institute), The University of Western Australia, Nedlands, Western Australia, Australia.,Department of Ophthalmology, Royal Perth Hospital, Wellington Square, Perth, Western Australia, Australia.,Department of Ophthalmology, Perth Children's Hospital, Nedlands, Western Australia, Australia
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32
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Louw A, Lee YCG, Acott N, Creaney J, van Vliet C, Chai SM. Diagnostic utility of BAP1 for malignant pleural mesothelioma in pleural fluid specimens with atypical morphology. Cytopathology 2021; 33:84-92. [PMID: 34033161 DOI: 10.1111/cyt.13015] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [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: 02/16/2021] [Revised: 05/07/2021] [Accepted: 05/14/2021] [Indexed: 01/02/2023]
Abstract
OBJECTIVE To assess the utility of BRCA1-associated protein 1 (BAP1) immunohistochemistry (IHC) for the diagnosis of malignant pleural mesothelioma (MPM) in fluid samples with atypical cytology. METHODS Pleural fluid samples with an atypical mesothelial proliferation (diagnostic categories: 'atypical' and 'suspicious') received between January 2015 and March 2018 at a tertiary referral centre were identified. Results of routine IHC testing were recorded for each case. BAP1 by IHC was performed and a final diagnosis sought from subsequent pathology specimens, medical records, or consensus clinical diagnosis. RESULTS Of 50 cases identified, 41 were reported as atypical and 9 as suspicious. Seven (14%) demonstrated loss of BAP1 staining, 40 retained BAP1 staining, 1 had heterogeneous staining, and 2 had insufficient cells for analysis. All seven cases with BAP1 loss were diagnosed with MPM on follow-up. Of those with retained BAP1, 52.5% (21) were subsequently diagnosed with MPM, while 40% (16) had non-MPM diagnoses after a median follow-up of 24 months. Three cases were not further investigated based on patient and clinician decision. The case with heterogeneous staining was diagnosed as mesothelioma by clinical consensus. CONCLUSIONS BAP1 IHC loss is highly specific for malignancy and has value as a rule-in test. Even in a tertiary centre with clinical interest in the cytological diagnosis of MPM this investigation was able to increase diagnostic accuracy beyond routine IHC studies. Cytological criteria remain valuable, as retained BAP1 in an atypical or suspicious mesothelial proliferation cannot exclude malignancy.
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Affiliation(s)
- Amber Louw
- Department of Anatomical Pathology, PathWest Laboratory Medicine, QEII Medical Centre, Nedlands, WA, Australia.,School of Medical and Health Sciences, Edith Cowan University, Perth, WA, Australia.,National Centre for Asbestos Related Diseases, University of Western Australia, Nedlands, WA, Australia.,Institute for Respiratory Health, Nedlands, WA, Australia
| | - Y C Gary Lee
- Institute for Respiratory Health, Nedlands, WA, Australia.,Department of Respiratory Medicine, Sir Charles Gairdner Hospital, Nedlands, WA, Australia.,School of Medicine, University of Western Australia, Nedlands, WA, Australia
| | - Nathan Acott
- Department of Anatomical Pathology, PathWest Laboratory Medicine, QEII Medical Centre, Nedlands, WA, Australia
| | - Jenette Creaney
- National Centre for Asbestos Related Diseases, University of Western Australia, Nedlands, WA, Australia.,Institute for Respiratory Health, Nedlands, WA, Australia.,Department of Respiratory Medicine, Sir Charles Gairdner Hospital, Nedlands, WA, Australia
| | - Chris van Vliet
- Department of Anatomical Pathology, PathWest Laboratory Medicine, QEII Medical Centre, Nedlands, WA, Australia
| | - Siaw Ming Chai
- Department of Anatomical Pathology, PathWest Laboratory Medicine, QEII Medical Centre, Nedlands, WA, Australia
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33
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Popowicz N, Cheah HM, Gregory C, Miranda A, Dick IM, Lee YCG, Creaney J. Neutrophil-to-lymphocyte ratio in malignant pleural fluid: Prognostic significance. PLoS One 2021; 16:e0250628. [PMID: 33901252 PMCID: PMC8075197 DOI: 10.1371/journal.pone.0250628] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/24/2020] [Accepted: 04/10/2021] [Indexed: 01/04/2023] Open
Abstract
Predicting survival of patients with malignant pleural effusions (MPEs) is notoriously difficult. A robust prognostic marker can guide clinical decision making. The neutrophil-to-lymphocyte ratio (NLR) in blood has been shown to predict survival in many cancers. Pleural fluid bathes the malignant pleural tissues, thus the NLR of the pleural fluid may reflect more closely the local tumour environment. The objective of this study was to explore the prognostic significance of pleural effusion NLR for MPE. We analysed matched effusion and blood from 117 patients with malignant and 24 with benign pleural effusions. Those who had received recent chemotherapy or had a pleurodesis were excluded. Neutrophil and lymphocyte counts in effusions were performed by manual review of cytospin cell preparations by trained observers. Clinical data were extracted from a state-wide hospital database. We found significantly fewer neutrophils (expressed as percentage of total leukocyte count) in pleural fluid than in corresponding blood (9% vs 73%; p<0.001). The NLR was an order of magnitude lower in pleural fluid than in corresponding blood: median [IQR] = 0.20 [0.04-1.18] vs 4.9 [3.0-8.3], p<0.001. Correlation between blood and pleural fluid NLR in MPE patients was moderate (rs = 0.321, p<0.001). In univariate analysis, NLR (>0.745)) in malignant pleural fluid was predictive of poorer survival (HR = 1.698 [1.0054-2.736]; p = 0.030), and remained significant after adjustment for age, sex, presence of a chest drain, cancer type, concurrent infection and subsequent treatment with chemotherapy (HR = 1.786 [1.089-2.928]; p = 0.022). Patients with pleural fluid NLR > 0.745 had a significantly shorter median survival of 130 (95% CI 0-282) days compared to 312 (95% CI 195-428) days for pleural NLR < 0.745, p = 0.026. The NLR in blood was also predictive of poorer survival in MPE patients (HR = 1.959 [1.019-3.096]; p<0.001). The proportion of neutrophils in pleural fluid was predictive of prognosis more strongly than lymphocytes. This study provides evidence that NLR in malignant effusions can predict survival, and therefore may provide prognostic information for this cohort. This prognostic association in the fluid is driven by the presence of neutrophils.
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Affiliation(s)
- Natalia Popowicz
- Pharmacy Department, Sir Charles Gairdner Hospital, Perth, Australia
- Institute for Respiratory Health, University of Western Australia, Perth, Australia
| | - Hui Min Cheah
- Institute for Respiratory Health, University of Western Australia, Perth, Australia
| | - Cynthia Gregory
- National Centre for Asbestos Related Disease, Health and Medical Science, University of Western Australia, Perth, Australia
| | - Alina Miranda
- National Centre for Asbestos Related Disease, Health and Medical Science, University of Western Australia, Perth, Australia
| | - Ian M. Dick
- National Centre for Asbestos Related Disease, Health and Medical Science, University of Western Australia, Perth, Australia
| | - Y. C. Gary Lee
- Institute for Respiratory Health, University of Western Australia, Perth, Australia
- Department of Respiratory Medicine, Sir Charles Gairdner Hospital, Perth, Australia
| | - Jenette Creaney
- Institute for Respiratory Health, University of Western Australia, Perth, Australia
- National Centre for Asbestos Related Disease, Health and Medical Science, University of Western Australia, Perth, Australia
- Department of Respiratory Medicine, Sir Charles Gairdner Hospital, Perth, Australia
- * E-mail:
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Fitzgerald DB, Muruganandan S, Tsim S, Ip H, Asciak R, Walker S, Uribe Becerra JP, Majid A, Ahmed L, Rahman NM, Maskell NA, Blyth KG, Lee YCG. Intrapleural Fibrinolytics and Deoxyribonuclease for Treatment of Indwelling Pleural Catheter-Related Pleural Infection: A Multi-Center Observational Study. Respiration 2021; 100:452-460. [PMID: 33784710 DOI: 10.1159/000514643] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [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: 08/08/2020] [Accepted: 01/07/2021] [Indexed: 11/19/2022] Open
Abstract
BACKGROUND Indwelling pleural catheters (IPC) are increasingly used for management of recurrent (especially malignant) effusions. Pleural infection associated with IPC use remains a concern. Intrapleural therapy with tissue plasminogen activator (tPA) and deoxyribonuclease (DNase) significantly reduces surgical referrals in non-IPC pleural infection, but data on its use in IPC-related pleural infection are scarce. OBJECTIVE To assess the safety and efficacy of intrapleural tPA and DNase in IPC-related pleural infection. METHODS Patients with IPC-related pleural infection who received intrapleural tPA/DNase in five Australian and UK centers were identified from prospective databases. Outcomes on feasibility of intrapleural tPA/DNase delivery, its efficacy and safety were recorded. RESULTS Thirty-nine IPC-related pleural infections (predominantly Staphylococcus aureus and gram-negative organisms) were treated in 38 patients; 87% had malignant effusions. In total, 195 doses (median 6 [IQR = 3-6]/patient) of tPA (2.5 mg-10 mg) and DNase (5 mg) were instilled. Most (94%) doses were delivered via IPCs using local protocols for non-IPC pleural infections. The mean volume of pleural fluid drained during the first 72 h of treatment was 3,073 (SD = 1,685) mL. Most (82%) patients were successfully treated and survived to hospital discharge without surgery; 7 required additional chest tubes or therapeutic aspiration. Three patients required thoracoscopic surgery. Pleurodesis developed post-infection in 23/32 of successfully treated patients. No major morbidity/mortality was associated with tPA/DNase. Four patients received blood transfusions; none had systemic or significant pleural bleeding. CONCLUSION Treatment of IPC-related pleural infection with intrapleural tPA/DNase instillations via the IPC appears feasible and safe, usually without additional drainage procedures or surgery. Pleurodesis post-infection is common.
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Affiliation(s)
- Deirdre B Fitzgerald
- Sir Charles Gairdner Hospital, Perth, Washington, Australia.,Institute for Respiratory Health, Perth, Washington, Australia.,University of Western Australia, Perth, Washington, Australia
| | - Sanjeevan Muruganandan
- Sir Charles Gairdner Hospital, Perth, Washington, Australia.,University of Western Australia, Perth, Washington, Australia.,Northern Hospital, Epping, Victoria, Australia
| | - Selina Tsim
- Queen Elizabeth University Hospital, Glasgow, United Kingdom.,Institute of Cancer Sciences, University of Glasgow, Glasgow, United Kingdom
| | - Hugh Ip
- Guy's and St. Thomas' Hospital, London, United Kingdom
| | - Rachelle Asciak
- Oxford University Hospitals NHS Foundation Trust, Oxford, United Kingdom
| | - Steven Walker
- Academic Respiratory Unit, School of Clinical Sciences, University of Bristol, Bristol, United Kingdom
| | | | - Adnan Majid
- Beth Israel Deaconess Medical Centre, Harvard Medical School, Boston, Massachusetts, USA
| | - Liju Ahmed
- Guy's and St. Thomas' Hospital, London, United Kingdom
| | - Najib M Rahman
- Oxford University Hospitals NHS Foundation Trust, Oxford, United Kingdom
| | - Nick A Maskell
- Academic Respiratory Unit, School of Clinical Sciences, University of Bristol, Bristol, United Kingdom
| | - Kevin G Blyth
- Queen Elizabeth University Hospital, Glasgow, United Kingdom.,Institute of Cancer Sciences, University of Glasgow, Glasgow, United Kingdom
| | - Y C Gary Lee
- Sir Charles Gairdner Hospital, Perth, Washington, Australia.,Institute for Respiratory Health, Perth, Washington, Australia.,University of Western Australia, Perth, Washington, Australia
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Louw A, Sidhu C, Fitzgerald DB, Creaney J, Chai SM, Lee YCG. Clump material within drainage chest tubes contains diagnostic information: a proof-of-concept case series. Eur Respir J 2021; 57:13993003.03248-2020. [PMID: 33184118 DOI: 10.1183/13993003.03248-2020] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/27/2020] [Accepted: 10/19/2020] [Indexed: 11/05/2022]
Affiliation(s)
- Amber Louw
- Dept of Anatomical Pathology, PathWest Laboratory Medicine, Queen Elizabeth II Medical Centre, Nedlands, Australia.,School of Medical and Health Sciences, Edith Cowan University, Perth, Australia.,National Centre for Asbestos Related Diseases, University of Western Australia, Perth, Australia.,Institute for Respiratory Health, Nedlands, Australia
| | - Calvin Sidhu
- Respiratory Medicine, Sir Charles Gairdner Hospital, Perth, Western Australia
| | - Deirdre B Fitzgerald
- Institute for Respiratory Health, Nedlands, Australia.,Respiratory Medicine, Sir Charles Gairdner Hospital, Perth, Western Australia.,Medical School, University of Western Australia, Perth, Australia
| | - Jenette Creaney
- National Centre for Asbestos Related Diseases, University of Western Australia, Perth, Australia.,Institute for Respiratory Health, Nedlands, Australia.,Respiratory Medicine, Sir Charles Gairdner Hospital, Perth, Western Australia
| | - Siaw Ming Chai
- Dept of Anatomical Pathology, PathWest Laboratory Medicine, Queen Elizabeth II Medical Centre, Nedlands, Australia
| | - Y C Gary Lee
- Institute for Respiratory Health, Nedlands, Australia .,Respiratory Medicine, Sir Charles Gairdner Hospital, Perth, Western Australia.,Medical School, University of Western Australia, Perth, Australia
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Mishra EK, Muruganandan S, Clark A, Bhatnagar R, Maskell N, Lee YCG, Rahman NM. Breathlessness Predicts Survival in Patients With Malignant Pleural Effusions: Meta-analysis of Individual Patient Data From Five Randomized Controlled Trials. Chest 2021; 160:351-357. [PMID: 33667489 DOI: 10.1016/j.chest.2021.02.052] [Citation(s) in RCA: 12] [Impact Index Per Article: 4.0] [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: 08/10/2020] [Revised: 01/28/2021] [Accepted: 02/03/2021] [Indexed: 02/01/2023] Open
Abstract
BACKGROUND Patients with malignant pleural effusions (MPEs) experience breathlessness and poor survival. Breathlessness is associated with poor survival in other conditions. RESEARCH QUESTION Is breathlessness, measured using a visual analog scale for dyspnea (VASD), associated with survival in patients with MPE? STUDY DESIGN AND METHODS Individual patient data from five randomized controlled trials of 553 patients undergoing interventions for MPE were analyzed. VASD was recorded at baseline and daily after intervention. Patients were followed up until death or end of trial. Univariate and multivariable Cox regression were used to identify factors associated with survival. RESULTS Baseline VASD was significantly associated with worse survival, with a hazard ratio of 1.10 (95% CI, 1.06-1.15) for a 10-mm increase in VASD. On multivariable regression, it remained a significant predictor of survival. Mean 7-day VASD and mean total VASD were also predictors of survival (mean 7-day VASD: hazard ratio [HR], 1.26 [95% CI, 1.19-1.34]; total VASD: HR, 1.25 [95% CI, 1.15-1.37]). Other predictors of survival were serum C-reactive protein level and tumor type. Previous treatment with chemotherapy, performance status, pleural fluid lactate dehydrogenase, serum albumin, hemoglobin, serum neutrophil:lymphocyte ratio, and size of effusion were associated with survival on univariate but not multivariable analysis. INTERPRETATION Breathlessness, measured using VASD at baseline and postprocedure, is a predictor of survival in patients with MPE.
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Affiliation(s)
- Eleanor K Mishra
- Norfolk and Norwich University Hospitals NHS Foundation Trust, Norwich, Norfolk, England; University of East Anglia, Norwich, Norfolk, England.
| | | | - Allan Clark
- University of East Anglia, Norwich, Norfolk, England
| | - Rahul Bhatnagar
- Academic Respiratory Unit, University of Bristol, Bristol, England
| | - Nick Maskell
- Academic Respiratory Unit, University of Bristol, Bristol, England
| | - Y C Gary Lee
- University of Western Australia, Perth, Australia
| | - Najib M Rahman
- Oxford Respiratory Trials Unit, University of Oxford, Oxford, England
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Popowicz ND, Piccolo F, Yap E, Wong C, Brockway B, Smith NA, Sullivan C, Musk AW, Lee YCG. Long-term follow-up after intrapleural tPA/DNase therapy for pleural infection. Respirology 2021; 26:388-391. [PMID: 33590570 DOI: 10.1111/resp.14015] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/06/2020] [Revised: 12/15/2020] [Accepted: 01/27/2021] [Indexed: 11/30/2022]
Affiliation(s)
- Natalia D Popowicz
- School of Medicine, University of Western Australia, Perth, WA, Australia.,Pleural Medicine Research, Institute for Respiratory Health, Perth, WA, Australia.,School of Allied Health, University of Western Australia, Perth, WA, Australia.,Department of Respiratory Medicine, Sir Charles Gairdner Hospital, Perth, WA, Australia
| | - Francesco Piccolo
- Respiratory and Sleep Medicine, St John of God Midland, Perth, WA, Australia
| | - Elaine Yap
- Department of Respiratory Medicine, Middlemore Hospital, Auckland, New Zealand
| | - Conroy Wong
- Department of Respiratory Medicine, Middlemore Hospital, Auckland, New Zealand
| | - Ben Brockway
- Department of Respiratory Medicine, Dunedin Public Hospital, Dunedin, New Zealand
| | - Nicola A Smith
- Respiratory Department, Wellington Regional Hospital, Wellington, New Zealand
| | - Cameron Sullivan
- Department of Respiratory Medicine, Middlemore Hospital, Auckland, New Zealand
| | - Arthur W Musk
- School of Medicine, University of Western Australia, Perth, WA, Australia.,Department of Respiratory Medicine, Sir Charles Gairdner Hospital, Perth, WA, Australia
| | - Y C Gary Lee
- School of Medicine, University of Western Australia, Perth, WA, Australia.,Pleural Medicine Research, Institute for Respiratory Health, Perth, WA, Australia.,Department of Respiratory Medicine, Sir Charles Gairdner Hospital, Perth, WA, Australia
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Cheah HM, Fitzgerald D, Louw A, Creaney J, Lee YCG. Hyaluronic acid in viscous malignant mesothelioma pleural effusion. Respirol Case Rep 2021; 9:e00694. [PMID: 33304592 PMCID: PMC7715921 DOI: 10.1002/rcr2.694] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/18/2020] [Revised: 11/03/2020] [Accepted: 11/15/2020] [Indexed: 12/23/2022] Open
Abstract
Malignant pleural effusion (MPE) is common with mesothelioma. We report two cases of extraordinarily viscous MPEs associated with mesothelioma. The viscosity prohibited spontaneous gravity-dependent drainage via indwelling pleural catheters. Our ex vivo experiments found very high hyaluronic acid (HA) content within the fluid. Treatment of the fluid with hyaluronidase, but not with deoxyribonucleases, significantly reduced fluid viscosity. The results provide proof that HA can contribute to high viscosity of pleural fluid in mesothelioma. Research into strategies of counteracting HA properties in the management of MPEs may provide further insight.
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Affiliation(s)
- Hui Min Cheah
- Pleural Medicine UnitCenter for Respiratory Health, University of Western AustraliaPerthWAAustralia
- Medical SchoolUniversity of Western AustraliaPerthWAAustralia
| | - Deirdre Fitzgerald
- Pleural Medicine UnitCenter for Respiratory Health, University of Western AustraliaPerthWAAustralia
- Medical SchoolUniversity of Western AustraliaPerthWAAustralia
- Department of Respiratory MedicineSir Charles Gairdner HospitalPerthWAAustralia
| | - Amber Louw
- PathWest Laboratory MedicineQEII Medical CentrePerthWAAustralia
- School of Medical and Health SciencesEdith Cowan UniversityJoondalupWAAustralia
| | - Jenette Creaney
- Medical SchoolUniversity of Western AustraliaPerthWAAustralia
- National Centre for Asbestos Related DiseasesPerthWAAustralia
| | - Y. C. Gary Lee
- Pleural Medicine UnitCenter for Respiratory Health, University of Western AustraliaPerthWAAustralia
- Medical SchoolUniversity of Western AustraliaPerthWAAustralia
- Department of Respiratory MedicineSir Charles Gairdner HospitalPerthWAAustralia
- School of Medical and Health SciencesEdith Cowan UniversityJoondalupWAAustralia
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MacMillan M, Roy B, McLaren S, Nowak AK, Thomas R, Lee YCG. Widespread pulmonary invasion by malignant pleural mesothelioma: an important diagnostic consideration. Respirol Case Rep 2020; 8:e00675. [PMID: 33133607 PMCID: PMC7586108 DOI: 10.1002/rcr2.675] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/16/2020] [Revised: 09/09/2020] [Accepted: 09/30/2020] [Indexed: 11/10/2022] Open
Abstract
We report a rare case of early and extensive pulmonary invasion of malignant pleural mesothelioma (MPM) in a 70-year-old woman. She first presented with a hydropneumothorax and subsequent workup, including video-assisted thoracoscopy (VAT), confirmed MPM. After VAT, she developed dyspnoea, cough, and widespread pulmonary infiltrates of uncertain aetiology. These infiltrates progressed over the following months, failed to respond to antibiotics, and were strongly fluorodeoxyglucose (FDG)-avid on positron emission tomography (PET). Bronchoalveolar lavage (BAL) yielded extremely viscous fluid containing mesothelioma cells. These cells were also found in the sputum when nebulized deoxyribonuclease (DNase) was trialled to enhance clearance of the pulmonary fluid. The patient deteriorated rapidly with progressive mediastinal and contralateral MPM involvement and died one month later. This case highlights the importance of including tumour invasion as a differential diagnosis of non-resolving pulmonary infiltrates in patients with MPM.
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Affiliation(s)
- Mia MacMillan
- Department of Respiratory MedicineSir Charles Gairdner HospitalPerthWAAustralia
| | - Bapti Roy
- Department of Respiratory MedicineSir Charles Gairdner HospitalPerthWAAustralia
| | | | - Anna K. Nowak
- Department of Medical OncologySir Charles Gairdner HospitalPerthWAAustralia
- National Centre for Asbestos Related DiseasesUniversity of Western AustraliaPerthWAAustralia
| | - Rajesh Thomas
- Department of Respiratory MedicineSir Charles Gairdner HospitalPerthWAAustralia
| | - Y. C. Gary Lee
- Department of Respiratory MedicineSir Charles Gairdner HospitalPerthWAAustralia
- Centre for Respiratory Health, School of MedicineUniversity of Western AustraliaPerthWAAustralia
- Department of MedicineUniversity of Hong KongHong Kong
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40
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Lee YCG, Creaney J. Endomicroscopy of the pleura highlights challenges and limitations of pleuroscopy. Respirology 2020; 26:138-139. [PMID: 33251664 DOI: 10.1111/resp.13982] [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: 11/09/2020] [Accepted: 11/15/2020] [Indexed: 11/26/2022]
Affiliation(s)
- Y C Gary Lee
- Department of Respiratory Medicine, Sir Charles Gairdner Hospital, Perth, WA, Australia.,Centre for Respiratory Health, School of Medicine, University of Western Australia, Perth, WA, Australia.,Pleural Medicine Unit, Institute for Respiratory Health, Perth, WA, Australia.,Department of Medicine, University of Hong Kong, Hong Kong
| | - Jenette Creaney
- Centre for Respiratory Health, School of Medicine, University of Western Australia, Perth, WA, Australia.,National Centre for Asbestos Related Diseases, University of Western Australia, Perth, WA, Australia
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41
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Miller CRJ, Chrissian AA, Lee YCG, Rahman NM, Wahidi MM, Tremblay A, Hsia DW, Almeida FA, Shojaee S, Mudambi L, Belanger AR, Bedi H, Gesthalter YB, Gaynor M, MacKenney KL, Lewis SZ, Casal RF. Key Highlights From the American Association for Bronchology and Interventional Pulmonology Evidence-Informed Guidelines and Expert Panel Report for the Management of Indwelling Pleural Catheters. Chest 2020; 159:920-923. [PMID: 33152319 DOI: 10.1016/j.chest.2020.09.282] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/20/2020] [Revised: 09/22/2020] [Accepted: 09/25/2020] [Indexed: 10/23/2022] Open
Affiliation(s)
- Cdr Russell J Miller
- Department of Pulmonary Medicine, Naval Medical Center San Diego, San Diego, CA; Department of Medicine, University of California San Diego, San Diego, CA.
| | - Ara A Chrissian
- Department of Medicine, Division of Pulmonary and Critical Care, Loma Linda University Medical Center, Loma Linda, CA
| | - Y C Gary Lee
- Centre for Respiratory Research, School of Medicine, University of Western Australia, Perth, Australia; Institute for Respiratory Health, University of Western Australia, Perth, Australia; Department of Respiratory Medicine, Sir Charles Gairdner Hospital, Perth, Australia; Edith Cowan University, Perth, Australia
| | - Najib M Rahman
- Oxford Respiratory Trials Unit, Nuffield Department of Experimental Medicine, University of Oxford, Oxford, UK
| | - Momen M Wahidi
- Department of Internal Medicine, Division of Pulmonary, Allergy, and Critical Care Medicine, Duke University Medical Center, Durham, NC
| | - Alain Tremblay
- Department of Medicine, Cumming School of Medicine, University of Calgary, Calgary, Canada
| | - David W Hsia
- Harbor-University of California Los Angeles Medical Center, Torrance, CA; The Lundquist Institute for Biomedical Innovation at Harbor-UCLA Medical Center, Torrance, CA
| | | | - Samira Shojaee
- Department of Internal Medicine, Division of Pulmonary and Critical Care Medicine, Virginia Commonwealth University, Richmond, VA
| | - Lakshmi Mudambi
- Section of Pulmonary & Critical Care Medicine, VA Portland Health Care System, Portland, OR; Department of Medicine, Division of Pulmonary & Critical Care Medicine, Oregon Health & Science University, Chapel Hill, NC
| | - Adam R Belanger
- Section of Interventional Pulmonology, Department of Medicine, University of North Carolina, Chapel Hill, NC
| | - Harmeet Bedi
- Department of Medicine, Division of Pulmonary and Critical Care Medicine, Stanford University School of Medicine, Stanford, CA
| | - Yaron B Gesthalter
- Department of Pulmonary, Critical Care, Allergy and Sleep Medicine, University of California San Francisco, San Francisco, CA
| | | | - Karen L MacKenney
- Department of Pulmonary Medicine, The University of Texas MD Anderson Cancer Center, Houston, TX
| | | | - Roberto F Casal
- Department of Pulmonary Medicine, The University of Texas MD Anderson Cancer Center, Houston, TX
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Miller RJ, Chrissian AA, Lee YCG, Rahman NM, Wahidi MM, Tremblay A, Hsia DW, Almeida FA, Shojaee S, Mudambi L, Belanger AR, Bedi H, Gesthalter YB, Gaynor M, MacKenney KL, Lewis SZ, Casal RF. AABIP Evidence-informed Guidelines and Expert Panel Report for the Management of Indwelling Pleural Catheters. J Bronchology Interv Pulmonol 2020; 27:229-245. [PMID: 32804745 DOI: 10.1097/lbr.0000000000000707] [Citation(s) in RCA: 14] [Impact Index Per Article: 3.5] [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] [Indexed: 11/25/2022]
Abstract
BACKGROUND While the efficacy of Indwelling pleural catheters for palliation of malignant pleural effusions is supported by relatively robust evidence, there is less clarity surrounding the postinsertion management. METHODS The Trustworthy Consensus-Based Statement approach was utilized to develop unbiased, scientifically valid guidance for the management of patients with malignant effusions treated with indwelling pleural catheters. A comprehensive electronic database search of PubMed was performed based on a priori crafted PICO questions (Population/Intervention/Comparator/Outcomes paradigm). Manual searches of the literature were performed to identify additional relevant literature. Dual screenings at the title, abstract, and full-text levels were performed. Identified studies were then assessed for quality based on a combination of validated tools. Appropriateness for data pooling and formation of evidence-based recommendations was assessed using predetermined criteria. All panel members participated in development of the final recommendations utilizing the modified Delphi technique. RESULTS A total of 7 studies were identified for formal quality assessment, all of which were deemed to have a high risk of bias. There was insufficient evidence to allow for data pooling and formation of any evidence-based recommendations. Panel consensus resulted in 11 ungraded consensus-based recommendations. CONCLUSION This manuscript was developed to provide clinicians with guidance on the management of patients with indwelling pleural catheters placed for palliation of malignant pleural effusions. Through a systematic and rigorous process, management suggestions were developed based on the best available evidence with augmentation by expert opinion when necessary. In addition, these guidelines highlight important gaps in knowledge which require further study.
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Affiliation(s)
- Russell J Miller
- Department of Pulmonary Medicine, Naval Medical Center San Diego
- Department of Medicine, University of California San Diego, San Diego
| | - Ara A Chrissian
- Department of Medicine, Division of Pulmonary and Critical Care, Loma Linda University Medical Center, Loma Linda
| | - Y C Gary Lee
- Centre for Respiratory Research, School of Medicine
- Institute for Respiratory Health, University of Western Australia
- Department of Respiratory Medicine, Sir Charles Gairdner Hospital
- Edith Cowan University, Perth, WA, Australia
| | - Najib M Rahman
- Oxford Respiratory Trials Unit, Nuffield Department of Experimental Medicine, University of Oxford, Oxford, UK
| | - Momen M Wahidi
- Department of Internal Medicine, Division of Pulmonary, Allergy, and Critical Care Medicine, Duke University Medical Center, Durham
| | - Alain Tremblay
- Department of Medicine, Cumming School of Medicine, University of Calgary, Calgary, AB, Canada
| | - David W Hsia
- Harbor-University of California Los Angeles Medical Center
- Los Angeles Biomedical Research Institute at Harbor-University of California Los Angeles, Torrance
| | | | - Samira Shojaee
- Department of Internal Medicine, Division of Pulmonary and Critical Care Medicine, Virginia Commonwealth University, Richmond, VA
| | - Lakshmi Mudambi
- Section of Pulmonary & Critical Care Medicine, VA Portland Health Care System
- Department of Medicine, Division of Pulmonary & Critical Care Medicine, Oregon Health & Science University, Portland, OR
| | - Adam R Belanger
- Section of Interventional Pulmonology, Department of Medicine, University of North Carolina, Chapel Hill, NC
| | - Harmeet Bedi
- Department of Medicine, Division of Pulmonary and Critical Care Medicine, Stanford University School of Medicine, Stanford
| | - Yaron B Gesthalter
- Department of Pulmonary, Critical Care, Allergy and Sleep Medicine, University of California San Francisco, San Francisco, CA
| | | | - Karen L MacKenney
- Department of Pulmonary Medicine, The University of Texas MD Anderson Cancer Center, Houston, TX
| | | | - Roberto F Casal
- Department of Pulmonary Medicine, The University of Texas MD Anderson Cancer Center, Houston, TX
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43
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Roy B, Teh MC, Kuok YJ, Lee YCG. Bronchopleural communication following intrapleural doses of tPA/DNase for empyema. Respirol Case Rep 2020; 8:e00646. [PMID: 32884812 PMCID: PMC7457088 DOI: 10.1002/rcr2.646] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/29/2020] [Accepted: 08/03/2020] [Indexed: 12/03/2022] Open
Abstract
Intrapleural tissue plasminogen activator (tPA) and deoxyribonuclease (DNase) therapy is a new treatment for pleural infection. Clinical experiences of tPA/DNase therapy, and its complications, are cumulating. We present a patient with multiloculated empyema but no initial evidence of a bronchopleural fistula. She was treated with antibiotics and chest tube drainage of the basal collection through which four doses of tPA/DNase were delivered with success. The lateral collection worsened necessitating separate tube drainage and tPA/DNase treatment. She reported chest "fullness" when instilled the second dose. The third instillation of tPA triggered immediate vigorous coughing and expectoration of salty-tasting fluid, likely the tPA/saline solution. The symptoms spontaneously settled after 15 min, with no evidence of air leak. The loculated fluid was successfully evacuated. The patient made a full recovery after an antibiotic course with no long-term consequences. Pulmonary migration of drugs via a bronchopleural communication, although rare, can occur with intrapleural tPA/DNase therapy.
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Affiliation(s)
- Bapti Roy
- Department of Respiratory MedicineSir Charles Gairdner HospitalPerthWAAustralia
| | - Mark C. Teh
- Department of RadiologySir Charles Gairdner HospitalPerthWAAustralia
| | - Yi Jin Kuok
- Department of RadiologySir Charles Gairdner HospitalPerthWAAustralia
| | - Y. C. Gary Lee
- Department of Respiratory MedicineSir Charles Gairdner HospitalPerthWAAustralia
- Centre for Respiratory HealthSchool of Medicine, University of Western AustraliaPerthWAAustralia
- Department of MedicineUniversity of Hong KongHong Kong
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44
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Gregory P, Rahman NM, Lee YCG. Osler Centenary Papers: Management of pleural infection: Osler's final illness and recent advances. Postgrad Med J 2020; 95:656-659. [PMID: 31754057 DOI: 10.1136/postgradmedj-2018-135893] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/09/2019] [Revised: 06/24/2019] [Accepted: 08/06/2019] [Indexed: 12/16/2022]
Abstract
Sir William Osler's great work and achievements are extensively documented. Less well known is his prolonged battle with postinfluenza pneumonia, lung abscess and pleural infection that eventually led to his demise. At the age of 70, he was a victim of the global Spanish influenza epidemic, and subsequently developed pneumonia. In the era before antibiotics, he received supportive care and opium for symptom control. The infection extended to the pleura and he required repeated thoracentesis which failed to halt his deterioration. He proceeded to open surgical drainage involving rib resection. Unfortunately, he died shortly after the operation from massive pleuropulmonary haemorrhage. In this article, we review the events leading up to Osler's death and contrast his care 100 years ago with contemporary state-of-the-art management in pleural infection.
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Affiliation(s)
- Prudence Gregory
- Respiratory Medicine, Sir Charles Gairdner Hospital, Perth, Western Australia, Australia
| | - Najib M Rahman
- Oxford Centre for Respiratory Medicine, University of Oxford, Oxford, UK
| | - Y C Gary Lee
- Respiratory Medicine, Sir Charles Gairdner Hospital, Perth, Western Australia, Australia .,School of Medicine & Centre for Respiratory Health, University of Western Australia, Perth, Western Australia, Australia
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45
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Thomas R, Rahman NM, Maskell NA, Lee YCG. Pleural effusions and pneumothorax: Beyond simple plumbing: Expert opinions on knowledge gaps and essential next steps. Respirology 2020; 25:963-971. [PMID: 32613624 DOI: 10.1111/resp.13881] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/25/2020] [Revised: 04/15/2020] [Accepted: 04/29/2020] [Indexed: 12/17/2022]
Abstract
Pleural diseases affect millions of people worldwide. Pleural infection, malignant pleural diseases and pneumothorax are common clinical challenges. A large number of recent clinical trials have provided an evidence-based platform to evaluate conventional and novel methods to drain pleural effusions/air which reduce morbidity and unnecessary interventions. These successes have generated significant enthusiasm and raised the profile of pleural medicine as a new subspecialty. The ultimate goal of pleural research is to prevent/stop development of pleural effusions/pneumothorax. Current research studies mainly focus on the technical aspects of pleural drainage. Significant knowledge gaps exist in many aspects such as understanding of the pathobiology of the underlying pleural diseases, pharmacokinetics of pleural drug delivery, etc. Answers to these important questions are needed to move the field forward. This article collates opinions of leading experts in the field in highlighting major knowledge gaps in common pleural diseases to provoke thinking beyond pleural drainage. Recognizing the key barriers will help prioritize future research in the quest to ultimately cure (rather than just drain) these pleural conditions.
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Affiliation(s)
- Rajesh Thomas
- Department of Respiratory Medicine, Sir Charles Gairdner Hospital, Perth, WA, Australia.,Pleural Medicine Unit, Institute for Respiratory Health, Perth, WA, Australia
| | - Najib M Rahman
- Oxford Centre for Respiratory Medicine, Churchill Hospital, Oxford, UK.,Oxford NIHR Biomedical Research Centre, Oxford, UK
| | - Nick A Maskell
- Academic Respiratory Unit, Bristol Medical School, University of Bristol, Bristol, UK.,North Bristol Lung Centre, North Bristol NHS Trust, Bristol, UK
| | - Y C Gary Lee
- Department of Respiratory Medicine, Sir Charles Gairdner Hospital, Perth, WA, Australia.,Pleural Medicine Unit, Institute for Respiratory Health, Perth, WA, Australia.,Centre for Respiratory Health, School of Medicine, University of Western Australia, Perth, WA, Australia
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46
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Idell S, Lee YCG. suPAR Surprises as a Biomarker of Invasive Outcomes in Pleural Infection. Am J Respir Crit Care Med 2020; 201:1470-1472. [PMID: 32176528 PMCID: PMC7301739 DOI: 10.1164/rccm.202003-0525ed] [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] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022] Open
Affiliation(s)
- Steven Idell
- Department of Cellular and Molecular BiologyUniversity of Texas Health Science Center at TylerTyler, Texasand
| | - Y. C. Gary Lee
- Sir Charles Gairdner Hospital and University of Western AustraliaPerth, Western Australia, Australia
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Muruganandan S, Azzopardi M, Thomas R, Fitzgerald DB, Kuok YJ, Cheah HM, Read CA, Budgeon CA, Eastwood PR, Jenkins S, Singh B, Murray K, Lee YCG. The Pleural Effusion And Symptom Evaluation (PLEASE) study of breathlessness in patients with a symptomatic pleural effusion. Eur Respir J 2020; 55:13993003.00980-2019. [PMID: 32079642 DOI: 10.1183/13993003.00980-2019] [Citation(s) in RCA: 30] [Impact Index Per Article: 7.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/15/2019] [Accepted: 02/05/2020] [Indexed: 01/18/2023]
Abstract
INTRODUCTION Pathophysiology changes associated with pleural effusion, its drainage and factors governing symptom response are poorly understood. Our objective was to determine: 1) the effect of pleural effusion (and its drainage) on cardiorespiratory, functional and diaphragmatic parameters; and 2) the proportion as well as characteristics of patients with breathlessness relief post-drainage. METHODS Prospectively enrolled patients with symptomatic pleural effusions were assessed at both pre-therapeutic drainage and at 24-36 h post-therapeutic drainage. RESULTS 145 participants completed pre-drainage and post-drainage tests; 93% had effusions ≥25% of hemithorax. The median volume drained was 1.68 L. Breathlessness scores improved post-drainage (mean visual analogue scale (VAS) score by 28.0±24 mm; dyspnoea-12 (D12) score by 10.5±8.8; resting Borg score before 6-min walk test (6-MWT) by 0.6±1.7; all p<0.0001). The 6-min walk distance (6-MWD) increased by 29.7±73.5 m, p<0.0001. Improvements in vital signs and spirometry were modest (forced expiratory volume in 1 s (FEV1) by 0.22 L, 95% CI 0.18-0.27; forced vital capacity (FVC) by 0.30 L, 95% CI 0.24-0.37). The ipsilateral hemi-diaphragm was flattened/everted in 50% of participants pre-drainage and 48% of participants exhibited paradoxical or no diaphragmatic movement. Post-drainage, hemi-diaphragm shape and movement were normal in 94% and 73% of participants, respectively. Drainage provided meaningful breathlessness relief (VAS score improved ≥14 mm) in 73% of participants irrespective of whether the lung expanded (mean difference 0.14, 95% CI 10.02-0.29; p=0.13). Multivariate analyses found that breathlessness relief was associated with significant breathlessness pre-drainage (odds ratio (OR) 5.83 per standard deviation (sd) decrease), baseline abnormal/paralyzed/paradoxical diaphragm movement (OR 4.37), benign aetiology (OR 3.39), higher pleural pH (OR per sd increase 1.92) and higher serum albumin level (OR per sd increase 1.73). CONCLUSIONS Breathlessness and exercise tolerance improved in most patients with only a small mean improvement in spirometry and no change in oxygenation. Breathlessness improvement was similar in participants with and without trapped lung. Abnormal hemi-diaphragm shape and movement were independently associated with relief of breathlessness post-drainage.
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Affiliation(s)
- Sanjeevan Muruganandan
- Dept of Respiratory Medicine, The Northern Hospital, Melbourne, Australia.,Pleural Medicine Unit, Institute for Respiratory Health, Perth, Australia.,Centre for Respiratory Health, School of Medicine and Pharmacology, University of Western Australia, Perth, Australia.,Joint first authors
| | - Maree Azzopardi
- Dept of Respiratory Medicine, Sunshine Coast University Hospital, Birtinya, Australia.,Joint first authors
| | - Rajesh Thomas
- Pleural Medicine Unit, Institute for Respiratory Health, Perth, Australia.,Centre for Respiratory Health, School of Medicine and Pharmacology, University of Western Australia, Perth, Australia.,Dept of Respiratory Medicine, Sir Charles Gairdner Hospital, Perth, Australia
| | - Deirdre B Fitzgerald
- Pleural Medicine Unit, Institute for Respiratory Health, Perth, Australia.,Centre for Respiratory Health, School of Medicine and Pharmacology, University of Western Australia, Perth, Australia.,Dept of Respiratory Medicine, Sir Charles Gairdner Hospital, Perth, Australia
| | - Yi Jin Kuok
- Dept of Radiology, Sir Charles Gairdner Hospital, Perth, Australia
| | - Hui Min Cheah
- Pleural Medicine Unit, Institute for Respiratory Health, Perth, Australia.,Centre for Respiratory Health, School of Medicine and Pharmacology, University of Western Australia, Perth, Australia
| | - Catherine A Read
- Pleural Medicine Unit, Institute for Respiratory Health, Perth, Australia.,Centre for Respiratory Health, School of Medicine and Pharmacology, University of Western Australia, Perth, Australia
| | - Charley A Budgeon
- Dept of Cardiovascular Sciences, University of Leicester, Leicester, UK.,School of Population and Global Health, University of Western Australia, Perth, Australia
| | - Peter R Eastwood
- West Australian Sleep Disorders Research Institute, Perth, Australia.,Centre for Sleep Science, School of Human Sciences, University of Western Australia, Perth, Australia.,Pulmonary Physiology and Sleep Medicine, Sir Charles Gairdner Hospital, Perth, Australia
| | - Susan Jenkins
- Physiotherapy Unit, Institute for Respiratory Health, Perth, Australia.,Physiotherapy Dept, Sir Charles Gairdner Hospital, Perth, Australia.,School of Physiotherapy and Exercise Science, Curtin University, Perth, Australia
| | - Bhajan Singh
- West Australian Sleep Disorders Research Institute, Perth, Australia.,Centre for Sleep Science, School of Human Sciences, University of Western Australia, Perth, Australia.,Pulmonary Physiology and Sleep Medicine, Sir Charles Gairdner Hospital, Perth, Australia
| | - Kevin Murray
- School of Population and Global Health, University of Western Australia, Perth, Australia
| | - Y C Gary Lee
- Pleural Medicine Unit, Institute for Respiratory Health, Perth, Australia .,Centre for Respiratory Health, School of Medicine and Pharmacology, University of Western Australia, Perth, Australia.,Dept of Respiratory Medicine, Sir Charles Gairdner Hospital, Perth, Australia
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48
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Brown SGA, Ball EL, Perrin K, Asha SE, Braithwaite I, Egerton-Warburton D, Jones PG, Keijzers G, Kinnear FB, Kwan BCH, Lam KV, Lee YCG, Nowitz M, Read CA, Simpson G, Smith JA, Summers QA, Weatherall M, Beasley R. Conservative versus Interventional Treatment for Spontaneous Pneumothorax. N Engl J Med 2020; 382:405-415. [PMID: 31995686 DOI: 10.1056/nejmoa1910775] [Citation(s) in RCA: 132] [Impact Index Per Article: 33.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/19/2022]
Abstract
BACKGROUND Whether conservative management is an acceptable alternative to interventional management for uncomplicated, moderate-to-large primary spontaneous pneumothorax is unknown. METHODS In this open-label, multicenter, noninferiority trial, we recruited patients 14 to 50 years of age with a first-known, unilateral, moderate-to-large primary spontaneous pneumothorax. Patients were randomly assigned to immediate interventional management of the pneumothorax (intervention group) or a conservative observational approach (conservative-management group) and were followed for 12 months. The primary outcome was lung reexpansion within 8 weeks. RESULTS A total of 316 patients underwent randomization (154 patients to the intervention group and 162 to the conservative-management group). In the conservative-management group, 25 patients (15.4%) underwent interventions to manage the pneumothorax, for reasons prespecified in the protocol, and 137 (84.6%) did not undergo interventions. In a complete-case analysis in which data were not available for 23 patients in the intervention group and 37 in the conservative-management group, reexpansion within 8 weeks occurred in 129 of 131 patients (98.5%) with interventional management and in 118 of 125 (94.4%) with conservative management (risk difference, -4.1 percentage points; 95% confidence interval [CI], -8.6 to 0.5; P = 0.02 for noninferiority); the lower boundary of the 95% confidence interval was within the prespecified noninferiority margin of -9 percentage points. In a sensitivity analysis in which all missing data after 56 days were imputed as treatment failure (with reexpansion in 129 of 138 patients [93.5%] in the intervention group and in 118 of 143 [82.5%] in the conservative-management group), the risk difference of -11.0 percentage points (95% CI, -18.4 to -3.5) was outside the prespecified noninferiority margin. Conservative management resulted in a lower risk of serious adverse events or pneumothorax recurrence than interventional management. CONCLUSIONS Although the primary outcome was not statistically robust to conservative assumptions about missing data, the trial provides modest evidence that conservative management of primary spontaneous pneumothorax was noninferior to interventional management, with a lower risk of serious adverse events. (Funded by the Emergency Medicine Foundation and others; PSP Australian New Zealand Clinical Trials Registry number, ACTRN12611000184976.).
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Affiliation(s)
- Simon G A Brown
- From the Centre for Clinical Research in Emergency Medicine, Harry Perkins Institute of Medical Research, Royal Perth Hospital, and the University of Western Australia (S.G.A.B., E.L.B., C.A.R.), Royal Perth Hospital Imaging (K.V.L.) and the Respiratory Department (E.L.B., Q.A.S.), Royal Perth Hospital, the Department of Respiratory Medicine, Sir Charles Gairdner Hospital (Y.C.G.L.), and the Centre for Respiratory Health, School of Medicine and Pharmacology, University of Western Australia (Y.C.G.L.), Perth, Aeromedical and Retrieval Services, Ambulance Tasmania (S.G.A.B.), and the Department of Respiratory Medicine, Royal Hobart Hospital (E.L.B.), Hobart, the Emergency Department, St. George Hospital, Kogarah, NSW (S.E.A.), St. George Clinical School, Faculty of Medicine, University of New South Wales, Kensington (S.E.A., B.C.H.K.), the Emergency Department, Monash Medical Centre (D.E.-W.), the Departments of Medicine (D.E.-W.) and Surgery (J.A.S.), School of Clinical Sciences at Monash Health, Monash University, and the Department of Cardiothoracic Surgery, Monash Health (J.A.S.), Clayton, VIC, the Emergency Department, Gold Coast Health Service District, the School of Medicine, Bond University, and the School of Medicine, Griffith University, Gold Coast, QLD (G.K.), Emergency Medical and Children's Services, Prince Charles Hospital, Chermside, QLD (F.B.K.), the University of Queensland, Brisbane (F.B.K.), the Department of Respiratory and Sleep Medicine, Sutherland Hospital, Sydney (B.C.H.K.), and the Department of Respiratory Medicine, Cairns Hospital, Cairns, QLD (G.S.) - all in Australia; the Medical Research Institute of New Zealand (K.P., I.B., M.W., R.B.), the Capital and Coast District Health Board (K.P., M.W., R.B.), and Pacific Radiology (M.N.), Wellington, and the Adult Emergency Department, Auckland City Hospital and University of Auckland, Auckland (P.G.J.) - all in New Zealand
| | - Emma L Ball
- From the Centre for Clinical Research in Emergency Medicine, Harry Perkins Institute of Medical Research, Royal Perth Hospital, and the University of Western Australia (S.G.A.B., E.L.B., C.A.R.), Royal Perth Hospital Imaging (K.V.L.) and the Respiratory Department (E.L.B., Q.A.S.), Royal Perth Hospital, the Department of Respiratory Medicine, Sir Charles Gairdner Hospital (Y.C.G.L.), and the Centre for Respiratory Health, School of Medicine and Pharmacology, University of Western Australia (Y.C.G.L.), Perth, Aeromedical and Retrieval Services, Ambulance Tasmania (S.G.A.B.), and the Department of Respiratory Medicine, Royal Hobart Hospital (E.L.B.), Hobart, the Emergency Department, St. George Hospital, Kogarah, NSW (S.E.A.), St. George Clinical School, Faculty of Medicine, University of New South Wales, Kensington (S.E.A., B.C.H.K.), the Emergency Department, Monash Medical Centre (D.E.-W.), the Departments of Medicine (D.E.-W.) and Surgery (J.A.S.), School of Clinical Sciences at Monash Health, Monash University, and the Department of Cardiothoracic Surgery, Monash Health (J.A.S.), Clayton, VIC, the Emergency Department, Gold Coast Health Service District, the School of Medicine, Bond University, and the School of Medicine, Griffith University, Gold Coast, QLD (G.K.), Emergency Medical and Children's Services, Prince Charles Hospital, Chermside, QLD (F.B.K.), the University of Queensland, Brisbane (F.B.K.), the Department of Respiratory and Sleep Medicine, Sutherland Hospital, Sydney (B.C.H.K.), and the Department of Respiratory Medicine, Cairns Hospital, Cairns, QLD (G.S.) - all in Australia; the Medical Research Institute of New Zealand (K.P., I.B., M.W., R.B.), the Capital and Coast District Health Board (K.P., M.W., R.B.), and Pacific Radiology (M.N.), Wellington, and the Adult Emergency Department, Auckland City Hospital and University of Auckland, Auckland (P.G.J.) - all in New Zealand
| | - Kyle Perrin
- From the Centre for Clinical Research in Emergency Medicine, Harry Perkins Institute of Medical Research, Royal Perth Hospital, and the University of Western Australia (S.G.A.B., E.L.B., C.A.R.), Royal Perth Hospital Imaging (K.V.L.) and the Respiratory Department (E.L.B., Q.A.S.), Royal Perth Hospital, the Department of Respiratory Medicine, Sir Charles Gairdner Hospital (Y.C.G.L.), and the Centre for Respiratory Health, School of Medicine and Pharmacology, University of Western Australia (Y.C.G.L.), Perth, Aeromedical and Retrieval Services, Ambulance Tasmania (S.G.A.B.), and the Department of Respiratory Medicine, Royal Hobart Hospital (E.L.B.), Hobart, the Emergency Department, St. George Hospital, Kogarah, NSW (S.E.A.), St. George Clinical School, Faculty of Medicine, University of New South Wales, Kensington (S.E.A., B.C.H.K.), the Emergency Department, Monash Medical Centre (D.E.-W.), the Departments of Medicine (D.E.-W.) and Surgery (J.A.S.), School of Clinical Sciences at Monash Health, Monash University, and the Department of Cardiothoracic Surgery, Monash Health (J.A.S.), Clayton, VIC, the Emergency Department, Gold Coast Health Service District, the School of Medicine, Bond University, and the School of Medicine, Griffith University, Gold Coast, QLD (G.K.), Emergency Medical and Children's Services, Prince Charles Hospital, Chermside, QLD (F.B.K.), the University of Queensland, Brisbane (F.B.K.), the Department of Respiratory and Sleep Medicine, Sutherland Hospital, Sydney (B.C.H.K.), and the Department of Respiratory Medicine, Cairns Hospital, Cairns, QLD (G.S.) - all in Australia; the Medical Research Institute of New Zealand (K.P., I.B., M.W., R.B.), the Capital and Coast District Health Board (K.P., M.W., R.B.), and Pacific Radiology (M.N.), Wellington, and the Adult Emergency Department, Auckland City Hospital and University of Auckland, Auckland (P.G.J.) - all in New Zealand
| | - Stephen E Asha
- From the Centre for Clinical Research in Emergency Medicine, Harry Perkins Institute of Medical Research, Royal Perth Hospital, and the University of Western Australia (S.G.A.B., E.L.B., C.A.R.), Royal Perth Hospital Imaging (K.V.L.) and the Respiratory Department (E.L.B., Q.A.S.), Royal Perth Hospital, the Department of Respiratory Medicine, Sir Charles Gairdner Hospital (Y.C.G.L.), and the Centre for Respiratory Health, School of Medicine and Pharmacology, University of Western Australia (Y.C.G.L.), Perth, Aeromedical and Retrieval Services, Ambulance Tasmania (S.G.A.B.), and the Department of Respiratory Medicine, Royal Hobart Hospital (E.L.B.), Hobart, the Emergency Department, St. George Hospital, Kogarah, NSW (S.E.A.), St. George Clinical School, Faculty of Medicine, University of New South Wales, Kensington (S.E.A., B.C.H.K.), the Emergency Department, Monash Medical Centre (D.E.-W.), the Departments of Medicine (D.E.-W.) and Surgery (J.A.S.), School of Clinical Sciences at Monash Health, Monash University, and the Department of Cardiothoracic Surgery, Monash Health (J.A.S.), Clayton, VIC, the Emergency Department, Gold Coast Health Service District, the School of Medicine, Bond University, and the School of Medicine, Griffith University, Gold Coast, QLD (G.K.), Emergency Medical and Children's Services, Prince Charles Hospital, Chermside, QLD (F.B.K.), the University of Queensland, Brisbane (F.B.K.), the Department of Respiratory and Sleep Medicine, Sutherland Hospital, Sydney (B.C.H.K.), and the Department of Respiratory Medicine, Cairns Hospital, Cairns, QLD (G.S.) - all in Australia; the Medical Research Institute of New Zealand (K.P., I.B., M.W., R.B.), the Capital and Coast District Health Board (K.P., M.W., R.B.), and Pacific Radiology (M.N.), Wellington, and the Adult Emergency Department, Auckland City Hospital and University of Auckland, Auckland (P.G.J.) - all in New Zealand
| | - Irene Braithwaite
- From the Centre for Clinical Research in Emergency Medicine, Harry Perkins Institute of Medical Research, Royal Perth Hospital, and the University of Western Australia (S.G.A.B., E.L.B., C.A.R.), Royal Perth Hospital Imaging (K.V.L.) and the Respiratory Department (E.L.B., Q.A.S.), Royal Perth Hospital, the Department of Respiratory Medicine, Sir Charles Gairdner Hospital (Y.C.G.L.), and the Centre for Respiratory Health, School of Medicine and Pharmacology, University of Western Australia (Y.C.G.L.), Perth, Aeromedical and Retrieval Services, Ambulance Tasmania (S.G.A.B.), and the Department of Respiratory Medicine, Royal Hobart Hospital (E.L.B.), Hobart, the Emergency Department, St. George Hospital, Kogarah, NSW (S.E.A.), St. George Clinical School, Faculty of Medicine, University of New South Wales, Kensington (S.E.A., B.C.H.K.), the Emergency Department, Monash Medical Centre (D.E.-W.), the Departments of Medicine (D.E.-W.) and Surgery (J.A.S.), School of Clinical Sciences at Monash Health, Monash University, and the Department of Cardiothoracic Surgery, Monash Health (J.A.S.), Clayton, VIC, the Emergency Department, Gold Coast Health Service District, the School of Medicine, Bond University, and the School of Medicine, Griffith University, Gold Coast, QLD (G.K.), Emergency Medical and Children's Services, Prince Charles Hospital, Chermside, QLD (F.B.K.), the University of Queensland, Brisbane (F.B.K.), the Department of Respiratory and Sleep Medicine, Sutherland Hospital, Sydney (B.C.H.K.), and the Department of Respiratory Medicine, Cairns Hospital, Cairns, QLD (G.S.) - all in Australia; the Medical Research Institute of New Zealand (K.P., I.B., M.W., R.B.), the Capital and Coast District Health Board (K.P., M.W., R.B.), and Pacific Radiology (M.N.), Wellington, and the Adult Emergency Department, Auckland City Hospital and University of Auckland, Auckland (P.G.J.) - all in New Zealand
| | - Diana Egerton-Warburton
- From the Centre for Clinical Research in Emergency Medicine, Harry Perkins Institute of Medical Research, Royal Perth Hospital, and the University of Western Australia (S.G.A.B., E.L.B., C.A.R.), Royal Perth Hospital Imaging (K.V.L.) and the Respiratory Department (E.L.B., Q.A.S.), Royal Perth Hospital, the Department of Respiratory Medicine, Sir Charles Gairdner Hospital (Y.C.G.L.), and the Centre for Respiratory Health, School of Medicine and Pharmacology, University of Western Australia (Y.C.G.L.), Perth, Aeromedical and Retrieval Services, Ambulance Tasmania (S.G.A.B.), and the Department of Respiratory Medicine, Royal Hobart Hospital (E.L.B.), Hobart, the Emergency Department, St. George Hospital, Kogarah, NSW (S.E.A.), St. George Clinical School, Faculty of Medicine, University of New South Wales, Kensington (S.E.A., B.C.H.K.), the Emergency Department, Monash Medical Centre (D.E.-W.), the Departments of Medicine (D.E.-W.) and Surgery (J.A.S.), School of Clinical Sciences at Monash Health, Monash University, and the Department of Cardiothoracic Surgery, Monash Health (J.A.S.), Clayton, VIC, the Emergency Department, Gold Coast Health Service District, the School of Medicine, Bond University, and the School of Medicine, Griffith University, Gold Coast, QLD (G.K.), Emergency Medical and Children's Services, Prince Charles Hospital, Chermside, QLD (F.B.K.), the University of Queensland, Brisbane (F.B.K.), the Department of Respiratory and Sleep Medicine, Sutherland Hospital, Sydney (B.C.H.K.), and the Department of Respiratory Medicine, Cairns Hospital, Cairns, QLD (G.S.) - all in Australia; the Medical Research Institute of New Zealand (K.P., I.B., M.W., R.B.), the Capital and Coast District Health Board (K.P., M.W., R.B.), and Pacific Radiology (M.N.), Wellington, and the Adult Emergency Department, Auckland City Hospital and University of Auckland, Auckland (P.G.J.) - all in New Zealand
| | - Peter G Jones
- From the Centre for Clinical Research in Emergency Medicine, Harry Perkins Institute of Medical Research, Royal Perth Hospital, and the University of Western Australia (S.G.A.B., E.L.B., C.A.R.), Royal Perth Hospital Imaging (K.V.L.) and the Respiratory Department (E.L.B., Q.A.S.), Royal Perth Hospital, the Department of Respiratory Medicine, Sir Charles Gairdner Hospital (Y.C.G.L.), and the Centre for Respiratory Health, School of Medicine and Pharmacology, University of Western Australia (Y.C.G.L.), Perth, Aeromedical and Retrieval Services, Ambulance Tasmania (S.G.A.B.), and the Department of Respiratory Medicine, Royal Hobart Hospital (E.L.B.), Hobart, the Emergency Department, St. George Hospital, Kogarah, NSW (S.E.A.), St. George Clinical School, Faculty of Medicine, University of New South Wales, Kensington (S.E.A., B.C.H.K.), the Emergency Department, Monash Medical Centre (D.E.-W.), the Departments of Medicine (D.E.-W.) and Surgery (J.A.S.), School of Clinical Sciences at Monash Health, Monash University, and the Department of Cardiothoracic Surgery, Monash Health (J.A.S.), Clayton, VIC, the Emergency Department, Gold Coast Health Service District, the School of Medicine, Bond University, and the School of Medicine, Griffith University, Gold Coast, QLD (G.K.), Emergency Medical and Children's Services, Prince Charles Hospital, Chermside, QLD (F.B.K.), the University of Queensland, Brisbane (F.B.K.), the Department of Respiratory and Sleep Medicine, Sutherland Hospital, Sydney (B.C.H.K.), and the Department of Respiratory Medicine, Cairns Hospital, Cairns, QLD (G.S.) - all in Australia; the Medical Research Institute of New Zealand (K.P., I.B., M.W., R.B.), the Capital and Coast District Health Board (K.P., M.W., R.B.), and Pacific Radiology (M.N.), Wellington, and the Adult Emergency Department, Auckland City Hospital and University of Auckland, Auckland (P.G.J.) - all in New Zealand
| | - Gerben Keijzers
- From the Centre for Clinical Research in Emergency Medicine, Harry Perkins Institute of Medical Research, Royal Perth Hospital, and the University of Western Australia (S.G.A.B., E.L.B., C.A.R.), Royal Perth Hospital Imaging (K.V.L.) and the Respiratory Department (E.L.B., Q.A.S.), Royal Perth Hospital, the Department of Respiratory Medicine, Sir Charles Gairdner Hospital (Y.C.G.L.), and the Centre for Respiratory Health, School of Medicine and Pharmacology, University of Western Australia (Y.C.G.L.), Perth, Aeromedical and Retrieval Services, Ambulance Tasmania (S.G.A.B.), and the Department of Respiratory Medicine, Royal Hobart Hospital (E.L.B.), Hobart, the Emergency Department, St. George Hospital, Kogarah, NSW (S.E.A.), St. George Clinical School, Faculty of Medicine, University of New South Wales, Kensington (S.E.A., B.C.H.K.), the Emergency Department, Monash Medical Centre (D.E.-W.), the Departments of Medicine (D.E.-W.) and Surgery (J.A.S.), School of Clinical Sciences at Monash Health, Monash University, and the Department of Cardiothoracic Surgery, Monash Health (J.A.S.), Clayton, VIC, the Emergency Department, Gold Coast Health Service District, the School of Medicine, Bond University, and the School of Medicine, Griffith University, Gold Coast, QLD (G.K.), Emergency Medical and Children's Services, Prince Charles Hospital, Chermside, QLD (F.B.K.), the University of Queensland, Brisbane (F.B.K.), the Department of Respiratory and Sleep Medicine, Sutherland Hospital, Sydney (B.C.H.K.), and the Department of Respiratory Medicine, Cairns Hospital, Cairns, QLD (G.S.) - all in Australia; the Medical Research Institute of New Zealand (K.P., I.B., M.W., R.B.), the Capital and Coast District Health Board (K.P., M.W., R.B.), and Pacific Radiology (M.N.), Wellington, and the Adult Emergency Department, Auckland City Hospital and University of Auckland, Auckland (P.G.J.) - all in New Zealand
| | - Frances B Kinnear
- From the Centre for Clinical Research in Emergency Medicine, Harry Perkins Institute of Medical Research, Royal Perth Hospital, and the University of Western Australia (S.G.A.B., E.L.B., C.A.R.), Royal Perth Hospital Imaging (K.V.L.) and the Respiratory Department (E.L.B., Q.A.S.), Royal Perth Hospital, the Department of Respiratory Medicine, Sir Charles Gairdner Hospital (Y.C.G.L.), and the Centre for Respiratory Health, School of Medicine and Pharmacology, University of Western Australia (Y.C.G.L.), Perth, Aeromedical and Retrieval Services, Ambulance Tasmania (S.G.A.B.), and the Department of Respiratory Medicine, Royal Hobart Hospital (E.L.B.), Hobart, the Emergency Department, St. George Hospital, Kogarah, NSW (S.E.A.), St. George Clinical School, Faculty of Medicine, University of New South Wales, Kensington (S.E.A., B.C.H.K.), the Emergency Department, Monash Medical Centre (D.E.-W.), the Departments of Medicine (D.E.-W.) and Surgery (J.A.S.), School of Clinical Sciences at Monash Health, Monash University, and the Department of Cardiothoracic Surgery, Monash Health (J.A.S.), Clayton, VIC, the Emergency Department, Gold Coast Health Service District, the School of Medicine, Bond University, and the School of Medicine, Griffith University, Gold Coast, QLD (G.K.), Emergency Medical and Children's Services, Prince Charles Hospital, Chermside, QLD (F.B.K.), the University of Queensland, Brisbane (F.B.K.), the Department of Respiratory and Sleep Medicine, Sutherland Hospital, Sydney (B.C.H.K.), and the Department of Respiratory Medicine, Cairns Hospital, Cairns, QLD (G.S.) - all in Australia; the Medical Research Institute of New Zealand (K.P., I.B., M.W., R.B.), the Capital and Coast District Health Board (K.P., M.W., R.B.), and Pacific Radiology (M.N.), Wellington, and the Adult Emergency Department, Auckland City Hospital and University of Auckland, Auckland (P.G.J.) - all in New Zealand
| | - Ben C H Kwan
- From the Centre for Clinical Research in Emergency Medicine, Harry Perkins Institute of Medical Research, Royal Perth Hospital, and the University of Western Australia (S.G.A.B., E.L.B., C.A.R.), Royal Perth Hospital Imaging (K.V.L.) and the Respiratory Department (E.L.B., Q.A.S.), Royal Perth Hospital, the Department of Respiratory Medicine, Sir Charles Gairdner Hospital (Y.C.G.L.), and the Centre for Respiratory Health, School of Medicine and Pharmacology, University of Western Australia (Y.C.G.L.), Perth, Aeromedical and Retrieval Services, Ambulance Tasmania (S.G.A.B.), and the Department of Respiratory Medicine, Royal Hobart Hospital (E.L.B.), Hobart, the Emergency Department, St. George Hospital, Kogarah, NSW (S.E.A.), St. George Clinical School, Faculty of Medicine, University of New South Wales, Kensington (S.E.A., B.C.H.K.), the Emergency Department, Monash Medical Centre (D.E.-W.), the Departments of Medicine (D.E.-W.) and Surgery (J.A.S.), School of Clinical Sciences at Monash Health, Monash University, and the Department of Cardiothoracic Surgery, Monash Health (J.A.S.), Clayton, VIC, the Emergency Department, Gold Coast Health Service District, the School of Medicine, Bond University, and the School of Medicine, Griffith University, Gold Coast, QLD (G.K.), Emergency Medical and Children's Services, Prince Charles Hospital, Chermside, QLD (F.B.K.), the University of Queensland, Brisbane (F.B.K.), the Department of Respiratory and Sleep Medicine, Sutherland Hospital, Sydney (B.C.H.K.), and the Department of Respiratory Medicine, Cairns Hospital, Cairns, QLD (G.S.) - all in Australia; the Medical Research Institute of New Zealand (K.P., I.B., M.W., R.B.), the Capital and Coast District Health Board (K.P., M.W., R.B.), and Pacific Radiology (M.N.), Wellington, and the Adult Emergency Department, Auckland City Hospital and University of Auckland, Auckland (P.G.J.) - all in New Zealand
| | - K V Lam
- From the Centre for Clinical Research in Emergency Medicine, Harry Perkins Institute of Medical Research, Royal Perth Hospital, and the University of Western Australia (S.G.A.B., E.L.B., C.A.R.), Royal Perth Hospital Imaging (K.V.L.) and the Respiratory Department (E.L.B., Q.A.S.), Royal Perth Hospital, the Department of Respiratory Medicine, Sir Charles Gairdner Hospital (Y.C.G.L.), and the Centre for Respiratory Health, School of Medicine and Pharmacology, University of Western Australia (Y.C.G.L.), Perth, Aeromedical and Retrieval Services, Ambulance Tasmania (S.G.A.B.), and the Department of Respiratory Medicine, Royal Hobart Hospital (E.L.B.), Hobart, the Emergency Department, St. George Hospital, Kogarah, NSW (S.E.A.), St. George Clinical School, Faculty of Medicine, University of New South Wales, Kensington (S.E.A., B.C.H.K.), the Emergency Department, Monash Medical Centre (D.E.-W.), the Departments of Medicine (D.E.-W.) and Surgery (J.A.S.), School of Clinical Sciences at Monash Health, Monash University, and the Department of Cardiothoracic Surgery, Monash Health (J.A.S.), Clayton, VIC, the Emergency Department, Gold Coast Health Service District, the School of Medicine, Bond University, and the School of Medicine, Griffith University, Gold Coast, QLD (G.K.), Emergency Medical and Children's Services, Prince Charles Hospital, Chermside, QLD (F.B.K.), the University of Queensland, Brisbane (F.B.K.), the Department of Respiratory and Sleep Medicine, Sutherland Hospital, Sydney (B.C.H.K.), and the Department of Respiratory Medicine, Cairns Hospital, Cairns, QLD (G.S.) - all in Australia; the Medical Research Institute of New Zealand (K.P., I.B., M.W., R.B.), the Capital and Coast District Health Board (K.P., M.W., R.B.), and Pacific Radiology (M.N.), Wellington, and the Adult Emergency Department, Auckland City Hospital and University of Auckland, Auckland (P.G.J.) - all in New Zealand
| | - Y C Gary Lee
- From the Centre for Clinical Research in Emergency Medicine, Harry Perkins Institute of Medical Research, Royal Perth Hospital, and the University of Western Australia (S.G.A.B., E.L.B., C.A.R.), Royal Perth Hospital Imaging (K.V.L.) and the Respiratory Department (E.L.B., Q.A.S.), Royal Perth Hospital, the Department of Respiratory Medicine, Sir Charles Gairdner Hospital (Y.C.G.L.), and the Centre for Respiratory Health, School of Medicine and Pharmacology, University of Western Australia (Y.C.G.L.), Perth, Aeromedical and Retrieval Services, Ambulance Tasmania (S.G.A.B.), and the Department of Respiratory Medicine, Royal Hobart Hospital (E.L.B.), Hobart, the Emergency Department, St. George Hospital, Kogarah, NSW (S.E.A.), St. George Clinical School, Faculty of Medicine, University of New South Wales, Kensington (S.E.A., B.C.H.K.), the Emergency Department, Monash Medical Centre (D.E.-W.), the Departments of Medicine (D.E.-W.) and Surgery (J.A.S.), School of Clinical Sciences at Monash Health, Monash University, and the Department of Cardiothoracic Surgery, Monash Health (J.A.S.), Clayton, VIC, the Emergency Department, Gold Coast Health Service District, the School of Medicine, Bond University, and the School of Medicine, Griffith University, Gold Coast, QLD (G.K.), Emergency Medical and Children's Services, Prince Charles Hospital, Chermside, QLD (F.B.K.), the University of Queensland, Brisbane (F.B.K.), the Department of Respiratory and Sleep Medicine, Sutherland Hospital, Sydney (B.C.H.K.), and the Department of Respiratory Medicine, Cairns Hospital, Cairns, QLD (G.S.) - all in Australia; the Medical Research Institute of New Zealand (K.P., I.B., M.W., R.B.), the Capital and Coast District Health Board (K.P., M.W., R.B.), and Pacific Radiology (M.N.), Wellington, and the Adult Emergency Department, Auckland City Hospital and University of Auckland, Auckland (P.G.J.) - all in New Zealand
| | - Mike Nowitz
- From the Centre for Clinical Research in Emergency Medicine, Harry Perkins Institute of Medical Research, Royal Perth Hospital, and the University of Western Australia (S.G.A.B., E.L.B., C.A.R.), Royal Perth Hospital Imaging (K.V.L.) and the Respiratory Department (E.L.B., Q.A.S.), Royal Perth Hospital, the Department of Respiratory Medicine, Sir Charles Gairdner Hospital (Y.C.G.L.), and the Centre for Respiratory Health, School of Medicine and Pharmacology, University of Western Australia (Y.C.G.L.), Perth, Aeromedical and Retrieval Services, Ambulance Tasmania (S.G.A.B.), and the Department of Respiratory Medicine, Royal Hobart Hospital (E.L.B.), Hobart, the Emergency Department, St. George Hospital, Kogarah, NSW (S.E.A.), St. George Clinical School, Faculty of Medicine, University of New South Wales, Kensington (S.E.A., B.C.H.K.), the Emergency Department, Monash Medical Centre (D.E.-W.), the Departments of Medicine (D.E.-W.) and Surgery (J.A.S.), School of Clinical Sciences at Monash Health, Monash University, and the Department of Cardiothoracic Surgery, Monash Health (J.A.S.), Clayton, VIC, the Emergency Department, Gold Coast Health Service District, the School of Medicine, Bond University, and the School of Medicine, Griffith University, Gold Coast, QLD (G.K.), Emergency Medical and Children's Services, Prince Charles Hospital, Chermside, QLD (F.B.K.), the University of Queensland, Brisbane (F.B.K.), the Department of Respiratory and Sleep Medicine, Sutherland Hospital, Sydney (B.C.H.K.), and the Department of Respiratory Medicine, Cairns Hospital, Cairns, QLD (G.S.) - all in Australia; the Medical Research Institute of New Zealand (K.P., I.B., M.W., R.B.), the Capital and Coast District Health Board (K.P., M.W., R.B.), and Pacific Radiology (M.N.), Wellington, and the Adult Emergency Department, Auckland City Hospital and University of Auckland, Auckland (P.G.J.) - all in New Zealand
| | - Catherine A Read
- From the Centre for Clinical Research in Emergency Medicine, Harry Perkins Institute of Medical Research, Royal Perth Hospital, and the University of Western Australia (S.G.A.B., E.L.B., C.A.R.), Royal Perth Hospital Imaging (K.V.L.) and the Respiratory Department (E.L.B., Q.A.S.), Royal Perth Hospital, the Department of Respiratory Medicine, Sir Charles Gairdner Hospital (Y.C.G.L.), and the Centre for Respiratory Health, School of Medicine and Pharmacology, University of Western Australia (Y.C.G.L.), Perth, Aeromedical and Retrieval Services, Ambulance Tasmania (S.G.A.B.), and the Department of Respiratory Medicine, Royal Hobart Hospital (E.L.B.), Hobart, the Emergency Department, St. George Hospital, Kogarah, NSW (S.E.A.), St. George Clinical School, Faculty of Medicine, University of New South Wales, Kensington (S.E.A., B.C.H.K.), the Emergency Department, Monash Medical Centre (D.E.-W.), the Departments of Medicine (D.E.-W.) and Surgery (J.A.S.), School of Clinical Sciences at Monash Health, Monash University, and the Department of Cardiothoracic Surgery, Monash Health (J.A.S.), Clayton, VIC, the Emergency Department, Gold Coast Health Service District, the School of Medicine, Bond University, and the School of Medicine, Griffith University, Gold Coast, QLD (G.K.), Emergency Medical and Children's Services, Prince Charles Hospital, Chermside, QLD (F.B.K.), the University of Queensland, Brisbane (F.B.K.), the Department of Respiratory and Sleep Medicine, Sutherland Hospital, Sydney (B.C.H.K.), and the Department of Respiratory Medicine, Cairns Hospital, Cairns, QLD (G.S.) - all in Australia; the Medical Research Institute of New Zealand (K.P., I.B., M.W., R.B.), the Capital and Coast District Health Board (K.P., M.W., R.B.), and Pacific Radiology (M.N.), Wellington, and the Adult Emergency Department, Auckland City Hospital and University of Auckland, Auckland (P.G.J.) - all in New Zealand
| | - Graham Simpson
- From the Centre for Clinical Research in Emergency Medicine, Harry Perkins Institute of Medical Research, Royal Perth Hospital, and the University of Western Australia (S.G.A.B., E.L.B., C.A.R.), Royal Perth Hospital Imaging (K.V.L.) and the Respiratory Department (E.L.B., Q.A.S.), Royal Perth Hospital, the Department of Respiratory Medicine, Sir Charles Gairdner Hospital (Y.C.G.L.), and the Centre for Respiratory Health, School of Medicine and Pharmacology, University of Western Australia (Y.C.G.L.), Perth, Aeromedical and Retrieval Services, Ambulance Tasmania (S.G.A.B.), and the Department of Respiratory Medicine, Royal Hobart Hospital (E.L.B.), Hobart, the Emergency Department, St. George Hospital, Kogarah, NSW (S.E.A.), St. George Clinical School, Faculty of Medicine, University of New South Wales, Kensington (S.E.A., B.C.H.K.), the Emergency Department, Monash Medical Centre (D.E.-W.), the Departments of Medicine (D.E.-W.) and Surgery (J.A.S.), School of Clinical Sciences at Monash Health, Monash University, and the Department of Cardiothoracic Surgery, Monash Health (J.A.S.), Clayton, VIC, the Emergency Department, Gold Coast Health Service District, the School of Medicine, Bond University, and the School of Medicine, Griffith University, Gold Coast, QLD (G.K.), Emergency Medical and Children's Services, Prince Charles Hospital, Chermside, QLD (F.B.K.), the University of Queensland, Brisbane (F.B.K.), the Department of Respiratory and Sleep Medicine, Sutherland Hospital, Sydney (B.C.H.K.), and the Department of Respiratory Medicine, Cairns Hospital, Cairns, QLD (G.S.) - all in Australia; the Medical Research Institute of New Zealand (K.P., I.B., M.W., R.B.), the Capital and Coast District Health Board (K.P., M.W., R.B.), and Pacific Radiology (M.N.), Wellington, and the Adult Emergency Department, Auckland City Hospital and University of Auckland, Auckland (P.G.J.) - all in New Zealand
| | - Julian A Smith
- From the Centre for Clinical Research in Emergency Medicine, Harry Perkins Institute of Medical Research, Royal Perth Hospital, and the University of Western Australia (S.G.A.B., E.L.B., C.A.R.), Royal Perth Hospital Imaging (K.V.L.) and the Respiratory Department (E.L.B., Q.A.S.), Royal Perth Hospital, the Department of Respiratory Medicine, Sir Charles Gairdner Hospital (Y.C.G.L.), and the Centre for Respiratory Health, School of Medicine and Pharmacology, University of Western Australia (Y.C.G.L.), Perth, Aeromedical and Retrieval Services, Ambulance Tasmania (S.G.A.B.), and the Department of Respiratory Medicine, Royal Hobart Hospital (E.L.B.), Hobart, the Emergency Department, St. George Hospital, Kogarah, NSW (S.E.A.), St. George Clinical School, Faculty of Medicine, University of New South Wales, Kensington (S.E.A., B.C.H.K.), the Emergency Department, Monash Medical Centre (D.E.-W.), the Departments of Medicine (D.E.-W.) and Surgery (J.A.S.), School of Clinical Sciences at Monash Health, Monash University, and the Department of Cardiothoracic Surgery, Monash Health (J.A.S.), Clayton, VIC, the Emergency Department, Gold Coast Health Service District, the School of Medicine, Bond University, and the School of Medicine, Griffith University, Gold Coast, QLD (G.K.), Emergency Medical and Children's Services, Prince Charles Hospital, Chermside, QLD (F.B.K.), the University of Queensland, Brisbane (F.B.K.), the Department of Respiratory and Sleep Medicine, Sutherland Hospital, Sydney (B.C.H.K.), and the Department of Respiratory Medicine, Cairns Hospital, Cairns, QLD (G.S.) - all in Australia; the Medical Research Institute of New Zealand (K.P., I.B., M.W., R.B.), the Capital and Coast District Health Board (K.P., M.W., R.B.), and Pacific Radiology (M.N.), Wellington, and the Adult Emergency Department, Auckland City Hospital and University of Auckland, Auckland (P.G.J.) - all in New Zealand
| | - Quentin A Summers
- From the Centre for Clinical Research in Emergency Medicine, Harry Perkins Institute of Medical Research, Royal Perth Hospital, and the University of Western Australia (S.G.A.B., E.L.B., C.A.R.), Royal Perth Hospital Imaging (K.V.L.) and the Respiratory Department (E.L.B., Q.A.S.), Royal Perth Hospital, the Department of Respiratory Medicine, Sir Charles Gairdner Hospital (Y.C.G.L.), and the Centre for Respiratory Health, School of Medicine and Pharmacology, University of Western Australia (Y.C.G.L.), Perth, Aeromedical and Retrieval Services, Ambulance Tasmania (S.G.A.B.), and the Department of Respiratory Medicine, Royal Hobart Hospital (E.L.B.), Hobart, the Emergency Department, St. George Hospital, Kogarah, NSW (S.E.A.), St. George Clinical School, Faculty of Medicine, University of New South Wales, Kensington (S.E.A., B.C.H.K.), the Emergency Department, Monash Medical Centre (D.E.-W.), the Departments of Medicine (D.E.-W.) and Surgery (J.A.S.), School of Clinical Sciences at Monash Health, Monash University, and the Department of Cardiothoracic Surgery, Monash Health (J.A.S.), Clayton, VIC, the Emergency Department, Gold Coast Health Service District, the School of Medicine, Bond University, and the School of Medicine, Griffith University, Gold Coast, QLD (G.K.), Emergency Medical and Children's Services, Prince Charles Hospital, Chermside, QLD (F.B.K.), the University of Queensland, Brisbane (F.B.K.), the Department of Respiratory and Sleep Medicine, Sutherland Hospital, Sydney (B.C.H.K.), and the Department of Respiratory Medicine, Cairns Hospital, Cairns, QLD (G.S.) - all in Australia; the Medical Research Institute of New Zealand (K.P., I.B., M.W., R.B.), the Capital and Coast District Health Board (K.P., M.W., R.B.), and Pacific Radiology (M.N.), Wellington, and the Adult Emergency Department, Auckland City Hospital and University of Auckland, Auckland (P.G.J.) - all in New Zealand
| | - Mark Weatherall
- From the Centre for Clinical Research in Emergency Medicine, Harry Perkins Institute of Medical Research, Royal Perth Hospital, and the University of Western Australia (S.G.A.B., E.L.B., C.A.R.), Royal Perth Hospital Imaging (K.V.L.) and the Respiratory Department (E.L.B., Q.A.S.), Royal Perth Hospital, the Department of Respiratory Medicine, Sir Charles Gairdner Hospital (Y.C.G.L.), and the Centre for Respiratory Health, School of Medicine and Pharmacology, University of Western Australia (Y.C.G.L.), Perth, Aeromedical and Retrieval Services, Ambulance Tasmania (S.G.A.B.), and the Department of Respiratory Medicine, Royal Hobart Hospital (E.L.B.), Hobart, the Emergency Department, St. George Hospital, Kogarah, NSW (S.E.A.), St. George Clinical School, Faculty of Medicine, University of New South Wales, Kensington (S.E.A., B.C.H.K.), the Emergency Department, Monash Medical Centre (D.E.-W.), the Departments of Medicine (D.E.-W.) and Surgery (J.A.S.), School of Clinical Sciences at Monash Health, Monash University, and the Department of Cardiothoracic Surgery, Monash Health (J.A.S.), Clayton, VIC, the Emergency Department, Gold Coast Health Service District, the School of Medicine, Bond University, and the School of Medicine, Griffith University, Gold Coast, QLD (G.K.), Emergency Medical and Children's Services, Prince Charles Hospital, Chermside, QLD (F.B.K.), the University of Queensland, Brisbane (F.B.K.), the Department of Respiratory and Sleep Medicine, Sutherland Hospital, Sydney (B.C.H.K.), and the Department of Respiratory Medicine, Cairns Hospital, Cairns, QLD (G.S.) - all in Australia; the Medical Research Institute of New Zealand (K.P., I.B., M.W., R.B.), the Capital and Coast District Health Board (K.P., M.W., R.B.), and Pacific Radiology (M.N.), Wellington, and the Adult Emergency Department, Auckland City Hospital and University of Auckland, Auckland (P.G.J.) - all in New Zealand
| | - Richard Beasley
- From the Centre for Clinical Research in Emergency Medicine, Harry Perkins Institute of Medical Research, Royal Perth Hospital, and the University of Western Australia (S.G.A.B., E.L.B., C.A.R.), Royal Perth Hospital Imaging (K.V.L.) and the Respiratory Department (E.L.B., Q.A.S.), Royal Perth Hospital, the Department of Respiratory Medicine, Sir Charles Gairdner Hospital (Y.C.G.L.), and the Centre for Respiratory Health, School of Medicine and Pharmacology, University of Western Australia (Y.C.G.L.), Perth, Aeromedical and Retrieval Services, Ambulance Tasmania (S.G.A.B.), and the Department of Respiratory Medicine, Royal Hobart Hospital (E.L.B.), Hobart, the Emergency Department, St. George Hospital, Kogarah, NSW (S.E.A.), St. George Clinical School, Faculty of Medicine, University of New South Wales, Kensington (S.E.A., B.C.H.K.), the Emergency Department, Monash Medical Centre (D.E.-W.), the Departments of Medicine (D.E.-W.) and Surgery (J.A.S.), School of Clinical Sciences at Monash Health, Monash University, and the Department of Cardiothoracic Surgery, Monash Health (J.A.S.), Clayton, VIC, the Emergency Department, Gold Coast Health Service District, the School of Medicine, Bond University, and the School of Medicine, Griffith University, Gold Coast, QLD (G.K.), Emergency Medical and Children's Services, Prince Charles Hospital, Chermside, QLD (F.B.K.), the University of Queensland, Brisbane (F.B.K.), the Department of Respiratory and Sleep Medicine, Sutherland Hospital, Sydney (B.C.H.K.), and the Department of Respiratory Medicine, Cairns Hospital, Cairns, QLD (G.S.) - all in Australia; the Medical Research Institute of New Zealand (K.P., I.B., M.W., R.B.), the Capital and Coast District Health Board (K.P., M.W., R.B.), and Pacific Radiology (M.N.), Wellington, and the Adult Emergency Department, Auckland City Hospital and University of Auckland, Auckland (P.G.J.) - all in New Zealand
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Chan JYH, Lee YCG. Pleurodesis and systemic inflammatory markers: Lessons and insights. Respirology 2020; 25:676-677. [PMID: 31945800 DOI: 10.1111/resp.13765] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/04/2020] [Accepted: 01/06/2020] [Indexed: 11/27/2022]
Affiliation(s)
- John Y H Chan
- Department of Medicine and Geriatrics, Princess Margaret Hospital, Hong Kong SAR, China
| | - Y C Gary Lee
- Department of Respiratory Medicine, Sir Charles Gairdner Hospital, Perth, WA, Australia.,Centre for Respiratory Health, School of Medicine, University of Western Australia, Perth, WA, Australia.,Pleural Medicine Unit, Institute for Respiratory Health, Perth, WA, Australia
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Fysh ETH, Smallbone P, Mattock N, McCloskey C, Litton E, Wibrow B, Ho KM, Lee YCG. Clinically Significant Pleural Effusion in Intensive Care: A Prospective Multicenter Cohort Study. Crit Care Explor 2020; 2:e0070. [PMID: 32166290 PMCID: PMC7063904 DOI: 10.1097/cce.0000000000000070] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022] Open
Abstract
OBJECTIVES The prevalence and optimal management of clinically significant pleural effusion, confirmed by thoracic ultrasound, in the critically ill is unknown. This study aimed to determine: 1) the prevalence, characteristics, and outcomes of patients treated in intensive care with clinically significant effusion and 2) the comparative efficacy and safety of pleural drainage or expectant medical management. DESIGN A prospective multicenter cohort study. SETTING ICUs in four teaching hospitals in Western Australia. PATIENTS Consecutive patients with clinically significant pleural effusions (depth ≥ 2 cm on thoracic ultrasound with clinician-determined adverse effects on patient progress). INTERVENTIONS None. MEASUREMENTS AND MAIN RESULTS Primary outcome was the change in Pao2:Fio2 (mm Hg) ratio from baseline to 24 hours. Changes in diagnosis and treatment based on pleural fluid analysis and pleural effusion related serious adverse events between those who underwent either drainage within 24 hours or expectant management were compared. Of the 7,342 patients screened, 226 patients (3.1%) with 300 pleural effusions were enrolled. Early drainage of pleural effusion occurred in 76 patients (34%) and significantly improved oxygenation (Pao2:Fio2 ratio 203 at baseline vs 263 at 24 hr, +29.6% increment; p < 0.01). This was not observed in the other 150 patients who had expectant management (Pao2:Fio2 ratio 250 at baseline vs 268 at 24 hr, +7.2% increment; p = 0.44). The improvement in oxygenation after early drainage remained unchanged after adjustment for a propensity score on the decision to initiate early drainage. Pleural effusion related serious adverse events were not different between the two groups (early drainage 10.5% vs no early drainage 16.0%; p = 0.32). Improvements in diagnosis were noted in 91 initial (nonrepetitive) drainages (76.5% out of 119); treatment strategy was optimized after 80 drainage episodes (59.7% out of 134). CONCLUSIONS Early drainage of clinically significant pleural effusion was associated with improved oxygenation and diagnostic accuracy without increased complications.
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Affiliation(s)
- Edward T H Fysh
- Faculty of Medicine and Health Sciences, University of Western Australia, Perth, WA, Australia
- Pleural Diseases Unit, Department of General Medicine, Sir Charles Gairdner Hospital, Perth, WA, Australia
- Intensive Care Unit, St John of God Midland Public and Private Hospitals, Perth, WA, Australia
| | - Portia Smallbone
- Pleural Diseases Unit, Department of General Medicine, Sir Charles Gairdner Hospital, Perth, WA, Australia
| | - Nicholas Mattock
- Faculty of Medicine and Health Sciences, University of Western Australia, Perth, WA, Australia
| | | | - Edward Litton
- Faculty of Medicine and Health Sciences, University of Western Australia, Perth, WA, Australia
- Intensive Care Unit, Fiona Stanley Hospital, Perth, WA, Australia
| | - Bradley Wibrow
- Faculty of Medicine and Health Sciences, University of Western Australia, Perth, WA, Australia
- Intensive Care Unit, Sir Charles Gairdner Hospital, Perth, WA, Australia
| | - Kwok M Ho
- Intensive Care Unit, Royal Perth Hospital, Perth, WA, Australia
- School of Veterinary & Life Sciences, Murdoch, Perth, WA, Australia
| | - Y C Gary Lee
- Faculty of Medicine and Health Sciences, University of Western Australia, Perth, WA, Australia
- Pleural Diseases Unit, Department of General Medicine, Sir Charles Gairdner Hospital, Perth, WA, Australia
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