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Leicester, United States

Video-assisted thoracoscopy under local anesthesia (VAT-LA) is a key investigation in the diagnosis and management of suspected malignant pleural effusion. Two problems encountered at VAT-LA are accessing the pleural space and fibrinous intrapleural septa. Thoracic sonography (TUS) is known to facilitate thoracocentesis after dry tap but has not been studied in detail before VAT-LA. We report a case of lateral decubitus pre-VAT TUS that helped locate the optimal access to the pleural space and demonstrated fibrinous intrapleural septation, thereby affecting the decision to avoid thoracoscopic pleurodesis. © 2009 Wiley Periodicals, Inc. Source

Riaz S.P.,Kings College London | Coupland V.H.,Kings College London | Luchtenborg M.,Kings College London | Peake M.D.,Glenfield Hospital | Moller H.,Kings College London
European Respiratory Journal

We estimated the past and future age-standardised incidence rates of mesothelioma by birth cohort and by period of diagnosis in South East England. We extracted data on patients diagnosed with mesothelioma (International Classification of Diseases-10 C45) between 1960 and 2009 from the Thames Cancer Registry. We calculated the age-standardised incidence rates using the European standard population. We used age-cohort and age-period modelling to estimate the age-specific incidence rates for the 1900 to 1950 birth cohorts and the 1935 to 2034 calendar periods. A much more pronounced increase in mesothelioma incidence between 1972 and 2007 was observed in males than in females. In both sexes, the incidence rates increased in successive generations up to the 1945 birth cohort. Projection of rates in the future showed an increase in incidence in males until 2022 and a decrease thereafter. Among females, the incidence rate was predicted to increase gradually until reaching its maximum around 2027, and to remain stable thereafter. The occurrence of mesothelioma is closely linked to occupational exposure to asbestos in the 1960s and 1970s and, due to the long latency period, the incidence of mesothelioma is projected to increase until the 2020s. Copyright©ERS 2012. Source

Rintoul R.C.,Papworth Hospital | Ritchie A.J.,Essex Cardiothoracic Center | Edwards J.G.,Northern General Hospital | Waller D.A.,Glenfield Hospital | And 8 more authors.
The Lancet

Background: Malignant pleural mesothelioma incidence continues to rise, with few available evidence-based therapeutic options. Results of previous non-randomised studies suggested that video-assisted thoracoscopic partial pleurectomy (VAT-PP) might improve symptom control and survival. We aimed to compare efficacy in terms of overall survival, and cost, of VAT-PP and talc pleurodesis in patients with malignant pleural mesothelioma.Methods: We undertook an open-label, parallel-group, randomised, controlled trial in patients aged 18 years or older with any subtype of confirmed or suspected mesothelioma with pleural effusion, recruited from 12 hospitals in the UK. Eligible patients were randomly assigned (1:1) to either VAT-PP or talc pleurodesis by computer-generated random numbers, stratified by European Organisation for Research and Treatment of Cancer risk category (high vs low). The primary outcome was overall survival at 1 year, analysed by intention to treat (all patients randomly assigned to a treatment group with a final diagnosis of mesothelioma). This trial is registered with ClinicalTrials.gov, number NCT00821860.Findings: Between Oct 24, 2003, and Jan 24, 2012, we randomly assigned 196 patients, of whom 175 (88 assigned to talc pleurodesis, 87 assigned to VAT-PP) had confirmed mesothelioma. Overall survival at 1 year was 52% (95% CI 41-62) in the VAT-PP group and 57% (46-66) in the talc pleurodesis group (hazard ratio 1·04 [95% CI 0·76-1·42]; p=0·81). Surgical complications were significantly more common after VAT-PP than after talc pleurodesis, occurring in 24 (31%) of 78 patients who completed VAT-PP versus ten (14%) of 73 patients who completed talc pleurodesis (p=0·019), as were respiratory complications (19 [24%] vs 11 [15%]; p=0·22) and air-leak beyond 10 days (five [6%] vs one [1%]; p=0·21), although not significantly so. Median hospital stay was longer at 7 days (IQR 5-11) in patients who received VAT-PP compared with 3 days (2-5) for those who received talc pleurodesis (p<0·0001).Interpretation VAT-PP is not recommended to improve overall survival in patients with pleural effusion due to malignant pleural mesothelioma, and talc pleurodesis might be preferable considering the fewer complications and shorter hospital stay associated with this treatment. © 2014 Elsevier Ltd. Source

Abdul Aziz K.A.,Glenfield Hospital | Meduoye A.,Glenfield Hospital
Interactive Cardiovascular and Thoracic Surgery

A best evidence topic in cardiac surgery was written according to a structured protocol. The question addressed was whether pH-stat or alpha-stat is the best technique to follow in patients undergoing deep hypothermic circulatory arrest. Altogether 206 papers were found using the reported search, of which 16 represent the best evidence to answer the clinical question. The authors, journal, date and country of publication, patient group studied, study type, relevant outcomes and results of these papers are tabulated. Excluding one paper which provided inconclusive results, six studies found better cerebrovascular metabolism with alpha-stat while three studies found better cerebrovascular metabolism with pH-stat. Four other studies showed no significant difference in the cerebrovascular metabolism between the two acid-base management strategies in patients undergoing deep hypothermic circulatory arrest. Nine studies compared the neuropsychological outcome in patients who underwent deep hypothermic circulatory arrest with three studies supporting each alternative conclusion of preference towards alpha-stat or pH-stat management. The remaining three studies showed no significant difference between the two groups of acid-base management. Comparing the 16 studies based on the age of the patients studied, three out of the four papers which demonstrated that the pH-stat method is a better strategy to improve intraoperative and postoperative outcome were based on a sample of paediatric patients. Conversely, all seven papers that suggested alpha-stat method is associated with better intraoperative and postoperative outcome were based on studies done on adult patients. The remaining four papers suggested no significant difference between the pH-stat group and alpha-stat group. In conclusion, there is evidence to suggest that the best technique to follow in the management of acid-base in patients undergoing deep hypothermic circulatory arrest during cardiac surgery is dependent upon the age of the patient with better results using pH-stat in the paediatric patient and alpha-stat in the adult patient. Source

Nakas A.,Glenfield Hospital | Waller D.,Glenfield Hospital
European Journal of Cardio-thoracic Surgery

Objectives: The aim of radical surgery for malignant pleural mesothelioma (MPM) is to achieve greater survival than from chemotherapy alone. Although adverse overall prognostic factors have already been determined, our aim was to identify the most important factors affecting long-term survival arbitrarily defined as >24 months. Methods: We retrospectively reviewed the records of 252 patients (35 females; 193 epithelioid and 59 biphasic; 112 extrapleural pneumonectomy (EPP); 140 extended pleurectomy decortication (EPD)) who survived for at least 90 postoperative days. We tested for factors affecting overall cancer-related mortality and specific clinical factors predicting the 24-month survival. Results: The overall median survival was 18.2 (SE 1.3, 95% CI 15.8-20.7 months). There was no difference in survival between EPP and EPD (P = 0.92). One hundred and twenty-eight patients received induction, adjuvant or palliative chemotherapy. Seventy-seven (30.6%) patients survived for >24 months. On univariate analysis, age at operation over 60 years (P = 0.044), pT4 stage (P = 0.041), any lymph node metastases (P = 0.002), biphasic cell type (P = 0.00) and no administration of chemotherapy (P = 0.00) were associated with decreased survival. On multivariate analysis, age <60 (P = 0.018, OR = 0.7), epithelioid disease (P = 0.001, OR = 0.56) and negative nodes (P = 0.009, OR = 0.67) were associated with increased survival and no administration of chemotherapy (P = 0.00, OR = 1.9) with decreased survival. Factors predicting survival over 24 months included: age at operation under 60 (P = 0.014), epithelioid histology (P ≤ 0.00), negative nodes (P = 0.002) and chemotherapy (P = 0.022). Conclusions: These results support a policy of accurate preoperative tissue diagnosis, nodal staging and induction chemotherapy prior to radical surgery for MPM, which can result in long-term survival. Trials investigating the role of surgery should be focused on confirming and refining these selection criteria. © The Author 2014. Published by Oxford University Press on behalf of the European Association for Cardio-Thoracic Surgery. All rights reserved. Source

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