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Najib M. Rahman - One of the best experts on this subject based on the ideXlab platform.

  • Management of Pleural Infection
    Pulmonary Therapy, 2020
    Co-Authors: Anand Sundaralingam, Radhika Banka, Najib M. Rahman
    Abstract:

    Pleural Infection is a millennia-spanning condition that has proved challenging to treat over many years. Fourteen percent of cases of pneumonia are reported to present with a Pleural effusion on chest X-ray (CXR), which rises to 44% on ultrasound but many will resolve with prompt antibiotic therapy. To guide treatment, parapneumonic effusions have been separated into distinct categories according to their biochemical, microbiological and radiological characteristics. There is wide variation in causative organisms according to geographical location and healthcare setting. Positive cultures are only obtained in 56% of cases; therefore, empirical antibiotics should provide Gram-positive, Gram-negative and anaerobic cover whilst providing adequate Pleural penetrance. With the advent of next-generation sequencing techniques, yields are expected to improve. Complicated parapneumonic effusions and empyema necessitate prompt tube thoracostomy. It is reported that 16–27% treated in this way will fail on this therapy and require some form of escalation. The now seminal Multi-centre IntraPleural Sepsis Trials (MIST) demonstrated the use of combination fibrinolysin and DNase as more effective in the treatment of empyema compared to either agent alone or placebo, and success rates of 90% are reported with this technique. The focus is now on dose adjustments according to the patient’s specific ‘fibrinolytic potential’, in order to deliver personalised therapy. Surgery has remained a cornerstone in the management of Pleural Infection and is certainly required in late-stage manifestations of the disease. However, its role in early-stage disease and optimal patient selection is being re-explored. A number of adjunct and exploratory therapies are also discussed in this review, including the use of local anaesthetic thoracoscopy, indwelling Pleural catheters, intraPleural antibiotics, Pleural irrigation and steroid therapy.

  • Osler Centenary Papers: Management of Pleural Infection: Osler's final illness and recent advances.
    Postgraduate medical journal, 2019
    Co-Authors: Prudence Gregory, Najib M. Rahman, Y. C. Gary Lee
    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.

  • P103 Antibiotic use and comorbid Pleural Infection in patients with malignant Pleural effusion
    Malignant pleural disease, 2019
    Co-Authors: V. George, Rachel M. Mercer, A Dudina, E Bedawi, Najib M. Rahman
    Abstract:

    Introduction and objectives Malignant Pleural effusion (MPE) affects 15% of all patients with cancer. (1) Despite this, diagnosis can be difficult and patients are often treated with antibiotics for presumed Pleural Infection. While many of these cases represent initial misdiagnosis, there is a subset of patients with MPE who have comorbid Infection at presentation. We attempted to quantify the proportion of patients with MPE who receive antibiotics at presentation, and evaluate how many had evidence of Pleural Infection. Methods All Pleural fluid samples collected at our centre over the 3 years prior to December 31 2017 were retrospectively reviewed. Patients with MPE were examined to identify those that received antibiotics for Pleural Infection prior to their pathological diagnosis. The Pleural fluid chemistry and microbiology and response to treatment were then reviewed. Results 1352 Pleural fluid samples were collected over the 3-year period in 1061 patients. 335 of these individuals were diagnosed with MPE. Preliminary analysis of 67 cases demonstrated that 15 (22%) received antibiotics during hospital presentation with effusion. Of these, none had positive Pleural microbiology or macroscopic pus, 1 (6.6%) had a pH Three individuals received a 4–6 week course of antibiotics for presumed comorbid empyema, with 1 demonstrating a significant reduction in inflammatory markers. The remaining 12 (80%) received shorter courses of antibiotics, without clear evidence of Infection. Conclusions MPE presents with non-specific symptoms and patients can often have raised inflammatory markers. Even in the tertiary setting our ability to promptly and accurately differentiate malignancy from Pleural Infection is poor and often leads to unwarranted antibiotic therapy. This is likely to be associated with diagnostic delay, antibiotic related morbidity and increased healthcare costs. In most cases presumptive treatment is commenced well before the involvement of specialist Pleural services. Increased education of frontline staff and new strategies, such as the routine addition of serum procalcitonin and increased acquisition of Pleural biopsies, should now be studied. Reference Clive AO, Jones HE, Bhatnagar R, Preston NJ, Maskell N. Interventions for the management of malignant Pleural effusions: a network meta-analysis (Review). 2018;(5).

  • P142 Does the appearance of the chest radiograph matter in Pleural Infection
    Respiratory infections: getting it right, 2019
    Co-Authors: Eihab O. Bedawi, Najib M. Rahman, V. George, Rachel M. Mercer, A Dudina, N I Kanellakis, A Kim, Al Pattabi, Robert J. Hallifax
    Abstract:

    Introduction The chest radiograph is used in clinical practice to guide decision-making in the treatment of Pleural Infection. This outcome was used as the primary endpoint in the randomised second Multicentre IntraPleural Sepsis Trial (MIST-2), defined as the change in area of Pleural opacity, measured as the percentage of the ipsilateral hemithorax occupied by effusion, from day 1 to day 7 [1]. The value of this radiographic outcome measure as a surrogate for predicting clinically important outcomes, e.g. time in hospital (LOS), surgery at 3 months and 3-month mortality, has not been directly addressed. Methods Retrospective analyses were conducted using the prospectively collected data from the MIST-2 database (n=210). Regression analyses were modelled with number of days in hospital (linear), and surgery or death at 3 months, both individually and as a combined outcome (yes/no; logistic), as dependent variables. The independent variables were absolute change in chest radiograph opacity (MIST-2 primary endpoint) and relative change, which is more clinically applicable in daily practice (a secondary endpoint in MIST-2). Each of the analyses was corrected for day 1 radiograph appearance to account for baseline variability. SPSS v25 was used for all analyses. Results Absolute and relative change in chest radiograph opacity were associated with hospital LOS and either surgery or death at 3 months (combined outcome) with strong statistical significance (p≤0.01). Analysing the components of the combined outcome individually, absolute and relative change were associated with surgery at 3 months (p≤0.01 and p=0.021 respectively). Absolute and relative change in chest radiograph to death at 3 months alone was borderline significant (p=0.089) and non-significant (p=0.16) respectively. Conclusion These findings demonstrate that change in chest radiograph during the course of treatment of Pleural Infection is a robust and clinically important surrogate endpoint which appears to predict meaningful outcomes. Although surgery may be decided upon solely on the basis of the radiograph (which would explain this result), change in x-ray appearance predicts other important outcomes (length of stay). This data supports its clinical utility, and suggests its robust use as a research outcome measure.

  • P143 Association between platelet count and Pleural Infection
    Respiratory infections: getting it right, 2019
    Co-Authors: A Dudina, Robert J. Hallifax, Eihab O. Bedawi, V. George, Rachel M. Mercer, Najib M. Rahman
    Abstract:

    Introduction Secondary thrombocytosis is one of the commonest reactive processes in clinical settings of acute bacterial and viral Infection. Platelet response could be similar to any other markers of inflammation such as C-reactive protein (CRP) and white cell count (WCC). Objectives The aim of this study was to analyse whether change in platelet counts could be associated with time of recovery in patients with Pleural Infection on day 7 as compared with day 1. What is the association of platelet count with other inflammatory markers? Subjects and methods This was a retrospective study using data from MIST2 trial recorded in 11 centres in the UK within 3 years (2005–2008).1 For our analysis there were available 25 patients in placebo group, 23 - in t-PA group, 21 patients in DNase group and 25 patients in t-PA and DNase group. We calculated the change in inflammatory markers in all groups of treatment. Paired t-test was applied to calculate the mean difference in platelets, CRP and WCC during recovery time. Spearman’s rank test used for comparison of means in four groups of treatment. Results The analysis revealed an increase in mean platelets count from 489.25±215 to 575.78±231 9/L (p=0.000) by day 7 in whole data population with the highest increase in tPA&Dnase group and slight fall in tPA arm (Figure 1). Platelets correlate negatively with WCC and CRP which decreased by 3.05 (p=0.000) and 76.29 (p=0.000) respectively. But there is a weak correlation with the decreased WCC and CRP in the group treated with tPA and DNase. Conclusion The reaction of platelets seems to be stronger than reaction of other inflammatory markers during treatment with tPA&DNase arm. This might be due to interaction between these two medications or platelets fall more slowly during recovery. A better understanding of the platelets role in Pleural Infection might help to produce new prognostic and therapeutic approaches. Reference Rahman NM, MN., West A, et al. IntraPleural use of tissue plasminogen activator and DNase in Pleural Infection. N Engl J Med 2011;365(6):518.

Nick A Maskell - One of the best experts on this subject based on the ideXlab platform.

  • Is Pleural Infection associated with longer survival in mesothelioma? A population-based cohort study using data from Hospital Episode Statistics.
    Cancer epidemiology, 2019
    Co-Authors: Anna C. Bibby, Duneesha De Fonseka, David Carslake, Nick A Maskell
    Abstract:

    Abstract Background Historically Pleural Infection was thought to be associated with longer survival in thoracic malignancies. The aim of this population-based cohort study was to investigate this hypothesis in mesothelioma, using national data from a high incidence country. Methods Case records for all patients with mesothelioma seen in English hospitals between 01/01/2005 and 31/12/2014 were extracted from Hospital Episode Statistics using International Classification of Diseases Tenth Edition (ICD-10) codes. Episodes of Pleural Infection were identified. Linked mortality data was obtained from the Office of National Statistics. The primary outcome was all-cause mortality. The explanatory variable was Pleural Infection. Cox proportional hazards model was used to analyse survival, with Pleural Infection, chemotherapy and thoracic surgery handled as time-variable co-factors. Results Of 22,215 patients with mesothelioma, 512 (2.3%) developed Pleural Infection at some point in their illness. Overall median survival was 7.0 months (IQR 2.3–16.4). Pleural Infection was associated with shorter survival in the immediate post-Infection period (up to 30 days – HR 1.81, 95% CI 1.45–2.22) and longer term (>30 days – HR 1.81, 95% CI 1.63–1.99). Other factors associated with increased mortality were age, male gender and being diagnosed as an inpatient. Receiving chemotherapy and being less economically deprived were associated with longer survival. Conclusion Pleural Infection occurred in 2.3% of people with mesothelioma and was associated with shorter survival. This refutes previous reports suggesting Pleural Infection may be associated with better outcomes in thoracic malignancy.

  • P264 Is Pleural Infection associated with longer survival in mesothelioma? a population-based cohort study using data from hospital episode statistics
    Developing pleural and interventional services, 2018
    Co-Authors: Anna C. Bibby, David Carslake, D De Fonseka, Nick A Maskell
    Abstract:

    Background Historically Pleural Infection was thought to be associated with longer survival in lung cancer, and small observational studies have reported a similar trend in mesothelioma. The aim of this population-based cohort study was to investigate whether Pleural Infection was associated with survival with mesothelioma. Methods Case records for all patients with mesothelioma seen in English hospitals between 01/01/2005 and 1/12/2014 were extracted from Hospital Episode Statistics using International Classification of Diseases Tenth Edition (ICD-10) codes. Episodes of Pleural Infection were identified. Linked mortality data was obtained from the Office of National Statistics. The primary outcome was all-cause mortality. The explanatory variable was Pleural Infection. Cox proportional hazards model was used to analyse survival, with Pleural Infection, chemotherapy and thoracic surgery handled as time-variable co-factors. Findings Of 22 215 patients with mesothelioma, 512 (2.3%) experienced Pleural Infection. Overall median survival was 7.0 months. Pleural Infection was associated with shorter survival in the immediate post-Infection period (up to 30 days – HR 1.78, 95% CI 1.44 to 2.19) and longer term (>30 days – HR 1.77, 95% CI 1.60 to 1.96)). Other factors associated with increased mortality were age, male gender, being diagnosed as an inpatient and having documented asbestos exposure or Pleural plaques (see table 1). Receiving chemotherapy and being less economically deprived were associated with longer survival. Discussion Pleural Infection occurs more frequently in patients with mesothelioma than in the general population and is associated with shorter survival. This refutes previous reports suggesting Pleural Infection may be associated with better outcomes in malignancy. However, certain prognostic data was unavailable, including patients‘ performance status and tumour histological sub-type, and therefore confounding may have affected this result.

  • The role of procalcitonin in the management of Pleural Infection.
    Current opinion in pulmonary medicine, 2018
    Co-Authors: Duneesha De Fonseka, Nick A Maskell
    Abstract:

    Purpose of review Pleural Infection is a common problem associated with significant morbidity and mortality. Systemic or Pleural fluid markers for reliably identifying Pleural Infection are limited. Procalcitonin (PCT) is known to be elevated in bacterial Infection and is currently used for diagnosis and decision-making regarding antibiotic duration in respiratory Infections. This review investigates if there is a role for serum and Pleural fluid PCT (pf-PCT) in diagnosis and management of Pleural Infection. Recent findings Studies investigating the role of PCT have been limited by small patient numbers and heterogenous control populations. Overall, serum PCT (s-PCT) does not have a role superior to that of C-reactive protein (CRP) or leucocyte count (LCC) in diagnosing Pleural Infection or monitoring response to treatment. Similarly, pf-PCT demonstrated low sensitivity and specificity for diagnosing Pleural Infection. There was no role for PCT in determining which patients would require surgery as opposed to tube drainage alone. Summary There is currently insufficient evidence to recommend routine use of PCT for diagnosis and monitoring of Pleural Infection.

  • The role of serum procalcitonin in establishing the diagnosis and prognosis of Pleural Infection.
    Respiratory research, 2017
    Co-Authors: Giles Dixon, Oliver J Bintcliffe, Anna J Morley, Adriana Lama-lopez, Ce Hooper, Nick A Maskell
    Abstract:

    Background Bacterial Pleural Infection requires prompt identification to enable appropriate investigation and treatment. In contrast to commonly used biomarkers such as C-reactive protein (CRP) and white cell count (WCC), which can be raised due to non-infective inflammatory processes, procalcitonin (PCT) has been proposed as a specific biomarker of bacterial Infection. The utility of PCT in this role is yet to be validated in a large prospective trial. This study aimed to identify whether serum PCT is superior to CRP and WCC in establishing the diagnosis of bacterial Pleural Infection.

  • The role of serum procalcitonin in establishing the diagnosis and prognosis of Pleural Infection
    Respiratory Research, 2017
    Co-Authors: Giles Dixon, Oliver J Bintcliffe, Anna J Morley, Adriana Lama-lopez, Clare E. Hooper, Nick A Maskell
    Abstract:

    Background Bacterial Pleural Infection requires prompt identification to enable appropriate investigation and treatment. In contrast to commonly used biomarkers such as C-reactive protein (CRP) and white cell count (WCC), which can be raised due to non-infective inflammatory processes, procalcitonin (PCT) has been proposed as a specific biomarker of bacterial Infection. The utility of PCT in this role is yet to be validated in a large prospective trial. This study aimed to identify whether serum PCT is superior to CRP and WCC in establishing the diagnosis of bacterial Pleural Infection. Methods Consecutive patients presenting to a tertiary Pleural service between 2008 and 2013 were recruited to a well-established Pleural disease study. Consent was obtained to store Pleural fluid and relevant clinical information. Serum CRP, WCC and PCT were measured. A diagnosis was agreed upon by two independent consultants after a minimum of 12 months. The study was performed and reported according to the STARD reporting guidelines. Results 80/425 patients enrolled in the trial had a unilateral Pleural effusion secondary to Infection. 10/80 (12.5%) patients had positive Pleural fluid microbiology. Investigations for viral causes of effusion were not performed. ROC curve analysis of 425 adult patients with unilateral undiagnosed Pleural effusions showed no statistically significant difference in the diagnostic utility of PCT (AUC 0.77), WCC (AUC 0.77) or CRP (AUC 0.85) for the identification of bacterial Pleural Infection. Serum procalcitonin >0.085 μg/l has a sensitivity, specificity, negative predictive value and positive predictive value of 0.69, 0.80, 0.46 and 0.91 respectively for the identification of Pleural Infection. The diagnostic utility of procalcitonin was not affected by prior antibiotic use ( p  = 0.80). Conclusions The study presents evidence that serum procalcitonin is not superior to CRP and WCC for the diagnosis of bacterial Pleural Infection. The study suggests routine procalcitonin testing in all patients with unilateral Pleural effusion is not beneficial however further investigation may identify specific patient subsets that may benefit. Trial registration The trial was registered with the UK Clinical Research Network ( UKCRN ID 8960 ). The trial was approved by the South West Regional Ethics Committee (Ethical approval number 08/H0102/11).

John Wrightson - One of the best experts on this subject based on the ideXlab platform.

  • s13 the microbiology of Pleural Infection an approach based on 16s rrna gene next generation sequencing
    Thorax, 2019
    Co-Authors: N I Kanellakis, John P. Corcoran, Eihab O. Bedawi, John Wrightson, Rachel Mercer, Stephen Gerry, R J Hallifax, V George, Alexandra Dudina, R Asciak
    Abstract:

    Background Pleural Infection (PI) is a common and complicated disease, bearing a heavy healthcare burden worldwide. Definitive pathogen identification based on current methods occurs in only 40% of cases, mainly due to prior antibiotic administration and special bacterial nutritional culture requirements. To this end PI microbiology knowledge remains incomplete. Novel deep sequencing techniques could increase the rate of reliable pathogen identification and shed light on the complex polymicrobial patterns of PI. Aim To investigate and further characterise the microbial nature of PI using next generation sequencing (NGS). Methods Pleural fluid samples from the ‘Pleural Infection Longitudinal Outcome Study’ (PILOT, ISRCTN50236700, n=243) underwent bacterial DNA extraction followed by 16S rRNA NGS using Illumina MiSeq. Data were analysed with DADA2 and Phyloseq R packages. Results Bacterial DNA from Pleural fluid samples was successfully extracted and sequenced. NGS detected 391 diverse pathogens up to the genus level and analysis showed that PI is a polymicrobial disease. 131 (54%) samples had one pathogen with relative abundance over 50% and 89 (36%) samples had at least 3 pathogens with relative abundance over 10%. Streptococcus Pneumoniae was detected in 40 (16%) and Staphylococcus Aureus in 20 (8%) samples. Discussion It is feasible to extract and sequence bacterial DNA from Pleural fluid samples from patients with PI. 16S rRNA NGS is a robust method for investigating the total bacteriology of Pleural fluid samples. Funding National Institute for Health Research (NIHR) Oxford Biomedical Research Centre (BRC).

  • s57 sonographic septations in Pleural Infection what do they actually mean
    Thorax, 2018
    Co-Authors: Eihab O. Bedawi, Maged Hassan, John Wrightson, Elinor Harriss, Rachelle Asciak, David J. Mccracken, Rachel Mercer, Najib M. Rahman
    Abstract:

    Introduction It is well established that when associated with Infection, Pleural effusions carry a significant morbidity and mortality. Sonographic septations are assumed to be associated with poor fluid drainage and some clinicians use this radiological parameter as an indication to proceed directly to surgical drainage, but the evidence for this was unclear. We therefore undertook a literature review to assess the relationship between septations and Pleural Infection outcome. Methods A systematic literature search was conducted using Medline (1946 to present), Embase (1974 to present), Cochrane database of systematic reviews, Cochrane Central Register of Controlled Trials, Scopus and Web of Science Core Collection. The search did not restrict on language and included all age groups. Septated effusions were captured using the following MeSH terms; [septations, septae, locules, loculations, septated Pleural effusions, Pleural Infection, empyema and parapneumonic effusion]. The outcomes assessed included length of hospital stay, mortality, sepsis, surgery, VATS, decortication, intensive care, death and a number of patient centred outcomes. Results The search resulted in a total of 267 publications. After de-duplication, two researchers independently reviewed the remaining 136 papers for inclusion criteria. Only 6 papers examined baseline sonographic appearances and related these to outcomes, and these were further evaluated. Apart from one, these were all retrospective studies (see table 1). Only 2 similar papers from the same group (Chen et al) addressed our question directly and concluded that patients with a complex septated sonographic pattern have a poorer prognosis. Lai et al specifically addressed septations as a predictor of residual Pleural thickening in tuberculous pleurisy. Whilst some papers suggested that the presence of loculations carries a prognostic value and possibly indicate need for early surgery (Cheng et al, Bongiolatti et al), others (Kearney et al) concluded that no sonographic findings reliably influence outcomes. Conclusion This systematic review demonstrates that there is a paucity of evidence linking septations and outcome in Pleural Infection. Previous large Pleural Infection trials (MIST1 and MIST2) were conducted prior to the era of common ultrasound. The oft-held belief that a septated effusion requires upfront surgical treatment is not currently evidence based and necessitates urgent further prospective studies.

  • S57 Sonographic septations in Pleural Infection – what do they actually mean?
    Do you need to stick a needle in it? Pleural infection and pneumothorax, 2018
    Co-Authors: Eihab O. Bedawi, Maged Hassan, John Wrightson, Elinor Harriss, Rachelle Asciak, Rachel M. Mercer, David J. Mccracken, Najib M. Rahman
    Abstract:

    Introduction It is well established that when associated with Infection, Pleural effusions carry a significant morbidity and mortality. Sonographic septations are assumed to be associated with poor fluid drainage and some clinicians use this radiological parameter as an indication to proceed directly to surgical drainage, but the evidence for this was unclear. We therefore undertook a literature review to assess the relationship between septations and Pleural Infection outcome. Methods A systematic literature search was conducted using Medline (1946 to present), Embase (1974 to present), Cochrane database of systematic reviews, Cochrane Central Register of Controlled Trials, Scopus and Web of Science Core Collection. The search did not restrict on language and included all age groups. Septated effusions were captured using the following MeSH terms; [septations, septae, locules, loculations, septated Pleural effusions, Pleural Infection, empyema and parapneumonic effusion]. The outcomes assessed included length of hospital stay, mortality, sepsis, surgery, VATS, decortication, intensive care, death and a number of patient centred outcomes. Results The search resulted in a total of 267 publications. After de-duplication, two researchers independently reviewed the remaining 136 papers for inclusion criteria. Only 6 papers examined baseline sonographic appearances and related these to outcomes, and these were further evaluated. Apart from one, these were all retrospective studies (see table 1). Only 2 similar papers from the same group (Chen et al) addressed our question directly and concluded that patients with a complex septated sonographic pattern have a poorer prognosis. Lai et al specifically addressed septations as a predictor of residual Pleural thickening in tuberculous pleurisy. Whilst some papers suggested that the presence of loculations carries a prognostic value and possibly indicate need for early surgery (Cheng et al, Bongiolatti et al), others (Kearney et al) concluded that no sonographic findings reliably influence outcomes. Conclusion This systematic review demonstrates that there is a paucity of evidence linking septations and outcome in Pleural Infection. Previous large Pleural Infection trials (MIST1 and MIST2) were conducted prior to the era of common ultrasound. The oft-held belief that a septated effusion requires upfront surgical treatment is not currently evidence based and necessitates urgent further prospective studies.

  • IntraPleural tPA increases Pleural fluid output in Pleural Infection, independent of chest X-ray opacification
    10.1 Respiratory Infections, 2015
    Co-Authors: John Wrightson, John P. Corcoran, Robert J. Hallifax, Nick A Maskell, Ioannis Psallidas, Najib M. Rahman
    Abstract:

    The MIST2 RCT examined the role of intraPleural drugs in Pleural Infection, demonstrating improved outcomes (X-ray opacification, surgery, length of stay) with combination tPA+DNase (but not tPA or DNase alone). Animal models suggest that tPA causes fluid production even without Pleural Infection. We therefore analysed MIST2 data to evaluate the effects of tPA and DNase on fluid output. Aims: We hypothesised that drain output is temporally-related to tPA. Methods: 210 patients were randomized to 3 days of tPA+DNase, tPA, DNase or placebo as described in the MIST2 study. Daily (days 0-7) and total fluid drainage was measured. Data were analysed using linear regression, adjusted for x-ray opacity and other minimisation factors. Results: tPA and tPA+DNase led to similar significant ( p Conclusions: tPA increases fluid output regardless of Pleural collection size. Given previously-demonstrated benefits of combination tPA+DNase (but not tPA alone), this suggests that the actions of combination tPA+DNase do more than simply increasing drainage, and may include possible DNase-induced biofilm disruption. The significant fluid output with placebo alone mandates the use of such a comparator in all studies. Future RCTs should not rely on fluid output as a primary outcome.

  • Pleural Infection: past, present, and future directions
    The Lancet. Respiratory medicine, 2015
    Co-Authors: John P. Corcoran, John Wrightson, Elizabeth Belcher, Malcolm M. Decamp, David Feller-kopman, Najib M. Rahman
    Abstract:

    Summary Pleural space Infections are increasing in incidence and continue to have high associated morbidity, mortality, and need for invasive treatments such as thoracic surgery. The mechanisms of progression from a non-infected, pneumonia-related effusion to a confirmed Pleural Infection have been well described in the scientific literature, but the route by which pathogenic organisms access the Pleural space is poorly understood. Data suggests that not all Pleural Infections can be related to lung parenchymal Infection. Studies examining the microbiological profile of Pleural Infection inform antibiotic choice and can help to delineate the source and pathogenesis of Infection. The development of radiological methods and use of clinical indices to predict which patients with Pleural Infection will have a poor outcome, as well as inform patient selection for more invasive treatments, is particularly important. Randomised clinical trial and case series data have shown that the combination of an intraPleural tissue plasminogen activator and deoxyribonuclease therapy can potentially improve outcomes, but the use of this treatment as compared with surgical options has not been precisely defined, particularly in terms of when and in which patients it should be used.

Anna J Morley - One of the best experts on this subject based on the ideXlab platform.

  • The role of serum procalcitonin in establishing the diagnosis and prognosis of Pleural Infection.
    Respiratory research, 2017
    Co-Authors: Giles Dixon, Oliver J Bintcliffe, Anna J Morley, Adriana Lama-lopez, Ce Hooper, Nick A Maskell
    Abstract:

    Background Bacterial Pleural Infection requires prompt identification to enable appropriate investigation and treatment. In contrast to commonly used biomarkers such as C-reactive protein (CRP) and white cell count (WCC), which can be raised due to non-infective inflammatory processes, procalcitonin (PCT) has been proposed as a specific biomarker of bacterial Infection. The utility of PCT in this role is yet to be validated in a large prospective trial. This study aimed to identify whether serum PCT is superior to CRP and WCC in establishing the diagnosis of bacterial Pleural Infection.

  • The role of serum procalcitonin in establishing the diagnosis and prognosis of Pleural Infection
    Respiratory Research, 2017
    Co-Authors: Giles Dixon, Oliver J Bintcliffe, Anna J Morley, Adriana Lama-lopez, Clare E. Hooper, Nick A Maskell
    Abstract:

    Background Bacterial Pleural Infection requires prompt identification to enable appropriate investigation and treatment. In contrast to commonly used biomarkers such as C-reactive protein (CRP) and white cell count (WCC), which can be raised due to non-infective inflammatory processes, procalcitonin (PCT) has been proposed as a specific biomarker of bacterial Infection. The utility of PCT in this role is yet to be validated in a large prospective trial. This study aimed to identify whether serum PCT is superior to CRP and WCC in establishing the diagnosis of bacterial Pleural Infection. Methods Consecutive patients presenting to a tertiary Pleural service between 2008 and 2013 were recruited to a well-established Pleural disease study. Consent was obtained to store Pleural fluid and relevant clinical information. Serum CRP, WCC and PCT were measured. A diagnosis was agreed upon by two independent consultants after a minimum of 12 months. The study was performed and reported according to the STARD reporting guidelines. Results 80/425 patients enrolled in the trial had a unilateral Pleural effusion secondary to Infection. 10/80 (12.5%) patients had positive Pleural fluid microbiology. Investigations for viral causes of effusion were not performed. ROC curve analysis of 425 adult patients with unilateral undiagnosed Pleural effusions showed no statistically significant difference in the diagnostic utility of PCT (AUC 0.77), WCC (AUC 0.77) or CRP (AUC 0.85) for the identification of bacterial Pleural Infection. Serum procalcitonin >0.085 μg/l has a sensitivity, specificity, negative predictive value and positive predictive value of 0.69, 0.80, 0.46 and 0.91 respectively for the identification of Pleural Infection. The diagnostic utility of procalcitonin was not affected by prior antibiotic use ( p  = 0.80). Conclusions The study presents evidence that serum procalcitonin is not superior to CRP and WCC for the diagnosis of bacterial Pleural Infection. The study suggests routine procalcitonin testing in all patients with unilateral Pleural effusion is not beneficial however further investigation may identify specific patient subsets that may benefit. Trial registration The trial was registered with the UK Clinical Research Network ( UKCRN ID 8960 ). The trial was approved by the South West Regional Ethics Committee (Ethical approval number 08/H0102/11).

  • a randomised controlled trial of saline irrigation for Pleural Infection the pit trial
    2015
    Co-Authors: Ce Hooper, Anthony Edey, Amelia O Clive, Anna J Morley, Adam Wallis, Paul D White, Arl Medford, John E Harvey, M Darby, Zahan N Evans
    Abstract:

    Pleural Infection is increasing in incidence. Despite optimal medical management, up to 30% of patients will die or require surgery. Case reports suggest that irrigation of the Pleural space with saline may be beneficial. A randomised controlled pilot study in which saline Pleural irrigation (three times per day for 3 days) plus best-practice management was compared with best-practice management alone was performed in patients with Pleural Infection requiring chest-tube drainage. The primary outcome was percentage change in computed tomography Pleural fluid volume from day 0 to day 3. Secondary outcomes included surgical referral rate, hospital stay and adverse events. 35 patients were randomised. Patients receiving saline irrigation had a significantly greater reduction in Pleural collection volume on computed tomography compared to those receiving standard care (median (interquartile range) 32.3% (19.6–43.7%) reduction versus 15.3% (−5.5–28%) reduction) (p<0.04). Significantly fewer patients in the irrigation group were referred for surgery (OR 7.1, 95% CI 1.23–41.0; p=0.03). There was no difference in length of hospital stay, fall in C-reactive protein, white cell count or procalcitonin or adverse events between the treatment groups, and no serious complications were documented. Saline irrigation improves Pleural fluid drainage and reduces referrals for surgery in Pleural Infection. A large multicentre randomised controlled trial is now warranted to evaluate its effects further.

  • A randomised controlled trial of saline irrigation for Pleural Infection (The PIT trial)
    2015
    Co-Authors: Ce Hooper, Anthony Edey, Amelia O Clive, Anna J Morley, Adam Wallis, Paul D White, Arl Medford, John E Harvey, M Darby, N. Zahan Evans
    Abstract:

    Pleural Infection is increasing in incidence. Despite optimal medical management, up to 30% of patients will die or require surgery. Case reports suggest that irrigation of the Pleural space with saline may be beneficial. A randomised controlled pilot study in which saline Pleural irrigation (three times per day for 3 days) plus best-practice management was compared with best-practice management alone was performed in patients with Pleural Infection requiring chest-tube drainage. The primary outcome was percentage change in computed tomography Pleural fluid volume from day 0 to day 3. Secondary outcomes included surgical referral rate, hospital stay and adverse events. 35 patients were randomised. Patients receiving saline irrigation had a significantly greater reduction in Pleural collection volume on computed tomography compared to those receiving standard care (median (interquartile range) 32.3% (19.6–43.7%) reduction versus 15.3% (−5.5–28%) reduction) (p

  • Pleural irrigation trial pit a randomised controlled trial of Pleural irrigation with normal saline versus standard care in patients with Pleural Infection
    European Respiratory Journal, 2015
    Co-Authors: Anthony Edey, Amelia O Clive, Anna J Morley, Ce Hooper, Paul D White, Arl Medford, Anthony Wallis, John E Harvey
    Abstract:

    Pleural Infection is increasing in incidence. Despite optimal medical management, up to 30% of patients will die or require surgery. Case reports suggest that irrigation of the Pleural space with saline may be beneficial.A randomised controlled pilot study in which saline Pleural irrigation (three times per day for 3 days) plus best-practice management was compared with best-practice management alone was performed in patients with Pleural Infection requiring chest-tube drainage. The primary outcome was percentage change in computed tomography Pleural fluid volume from day 0 to day 3. Secondary outcomes included surgical referral rate, hospital stay and adverse events.35 patients were randomised. Patients receiving saline irrigation had a significantly greater reduction in Pleural collection volume on computed tomography compared to those receiving standard care (median (interquartile range) 32.3% (19.6-43.7%) reduction versus 15.3% (-5.5-28%) reduction) (p<0.04). Significantly fewer patients in the irrigation group were referred for surgery (OR 7.1, 95% CI 1.23-41.0; p=0.03). There was no difference in length of hospital stay, fall in C-reactive protein, white cell count or procalcitonin or adverse events between the treatment groups, and no serious complications were documented.Saline irrigation improves Pleural fluid drainage and reduces referrals for surgery in Pleural Infection. A large multicentre randomised controlled trial is now warranted to evaluate its effects further.

Ce Hooper - One of the best experts on this subject based on the ideXlab platform.

  • The role of serum procalcitonin in establishing the diagnosis and prognosis of Pleural Infection.
    Respiratory research, 2017
    Co-Authors: Giles Dixon, Oliver J Bintcliffe, Anna J Morley, Adriana Lama-lopez, Ce Hooper, Nick A Maskell
    Abstract:

    Background Bacterial Pleural Infection requires prompt identification to enable appropriate investigation and treatment. In contrast to commonly used biomarkers such as C-reactive protein (CRP) and white cell count (WCC), which can be raised due to non-infective inflammatory processes, procalcitonin (PCT) has been proposed as a specific biomarker of bacterial Infection. The utility of PCT in this role is yet to be validated in a large prospective trial. This study aimed to identify whether serum PCT is superior to CRP and WCC in establishing the diagnosis of bacterial Pleural Infection.

  • a randomised controlled trial of saline irrigation for Pleural Infection the pit trial
    2015
    Co-Authors: Ce Hooper, Anthony Edey, Amelia O Clive, Anna J Morley, Adam Wallis, Paul D White, Arl Medford, John E Harvey, M Darby, Zahan N Evans
    Abstract:

    Pleural Infection is increasing in incidence. Despite optimal medical management, up to 30% of patients will die or require surgery. Case reports suggest that irrigation of the Pleural space with saline may be beneficial. A randomised controlled pilot study in which saline Pleural irrigation (three times per day for 3 days) plus best-practice management was compared with best-practice management alone was performed in patients with Pleural Infection requiring chest-tube drainage. The primary outcome was percentage change in computed tomography Pleural fluid volume from day 0 to day 3. Secondary outcomes included surgical referral rate, hospital stay and adverse events. 35 patients were randomised. Patients receiving saline irrigation had a significantly greater reduction in Pleural collection volume on computed tomography compared to those receiving standard care (median (interquartile range) 32.3% (19.6–43.7%) reduction versus 15.3% (−5.5–28%) reduction) (p<0.04). Significantly fewer patients in the irrigation group were referred for surgery (OR 7.1, 95% CI 1.23–41.0; p=0.03). There was no difference in length of hospital stay, fall in C-reactive protein, white cell count or procalcitonin or adverse events between the treatment groups, and no serious complications were documented. Saline irrigation improves Pleural fluid drainage and reduces referrals for surgery in Pleural Infection. A large multicentre randomised controlled trial is now warranted to evaluate its effects further.

  • A randomised controlled trial of saline irrigation for Pleural Infection (The PIT trial)
    2015
    Co-Authors: Ce Hooper, Anthony Edey, Amelia O Clive, Anna J Morley, Adam Wallis, Paul D White, Arl Medford, John E Harvey, M Darby, N. Zahan Evans
    Abstract:

    Pleural Infection is increasing in incidence. Despite optimal medical management, up to 30% of patients will die or require surgery. Case reports suggest that irrigation of the Pleural space with saline may be beneficial. A randomised controlled pilot study in which saline Pleural irrigation (three times per day for 3 days) plus best-practice management was compared with best-practice management alone was performed in patients with Pleural Infection requiring chest-tube drainage. The primary outcome was percentage change in computed tomography Pleural fluid volume from day 0 to day 3. Secondary outcomes included surgical referral rate, hospital stay and adverse events. 35 patients were randomised. Patients receiving saline irrigation had a significantly greater reduction in Pleural collection volume on computed tomography compared to those receiving standard care (median (interquartile range) 32.3% (19.6–43.7%) reduction versus 15.3% (−5.5–28%) reduction) (p

  • Pleural irrigation trial pit a randomised controlled trial of Pleural irrigation with normal saline versus standard care in patients with Pleural Infection
    European Respiratory Journal, 2015
    Co-Authors: Anthony Edey, Amelia O Clive, Anna J Morley, Ce Hooper, Paul D White, Arl Medford, Anthony Wallis, John E Harvey
    Abstract:

    Pleural Infection is increasing in incidence. Despite optimal medical management, up to 30% of patients will die or require surgery. Case reports suggest that irrigation of the Pleural space with saline may be beneficial.A randomised controlled pilot study in which saline Pleural irrigation (three times per day for 3 days) plus best-practice management was compared with best-practice management alone was performed in patients with Pleural Infection requiring chest-tube drainage. The primary outcome was percentage change in computed tomography Pleural fluid volume from day 0 to day 3. Secondary outcomes included surgical referral rate, hospital stay and adverse events.35 patients were randomised. Patients receiving saline irrigation had a significantly greater reduction in Pleural collection volume on computed tomography compared to those receiving standard care (median (interquartile range) 32.3% (19.6-43.7%) reduction versus 15.3% (-5.5-28%) reduction) (p<0.04). Significantly fewer patients in the irrigation group were referred for surgery (OR 7.1, 95% CI 1.23-41.0; p=0.03). There was no difference in length of hospital stay, fall in C-reactive protein, white cell count or procalcitonin or adverse events between the treatment groups, and no serious complications were documented.Saline irrigation improves Pleural fluid drainage and reduces referrals for surgery in Pleural Infection. A large multicentre randomised controlled trial is now warranted to evaluate its effects further.

  • Pleural irrigation trial (PIT): a randomised controlled trial of Pleural irrigation with normal saline versus standard care in patients with Pleural Infection
    The European respiratory journal, 2015
    Co-Authors: Ce Hooper, Anthony Edey, Amelia O Clive, Anna J Morley, Paul D White, Arl Medford, John E Harvey, M Darby, Anthony Wallis, Natalie Zahan-evans
    Abstract:

    Pleural Infection is increasing in incidence. Despite optimal medical management, up to 30% of patients will die or require surgery. Case reports suggest that irrigation of the Pleural space with saline may be beneficial.A randomised controlled pilot study in which saline Pleural irrigation (three times per day for 3 days) plus best-practice management was compared with best-practice management alone was performed in patients with Pleural Infection requiring chest-tube drainage. The primary outcome was percentage change in computed tomography Pleural fluid volume from day 0 to day 3. Secondary outcomes included surgical referral rate, hospital stay and adverse events.35 patients were randomised. Patients receiving saline irrigation had a significantly greater reduction in Pleural collection volume on computed tomography compared to those receiving standard care (median (interquartile range) 32.3% (19.6-43.7%) reduction versus 15.3% (-5.5-28%) reduction) (p