Maged Hassan

Respiratory training in Egypt

In Egypt, respiratory medicine (more commonly termed “chest diseases”) is regarded as a separate speciality rather than a subspecialty of internal medicine. All graduates of Egyptian Medical Schools have to complete a year of internship at teaching hospitals rotating between different medical and surgical departments. Following internship and obtaining licence to practice, doctors are required to work for 6–12u2005months at primary healthcare facilities around the country. At the end of this period, a doctor can start their specialty training; the choice of which depends on the cumulative score they achieved at medical school.

Lung abscess or empyema? Taking a closer look

Maged Hassan (MH): I would like to present three cases of patients who presented with symptoms of lower respiratory tract infection, fever and cough productive of small amount of sputum. The three patients had complained of symptoms for at least 2u2009weeks before presentation. The chest X-rays showed large encysted collections (figure 1A) which required chest CT to delineate the source of the abnormality. The CT studies (case 1: figure 1B,xa0C; case 2: figure 2A and case 3: figure 2C) caused prolonged discussion between the treating clinicians with opinions divided on the nature of the lesion in each case being either an encysted empyema or a large peripheral lung abscess. Clinically, the differentiation between empyema and lung abscess was important because empyema is treated with tube drainage which is only resorted to in limited situations in lung abscess with the attendant risk of creating a bronchopleural fistula or extending the infection to the pleura.nnnnFigure 1 nCase 1. (A) Chest X-ray shows right side cavity with air-fluid level. (B) Chest CT with contrast, axial cut, shows right side spherical lesion with air-fluid level causing lung collapse at the hilum (hollow arrow). Note pleural enhancement and extrapleural fat hypertrophy (arrowheads)

Bilious pleuritis following transpulmonary radiofrequency ablation of liver metastases

A 55-year-old man with pancreatic cancer metastatic to the liver underwent percutaneous radiofrequency ablation (RFA) of the liver deposits. The liver harboured four metastatic foci, the largest of which was located at the posterior part of the right lobe just below the diaphragm (figure 1A). Due to the difficult anatomic location, transpulmonary approach was chosen for RFA and CT guidance was needed rather than ultrasound.nnnnFigure 1 n(A) The main metastatic deposit at the posterior portion of the right liver lobe. (B,C) Bile-stained pleural fluid drained.nnnnUnder CT guidance an Accu 2i probe (Acculis Microwave Tissue Ablation System, AngioDynamics, Latham, New York, USA) was advanced into the four liver metastases. Ablation was performed at 140W at multiple sites for a total of 50u2009min. Small subcapsular haematoma …

The Hospital and Patient Burden of Indwelling Pleural Catheters: A Retrospective Case Series of 210 Indwelling Pleural Catheter Insertions

Background: Indwelling pleural catheters (IPC) offer an alternative to talc pleurodesis in recurrent effusion, especially in patients wishing to avoid hospitalization. Two randomized trials have demonstrated reduced time in hospital using IPCs versus talc pleurodesis in malignant pleural effusion (MPE). However, the impact of IPCs on hospital services and patients has not been well studied. Objectives: To analyze long-term outcomes of IPCs and understand the hospital burden in terms of requirement for hospital visits and contacts with healthcare, while the IPC was in situ. Methods: IPC insertions in a tertiary pleural center were analyzed retrospectively. Reviews of patients with IPCs in situ considered “additional” to routine clinical follow-up were defined pre-hoc. Results: A total of 202 cases were analyzed: 89.6% MPE group (n = 181) and 10.4% non-MPE group (n = 21). There were a median 3.0 (interquartile range [IQR] 3) and 2.0 (IQR 2) ipsilateral pleural procedures prior to each IPC insertion in non-MPE and MPE groups, respectively (p = 0.26), and a mean 1.3 (SD 1.7) planned IPC-related outpatient follow-up visits per patient. There were 2 (9.5%) and 14 (7.7%) IPC-related infections in non-MPE and MPE groups, respectively. Four (19.0%) and 44 (24.3%) patients required additional IPC-related reviews in non-MPE and MPE groups, respectively (p = 0.6), and these occurred within 250 days post IPC insertion. Conclusions: Although IPCs decrease initial length of hospital stay compared to talc pleurodesis via chest drain, IPCs are associated with significant hospital-visit burden, in addition to planned visits and regular home IPC drainages. IPC-using services need to be prepared for this additional work to run an IPC service effectively.

Chest Drain Fall-Out Rate According to Suturing Practices: A Retrospective Direct Comparison

Background: Chest drains often become displaced and require replacement, adding unnecessary risks to patients. Simple measures such as suturing of the drain may reduce fall-out rates; however, there is no direct data to demonstrate this and no standardized recommended practice that is evidence based. Objectives: The study aimed to analyze the rate of chest drain fall out according to suturing practice. Methods: Retrospective analysis of all chest drain insertions (radiology and pleural teams) in 2015–2016. Details of chest drain fall out were collected from patient electronic records. Drain “fall out” was pre-hoc defined as the drain tip becoming dislodged outside the pleural cavity unintentionally before a clinical decision was taken to remove the drain. Results: A total of 369 chest drains were inserted: sutured (n = 106, 28.7%; 44 male [41.5%], median age 74 [interquartile range (IQR) 21] years), and unsutured (n = 263, 71.3%; 139 male [52.9%], median age 68 [IQR 21] years). Of the sutured drains, 7 (6.6%) fell out after a mean of 3.3 days (SD 2.6) compared to 39 (14.8%; p = 0.04) unsutured drains falling out after a mean of 2.7 days (SD 2.0; p = 0.8). Conclusions: Within the limits of this retrospective analysis, these results suggest that suturing of drains is associated with lower fall-out rates.

The role of pleurodesis in respiratory diseases

ABSTRACT Introduction: Pleurodesis is used to obliterate the pleural space, most commonly in patients with symptomatic malignant pleural effusions but also in patients with benign effusions or pneumothorax. Areas covered: Traditionally, chemical pleurodesis has been undertaken at thoracoscopy or using instillation of a slurry through a chest drain. The optimum method of achieving pleurodesis, whether surgical or medical, has yet to be proven. Evidence in the different disease areas will be reviewed, along with ongoing trial evidence, which may change practice. Expert commentary: Newer methods of achieving pleurodesis are being introduced. Studies have shown that instilling sclerosing agents via an indwelling pleural catheter or introducing drug-eluting catheters are safe and effective ways of inducing pleurodesis. There is evidence that pleurodesis might increase in survival, especially after pleural infection, possibly due to activation of the immune system. Multiple studies are currently underway to answer some of these questions and the future landscape may be very different from the present.

Recent developments in the management of pleural infection: A comprehensive review

Pleural infection is a condition commonly encountered by the respiratory physician. This review aims to provide the reader with an update on the most recent data regarding the epidemiology, microbiology, and the management of pleural infection.

Thoracic Ultrasound as an Early Predictor of Pleurodesis Success in Malignant Pleural Effusion

BACKGROUND: Malignant pleural effusion (MPE) is common and imposes a significant burden on patients and health‐care providers. Most patients require definitive treatment, usually drainage and chemical pleurodesis, to relieve symptoms and prevent fluid recurrence. Thoracic ultrasound (TUS) can identify the presence of pleural adhesions in other clinical scenarios, and could therefore have a role in predicting long‐term pleurodesis success or failure in MPE. METHODS: Patients undergoing chest tube drainage and talc slurry pleurodesis for symptomatic MPE were recruited to a prospective observational cohort pilot study assessing whether TUS findings pre‐talc and post‐talc instillation predicted treatment outcome. Participants underwent TUS examination immediately before, and 24 h after talc slurry administration to derive pleural adherence scores for the affected hemithorax. The recorded TUS scans were additionally scored by two independent assessors blinded to the patients clinical status. The primary outcome was pleurodesis success at 1‐month and 3‐month follow‐up. RESULTS: Eighteen participants were recruited to the pilot study. Participants who suffered pleurodesis failure had a lower pleural adherence score at 24 h post‐talc instillation than those who were successful (difference of 6.27; 95% CI, 3.94‐8.59). TUS examination was acceptable to patients, while TUS scoring was highly consistent across all assessors (intraclass correlation coefficient, 0.762; 95% CI, 0.605‐0.872). CONCLUSION: A TUS‐derived pleural adherence score may facilitate early prediction of long‐term outcomes following chemical pleurodesis, with implications for personalized care and decision making in MPE. Further research is needed to evaluate this novel finding. TRIAL REGISTRY: ClinicalTrials.gov; No. NCT02625675; URL: www.clinicaltrials.gov.

P233 Thoracic ultrasonography as a predictor of pleurodesis success in malignant pleural effusion

Background Over 50u2009000 patients with malignant pleural effusion (MPE) are seen annually in the UK. The majority develop recurrent symptomatic disease requiring definitive treatment. MPE is most frequently managed with talc slurry pleurodesis via intercostal chest drain. This involves a lengthy inpatient stay and has a success rate of around 70%, with no means of predicting which patients will suffer pleurodesis failure. Thoracic ultrasound (TUS) is widely used by respiratory physicians, and data from animal and human studies suggest it can identify pleural adhesions (through the absence of normal lung sliding) in a range of conditions. By extension, TUS may allow clinicians to diagnose the presence or absence of adhesions post-pleurodesis in MPE, identifying patients suitable for discharge or needing further intervention. Abstract P233 Table 1 Ultrasonographic pleurodesis score at day 0 (pre-pleurodesis) and day 1 (24 hours post-pleurodesis) in patients being treated for malignant pleural effusion Successful pleurodesis n=11/15 (73.3%) patients Failed pleurodesis n=4/15 (26.7%) patients p value unpaired t-test Day 0 pleurodesis score (mean±SD, total out of 18) 10.89±3.98 6.50±1.29 0.054 Difference=4.39 (95% CI −0.09 to 8.86) Day 1 pleurodesis score (mean±SD, total out of 18) 13.45±2.63 6.75±2.94 0.002 Difference=6.70 (95% CI 3.08 to 10.33) Change from day 0 to 1 (mean±SD) 2.57±3.98 0.25±3.59 0.326 Difference=2.32 (95% CI −2.59 to 7.23) Method We recruited 18 adult patients with MPE undergoing drainage and talc slurry pleurodesis to a prospective single-centre cohort study. Patients underwent standardised TUS assessment pre- and post-pleurodesis, evaluating pleural sliding and adhesions at nine points (three anterior, three lateral, three posterior) across the affected hemithorax. Lung sliding was graded as per Zhu et al.,1 creating a total pleurodesis score out of 18. Pleurodesis failure was defined as radiological and symptomatic fluid recurrence in the same hemithorax requiring further intervention at any point up to 3 months post-pleurodesis. Patients also completed a questionnaire addressing satisfaction with TUS assessment. Results 3/18 patients (16.7%) died before 1u2009month follow-up. Of 15 patients seen at one month, 11 (73.3%) had successful pleurodesis and 4 (26.7%) had failed. No patient had delayed pleurodesis failure between 1 and 3u2009month follow-up. There was a significant difference observed in the day 1 TUS pleurodesis score between patients who went on to have successful pleurodesis and those who failed during follow-up (table 1). TUS assessment was acceptable to patients, with none considering it either time-consuming or unwilling to have it again if needed. Conclusion Our data suggest TUS assessment 24u2009hours post-pleurodesis for MPE predicts success or failure of this intervention, with significant implications for clinical care. A larger randomised study is now underway to further evaluate this hypothesis. Reference Chest2005;128(2):934–9.

P237 Pleural abnormalities predating the development of mesothelioma

Background Mesothelioma is an aggressive tumour of the pleura that is closely related to asbestos exposure. Asbestos is known to cause benign pleural thickening, effusion and plaques and the majority of patients with these abnormalities do not develop mesothelioma. It has been noted, however, that asbestos-exposed patients who have pleural plaques are at increased risk of mesothelioma.[1] This study aimed to describe the range of pleural abnormalities seen on CT done at some time before the diagnosis of mesothelioma was made. Methods Electronic radiological records of all patients who were diagnosed with mesothelioma in the trust from 2009 till June 2017 were screened for any chest CT (or abdomen CT with at least half of the thorax imaged) obtained at least 6 months prior to the CT that triggered the diagnosis of mesothelioma. CTs were examined for the presence of pleural plaques, thickening, nodules and/or effusion. CT studies were divided into 3 time periods: within one year (A), 1–3 years before (B), and more than 3 years before (C) the diagnostic CT. Results 170 patients were screened. 39 patients had one or more pre-diagnosis CTs. A total of 53 CTs were available for comparison. Effusion was the most common abnormality seen in 23/53 CTs followed by thickening seen in 17/53, then plaques 15/53 and pleural nodules in 5/53. Four nodules (2 in period A and 2 in period B) progressed to tumour later on. Effusion was seen in 50% of studies from periods A and B. Pleural thickening and plaques were noticeable in around 40% of CTs from periods A and B. 13 studies did not show any pleural abnormality (3 studies in period A, 4 in period B and 6 in period C). Conclusion Mesothelioma is a rapidly progressive disease that can be difficult to track in radiological studies done before clinical presentation. Pleural effusion, followed by smooth thickening and plaques, are fairly common abnormalities in pre-diagnosis CTs. Reference Pairon J-C, Laurent F, Rinaldo M, et al. Pleural plaques and the risk of pleural mesothelioma. J Natl Cancer Inst 2013;105:293–301. doi:10.1093/jnci/djs513