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Dive into the research topics where Rj Hallifax is active.

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Featured researches published by Rj Hallifax.


JAMA | 2015

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

Najib M. Rahman; Justin Pepperell; Sunita Rehal; Tarek Saba; A Tang; N Ali; Alex West; G Hettiarachchi; D Mukherjee; J Samuel; A Bentley; Lee J. Dowson; J Miles; Cf Ryan; Ky Yoneda; Anoop Chauhan; John P. Corcoran; Ioannis Psallidas; John Wrightson; Rj Hallifax; Helen E. Davies; Ycg Lee; M Dobson; Emma L. Hedley; D Seaton; N Russell; M Chapman; Bm McFadyen; Ra Shaw; R J O Davies

IMPORTANCE For treatment of malignant pleural effusion, nonsteroidal anti-inflammatory drugs (NSAIDs) are avoided because they may reduce pleurodesis efficacy. Smaller chest tubes may be less painful than larger tubes, but efficacy in pleurodesis has not been proven. OBJECTIVE To assess the effect of chest tube size and analgesia (NSAIDs vs opiates) on pain and clinical efficacy related to pleurodesis in patients with malignant pleural effusion. DESIGN, SETTING, AND PARTICIPANTS A 2×2 factorial phase 3 randomized clinical trial among 320 patients requiring pleurodesis in 16 UK hospitals from 2007 to 2013. INTERVENTIONS Patients undergoing thoracoscopy (n = 206; clinical decision if biopsy was required) received a 24F chest tube and were randomized to receive opiates (n = 103) vs NSAIDs (n = 103), and those not undergoing thoracoscopy (n = 114) were randomized to 1 of 4 groups (24F chest tube and opioids [n = 28]; 24F chest tube and NSAIDs [n = 29]; 12F chest tube and opioids [n = 29]; or 12F chest tube and NSAIDs [n = 28]). MAIN OUTCOMES AND MEASURES Pain while chest tube was in place (0- to 100-mm visual analog scale [VAS] 4 times/d; superiority comparison) and pleurodesis efficacy at 3 months (failure defined as need for further pleural intervention; noninferiority comparison; margin, 15%). RESULTS Pain scores in the opiate group (n = 150) vs the NSAID group (n = 144) were not significantly different (mean VAS score, 23.8 mm vs 22.1 mm; adjusted difference, -1.5 mm; 95% CI, -5.0 to 2.0 mm; P = .40), but the NSAID group required more rescue analgesia (26.3% vs 38.1%; rate ratio, 2.1; 95% CI, 1.3-3.4; P = .003). Pleurodesis failure occurred in 30 patients (20%) in the opiate group and 33 (23%) in the NSAID group, meeting criteria for noninferiority (difference, -3%; 1-sided 95% CI, -10% to ∞; P = .004 for noninferiority). Pain scores were lower among patients in the 12F chest tube group (n = 54) vs the 24F group (n = 56) (mean VAS score, 22.0 mm vs 26.8 mm; adjusted difference, -6.0 mm; 95% CI, -11.7 to -0.2 mm; P = .04) and 12F chest tubes vs 24F chest tubes were associated with higher pleurodesis failure (30% vs 24%), failing to meet noninferiority criteria (difference, -6%; 1-sided 95% CI, -20% to ∞; P = .14 for noninferiority). Complications during chest tube insertion occurred more commonly with 12F tubes (14% vs 24%; odds ratio, 1.91; P = .20). CONCLUSIONS AND RELEVANCE Use of NSAIDs vs opiates resulted in no significant difference in pain scores but was associated with more rescue medication. NSAID use resulted in noninferior rates of pleurodesis efficacy at 3 months. Placement of 12F chest tubes vs 24F chest tubes was associated with a statistically significant but clinically modest reduction in pain but failed to meet noninferiority criteria for pleurodesis efficacy. TRIAL REGISTRATION isrctn.org Identifier: ISRCTN33288337.


Thorax | 2012

Role of CT in assessing pleural malignancy prior to thoracoscopy

Rj Hallifax; Mohammed Haris; John P. Corcoran; S Leyakathalikhan; E Brown; D Srikantharaja; Ari Manuel; Fergus V. Gleeson; Mohammed Munavvar; Najib M. Rahman

The definitive diagnosis of pleural malignancy depends upon histological confirmation by pleural biopsy. CT is reported to have a high sensitivity and specificity for the diagnosis of malignant pleural disease, and is part of the routine diagnostic workup of these patients. The aim of this study was to assess the sensitivity and specificity of CT in detecting pleural malignancy prior to definitive histology obtained via thoracoscopy in a large cohort of patients with suspected malignant pleural disease. Retrospective review of thoracoscopies between January 2008 and January 2013 at two UK tertiary referral centres: Oxford and Preston. The histological results were compared with the CT reported diagnosis before the procedure. CT scan reports were assessed by independent respiratory physicians as to whether the radiologist concluded evidence of malignant pleural disease or benign features only. 211 (57%) of 370 patients included in the analysis had malignant disease: CT scans were reported as ‘malignant’ in 144, giving a sensitivity of 68% (95% CI 62% to 75%). Of the 159 patients with benign disease, 124 had CT scans reported as benign: specificity 78% (72% to 84%). The positive predictive value of a malignant CT report was 80% (75% to 86%), with a negative predictive value of 65% (58% to 72%). A significant proportion of patients being investigated for malignant disease will have malignancy despite a negative CT report. The use of CT alone in determining which patients should have invasive pleural biopsies should be re-evaluated, and further studies to define the diagnostic pathway are now required.


PLOS ONE | 2015

Defining the minimal important difference for the visual analogue scale assessing dyspnea in patients with malignant pleural effusions.

John P. Corcoran; Rj Hallifax; John Stradling; Nick A Maskell; Najib M. Rahman

Background The minimal important difference (MID) is essential for interpreting the results of randomised controlled trials (RCTs). Despite a number of RCTs in patients with malignant pleural effusions (MPEs) which use the visual analogue scale for dyspnea (VASD) as an outcome measure, the MID has not been established. Methods Patients with suspected MPE undergoing a pleural procedure recorded their baseline VASD and their post-procedure VASD (24 hours after the pleural drainage), and in parallel assessed their breathlessness on a 7 point Likert scale. Findings The mean decrease in VASD in patients with a MPE reporting a ‘small but just worthwhile decrease’ in their dyspnea (i.e. equivalent to the MID) was 19mm (95% CI 14-24mm). The mean drainage volume required to produce a change in VASD of 19mm was 760ml. Interpretation The mean MID for the VASD in patients with a MPE undergoing a pleural procedure is 19mm (95% CI 14-24mm). Thus choosing an improvement of 19mm in the VASD would be justifiable in the design and analysis of future MPE studies.


Current Opinion in Infectious Diseases | 2013

New therapeutic approaches to pleural infection.

John P. Corcoran; Rj Hallifax; Najib M. Rahman

Purpose of review Pleural infection is a common and serious clinical problem that because of its high morbidity and mortality imposes a significant burden on clinicians, healthcare resources and patients of all ages. Defining the optimal management strategy for pleural infection remains a cause for research and debate. This review considers the areas of interest including bacteriology and antibiotic selection, intrapleural fibrinolytics and the role of surgery. Recent findings Pleural infection is increasing in the adult and paediatric populations without clear explanation and with clinical and financial consequences. The bacteriology of pleural infection is recognized as being unique from parenchymal lung infection with implications for its treatment. Although established in paediatric management, intrapleural fibrinolytics remain of uncertain benefit in adults, though the novel combination of tissue plasminogen activator and deoxyribonuclease used in the MIST2 study offers cause for optimism. Surgery remains a key intervention in pleural infection, but its precise role is unclear with no robust evidence to show when and in whom it should be optimally utilized. Summary The high mortality in adults from pleural infection despite advances in clinical knowledge, diagnostics and therapeutics highlights the need for ongoing research. Future studies are required to focus on improving the clinical outcomes, with the identification of those patients at greatest risk of poor outcomes at presentation and most likely to benefit from more radical treatment a priority to allow the delivery of individualized care.


Thorax | 2015

Ultrasound-guided pneumothorax induction prior to local anaesthetic thoracoscopy

John P. Corcoran; Ioannis Psallidas; Rj Hallifax; A Talwar; Annemarie Sykes; Najib M. Rahman

Local anaesthetic thoracoscopy (LAT) is performed by a growing number of respiratory physicians in the context of an expanding population with pleural disease. Most LATs occur in patients with moderate to large effusions where the presence of fluid allows safe access to the pleural space. Patients with little or no fluid, but other features concerning for pleural disease, are usually investigated by surgical means. Advanced LAT practitioners can also provide this service through pneumothorax induction, although there is little published data on the safety or efficacy of this technique. We present data from a series of 77 consecutive patients in whom ultrasound-guided pneumothorax induction and LAT were attempted. 67 procedures (87.0%) were successful, with the most common histopathological diagnoses being chronic pleuritis (58.2%) and mesothelioma (16.4%). No adverse events were reported secondary to the procedure. These findings demonstrate the utility of this approach and should inform future practice and guidelines.


American Journal of Respiratory and Critical Care Medicine | 2017

Randomised Controlled Trial of Urokinase versus Placebo for Non-draining Malignant Pleural Effusion.

Mishra Ek Bm BCh Ma Mrcp; Clive Ao; Wills Gh; Davies He Md Mrcp; Stanton Ae; Al-Aloul M; Hart-Thomas A; Pepperell J; Evison M; Saba T; Harrison Rn; Guhan A; Callister Me; Sathyamurthy R; Rehal S; John P. Corcoran; Rj Hallifax; Ioannis Psallidas; Russell N; Shaw R; Dobson M; Wrightson Jm; West A; Lee Ycg; Andrew Nunn; Miller Rf; Nick A Maskell; Najib M. Rahman

Rationale: Patients with malignant pleural effusion experience breathlessness, which is treated by drainage and pleurodesis. Incomplete drainage results in residual dyspnea and pleurodesis failure. Intrapleural fibrinolytics lyse septations within pleural fluid, improving drainage. Objectives: To assess the effects of intrapleural urokinase on dyspnea and pleurodesis success in patients with nondraining malignant effusion. Methods: We conducted a prospective, double‐blind, randomized trial. Patients with nondraining effusion were randomly allocated in a 1:1 ratio to intrapleural urokinase (100,000 IU, three doses, 12‐hourly) or matched placebo. Measurements and Main Results: Co‐primary outcome measures were dyspnea (average daily 100‐mm visual analog scale scores over 28 d) and time to pleurodesis failure to 12 months. Secondary outcomes were survival, hospital length of stay, and radiographic change. A total of 71 subjects were randomized (36 received urokinase, 35 placebo) from 12 U.K. centers. The baseline characteristics were similar between the groups. There was no difference in mean dyspnea between groups (mean difference, 3.8 mm; 95% confidence interval [CI], ‐12 to 4.4 mm; P = 0.36). Pleurodesis failure rates were similar (urokinase, 13 of 35 [37%]; placebo, 11 of 34 [32%]; adjusted hazard ratio, 1.2; P = 0.65). Urokinase was associated with decreased effusion size visualized by chest radiography (adjusted relative improvement, ‐19%; 95% CI, ‐28 to ‐11%; P < 0.001), reduced hospital stay (1.6 d; 95% CI, 1.0 to 2.6; P = 0.049), and improved survival (69 vs. 48 d; P = 0.026). Conclusions: Use of intrapleural urokinase does not reduce dyspnea or improve pleurodesis success compared with placebo and cannot be recommended as an adjunct to pleurodesis. Other palliative treatments should be used. Improvements in hospital stay, radiographic appearance, and survival associated with urokinase require further evaluation. Clinical trial registered with ISRCTN (12852177) and EudraCT (2008‐000586‐26).


Respirology | 2016

Diagnostic value of radiological imaging pre‐ and post‐drainage of pleural effusions

John P. Corcoran; Louise Acton; Asia Ahmed; Rj Hallifax; Ioannis Psallidas; John Wrightson; Najib M. Rahman; Fergus V. Gleeson

Patients with an unexplained pleural effusion often require urgent investigation. Clinical practice varies due to uncertainty as to whether an effusion should be drained completely before diagnostic imaging. We performed a retrospective study of patients undergoing medical thoracoscopy for an unexplained effusion. In 110 patients with paired (pre‐ and post‐drainage) chest X‐rays and 32 patients with paired computed tomography scans, post‐drainage imaging did not provide additional information that would have influenced the clinical decision‐making process.


Thorax | 2015

A 63-year-old man with a recurrent right-sided pleural effusion

John P. Corcoran; Emma L. Culver; Ioannis Psallidas; Rj Hallifax; Susan J Davies; Adrian C Bateman; Eleanor Barnes; Najib M. Rahman

JPC : A 63-year-old Caucasian man was seen in clinic having been referred by his general practitioner with a 10 -week history of progressive exertional dyspnoea, associated with dry cough and retrosternal discomfort over the preceding fortnight. There was no history of fever, weight loss, anorexia, haemoptysis, dysphagia or other localising systemic symptoms. His past medical history included psoriatic arthropathy, atrial fibrillation, hypertension and gastro-oesophageal reflux; of note, there was no recent history of palpitations or worsening peripheral oedema, while his joint disease remained quiescent. Current medications (all long-standing) included methotrexate, omeprazole, bisoprolol, aspirin, ramipril and simvastatin. He was a lifelong non-smoker and retired solicitor with no occupational risk factors for lung disease. On examination he was afebrile with no palpable lymphadenopathy or clubbing. Cardiovascular examination demonstrated rate-controlled atrial fibrillation only; abdominal examination was normal. Respiratory examination revealed dull percussion note and reduced breath sounds at the right lung base, with normal resting oxygen saturations. Chest radiograph and thoracic ultrasound confirmed the presence of a large right-sided pleural effusion. Routine bloods including full blood count, clotting studies, renal function, liver function and serum calcium were unremarkable. I performed a diagnostic and therapeutic pleural aspiration, draining 1500 mL of straw-coloured fluid with no complications. Laboratory analysis showed the effusion to be an exudate (protein 46 g/L, lactate dehydrogenase (LDH) 961 IU/L, glucose 0.4 mmol/L); pleural fluid culture and cytology (including flow cytometry) were negative. NMR : The presence of a cytology-negative exudative pleural effusion of unknown aetiology in a previously well individual requires urgent further investigation. The low pleural fluid glucose and high LDH may imply infection, although these findings are non-specific and can also be seen in the context of chronic inflammation or malignancy; furthermore, the clinical history and negative culture go against an infective cause. The presence of an inflammatory arthropathy may prompt consideration …


Postgraduate Medical Journal | 2015

Intercostal chest drain insertion by general physicians: attitudes, experience and implications for training, service and patient safety

John P. Corcoran; Rj Hallifax; A Talwar; Ioannis Psallidas; Annemarie Sykes; Najib M. Rahman

Background Intercostal chest drain (ICD) insertion is considered a core skill for the general physician. Recent guidelines have highlighted the risks of this procedure, while UK medical trainees have reported a concurrent decline in training opportunities and confidence in their procedural skills. Objectives We explored clinicians’ attitudes, experience and knowledge relating to pleural interventions and ICD insertion in order to determine what changes might be needed to maintain patient safety and quality of training. Methods Consultants and trainees delivering general medical services across five hospitals in England were invited to complete a questionnaire survey over a 5-week period in July and August 2014. Results 117 general physicians (32.4% of potential participants; comprising 31 consultants, 48 higher specialty trainees, 38 core trainees) responded. Respondents of all grades regarded ICD insertion as a core procedural skill. Respondents were asked to set a minimum requirement for achieving and maintaining independence at ICD insertion; however, only 25% of higher specialty trainees reported being able to attain this self-imposed standard. A knowledge gap was also revealed, with trainees managing clinical scenarios correctly in only 51% of cases. Conclusions Given the disparity between clinical reality and what is expected of the physician-in-training, it is unclear whether ICD insertion can remain a core procedural skill for general physicians. Consideration should be given to how healthcare providers and training programmes might address issues relating to clinical experience and knowledge given the implications for patient safety and service provision.


Journal of Thoracic Disease | 2015

Pleural procedural complications: prevention and management

John P. Corcoran; Ioannis Psallidas; John Wrightson; Rj Hallifax; Najib M. Rahman

Pleural disease is common with a rising case frequency. Many of these patients will be symptomatic and require diagnostic and/or therapeutic procedures. Patients with pleural disease present to a number of different medical specialties, and an equally broad range of clinicians are therefore required to have practical knowledge of these procedures. There is often underestimation of the morbidity and mortality associated with pleural interventions, even those regarded as being relatively straightforward, with potentially significant implications for processes relating to patient safety and informed consent. The advent of thoracic ultrasound (TUS) has had a major influence on patient safety and the number of physicians with the necessary skill set to perform pleural procedures. As the variety and complexity of pleural interventions increases, there is increasing recognition that early specialist input can reduce the risk of complications and number of procedures a patient requires. This review looks at the means by which complications of pleural procedures arise, along with how they can be managed or ideally prevented.

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A Talwar

University of Oxford

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