Day case thoracoscopy in a UK district general hospital

Background: Day case local anaesthetic thoracoscopy (LAT) with indwelling pleural catheter (IPC) insertion is currently being advocated to mininize length of stay in the Covid pandemic. As part of this innovation, continuous service reviews are warranted. All local procedures are performed in theatre. Rapid pleurodesis with talc is not performed due to staffing problems. All patients receive erector spinae catheters to control post-op pain. Method(s): All patients undergoing day case LAT between Dec 2019-Jan2022 were analysed. Basic demographics and outcomes were collected for a descriptive analysis of data. Result(s): 32 patients underwent day case LAT. All had negative pre-op Covid-19 swabs: mean age 72.4 years (range 34-83);22M/10M. Diagnoses were 9 lung cancers, 11 mesotheliomas and 9 fibrinous pleuritis (1 of those went for VATS and proved mesothelioma). The lung did not deflate, not enabling biopsies in 3 (Non-malignant diagnoses). 28 IPCs and 2 large bore drains were inserted due to surgical emphysema. 1 patient developed an empyema and 1 had cellulitis within 30 days. 28 IPCs have already been removed due to pleurodesis (median 54 range 21-197). All were discharged the same day except the 2 requiring a large bore drains. Mean length of stay is 0 days. Diagnostic sensitivity of LAT is 96.5%. Pain scores at day 0,1,2 of surgery were consistently low. No patient caught Covid in the 30 days post surgery. Conclusion(s): Day case LAT is feasible with our current set up and should be widely adopted. The health economics of preventing admission are considerable.

PLEUROPARENCHYMAL FIBROELASTOSIS UNCOVERED IN A PATIENT WITH COVID-19 PRESENTING WITH PNEUMOTHORAX

SESSION TITLE: Diagnosis of Lung Disease through Pathology Case Posters SESSION TYPE: Case Report Posters PRESENTED ON: 10/19/2022 12:45 pm - 01:45 pm INTRODUCTION: This report describes the case of a patient presenting with pneumothorax and Severe Acute Respiratory Syndrome (SARS) Coronavirus-2 (SARS-cov-2) infection leading to Coronavirus Disease 2019 (COVID-19) pneumonia, with worsening presentation, later found to have underlying Pleuroparenchymal Fibroelastosis (PPFE). CASE PRESENTATION: A 68 year old male with a past medical history of hypertension and type 2 diabetes presented to his primary care clinic with shortness of breath. He underwent a Chest X-Ray as an outpatient which revealed a moderate right-sided pneumothorax (PTX), and he was sent to the Emergency Department by his primary care provider. He was found to be COVID positive on initial workup, also requiring supplemental oxygen. Other routine laboratory tests did not reveal any significant abnormalities. His shortness of breath worsened and on repeat X-rays his pneumothorax increased in size therefore a chest tube was placed by Cardiothoracic Surgery. Computerized Tomography of the chest revealed moderate right pneumothorax, bilateral diffuse ground glass opacities and pulmonary micronodules [Figure 1]. The patient had mild initial improvement and the chest tube was removed but he had recurrence of the PTX and he underwent urgent Video Assisted Thoracoscopic Surgery (VATS), with right upper lobe wedge resection and talc pleurodesis. A biopsy of the resected lung revealed a benign lung with fibroelastotic scarring, diffusely involving subpleural tissue and prominently extending into and entrapping areas of underlying alveolated tissue, with no inflammation, granulomas or pneumonia noted. Workup for tuberculosis, autoimmune disorders, HIV was negative. He eventually was discharged home with close pulmonology and cardiothoracic surgery follow ups, planned for disease surveillance and malignancy workup. DISCUSSION: PPFE is a rare entity, and classified amongst rare causes of idiopathic interstitial pneumonias (IIP) [1]. It is characterized by upper lobe fibrosis, supleural and parenchymal scarring. It can occur at any age, and the usual presentation is of pneumothorax in a thin male, with a shortened anteroposterior diameter of the chest. Radiographic findings typically include subpleural nodular or reticular opacities in the upper lobes, usually sparing the middle and lower lobes. Pathology reveals increased elastic tissue and dense collagen fibers, along with subpleural fibrosis [2]. Pulmonary function testing reveals a restrictive pattern with reduced diffusion capacity and it is usually resistant to steroids [3]. CONCLUSIONS: PPFE is an uncommon cause of insidious, slowly progressive fibrotic lung disease often limited to the upper lobes. It should be suspected in any person presenting with recurrent pneumothorax or blebs without other known inciting causes. Lung biopsy helps establish the diagnosis. Patients with this condition need close pulmonology follow up to assess progression. Reference #1: Travis WD, Costabel U, Hansell DM, King TE Jr, Lynch DA, Nicholson AG, Ryerson CJ, Ryu JH, Selman M, Wells AU, Behr J, Bouros D, Brown KK, Colby TV, Collard HR, Cordeiro CR, Cottin V, Crestani B, Drent M, Dudden RF, Egan J, Flaherty K, Hogaboam C, Inoue Y, Johkoh T, Kim DS, Kitaichi M, Loyd J, Martinez FJ, Myers J, Protzko S, Raghu G, Richeldi L, Sverzellati N, Swigris J, Valeyre D;ATS/ERS Committee on Idiopathic Interstitial Pneumonias. An official American Thoracic Society/European Respiratory Society statement: Update of the international multidisciplinary classification of the idiopathic interstitial pneumonias. Am J Respir Crit Care Med. 2013 Sep 15;188(6):733-48. doi: 10.1164/rccm.201308-1483ST. PMID: 24032382;PMCID: PMC5803655. Reference #2: Frankel SK, Cool CD, Lynch DA, Brown KK. Idiopathic pleuroparenchymal fibroelastosis: description of a novel clinicopathologic entity. Chest. 2004 Dec;126(6):2007-13. doi: 10.1378/chest.126.6.2007. PMID: 1559 706. Reference #3: Watanabe K. Pleuroparenchymal Fibroelastosis: Its Clinical Characteristics. Curr Respir Med Rev. 2013 Jun;9(4):299-237. doi: 10.2174/1573398X0904140129125307. PMID: 24578677;PMCID: PMC3933942. DISCLOSURES: No relevant relationships by FNU Amisha No relevant relationships by Perminder Gulani No relevant relationships by Hyomin Lim No relevant relationships by paras malik No relevant relationships by Divya Reddy

Gestión turística ¿asignatura pendiente?

Se habla mucho de la gestión turístico mas se ejerce poco. Se utiliza el modelo TALC (Butler 1980) como gran angular para explorar algunos de los temas problemáticos enfrentados por la mayoría de los destinos turísticos en la actualidad (pre-COVID). Se centra en algunos aspectos básicos del modelo TALC como son la capacidad de carga y otras fuerzas endógenas o externas desencadenantes de cambios determinantes en los destinos turísticos. Se argumenta asimismo que exista cierta reticencia por parte de muchos stakeholders, sobre todo los elementos políticos a la hora de gestionar para la sostenibilidad, hecho que aboca a muchos destinos al sobreturismo y a la pérdida de calidad de vida. Hace falta visibilizar el papel político como cuarta pata de la sostenibilidad, ya que sin voluntad política, todo esfuerzo hacia la sostenibilidad termine fracasando. Hace falta asimismo redefinir la escala y la calidad del turismo ofrecido además de medir el éxito de un destino según parámetros muy distintos a los cuantitativos (números de turistas y cantidad bruta del gasto turístico) que se han utilizado en la época pre-pandémica: es decir, gestionar hacia la sostenibilidad y la seguridad, claves del éxito en el futuro post-COVID.Alternate : The paper argues that despite the widespread use of the term management in the context of tourism destinations, there is little actual management of tourism or tourists in most destinations. The paper uses the Tourism Area Life Cycle (TALC) model (Butler 1980) as a lens through which to view some current issues and problems facing tourism destinations. It explores some of the basic elements of the TALC model including carrying capacity and triggers or forces bringing about change in destinations and argues that the reluctance of many stakeholders to adopt sustainable principles is reflected in current problems such as overtourism. Recognition of the often ignored political element in the sustainable triumvirate of economic, environmental and social components is important because without political support for appropriate initiatives has meant that efforts to move towards more sustainable destinations have often proved fruitless. The paper concludes that despite calls for new ways of defining success for tourism destinations and for drastically changing the nature and scale of tourism in the post-pandemic future, it is likely that tourism will resume, at least for the short to medium term, in a form very similar to what existed before the advent of COVID 19.

Managing Tourism – A Missing Element?: Gestión turística ¿asignatura pendiente?

The paper argues that despite the widespread use of the term management in the context of tourism destinations, there is little actual management of tourism or tourists in most destinations. The paper uses the Tourism Area Life Cycle (TALC) model (Butler 1980) as a lens through which to view some current issues and problems facing tourism destinations. It explores some of the basic elements of the TALC model including carrying capacity and triggers or forces bringing about change in destinations and argues that the reluctance of many stakeholders to adopt sustainable principles is reflected in current problems such as overtourism. Recognition of the often ignored political element in the sustainable triumvirate of economic, environmental and social components is important because without political support for appropriate initiatives has meant that efforts to move towards more sustainable destinations have often proved fruitless. The paper concludes that despite calls for new ways of defining success for tourism destinations and for drastically changing the nature and scale of tourism in the post-pandemic future, it is likely that tourism will resume, at least for the short to medium term, in a form very similar to what existed before the advent of COVID 19.Alternate : Se habla mucho de la gestión turístico más se ejerce poco. Se utiliza el modelo TALC (Butler 1980) como gran angular para explorar algunos de los temas problemáticos enfrentados por la mayoría de los destinos turísticos en la actualidad (pre-COVID). Se centra en algunos aspectos básicos del modelo TALC como son la capacidad de carga y otras fuerzas endógenas o externas desencadenantes de cambios determinantes en los destinos turísticos. Se argumenta asimismo que exista cierta reticencia por parte de muchos stakeholders, sobre todo los elementos políticos a la hora de gestionar para la sostenibilidad, hecho que aboca a muchos destinos al sobreturismo y a la pérdida de calidad de vida. Hace falta visibilizar el papel político como cuarta pata de la sostenibilidad, ya que, sin voluntad política, todo esfuerzo hacia la sostenibilidad termine fracasando. Hace falta asimismo redefinir la escala y la calidad del turismo ofrecido además de medir el éxito de un destino según parámetros muy distintos a los cuantitativos (números de turistas y cantidad bruta del gasto turístico) que se han utilizado en la época pre-pandémica: es decir, gestionar hacia la sostenibilidad y la seguridad, claves del éxito en el futuro post-COVID.Alternate : A gestão do turismo é muito falada mas pouco exercida. O modelo TALC (Butler 1980) é utilizado como um ângulo amplo para explorar algumas das questões problemáticas enfrentadas pela maioria dos destinos turísticos actuais (pré-COVID). Centra-se em alguns aspectos básicos do modelo TALC, tais como a capacidade de carga e outras forças endógenas ou externas que desencadeiam mudanças determinísticas nos destinos turísticos. Argumenta-se também que existe uma certa relutância por parte de muitos intervenientes, especialmente os elementos políticos, em gerir pela sustentabilidade, um facto que leva muitos destinos ao sobre-turismo e à perda de qualidade de vida. O papel político tem de se tornar visível como a quarta vertente da sustentabilidade, pois sem vontade política, qualquer esforço no sentido da sustentabilidade falhará. É também necessário redefinir a escala e a qualidade da oferta turística e medir o sucesso de um destino de acordo com parâmetros muito diferentes dos quantitativos (número de turistas e despesas turísticas brutas) utilizados na era pré-pandémica: por outras palavras, para gerir no sentido da sustentabilidade e da segurança, as chaves do sucesso no futuro pós-COVID.

Dasatinib Related Pleural Effusions: Real-World Experience in a District General Hospital

Dasatinib, a second-generation BCRABL1 tyrosine kinase inhibitor (TKI), is an approved treatment for chronic myeloid leukaemia, both as first-line therapy and following imatinib intolerance or resistance. It is generally well tolerated, however, dasatinib has been associated with a higher risk for pleural effusions. Frequency, risk factors and outcomes of this significant side effect were analysed in the phase 3 DASISION and 034/Dose-optimization trials. Annual risk of 5%-15% was reported. Drug-related pleural effusion occurred in 28%-33% of patients in a minimum of 5-year follow-up period. One major risk factor was advanced age. We therefore reviewed a cohort of 34 patients treated with dasatinib between 2016 and 2021, to determine 'real-world' data of this toxicity. Case notes, pathology results and radiological reports were analysed. We identified 12 (35%) cases of pleural effusions. Eight (66%) cases were male. The median average age of patients with and without drug-related pleural effusion were 59.5 years (range: 31-91 years) and 54.5 years (range: 20-88 years) respectively. Cardiovascular and respiratory comorbidities were noted in eight patients (66.6%) with pleural effusion (ischaemic heart disease, hypertension, lung cancer, COVID, peripheral vascular disease and hyperlipidaemia) and nine patients (41%) without pleural effusion (prior non-TKI pleural effusion, hypertension, asthma, congenital heart defect, COPD and atrial fibrillation). Nine cases (75%) of those with pleural effusion were non-smokers. Lymphocytosis was not noted in any of those 12 cases of drug-related pleural effusion. Ten cases (83%) were on dasatinib 100 mg daily when pleural effusion was diagnosed, one was on 50 mg daily and the other was on 20 mg daily. Pleural effusion occurred after a median of 36 months (range: 6-108 months). Nine cases (75%) were mild to moderate in severity-Common Terminology Criteria for Adverse Events (CTCAE ) grade 1-2, two were grade 3 and one was grade 4. Two required no intervention, three required only medical intervention (steroid+/-antibiotics), three required pleural tap and three required pleural drain. One required VATS procedure with talc pleurodesis. The patient with grade 1 pleural effusion required no treatment change. One required dose reduction of dasatinib without interruption. One required temporary interruption but restarted on the same dose. Six required temporary interruption of dasatinib followed by dose reduction to 50 mg daily. Two of these subsequently recurred on lower dose dasatinib and were then switched to an alternative TKI (bosutinib and imatinib). Two required temporary TKI interruption and were restarted on a different TKI (nilotinib). One case of pleural effusion persisted and the patient was kept off TKI treatment. Although the numbers are too small for statistically robust analysis, we have observed several trends which may help to guide patient counselling and selection. Pleural effusion has an incidence of 35% in our local population. Risk factors were cardiovascular and respiratory comorbidities, advanced age and male sex. Smoking status and lymphocytosis did not appear to be risk factors in our cohort, where they have been in other reports. Most effusions were mild to moderate in severity and could usually be managed by steroid+/-pleural tap+/-drain. Most patients required temporary interruption of their dasatinib but were successfully able to restart at a lower dose without recurrence..

Bronchoscopic management of bronchopleural fistula due to COVID-19 a nonsurgical option

Background: COVID-19 has become a dreadful pandemic. One of the important complication is the development of pneumothorax/ pneumomediastinum which gets further complicated by bronchopleural fistula. Case Study: A 44year male patient with severe COVID pneumonia developed Left sided pneumothorax and treated conservatively with ICD and negative suctioning for 2 months and referred to us with persistent pneumothorax with BPF. As patient was unfit for surgery, bronchoscopic management was planned. With flexible bronchoscope, 6F Fogarty balloon was passed and inflated, leak site was identified in left upper lobe upper division. A Watanabe spigot size 5 was deposited at the opening of upper division and manipulated to apical segment. Other small openings were sealed with cyanoacrylate glue and autologous blood patch. After procedure negative suction was reapplied. Repeat Xray showed resolution of pneumothorax. Pleurodesis was done with talc slurry, post pleurodesis showed no pneumothorax and ICD was removed. Patient was discharged, follow up X ray after 4weeks showed no evidence of pneumothorax. Discussion: In most cases of BPF, leak seals after tube thoracostomy, only 3-5% will continue to have persistent leak. For medically inoperable cases, bronchoscopic balloon occlusion of site and subsequent injection with fibrin glue, liquid bioadhesive or blood patch can be done. For large leak;Amplatzer device, stents, spigots, coils are used. Conclusion: Bronchoscopic treatment can work well for a medically inoperable, complicated pneumothorax in COVID-19 disease.

The new outpatient model indwelling pleural catheter(IPC) insertion pathway success in NBH

Introduction/Aim: NBH is a new hospital with a public/private partnership without an established pleural disease management pathway for malignant effusion. A new outpatient model of management of IPC was established in January 2021 and we aim to assess the success of the new outpatient model indwelling pleural catheter(IPC) insertion pathway. Methods: The NBH outpatient pleural service started in Jan 2021. Initial IPC's insertions were carried on the ward with overnight hospital stay to educate the nursing staff and establish the outpatient pathways. Alternatively, for outpatients, insertions were performed in the procedure room and discharged following two-hour of clinical monitoring and a Chest X-Ray. Drainage bottles were funded either by the private health funds or arrangement with the hospital for public patients. The drainage in the community was carried out by Northern Sydney North Home Nursing Service with follow up the day after the procedure. All patients had threetimes a week drainage to start with followed by review at four weeks at the pleural clinic and decided on need for talc pleurodesis. If auto-pleurodesis was achieved the IPC was removed. Results: Between January - September 2021, 14 IPC inserted in our service ( Service was suspended for 3 months during COVID lock down period ). Nine patients had autopleurodeses by 4 weeks and IPC removed. Two died whilst the IPC is in-situ. Two had ongoing effusion past 4 weeks and it was changed to symptomatic drainage. Two patients had talc insertion via the IPC. Two had IPC after surgical (VATS) pleurodesis. None of the patients returned to the hospital following insertion of IPC for a pleural effusion related issue. No infections were reported. One accidental dislodgement of the IPC reported. Ward nursing staff had an education session 30mins after the first 3 insertions and refresher anytime an insertion is performed in the ward. Procedure room nurses were educated by the advance trainee. Over 80% patients were privately insured. Conclusion: The new outpatient model of IPC insertion in a new hospital with a public/private model was successful with auto-pleurodesis rate at high level and infection rates were low. The model was successful as majority of patients were privately insured and the hospital had to bear a minimal cost. The Northern Sydney North Home Nursing Service was vital to the success of the programme.

Surface Response Analysis for the Optimization of Mechanical and Thermal Properties of Polypropylene Composite Drawn Fibers with Talc and Carbon Nanotubes.

A large portion of the produced Polypropylene (PP) is used in the form of fibers. In this industrially oriented study, the development of composite PP drawn fibers was investigated. Two types of fillers were used (ultra-fine talc and single-wall carbon nanotubes). Optimization of the thermal and mechanical properties of the produced composite drawn fibers was performed, based on the Box-Behnken design of experiments method (surface response analysis). The effect of additives, other than the filler, but typical in industrial applications, such as an antioxidant and a common compatibilizer, was investigated. The drawing ratio, the filler, and the compatibilizer or the antioxidant content were selected as design variables, whereas the tensile strength and the onset decomposition temperature were set as response variables. Fibers with very high tensile strength (up to 806 MPa) were obtained. The results revealed that the maximization of both the tensile strength and the thermal stability was not feasible for composites with talc due to multiple interactions among the used additives (antioxidant, compatibilizer, and filler). Additionally, it was found that the addition of talc in the studied particle size improved the mechanical strength of fibers only if low drawing ratios were used. On the other hand, the optimization targeting maximization of both tensile strength and thermal stability was feasible in the case of SWCNT composite fibers. It was found that the addition of carbon nanotubes improved the tensile strength; however, such improvement was rather small compared with the tremendous increase of tensile strength due to drawing.