Indwelling pleural catheters: an overview and real-life experience.

BACKGROUND: Indwelling pleural catheters (IPCs) are most frequently used in those with malignant pleural effusions, although their use is expanding to patients with non-malignant diseases. AIM: To provide an overview of IPCs and highlight how, when and why they can be used including our own real-life experience. DESIGN: Data were collected retrospectively from a large tertiary centre for all individuals who received an IPC between June 2010 and February 2018 inclusive. The data collected included gender, age, origin of malignancy, number of drains prior to IPC, whether they had received pleurodesis prior to IPC, presence of a trapped lung, date of insertion, documented complications, overall outcome and date of death. RESULTS: A total of 68 patients received an IPC, the majority were female (n = 38, 57%) with an overall median age of 68 years (range 40-90 years). The most common site of cancer origin was lung (n = 33, 49%) followed by pleura (n = 10, 15%) and breast (n = 9, 13%). The median survival of all patients was 141 days (IQR 26-181). Sixteen percent (n = 11) of patients underwent a spontaneous pleurodesis resulting in their IPC being removed. Only three individuals had a complication (4.4%). CONCLUSIONS: IPC insertion is a safe procedure and represents an exciting and expanding field in the management of pleural disease. Further longitudinal studies are required to fully delineate their place in the management of both malignant and benign effusions.

The management of chronic cough.

Chronic cough is a common presentation to primary care and constitutes a significant volume of referrals to secondary care. It affects around 10% of the adult population and has a plethora of respiratory and non-respiratory causes. It can have a significant impact on the quality of life of affected individuals. In many patients, minimal baseline investigations lead to an easily identifiable and treatable cause. In others, no cause can be identified even after extensive investigations in specialized cough clinics. This evidence-based review article outlines the approach to the adult patient presenting with chronic cough and focuses upon current management strategies in those with chronic idiopathic cough. It includes results from trials of speech and language therapies, and the emerging concept of chronic idiopathic cough as a neuropathic disorder with its own bespoke approach to management including the use of neuromodulatory agents.

Paper versus electronic feedback in high stakes assessment.

Tablet computers have emerged as increasingly useful tools in medical education, particularly for assessment. However, it is not fully established whether tablet computers influence the quality and/or quantity of feedback provided in high stakes assessments. It is also unclear how electronically-recorded feedback relates to student performance. Our primary aim was to determine whether differences existed in feedback depending on the tool used to record it. METHODS: We compared quantitative and qualitative feedback between paper-scoring sheets versus iPads™ across two consecutive years of a final year MBChB (UK medical degree) Objective Structured Clinical Examination. Quality of comments (using a validated five-point rating scale), number of examiner comments and number of words were compared across both methods of recording assessment performance using chi-squared analysis and independent t-test. We also explored relationships between student performance (checklist and global scoring) and feedback. RESULTS: Data from 190 students (2850 paper scored interactions) in 2015 and 193 (2895 iPad™ scored interactions) in 2016 were analysed. Overall, a greater number of comments were given with iPad™ compared to written (42% versus 20%; p < 0.001) but the quality of feedback did not differ significantly. For both written and electronic feedback, students with low global scores were more likely to receive comments (p < 0.001). CONCLUSION: The use of iPads™ in high stakes assessment increases the quantity of feedback compared to traditional paper scoring sheets. The quantity and quality of feedback for poorer performing candidates (by global score) were also better with iPad™ feedback.

The Scottish Academic Foundation Year Programme: what, why and how?

The Foundation Programme is well established in the UK and serves as the generic training scheme into which newly qualified doctors enter after gaining a medical degree. Although individual programmes have many differences, the range of competencies needing to be fulfilled to progress is uniform across Scotland and the rest of the UK. Some final year medical undergraduates may apply for the Academic Foundation Programme; this is designed to facilitate exposure to academic medicine over and above the clinical experience offered to Foundation Year doctors. This paper describes characteristics of the Academic Foundation Programme in general, with a particular focus on Scotland, which is one Foundation School.

Tablet computers in assessing performance in a high stakes exam: opinion matters.

Background Tablet computers have emerged as a tool to capture, process and store data in examinations, yet evidence relating to their acceptability and usefulness in assessment is limited. Methods We performed an observational study to explore opinions and attitudes relating to tablet computer use in recording performance in a final year objective structured clinical examination at a single UK medical school. Examiners completed a short questionnaire encompassing background, forced-choice and open questions. Forced choice questions were analysed using descriptive statistics and open questions by framework analysis. Results Ninety-two (97% response rate) examiners completed the questionnaire of whom 85% had previous use of tablet computers. Ninety per cent felt checklist mark allocation was 'very/quite easy', while approximately half considered recording 'free-type' comments was 'easy/very easy'. Greater overall efficiency of marking and resource savings were considered the main advantages of tablet computers, while concerns relating to technological failure and ability to record free type comments were raised. Discussion In a context where examiners were familiar with tablet computers, they were preferred to paper checklists, although concerns were raised. This study adds to the limited literature underpinning the use of electronic devices as acceptable tools in objective structured clinical examinations.

Inhaled treatment for chronic obstructive pulmonary disease: what's new and how does it fit?

Since chronic obstructive pulmonary disease (COPD) is characterized by progressive airflow obstruction, inhaled bronchodilators form the mainstay of treatment. A variety of new inhaled drugs and inhaler devices have recently been licensed and approved for prescribing to patients with COPD; many such drugs have been formulated in devices to deliver two different drugs at the same time. The evidence based review article highlights all of the drugs now licensed, describes some of the evidence surrounding their use and highlights practical steps in helping decide when these drugs should be considered in the context of guidelines.

Survival from malignant mesothelioma: where are we now?

BACKGROUND: The prognosis of malignant pleural mesothelioma has traditionally been poor. Whether this remains the case compared to historical data and within a specific geographical location is uncertain. Knowledge of predictive factors for survival with malignant pleural mesothelioma is also inadequate. METHODS: We conducted a retrospective local database analysis to determine overall prognosis of patients with malignant pleural mesothelioma and evaluate the influence of demographic characteristics, histological subtype and laboratory parameters. Patients with histological diagnoses of malignant pleural mesothelioma held on the NHS Grampian pathology database between 2002 and 2012 were analysed. Data on baseline demographics, mode of diagnosis, histological sub-type, and survival and serum laboratory parameters, were analysed; time to death was examined using Cox regression analyses. RESULTS: A total of 114 patients with malignant pleural mesothelioma were included in the analysis. The median survival was 345 days (IQR 99-600). Sarcomatoid malignant pleural mesothelioma carried a significantly worse prognosis with median survival of 125 days (IQR 44-289) vs 334 days (IQR 126-715) for biphasic, 412 days (IQR 201-656) for epithelioid and 345 days (IQR 99-600) for those with no definitive typing. Individuals who did not receive chemotherapy experienced a significantly worse prognosis (hazard ratio 2.7; 95%CI 1.5-4.7; p = 0.001), while a low albumin and raised urea at time of diagnosis were also associated with a significantly poorer prognosis. CONCLUSION: The survival of patients with malignant pleural mesothelioma remains poor and typically around 1 year. The presence of raised urea and low albumin is associated with a poorer prognosis, while patients with a good performance status and few co-morbidities should be encouraged to receive chemotherapy.

Predicting survival following non-invasive ventilation for hypercapnic exacerbations of chronic obstructive pulmonary disease.

INTRODUCTION: Non-invasive ventilation (NIV) has revolutionised the management of hypercapnic exacerbations of chronic obstructive pulmonary disease (COPD). We wished to evaluate factors related to its overall success in the 'real-life' setting. METHODS: A retrospective analysis of patients receiving NIV for a hypercapnic exacerbation of COPD was performed. Demographics, laboratory data, blood gases and outcomes (hospital discharge or in-patient death) were extracted and subsequently analysed to identify factors relating to its overall success or failure. RESULTS: Over 6 years, 240 patients (mean age 70 years), received NIV with mean pH and pCO(2) prior to NIV 7.24 and 10.4kPa respectively; of these, 167 survived to hospital discharge with a median age (70 vs. 74; p = 0.02) lower than non-survivors. Absolute values of pH and pCO(2) (higher and lower respectively) prior to NIV and at 1 h were both associated with successful hospital discharge. An improvement (p = 0.02) in pH within an hour of receiving NIV - but not pCO(2) - was associated with surviving to hospital discharge. Of all laboratory data assessed, only baseline urea was significantly (p = 0.021) associated with a successful outcome. CONCLUSION: Younger patients with a lower urea, higher pH and lower pCO(2) at baseline and who demonstrate an improvement in pH within 1 h, are more likely to have a successful outcome when given NIV for a hypercapnic exacerbation of COPD on an unselected basis. Prospective studies evaluating many other parameters are now required to help identify patients in whom NIV is likely to be successful.

Endobronchial ultrasound-transbronchial needle aspiration and its practical application.

Endobronchial ultrasound-transbronchial needle aspiration (EBUS-TBNA) has emerged over the past decade as one of the most exciting and innovative developments in the field of respiratory medicine. This procedure allows sampling of mediastinal lymph nodes and masses in both malignant and benign disease and overcomes some of the disadvantages associated with mediastinoscopy and blind transbronchial needle aspiration. We describe the clinical use, indications for and limitations of EBUS-TBNA along with several illustrated clinical examples.

Ward-based non-invasive ventilation for hypercapnic exacerbations of COPD: a 'real-life' perspective.

BACKGROUND: Non-invasive ventilation (NIV) has revolutionized the management of hypercapnic exacerbations of chronic obstructive pulmonary disease (COPD). However, most published data have evaluated highly selected patients within the context of randomized controlled trials. OBJECTIVE: We wished to evaluate the outcomes of ward-based NIV in 'real-life' patients admitted to hospital with a hypercapnic exacerbation of COPD. METHODS: Retrospective data (gender, age, baseline pH, PaCO(2) and values after 1 and 4 h of NIV, and outcomes) were evaluated for all patients receiving NIV in the respiratory unit of Aberdeen Royal Infirmary from January 2006 to December 2009. Data were analysed in three groups: as a whole, in those with baseline pH >or=7.25 and baseline pH <7.25. RESULTS: Data were available for all 392 patients commenced on ward-based NIV [45% male, mean age (range) 71 years (42-89)] with mean baseline pH of 7.24 and PaCO(2) of 10.1 kPa; respective values improved significantly (P <0.0001) following 1 and 4 h of NIV and treatment was considered successful in 66%. In those with baseline pH <7.25 and >or=7.25, the success rates of NIV were 58 and 72%, respectively. CONCLUSION: In hypercapnic exacerbations of COPD, ward-based NIV is useful in the 'real-life' setting with physiological parameters improving after only a short treatment period, while two-thirds of all patients were discharged from hospital. Further data are required to help determine factors other than pH which influence the outcome of NIV.