Vineeth George

Introduction: Current pathways for malignant pleural effusion (MPE) are slow and associated with poor patient experience. Thoracocentesis is considered first-line. However, cytology is often inadequate to guide treatment. Aim: This study assesses the feasibility of randomisation to usual MPE care versus a novel, rapid approach. Method STREAMLINE is a feasibility, randomised controlled trial, using a shared protocol across the UK and Australia. It enrolled symptomatic patients with a performance status of ≤3 with suspected MPE. Participants were randomised 1:1 to either usual care, as per the British Thoracic Society guidelines, or a new “streamlined” pathway. This combines pleural biopsy and indwelling pleural catheter insertion as initial interventions. Key outcomes included: feasibility of randomisation, time to actionable histocytology, procedural burden and dyspnoea. Results: In the Australian trial 26 patients were eligible, with 24 (92%) randomised over 14 months to March 2025. 21/24 (88%) were retained to 12 weeks. 20/24 (83%) were diagnosed with MPE, with mesothelioma accounting for 9/24 (38%). Preliminary analysis revealed median time to actionable histocytology was significantly shorter in the intervention arm (8.5 days (IQR 5-11) vs 27 days (IQR 20-34), MannWhitney U test, p=0.047). Fisher’s exact test demonstrated that participants in the intervention arm were significantly less likely to need one or more additional procedures (5/11 in the intervention arm compared to 12/13 in the usual care arm, p=0.023). Breathlessness data is under analysis. Conclusion STREAMLINE Australia met predefined feasibility criteria, suggesting a definitive study is feasible. Additionally, the streamlined pathway showed significant reductions in time to actionable histocytology and procedure burden.

Background: Pleural procedures are key skills for Intensive Care Unit (ICU) doctors but can be associated with serious complications. We aimed to explore ICU junior doctors’ self-reported training, experience, and confidence in performing pleural procedures. Methods: The study was a prospective, multi-centre, convergent parallel, mixed-method design, consisting of a survey of 21 questions with concurrent semi-structured interviews. The study involved four ICUs (two metropolitan and two regional) in New South Wales, Australia, which provide public Intensive Care services to 1.2 million Australians. All Postgraduate Year (PGY) 3 and above doctors working in these units were invited to participate ( N = 70). Consultants were excluded. Results: Of 70 doctors invited to participate, 40/70 (57%) completed the survey. 26/40 (65%) of survey respondents were PGY 5 or above. Purposive sampling was used to identify 8 (20%) of the survey respondents across a range of seniorities. They then underwent semi-structured interviews. Of the respondents, 19/40 (47.5%) had received formal training in pleural interventions, and 14/40 (35%) had received formal training in thoracic ultrasound. In the 12 months prior, 19/40 (47.5%) of respondents had not performed a chest drain of any type. Of those who had, 3/40 (7.5%) had completed more than 5. Across their careers 13/40 (32.5%) had not performed a Seldinger chest drain and 15/40 (37.5%) had performed five or fewer. Half of respondents had not performed a blunt-dissection chest drain in their career. 15/40 (37.5%) of respondents felt that they were confident to independently insert a chest drain. Almost all (38/40, 95%) felt they would benefit from simulation-based training in this area. The interviews highlighted factors that increased or decreased opportunities for gaining experience in performing pleural procedures. These factors were categorised into subthemes: patient, operator, situational, and organisational. Conclusions: This study demonstrates low levels of self-reported procedure volume, and self-perceived confidence in ICU junior doctors. Qualitative findings highlight barriers and opportunities to enhance training.

Malignant pleural mesothelioma is an aggressive, incurable cancer that is usually caused by asbestos exposure several decades before symptoms arise. Despite widespread prohibition of asbestos production and supply, its incidence continues to increase. It is heterogeneous in its presentation and behaviour, and diagnosis can be notoriously difficult. Identification of actionable gene mutations has proven challenging and current treatment options are largely ineffective, with a median survival of 10–12 months.However, the past few years have witnessed major advances in our understanding of the biology and pathogenesis of mesothelioma. This has also revealed the limitations of existing diagnostic algorithms and identified new treatment targets.Recent clinical trials have re-examined the role of surgery, provided new options for the management of associated pleural effusions and heralded the addition of targeted therapies. The increasing complexity of mesothelioma management, along with a desperate need for further research, means that a multidisciplinary team framework is essential for the delivery of contemporary mesothelioma care.This review provides a synthesised overview of the current state of knowledge and an update on the latest research in the field.

Introduction: Current guidelines recommend an initial pleural aspiration in the investigation and management of suspected malignant pleural effusions (MPEs) with the aim of establishing a diagnosis, identifying non-expansile lung (NEL) and, at times, providing a therapeutic procedure. A wealth of research has been published since the guidelines suggesting that results and outcomes from an aspiration may not always provide sufficient information to guide management. It is important to establish the validity of these findings in a ‘real world’ population. Methods: A retrospective analysis was conducted of all patients who underwent pleural fluid (PF) sampling, in a single centre, over 3 years to determine the utility of the initial aspiration. Results: A diagnosis of MPE was confirmed in 230/998 (23%) cases, a further 95/998 (9.5%) were presumed to represent MPE. Transudative biochemistry was found in 3% of cases of confirmed MPE. Positive PF cytology was only sufficient to guide management in 45/140 (32%) cases. Evidence of pleural thickening on CT was associated with both negative cytology (χ² 1df=26.27, p2 1df=10.39, p=0.001). In NEL 44.4% of patients did not require further procedures after pleurodesis compared with 72.7% of those with expansile lung (χ² 1df=5.49, p=0.019). In patients who required a combined diagnostic and therapeutic aspiration 106/113 (93.8%) required further pleural procedures. Conclusions: An initial pleural aspiration does not achieve either definitive diagnosis or therapy in the majority of patients. A new pathway prioritising symptom management while reducing procedures should be considered.

Introduction: Indwelling pleural catheters (IPCs) have transformed the management of malignant pleural effusion. They are now increasingly used for transudates despite concern regarding high complication rates. This study explores the outcomes of these patients at our institution. Methods: All IPCs inserted at the Oxford Centre for Respiratory Medicine over the 5 years to 31 December 2019 were retrospectively reviewed. Those inserted for transudates were assessed to evaluate underlying patient characteristics, outcomes and complication rates. Results: Of the 229 IPCs inserted, 14 (6%) were in 12 patients with transudates. 6 (50%) of these individuals had hepatic hydrothorax and 6 (50%) had cardiac failure. They underwent a median of 3 (IQR 2 - 4.8) thoracocenteses prior to IPC insertion. IPCs remained in-situ for a median of 2.2 months (IQR 1.3 – 4.4). Median survival was 3.4 months (IQR 2.1 – 8.3) post-insertion and patients spent a median of 20.5 days (IQR 13.3-28) in hospital during this period. 10 (71%) of the drains encountered complications. Pleural infection developed in 4 (29%), 3 (21%) required re-stitching or repositioning, 2 (14%) were removed due to blockage, and 1 (7%) for severe pain. E.coli was isolated in the pleural fluid of 4 (66%) patients with hepatic hydrothorax. However, only one case had biochemical evidence of pleural infection. Conclusions: Although this population has limited treatment options, the complication rates are high and patients still spend a significant amount of time in hospital. Significant caution is required when considering the use of IPCs in this setting. Prospective studies are required to further inform the risks of IPC insertion in this cohort.