Respiratory Services

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    The diagnosis and management of systemic autoimmune rheumatic disease-related interstitial lung disease: British Society for Rheumatology guideline scope.
    (Oxford Academic, 2024-04-18) Fahim, Ahmed
    Interstitial lung disease (ILD) is a significant complication of many systemic autoimmune rheumatic diseases (SARDs), although the clinical presentation, severity and outlook may vary widely between individuals. Despite the prevalence, there are no specific guidelines addressing the issue of screening, diagnosis and management of ILD across this diverse group. Guidelines from the ACR and EULAR are expected, but there is a need for UK-specific guidelines that consider the framework of the UK National Health Service, local licensing and funding strategies. This article outlines the intended scope for the British Society for Rheumatology guideline on the diagnosis and management of SARD-ILD developed by the guideline working group. It specifically identifies the SARDs for consideration, alongside the overarching principles for which systematic review will be conducted. Expert consensus will be produced based on the most up-to-date available evidence for inclusion within the final guideline. Key issues to be addressed include recommendations for screening of ILD, identifying the methodology and frequency of monitoring and pharmacological and non-pharmacological management. The guideline will be developed according to methods and processes outlined in Creating Clinical Guidelines: British Society for Rheumatology Protocol version 5.1.
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    "Will anybody listen?" parents' views on childhood asthma care: a qualitative study.
    (Royal College of General Practitioners., 2024-05-28) Warren, Kate
    Background: Asthma is the most common chronic disease in children, resulting in considerable morbidity and health care utilisation, especially in geographical areas with high deprivation. Parents play a pivotal role in children's asthma management. Aim: To explore the views of parents whose children have asthma, regarding barriers and facilitators to receiving adequate asthma care. Design & setting: A qualitative study conducted in an urban, multi-ethnic setting with high socioeconomic deprivation and paediatric asthma related hospital admissions. Method: The study used a pragmatic approach underpinned by a perspective of critical realism. Parents of children with asthma were recruited through purposive and convenience sampling and data collected through semi-structured interviews. Transcripts were analysed using thematic analysis, facilitated by NVivo software. Results: 10 parents participated in nine interviews. Six themes were identified relating to: (1) the establishment of a new life dynamic following a diagnosis of asthma; (2) the turbulent and drawn-out process of asthma diagnosis; (3) the roles and expectations of the partnership established between parents and healthcare services; (4) the importance of schools in asthma management; (5) sources and access to relevant information; and (6) the importance of social support networks. Parents frequently felt unsupported and misunderstood, particularly during the diagnostic process. Conclusion: Unmet parental educational and emotional needs, particularly around the time of diagnosis were identified as a key barrier to adequate asthma management. Deeper understanding of gaps in support can instruct asthma care delivery and inform co-produced interventions, thus improving asthma outcomes in children.
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    Extended pleurectomy decortication and chemotherapy versus chemotherapy alone for pleural mesothelioma (MARS 2): a phase 3 randomised controlled trial.
    (Elsevier, 2024-05-10) Koh, Pek
    Background: Extended pleurectomy decortication for complete macroscopic resection for pleural mesothelioma has never been evaluated in a randomised trial. The aim of this study was to compare outcomes after extended pleurectomy decortication plus chemotherapy versus chemotherapy alone. Methods: MARS 2 was a phase 3, national, multicentre, open-label, parallel two-group, pragmatic, superiority randomised controlled trial conducted in the UK. The trial took place across 26 hospitals (21 recruiting only, one surgical only, and four recruiting and surgical). Following two cycles of chemotherapy, eligible participants with pleural mesothelioma were randomly assigned (1:1) to surgery and chemotherapy or chemotherapy alone using a secure web-based system. Individuals aged 16 years or older with resectable pleural mesothelioma and adequate organ and lung function were eligible for inclusion. Participants in the chemotherapy only group received two to four further cycles of chemotherapy, and participants in the surgery and chemotherapy group received pleurectomy decortication or extended pleurectomy decortication, followed by two to four further cycles of chemotherapy. It was not possible to mask allocation because the intervention was a major surgical procedure. The primary outcome was overall survival, defined as time from randomisation to death from any cause. Analyses were done on the intention-to-treat population for all outcomes, unless specified. This study is registered with ClinicalTrials.gov, NCT02040272, and is closed to new participants. Findings: Between June 19, 2015, and Jan 21, 2021, of 1030 assessed for eligibility, 335 participants were randomly assigned (169 to surgery and chemotherapy, and 166 to chemotherapy alone). 291 (87%) participants were men and 44 (13%) women, and 288 (86%) were diagnosed with epithelioid mesothelioma. At a median follow-up of 22·4 months (IQR 11·3-30·8), median survival was shorter in the surgery and chemotherapy group (19·3 months [IQR 10·0-33·7]) than in the chemotherapy alone group (24·8 months [IQR 12·6-37·4]), and the difference in restricted mean survival time at 2 years was -1·9 months (95% CI -3·4 to -0·3, p=0·019). There were 318 serious adverse events (grade ≥3) in the surgery group and 169 in the chemotherapy group (incidence rate ratio 3·6 [95% CI 2·3 to 5·5], p<0·0001), with increased incidence of cardiac (30 vs 12; 3·01 [1·13 to 8·02]) and respiratory (84 vs 34; 2·62 [1·58 to 4·33]) disorders, infection (124 vs 53; 2·13 [1·36 to 3·33]), and additional surgical or medical procedures (15 vs eight; 2·41 [1·04 to 5·57]) in the surgery group. Interpretation: Extended pleurectomy decortication was associated with worse survival to 2 years, and more serious adverse events for individuals with resectable pleural mesothelioma, compared with chemotherapy alone.
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    Austrian syndrome: report of one case and a systematic review of case reports - new insights.
    (Elsevier, 2024-04-20) Cotton, James; Madu, Alpha
    Objective: The objective of this review was to gain new insight into the rare condition, Austrian syndrome: the triad of endocarditis, meningitis, and pneumonia caused by Streptococcus pneumoniae. Methods: A systematic review of case reports was conducted using the PRISMA guideline. Cases were rigorously screened to meet a set of well-defined inclusion criteria. Relevant data was aggregated and reported using descriptive statistics. Results: Seventy-one cases from 69 case reports were included in the final review. The mean age was 56.5 years with a male-to-female ratio of 2.4:1. Alcoholism was reported in 41% of patients. Altered mental state (69%) and fever (65%) (mean temperature on admission = 38.9°C) were the commonest presenting symptoms. The mean duration of symptoms before presentation to the hospital was 8 days. The aortic valve was most commonly affected (56%). The mean duration of antibiotic therapy was 5.6 weeks. Seventy percent of patients were admitted to the intensive care unit (ICU). Fifty-six percent of patients had valvular surgery. The average length of stay in the hospital was 36.9 days. Mortality was recorded in 28% of patients. Conclusion: Austrian syndrome is rare but deadly. The true incidence is unknown but is commoner in middle-aged men and in alcoholics. Affected patients are usually critically unwell, often requiring ICU admission and prolonged hospital stays. Treatment is aggressive including prolonged courses of antibiotics and often, surgery. Despite these, the case fatality rate is high, with death occurring in over a quarter of patients. Surgery appears to be associated with better prognosis.
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    Concurrent abdominal and mediastinal hydatid cystic disease: a rare case.
    (Springer Nature, 2024-03-06) Singh, Raminderjit
    Hydatid disease in humans is caused by accidental ingestion of Echinococcus in its larval form. It mostly affects the liver and lungs, but rarely the mediastinum and other areas as well. The diagnosis is mostly confirmed intraoperatively in cases of mediastinal disease. The mainstay of treatment in such cases is surgery. This is a case report of a rare finding of hydatid disease in mediastinum along with the abdomen and its surgical management. Introduction: Human hydatid disease is a zoonotic infection caused by accidental ingestion of the larval form of Echinococcus granulosus and is a common helminthic disease worldwide. After entering the blood circulation, they colonize various organ systems of the body. The most commonly affected areas are the liver and lungs, but the extrapulmonary location of hydatid disease in the thorax is very rare. Intrathoracic extrapulmonary locations involve the mediastinum, pleura, pericardium, and chest wall. Mediastinal hydatidosis is rare and has an incidence of 0.1-0.5%. Mediastinal hydatid cysts are difficult to distinguish from other mediastinal cystic lesions and diagnosis is only made during surgery. Concurrent abdominal and mediastinal hydatid cysts are a very rare entity. Various serological tests have been proposed to establish the diagnosis of the disease and their judicious use may confirm the diagnosis in 80-94% of hepatic hydatidosis and 65% of pulmonary hydatidosis. Ultrasonography, computed tomography (CT), and magnetic resonance imaging (MRI) help establish the diagnosis. Signs and symptoms of the cysts depend on their site and size. Large cysts can compress the vital organs and are responsible for pressure symptoms. Patients might present with retrosternal pain, cough, and shortness of breath in case of lung hydatidosis and abdominal pain, palpable mass, and abdominal distension in case of hepatic hydatidosis. Radical surgical excision is the gold standard of therapy and involves the removal of germinative membrane and pericyst. The role of albendazole is controversial [1]. We report a rare case of concurrent abdominal and mediastinal hydatid in a 60-year-old male.