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Pediatric Research Apr 2021Children with serious illness suffer from symptoms at the end of life that often fail to be relieved. An overview is required of healthcare interventions improving and...
BACKGROUND
Children with serious illness suffer from symptoms at the end of life that often fail to be relieved. An overview is required of healthcare interventions improving and decreasing quality of life (QOL) for children with serious illness at the end of life.
METHODS
A systematic review was performed in five databases, January 2000 to July 2018 without language limit. Reviewers selected quantitative studies with a healthcare intervention, for example, medication or treatment, and QOL outcomes or QOL-related measures, for example, symptoms, for children aged 1-17 years with serious illness. One author assessed outcomes with the QualSyst and GRADE (Grades of Recommendation, Assessment, Development, and Evaluation) Framework; two authors checked a 25% sample. QOL improvement or reduction was categorized.
RESULTS
Thirty-six studies met the eligibility criteria studying 20 unique interventions. Designs included 1 randomized controlled trial, 1 cross-sectional study, and 34 cohort studies. Patient-reported symptom monitoring increased QOL significantly in cancer patients in a randomized controlled trial. Dexmedetomidine, methadone, ventilation, pleurodesis, and palliative care were significantly associated with improved QOL, and chemotherapy, stem cell transplant, and hospitalization with reduced QOL, in cohort studies.
CONCLUSIONS
Use of patient-controlled symptom feedback, multidisciplinary palliative care teams with full-time practical support, inhalation therapy, and off-label sedative medication may improve QOL. Curative therapy may reduce QOL.
IMPACT
QOL for children at the end of life may be improved with patient-controlled symptom feedback, multidisciplinary palliative care teams with full-time practical support, inhalation therapy, and off-label sedative medication. QOL for children at the end of life may be reduced with therapy with a curative intent, such as curative chemotherapy or stem cell transplant. A comprehensive overview of current evidence to elevate currently often-failing QOL management for children at the end of life. New paradigm-level indicators for appropriate and inappropriate QOL management in children at the end of life. New hypotheses for future research, guided by the current knowledge within the field. Various healthcare interventions (as described above) could or might be employed as tools to provide relief in QOL management for children with serious illness, such as cancer, at the end of life, and therefore could be discussed in pediatrician end-of-life training to limit the often-failed QOL management in this population, cave the one-size-fits-all approach for individual cases. Multidisciplinary team efforts and 24/7 presence, especially practical support for parents, might characterize effective palliative care team interventions for children with serious illness at the end of life, suggesting a co-regulating link between well-being of the child partly to that of the parents Hypothesis-oriented research is needed, especially for children with nonmalignant disorders, such as genetic or neurological disorders at the end of life, as well as QOL outcomes for intervention research and psychosocial or spiritual outcomes.
Topics: Adolescent; Child; Child, Preschool; Humans; Infant; Quality of Life; Terminal Care; Terminally Ill
PubMed: 32645707
DOI: 10.1038/s41390-020-1036-x -
Revista Clinica Espanola Mar 2018Myelomatous pleural effusion (MPE) is rare in multiple myeloma, and therefore its characteristics are not well defined.
BACKGROUND
Myelomatous pleural effusion (MPE) is rare in multiple myeloma, and therefore its characteristics are not well defined.
METHODS
A systematic review (4 online databases) was conducted of articles describing the clinical characteristics of patients with MPE, pleural effusion's biochemical characteristics and treatment efficacy. We analysed isolated cases and small retrospective series.
RESULTS
We included 98 articles with a total of 153 patients with MPE. The median age was 62years, and the ratio of males to females was 1.7:1. The most common symptoms were dyspnoea (98.8%), bone pain (100%) and chest pain (95.3%), and the most relevant abnormal laboratory test results were anaemia (90.1%) and renal failure (53.8%). MPE was predominantly unilateral (63.9%) and covered more than two-thirds of the hemithorax (54.5%). The pleural fluid (PF) had a haematologic/serohaematologic appearance (87%) and met the criteria for lymphocytic (78.6%) exudate (94.7%). The most cost-effective diagnostic procedures were pleural cytology (95.9%) and the observation of a monoclonal peak in the PF (94.7%). In a significant proportion of patients (54.7%), the MPE did not respond to treatment, and the best response was achieved when chemotherapy (with/without corticosteroids) was combined with therapeutic thoracentesis, chest drainage or pleurodesis.
CONCLUSIONS
MPE predominates in middle to older age men, is symptomatic and is usually unilateral. PF is an exudate with a haemorrhagic appearance, and the most cost-effective diagnostic procedure is pleural cytology. Treatment response is unfavourable in more than half of patients.
PubMed: 29197468
DOI: 10.1016/j.rce.2017.11.001 -
Reviews on Recent Clinical Trials 2019Malignant pleural effusion, which is a common clinical problem in patients with cancer, may be due to both primary thoracic tumours or to a metastatic spread in the...
BACKGROUND
Malignant pleural effusion, which is a common clinical problem in patients with cancer, may be due to both primary thoracic tumours or to a metastatic spread in the chest and constitutes the first sign of disease in approximately 10% of patients. Almost all cancers can potentially produce a pleural effusion. The presence of malignant tumour cells in the pleural fluid is generally indicative of advanced disease and is associated with high morbidity and mortality with reduced therapeutic options. Dyspnoea during mild physical activity or at rest is generally the typical sign of restrictive respiratory failure.
METHODS
This is a systematic review of all the main articles in the English language on the topic of malignant pleural effusion and reported by the Pubmed database from 1959 to 2018. I reviewed the literature and guidelines with the aims to focus on what is known and on future pathways to follow the diagnosis and treatment of malignant pleural effusions.
RESULTS
The main goal of palliation of a malignant pleural effusion is a quick improvement in dyspnoea, while thoracentesis under ultrasound guidance is the treatment of choice for patients with a limited life expectancy or who are not candidates for more invasive procedures such as drainage using an indwelling small pleural catheter, chemical pleurodesis with sclerosing agents, pleurectomy or pleuro-peritoneal shunt.
CONCLUSION
Despite progress in therapeutic options, the prognosis remains severe, and the average survival is 4-9 months from the diagnosis of malignant pleural effusion. Moreover, mortality is higher for patients with malignant pleural effusion compared with those with metastatic cancer but no malignant pleural effusion. Therefore, the prognosis of these patients primarily depends on the underlying disease and the extension of a primary tumour. This review focuses on the most relevant updates in the management of malignant pleural effusion.
Topics: Disease Progression; Drainage; Female; Humans; Male; Needs Assessment; Neoplasms; Palliative Care; Pleural Effusion, Malignant; Pleurodesis; Prognosis; Risk Assessment; Severity of Illness Index; Survival Analysis; Thoracentesis; Treatment Outcome; Ultrasonography, Doppler
PubMed: 30514193
DOI: 10.2174/1574887114666181204105208 -
Pneumologie (Stuttgart, Germany) Jun 2021Chylothorax is a multifactorial complication, usually caused by surgery or traumatic injury, and more rarely by malignant disease. Because of the lack of prospective,...
BACKGROUND
Chylothorax is a multifactorial complication, usually caused by surgery or traumatic injury, and more rarely by malignant disease. Because of the lack of prospective, randomised trials, the evidence-based treatment rests upon personal experience, but ideally taking into account retrospective analysis.
MATERIAL AND METHODS
The aim of this review is to provide a comprehensive overview of the currently available modern treatment options. Another aspect is to show their advantages and disadvantages. For this purpose, a literature search was performed using the "PubMed" database. Publications older than ten years were excluded from this review. The literature search employed the keyword "chylothorax". The priority was set on publications including a comparative assessment of treatment approaches. The authors relied on many years of clinical experience to critically analyse and evaluate the treatment options and the given recommendations.
RESULTS
The success rate of the conservative treatment methods ranges widely, depending on the underlying cause of the disease (3-90 %). Non-invasive or semi-invasive procedures are successful in 50 to 100 % of the cases, also depending on the aetiology. After unsuccessful conservative treatment of operable patients, the standard surgical therapy consists of thoracic duct ligature, which is usually performed thoracoscopically. Alternatively, pleurodesis or the placement of a permanent chest drain (PleurX) or a pleuroperitoneal shunt may be performed. The success rate of these procedures is between 64 and 100 %. The morbidity and mortality rate can reach values up to 25 %.
CONCLUSION
Treatment of a chylothorax should be started conservatively. Subsequently, a more aggressive therapy may be gradually considered, based on the patient's health and the amount of the secretion. Interventional radiological procedures are safe, successful, and have a legitimate place alongside conservative or surgical treatment. However, they are currently only available in some larger centres.
Topics: Chylothorax; Humans; Pleurodesis; Prospective Studies; Retrospective Studies; Thoracic Duct
PubMed: 34116575
DOI: 10.1055/a-1172-7288 -
Journal of Thoracic Disease Aug 2019Non-intubated video-assisted thoracoscopic surgery (NIVATS) has been increasingly used in lobectomy, bullectomy, wedge resection, lung volume reduction, sympathectomy...
Non-intubated video-assisted thoracoscopic surgery intubated video-assisted thoracoscopic surgery for thoracic disease: a systematic review and meta-analysis of 1,684 cases.
BACKGROUND
Non-intubated video-assisted thoracoscopic surgery (NIVATS) has been increasingly used in lobectomy, bullectomy, wedge resection, lung volume reduction, sympathectomy and talc pleurodesis, which may reduce postoperative complications. However, the benefits of non-intubated and intubated methods of VATS remain controversial.
METHODS
We comprehensively searched PubMed, Web of Science, Embase and the Cochrane Library, and performed a systematic review to assess the two techniques. Random and fixed-effects meta-analytical models were used based on the low between-study heterogeneity. Study quality, publication bias, and heterogeneity were assessed.
RESULTS
Compared to intubated methods, NIVATS had a lower postoperative complications rate [odds ratio (OR): 0.63; 95% confidence interval (CI), 0.46-0.86; P<0.01], shorter global in-operating time [weighted mean difference (WMD): -35.96 min; 95% CI, -48.00 to -23.91; P<0.01], shorter hospital stay (WMD: -1.35 days; 95% CI, -1.72 to -0.98; P<0.01), shorter anesthesia time (WMD: -7.29 min; 95% CI, -13.30 to -1.29; P<0.01), shorter chest-tube placement time (WMD: -1.04 days; 95% CI, -1.75 to -0.33; P<0.01), less chest pain (WMD: -1.31; 95% CI, -2.45 to -0.17; P<0.05) and lower perioperative mortality rate (OR: 0.13; 95% CI, 0.02-0.99; P=0.05).
CONCLUSIONS
NIVATS is a safe, efficient and feasible technique for thoracic surgery and may be a better alternative procedure owing to its advantage in reducing postoperative complications rate, hospital stay, and chest pain.
PubMed: 31559062
DOI: 10.21037/jtd.2019.07.48 -
Zentralblatt Fur Chirurgie Jun 2019Chylothorax is a multifactorial complication, usually caused by surgery or traumatic injury, and more rarely by malignant disease. Because of the lack of prospective,...
BACKGROUND
Chylothorax is a multifactorial complication, usually caused by surgery or traumatic injury, and more rarely by malignant disease. Because of the lack of prospective, randomised trials, the evidence-based treatment rests upon personal experience, but ideally taking into account retrospective analysis.
MATERIAL AND METHODS
The aim of this review is to provide a comprehensive overview of the currently available modern treatment options. Another aspect is to show their advantages and disadvantages. For this purpose, a literature search was performed using the "PubMed" database. Publications older than ten years were excluded from this review. The literature search employed the keyword "chylothorax". The priority was set on publications including a comparative assessment of treatment approaches. The authors relied on many years of clinical experience to critically analyse and evaluate the treatment options and the given recommendations.
RESULTS
The success rate of the conservative treatment methods ranges widely, depending on the underlying cause of the disease (3 - 90%). Non-invasive or semi-invasive procedures are successful in 50 to 100% of the cases, also depending on the aetiology. After unsuccessful conservative treatment of operable patients, the standard surgical therapy consists of thoracic duct ligature, which is usually performed thoracoscopically. Alternatively, pleurodesis or the placement of a permanent chest drain (PleurX) or a pleuroperitoneal shunt may be performed. The success rate of these procedures is between 64 and 100%. The morbidity and mortality rate can reach values up to 25%.
CONCLUSION
Treatment of a chylothorax should be started conservatively. Subsequently, a more aggressive therapy may be gradually considered, based on the patient's health and the amount of the secretion. Interventional radiological procedures are safe, successful, and have a legitimate place alongside conservative or surgical treatment. However, they are currently only available in some larger centres.
Topics: Chylothorax; Humans; Pleurodesis; Thoracic Duct
PubMed: 30321883
DOI: 10.1055/a-0733-7268 -
Journal of Bronchology & Interventional... Oct 2020While the efficacy of Indwelling pleural catheters for palliation of malignant pleural effusions is supported by relatively robust evidence, there is less clarity... (Meta-Analysis)
Meta-Analysis
BACKGROUND
While the efficacy of Indwelling pleural catheters for palliation of malignant pleural effusions is supported by relatively robust evidence, there is less clarity surrounding the postinsertion management.
METHODS
The Trustworthy Consensus-Based Statement approach was utilized to develop unbiased, scientifically valid guidance for the management of patients with malignant effusions treated with indwelling pleural catheters. A comprehensive electronic database search of PubMed was performed based on a priori crafted PICO questions (Population/Intervention/Comparator/Outcomes paradigm). Manual searches of the literature were performed to identify additional relevant literature. Dual screenings at the title, abstract, and full-text levels were performed. Identified studies were then assessed for quality based on a combination of validated tools. Appropriateness for data pooling and formation of evidence-based recommendations was assessed using predetermined criteria. All panel members participated in development of the final recommendations utilizing the modified Delphi technique.
RESULTS
A total of 7 studies were identified for formal quality assessment, all of which were deemed to have a high risk of bias. There was insufficient evidence to allow for data pooling and formation of any evidence-based recommendations. Panel consensus resulted in 11 ungraded consensus-based recommendations.
CONCLUSION
This manuscript was developed to provide clinicians with guidance on the management of patients with indwelling pleural catheters placed for palliation of malignant pleural effusions. Through a systematic and rigorous process, management suggestions were developed based on the best available evidence with augmentation by expert opinion when necessary. In addition, these guidelines highlight important gaps in knowledge which require further study.
Topics: Catheters, Indwelling; Clinical Trials as Topic; Consensus; Delphi Technique; Evidence-Based Medicine; Humans; Palliative Care; Pleural Effusion, Malignant; Pleurodesis; Postoperative Complications; Practice Guidelines as Topic; Pulmonary Medicine; Retrospective Studies; Safety; Societies, Medical; Treatment Outcome; United States
PubMed: 32804745
DOI: 10.1097/LBR.0000000000000707 -
BMJ Supportive & Palliative Care Mar 2020Malignant pleural effusion (MPE) results in breathlessness and impairment of health-related quality of life (HRQOL). This study reviews the existing literature on HRQOL...
BACKGROUND
Malignant pleural effusion (MPE) results in breathlessness and impairment of health-related quality of life (HRQOL). This study reviews the existing literature on HRQOL following invasive interventions in MPE.
METHODS
Five electronic databases were systematically searched and assessed three times during the review process and last completed on 15 June 2018. We included all studies evaluating HRQOL outcomes for the following interventions: therapeutic thoracocentesis, talc slurry (TS) pleurodesis, indwelling pleural catheter (IPC) insertion and thoracoscopic talc poudrage (TTP) pleurodesis. Meta-analysis was not performed due to substantial heterogeneity in the published data.
RESULTS
17 studies were included in the review reporting HRQOL outcomes in 2515 patients. TTP, TS and IPC were associated with modest but inconsistent improvements in HRQOL up to 12 weeks. No intervention was significantly different from another in HRQOL outcomes at any time point. The attrition to follow-up was 48.3% (664/1374) at 3 months. The overall quality of studies was inadequate.
CONCLUSION
TTP, TS and IPC seem to improve HRQOL in MPE over 4-12 weeks, but there are insufficient longer term data due to high attrition rates. Evidence on the most effective treatment strategy is limited by the small number of randomised or comparative studies.
TRIAL REGISTRATION NUMBER
CRD42016051003.
Topics: Aged; Catheterization; Catheters, Indwelling; Female; Humans; Male; Middle Aged; Pleural Effusion, Malignant; Pleurodesis; Quality of Life; Talc; Thoracentesis; Thoracoscopy; Treatment Outcome
PubMed: 31243020
DOI: 10.1136/bmjspcare-2018-001610 -
Archivos de Bronconeumologia Sep 2023To compare the efficacy and safety of indwelling pleural catheters (IPC) in relation with the timing of systemic cancer therapy (SCT) (i.e., before, during, or after...
INTRODUCTION
To compare the efficacy and safety of indwelling pleural catheters (IPC) in relation with the timing of systemic cancer therapy (SCT) (i.e., before, during, or after SCT) in patients with malignant pleural effusion (MPE).
METHODS
Systematic review of randomized controlled trials (RCT), quasi-controlled trials, prospective and retrospective cohorts, and case series of over 20 patients, in which the timing of IPC insertion in relation to that of SCT was provided. Medline (via PubMed), Embase, and Cochrane Library were systematically searched from inception to January 2023. The risk of bias was assessed using the Cochrane Risk of Bias (ROB) tool for RCTs and the ROB in non-randomized studies of interventions (ROBINS-I) for non-randomized designs.
RESULTS
Ten studies (n=2907 patients; 3066 IPCs) were included. Using SCT while the IPC was in situ decreased overall mortality, increased survival time, and improved quality-adjusted survival. Timing of SCT had no effect on the risk of IPC-related infections (2.85% overall), even in immunocompromised patients with moderate or severe neutropenia (relative risk 0.98 [95%CI: 0.93-1.03] for patients treated with the combination of IPC and SCT). The inconsistency of the results or the lack of analysis of all outcome measures in relation to the SCT/IPC timing precluded drawing solid conclusions about time to IPC removal or need of re-interventions.
CONCLUSIONS
Based on observational evidence, the efficacy and safety of IPC for MPE does not seem to vary depending on the IPC insertion timing (before, during, or after SCT). The data most likely support early IPC insertion.
Topics: Humans; Pleural Effusion, Malignant; Catheters, Indwelling; Retrospective Studies; Pleurodesis; Catheter-Related Infections
PubMed: 37429748
DOI: 10.1016/j.arbres.2023.06.007 -
Journal of Cardiothoracic Surgery May 2020A polyglycolic acid (PGA) patch is often used in pulmonary bullae resection, but consensus has not been reached on its effect on patient recovery. The aim of the study... (Meta-Analysis)
Meta-Analysis
OBJECTIVES
A polyglycolic acid (PGA) patch is often used in pulmonary bullae resection, but consensus has not been reached on its effect on patient recovery. The aim of the study is to conduct a systematic review and meta-analysis of studies of polyglycolic acid for bullectomy.
METHODS
A comprehensive literature search was performed using ScienceDirect, EMBASE, Ovid MEDLINE, PubMed, The Cochrane Library, Scopus, and Google Scholar. Clinical trials that compared PGA versus non-PGA for bullectomy were selected. The clinical endpoints included postoperative recurrence, average postoperative air leakage, prolonged air leaks, drainage tube removal time, and postoperative hospital stay.
RESULTS
A total of eight articles (1095 patients) were included. Compared to the non-PGA approach, the PGA approach was associated with lower rates of postoperative recurrence (95% confidence interval [CI]: 0.16 to 0.39, p < 0.00001),) and of prolonged air leaks (95% CI: 0.29 to 0.72, p = 0.0007); a shorter time of drainage tube removal (95% CI: - 1.36 to - 0.13, p = 0.02); The time of average postoperative air leakage, postoperative hospital stay and operative time did not show a significant difference between the two groups.
CONCLUSIONS
These results suggest that the use of PGA patch might can prevent the postoperative recurrence of spontaneous pneumothorax and decrease the rates of prolonged air leaks. More large-scale, high-quality randomized controlled trials are required to confirm our finding.
Topics: Absorbable Implants; Blister; Humans; Pleurodesis; Pneumothorax; Polyglycolic Acid; Postoperative Complications; Recurrence
PubMed: 32460862
DOI: 10.1186/s13019-020-01137-8