Rapid pleurodesis is an outpatient alternative in patients with malignant pleural effusions: a prospective randomized controlled trial

Background

Chemical pleurodesis can be palliative for recurrent, symptomatic pleural effusions in patients who are not candidate for a thoracic surgical procedure. We hypothesized that effective pleurodesis could be accomplished with a rapid method of pleurodesis as effective as the standard method.

Methods

A prospective randomized ‘non-inferiority’ trial was conducted in 96 patients with malignant pleural effusion (MPE) who are not potentially curable and/or not amenable to any other surgical intervention. They were randomly allocated to group 1 (rapid pleurodesis) and to group 2 (standard protocol). In group 1, following complete fluid evacuation, talc slurry was instilled into the pleural space. This was accomplished within 2 h of thoracic catheter insertion, unless the drained fluid was more than 1,500 mL. After clamping the tube for 30 min, the pleural space was drained for 1 h, after which the thoracic catheter was removed. In group 2, talc-slurry was administered when the daily drainage was lower than 300 mL/day.

Results

No-complication developed due to talc-slurry in two groups. Complete or partial response was achieved in 35 (87.5%) and 33 (84.6%) patients in group 1 and group 2 respectively (P=0.670). The mean drainage time was 40.7 and 165.2 h in group 1 and group 2 respectively (P<0.001).

Conclusions

Rapid pleurodesis with talc slurry is safe and effective and it can be performed in an outpatient basis.     

滑石粉悬浊液胸腔灌洗术治疗自发性气胸50例疗效观察

目的研究医用滑石粉悬浊液胸腔灌洗术治疗自发性气胸的疗效。方法将90例自发性气胸的患者随机分为两组，治疗组50例采用滑石粉悬浊液胸腔灌洗术治疗，对照组40例采用常规胸膜固定术治疗。结果治疗组痊愈32例，好转13例，无效5例；对照组痊愈15例，好转12例，无效13例。两组疗效比较，差异有显著性（P〈0.01），治疗组优于对照组。结论滑石粉悬浊液胸腔灌洗术治疗自发性气胸疗效较好。     

Exploration of Novel Co-processed Multifunctional Diluent for the Development of Tablet Dosage Form

The aim of this investigation was to develop a novel multifunctional co-processed diluent consisting of microcrystalline cellulose (Avicel PH 102), crospovidone (Polyplasdone XL) and polyethylene glycol 4000. Colloidal silicon dioxide and talc were also incorporated as minor components in the diluent to improve tableting properties. Melt granulation was adopted for preparation of co-processed diluent. Percentage of Avicel PH 102, Polyplasdone XL and polyethylene glycol 4000 were selected as independent variables and disintegration time was chosen as a dependent variable in simplex lattice design. The co-processed diluent was characterised for angle of repose, bulk density, tapped density, Carr''s index, percentage of fines and dilution potential study. Acetaminophen and metformin were used as poorly compressible model drugs for preparation of tablets. The blend of granules of drug and extra-granular co-processed diluent exhibited better flow as compared to the blend of drug granules and physical mixture of diluents blend. The diluent exhibited satisfactory tableting properties. The tablets exhibited fairly rapid drug release. In conclusion, melt granulation is proposed as a method of preparing co-processed diluent. The concept can be used to bypass patents on excipient manufacturing.     

胸腔镜及较大剂量滑石粉诊治恶性胸腔积液30例

目的观察胸腔镜及较大剂量滑石粉诊治恶性胸腔积液的疗效。方法回顾分析30例恶性胸腔积液应用胸腔镜行胸膜活检、同时采用较大剂量滑石粉(10～30 g)固定胸膜。结果 30例恶性胸腔积液确诊率100%,治疗有效率93.3%。结论胸腔镜及较大剂量滑石粉诊治恶性胸腔积液是有效的方法。     

滑石粉浆对兔胸膜固定术的急性反应

【目的】研究胸腔内注入滑石粉浆的急性反应。【方法】50只新西兰雄性白兔胸腔内接受400mg/kg滑石粉后的6h、1、2、4和7d分成5组作实验观察,另10只作为对照组接受生理盐水。【结果】对照组1d内胸水基本吸收,实验组胸水渗出量在第4d达到高峰,第7d完全吸收。白细胞数明显升高,1d内以中性粒细胞占优势,此后则以淋巴细胞为主。LDH迅速增高,于第2天达高峰。胸膜粘连带在第6小时开始形成,第4天后明显增加。镜下胸膜炎症以第2天最严重,而纤维化则第7天最明显。【结论】滑石粉浆可引起急性胸膜炎症和纤维化,是安全、有效的硬化剂。注入后不必引流。     

Pathology of Cystoid Macular Edema

In order to define the pathology of cystoid macular edema (CME), 35 human cases with histopathologic features of CME were reviewed. The macular cysts appeared in different layers of the retina in eyes after cataract extraction, retinal vein occlusion, trauma, diabetes mellitus, and accelerated hypertension. The pathologic process varied from transudation, exudation to liquefaction necrosis. The experimental models of lens extraction and talc retinopathy in rhesus monkeys were examined. Disruption of the blood-retinal barrier at the retinal vasculature and retinal pigment epithelium were noted after lens extraction. Cystoid degeneration of the macula was seen in monkeys with talc retinopathy. The possibility that disruption of the blood-retinal barrier and microinfarction play important roles in the formation of the macular cysts is proposed     

Pleurodesis Induced by Talc or Silver Nitrate: Evaluation of Collagen and Elastic Fibers in Pleural Remodeling

This study evaluated the extracellular matrix (collagen and elastic fibers) in pleurodesis induced by intrapleural talc (TL) or silver nitrate (SN). Study subjects were 420 rabbits divided into two groups and sacrificed from 15 min to 12 months after the injection of the sclerosing agents at intervals previously defined. Pleural adhesions and fibrosis were graded (0-4), and the collagen and elastin were quantified. The maximum score of the pleural adhesions was observed two months after TL (2.80 +/- 0.99) and 15 days after SN (3.75 +/- 0.25). More intense pleural adhesions were observed in the SN group from day 5 (p < 0.05). Pleural thickness and pleural fibrosis were, in general, significantly higher after SN (p < 0.05). Increased deposition of collagen and elastin was observed in both groups but was more evident in the SN group. In the TL group, a linear correlation was observed between pleural adhesions and fibrosis (r = 0.775), between pleural adhesions and collagen (r = 0.779), and between fibrosis and collagen (r = 0.709). In the SN group, these correlations were acceptable (r = 0.605, 0.665, and 0.663). The elastin presented a correlation of 0.707 (p < 0.001) in the TL group and of 0.564 (p < 0.001) in the SN group. In conclusion, intrapleural 0.5% silver nitrate and talc (400 mg/kg) are effective in the induction of pleurodesis. However, the intensity of adhesions and the richness of collagen after SN, in combination with the early onset of tissue remodeling, demonstrate the local superiority of this agent. Considering the easy availability and instillation, the low cost, and the absence of important side effects, silver nitrate might be considered as a sclerosing agent to induce pleurodesis in humans.     

Industrial-grade talc exposure and the risk of mesothelioma

Industrial-grade talc deposits are complex mixtures of mineral particles and may vary substantially in composition across small geographical areas. Typical industrial-grade talc includes amphibole cleavage fragments, platy talc, serpentine minerals, talc in fibrous form, and a minor presence of transitional fibers. Industrial-grade talc was erroneously determined to be an asbestos-containing material due to an unintended consequence of Occupational Health and Safety Administration’s (OSHA’s) method for measuring airborne asbestos mandated in 1972. This error was repeated, most notably, by the National Institute for Occupational Safety and Health (NIOSH) in, 1980 for talc mined in northern New York State (NYS) by RT Vanderbilt Company (RTV). Subsequent exposure studies of northern NYS talc conducted through the, 1980s and one study published after, 2000 relied on the conclusion that talc was an asbestos-containing material to infer a causal relationship between talc and mesothelioma. The present review included (1) publications concerning talc’s cancer-causing potential issued by organizations concerned with occupational and public health; (2) talc exposure studies and animal and cellular studies of RTV talc; (3) mesothelioma rates in northern NYS; and (4) mesothelioma mortality among RTV mining employees. The review indicated that failure to correctly identify the mineral characteristics of talc resulted in misleading reports concerning the carcinogenic potential of talc. However, the collective data from animal and cellular studies, mesothelioma rates in northern NYS, exposure studies, and a mortality analysis of RTV mining employees do not support a causal relationship between RTV talc and mesothelioma. This conclusion is applicable to all mineral components in RTV talc and to other industrial-grade talcs and mineral aggregates with the same components.     

Correlative polarizing light and scanning electron microscopy for the assessment of talc in pelvic region lymph nodes

Perineal talc use is associated with ovarian carcinoma in many case-control studies. Such talc may migrate to pelvic organs and regional lymph nodes, with both clinical and legal significance. Our goal was to differentiate talc in pelvic lymph nodes due to exposure, versus contamination with talc in the laboratory. We studied 22 lymph nodes from ovarian tumor patients, some of which had documented talc exposure, to quantify talc using digestion of tissue taken from paraffin blocks and scanning electron microscopy/energy dispersive X-ray analysis (SEM/EDX). Talc particles correlated significantly with surface contamination assessments using polarized light microscopy. After adjusting for surface contamination, talc burdens in nodes correlated strongly with perineal talc use. In a separate group of lymph nodes, birefringent particles within the same plane of focus as the tissues in histological sections were highly correlated with talc particles within the tissue by in situ SEM/EDX (r = 0.80; p < 0.0001). We conclude that since talc can be a surface contaminant from tissue collection/preparation, digestion measurements may be influenced by contamination. Instead, because they preserve anatomic landmarks and permit identification of particles in cells and tissues, polarized light microscopy and in situ SEM/EDX are recommended to assess talc in lymph nodes.