硝酸银和滑石粉产生胸膜固定术的效果比较

目的 比较硝酸银和滑石粉浆在大鼠中产生胸膜固定术的效果。方法 健康成年雄性Sprague—Dawley大鼠60只,随机分为两组：T组（滑石粉组）和A组（硝酸银组）,在造成大鼠气胸模型后,A组注入硝酸银（0．1％硝酸银1ml）,B组注入200mg／kg滑石粉＋1．0ml 0．9％生理盐水。A组和T组分别在注射药物后第1、4,7d,2、4w时,进行剖胸探查收集标本,观察大鼠胸膜黏连积分、胸膜及肺组织炎性积分、胸膜纤维化积分及检测肺组织或胸膜组织中髓过氧化物酶（MPO）的活性。结果：滑石粉浆组产生胸膜黏连在初期较硝酸银组快,但从第二周开始,硝酸银组产生胸膜黏连效果好于滑石粉浆组,到第四周,滑石粉浆组黏连积分为1．8±0．1,而硝酸银组积分为3．3±0．2,显著高于滑石粉浆组;炎性积分和纤维化积分均为硝酸银组高于滑石粉浆组,两组肺组织内MPO活性随着注入硬化剂的时间延长而逐渐增加,其活性均在注入硬化剂后开始增高,第2周时达到高峰值,到第四周时降至正常水平。结论 0．1％硝酸银1ml产生胸膜固定术的效果好于200mg／kg滑石粉,具有临床使用价值。     

Serious complications with talc slurry pleurodesis

OBJECTIVE: Talc is a highly efficacious and commonly employed agent for chemical pleurodesis, which has generally been felt to be well tolerated. However, increasing reports of adult respiratory distress syndrome (ARDS) have heightened safety concerns. A recent case of ARDS prompted us to review our experience with talc pleurodesis. METHODOLOGY: We conducted a retrospective review of all patients who received talc slurry pleurodesis at Green Lane Hospital, Auckland, New Zealand, between 1 January 1998 and 31 December 1999 and documented all complications occurring within 48 h of the procedure. RESULTS: Thirty-three talc pleurodesis were performed on 29 patients, most commonly for a malignant pleural effusion. Complications occurred in 15 patients (52% of procedures). Minor complications included tachycardia (n = 11; 33%), pain (n = 9; 27%), fever (n = 8; 24%) and dyspnoea (n = 4; 12%). Major complications occurred in seven patients with hypoxaemia and hypotension. Two of these patients died; one death directly attributable to ARDS, the other hastened by a talc pleurodesis-related tachycardia. CONCLUSIONS: These results challenge the assumption that talc pleurodesis is a safe procedure. There were a significant number of serious complications, including a death, from ARDS. Physicians and patients should be aware that complications occur frequently after talc pleurodesis which may be life-threatening or fatal.     

A randomized controlled trial of the efficacy of cosmetic talc compared with iodopovidone for chemical pleurodesis

Background and objective: Talc is an effective and widely used agent for chemical pleurodesis. However, limited availability and high cost hamper the routine use of talc in resource poor countries. In this study, we compared the efficacy and safety of iodopovidone with that of cosmetic talc, for chemical pleurodesis. Methods: Patients with recurrent pleural effusions and/or spontaneous pneumothorax were prospectively randomized to undergo pleurodesis with cosmetic talc (5 g) or iodopovidone (20 mL of a 10% solution) by tube thoracostomy. The cosmetic talc was pretested for impurities (asbestos‐free) and particle size (20–60 µm), using energy dispersive analysis by X‐ray and scanning electron microscopy. The success rate (complete or partial), time to pleurodesis and safety of these two agents was compared. Results: Pleurodesis was performed in 73 patients (39 with iodopovidone, 34 with cosmetic talc; 56 men, 17 women; mean age 51.7 years; 38 pleural effusions, 35 pneumothoraces). A complete response was obtained in all patients with pneumothorax in both the iodopovidone and talc groups. Among patients with pleural effusions, a complete response was observed in 16/19 and 15/19 patients in the iodopovidone and talc groups, respectively. A partial response was observed in two additional patients from each group. The time to pleurodesis was similar in the two groups. Minor side‐effects (fever, chest pain) were observed with similar frequencies in the two groups. None of the patients experienced hypotension or ARDS. Conclusions: Iodopovidone and cosmetic talc are equally efficacious and safe agents for chemical pleurodesis.     

Frozen section of pleural biopsies at medical thoracoscopy assists in correctly identifying benign disease

OBJECTIVES: Medical thoracoscopy and thoracoscopic talc poudrage (TTP) are accepted procedures in the management of pleural effusions. The relative merits of TTP compared with pleurodesis via intercostal catheter (ICC) continue to be debated. However, of the two procedures, only medical thoracoscopy allows both tissue diagnosis and pleurodesis to be achieved reliably in one procedure. The aim of this study was to assess the feasibility and accuracy of using frozen section analysis of samples taken during medical thoracoscopy to assist the thoracoscopist's decision to complete the procedure with a TTP. METHODOLOGY: Twenty patients with undiagnosed pleural effusions after at least one diagnostic pleurocentesis underwent medical thoracoscopy and biopsy. RESULTS: Frozen sections were easily performed within the timeframe of medical thoracoscopy. The final diagnosis based on paraffin sections was malignant in 10 cases and benign in 10 cases. Frozen section at the time of thoracoscopy (before TTP) correctly identified nine of 10 cases as being benign and six of 10 cases as malignant. In the malignant group, reasons for incorrect identification as benign were sampling from superficial benign adipose tissue overlying the malignant deposits, difficult access to the most involved parts of the pleura and intense cellular infiltrate initially thought to be benign. CONCLUSION: Frozen sections taken during medical thoracoscopy have the potential to facilitate decision-making prior to pleurodesis, particularly for accurate identification of benign histology on thoracoscopic pleural biopsies, in order that pleurodesis is not performed unnecessarily.     

Comparing transforming growth factor-beta2, talc and bleomycin as pleurodesing agents in sheep

BACKGROUND: Transforming growth factor (TGF)-beta2 can produce effective pleurodesis in animals, but its efficacy has not been compared with commonly used pleurodesing agents in sheep, which have a thick pleura resembling that of humans. The acute physiological effects and the level of systemic TGF-beta absorption after its intrapleural administration have not been studied. The aims of the present study were to compare: (i) the effectiveness of TGF-beta2, talc and bleomycin in producing pleurodesis in sheep; (ii) the acute side-effects and systemic TGF-beta levels following the intrapleural administration of these agents; and (iii) histological changes after intrapleural injections of these agents. METHODOLOGY: Twelve sheep were divided into three groups and were given a single intrapleural dose of TGF-beta2 (0.25 microg/kg), talc slurry (5 g) or bleomycin (60 IU) via a chest tube. Saline or buffer was injected into the contralateral side, which served as the control. Arterial blood gases and respiratory and heart rates were monitored for the first 24 h. Plasma levels of TGF-beta1 and TGF-beta2 were measured. Pleurodesis was graded macroscopically from 1 (none) to 8 (symphysis > 50% of hemithorax) at day 14. RESULTS: At day 14, the pleurodesis score of the TGF-beta2 group (7.7+/-0.6) was similar to that of the talc (7.0+/-1.7) group and significantly higher than that of the bleomycin group (3.3+/-2.3; P < 0.05). No significant differences were seen in arterial blood gas analysis, vital signs and plasma TGF-beta1 and TGF-beta2 concentrations among the three groups. CONCLUSIONS: Transforming growth factor-beta2 was as effective as talc and more so than bleomycin in inducing pleurodesis in sheep. Intrapleural administration of TGF-beta2 appeared safe. No acute changes in gaseous exchange or macroscopic abnormalities were seen following intrapleural TGF-beta2. Importantly, there was no evidence of an increase in systemic TGF-beta levels following its intrapleural administration.     

Rigid and semirigid pleuroscopy: the future is bright

Abstract:   Pleuroscopy provides the pulmonologist with a unique opportunity to visualize the contents of the pleural space, perform biopsy of the parietal pleura under direct visual guidance, allow optimal chest tube placement and perform pleurodesis to prevent recurrent pleural effusion or pneumothorax in selected patients. We discuss the techniques, indications, contraindications and complications of pleuroscopy using rigid and semirigid instruments. In addition, the potential value and expanding role of pleuroscopy with semirigid instrumentation is debated.     

Prolonged survival after talc poudrage for malignant pleural mesothelioma: case series

OBJECTIVE: Malignant pleural mesothelioma is a fatal disease with a mean life expectancy of 6-12 months. Since 1982, we have performed thoracoscopic talc poudrage (TTP) as a primary therapy in mesothelioma patients presenting with pleural effusion. As the survival data for our patients surpassed that of many published series, the patient data was analyzed to determine whether talc poudrage can be considered as a contemporary palliative option. METHODOLOGY: We reviewed all 26 patients with a final diagnosis of malignant pleural mesothelioma from our prospective database of 228 consecutive patients who received thoracoscopy from the same physician for recurrent symptomatic pleural effusion. Patients were followed up until their death. RESULTS: Mean survival after TTP was 23.8 +/- 16.3 months (median 19.4, range 2.9-68). Pleurodesis palliated dyspnoea in all patients. No perioperative deaths and one postoperative complication (pneumonia) occurred. Mean hospital stay was 3.9 +/- 2.7 days. CONCLUSION: TTP remains a safe, low-morbidity, inexpensive primary palliative treatment option for malignant pleural mesothelioma and a valid control arm option for therapeutic trials. TTP is ideal for patients who wish to avoid thoracotomy, long hospital stays and morbidity from multimodality therapy. Prospective randomized studies are needed to compare quality of life and survival after talc poudrage and other therapies.     

Pleural controversy: pleurodesis versus indwelling pleural catheters for malignant effusions

Malignant pleural effusions (MPE) are a common complication of advanced malignancy. The treatment of MPE should be focused on palliation of associated symptoms. The traditional approach to MPE has been to attempt pleurodesis by introducing a sclerosant into the pleural space. A more recent development in the treatment of MPE has been the use of indwelling pleural catheters (IPC) for ongoing drainage of the pleural space. Controversy exists as to which approach is superior. Pleurodesis approaches will have the advantage of a time-limited course of treatment and high pleurodesis rate at the cost of a more invasive procedure requiring a general anaesthetic or conscious sedation (for thoracoscopic approaches) and an inpatient hospital stay. Use of IPC will allow the patient to be treated on an outpatient basis with a minimally invasive procedure, at the cost of long-term need for catheter drainage and care. Symptom control appears similar between techniques. Complication rates between the two approaches cannot be easily compared, but studies suggest more frequent severe complications such as respiratory failure, arrhythmias and even mortality following pleurodesis, with infection rates similar between the two approaches. IPC will likely see increasing utilization in the future but patient preference and local resources and expertise will continue to play a significant part in treatment decisions. Randomized trials directly comparing the two approaches are needed and some are underway. Novel combination approaches utilizing both IPC and pleurodesis agents have the potential to further improve the care of these patients.     

胸腔内注入顺铂联合滑石粉治疗恶性胸腔积液疗效比较

目的 探讨胸腔内注入顺铂（DDP）联合滑石粉治疗恶性胸腔积液的疗效。方法 病理确诊的恶性胸腔积液58例,经胸腔插管引流术排除胸水后,随机分为二组,开始均胸腔内注入80mg顺铂,治疗组（A组,30例）1周后重复一次,并注入3％滑石粉混悬液100ml;对照组（B组,28例）1周后使重复一次,观察疗效、生活质量、生存率及毒副反应。结果 治疗组总有效率80％,较对照组46％,差异有显著性（P〈O．01）。治疗组0．5、1年的生存率分别高于对照组,差异有显著性。结论 胸腔内联合注入DDP和滑石粉治疗恶性胸腔积液是一种有效的、经济的、副反应少的方法。     

Success rate of medical thoracoscopy and talc pleurodesis in malignant pleurisy: A single‐centre experience

Background and objective

Malignant pleurisy is associated with advanced oncological disease and dyspnoea is the most common presenting symptom. Pleurodesis is the preferred palliative and supportive treatment option, targeting symptom relief. The identification of clinical and endoscopic features that determine the success of talc pleurodesis in malignant pleurisy could guide clinical decision‐making.

Methods

All symptomatic patients with malignant pleurisy subjected to talc pleurodesis through medical thoracoscopy between January 2012 and December 2015 were included. Univariate and multivariate analyses were performed to identify factors associated with successful pleurodesis.

Results

Of the 155 patients, 122 (78%) were classified as having a successful pleurodesis based on clinical and radiological criteria. Factors associated with unsuccessful pleurodesis (univariate analysis) were the presence of pleural adhesions (odds ratio (OR): 0.43 (95% CI: 0.19–0.96); P = 0.04), extensive spread of pleural lesions (OR: 0.17 (95% CI: 0.05–0.59); P = 0.001), the use of systemic corticosteroids (OR: 0.28 (95% CI: 0.10–0.83); P = 0.02) and a prolonged time period between the clinical diagnosis of the pleural effusion and the moment of pleurodesis (OR: 0.14 (95% CI: 0.06–0.32); P < 0.0001). The latter being associated with failure of pleurodesis in a multivariate analysis (OR: 0.08 (95% CI: 0.01–0.25); P < 0.0001). Chest ultrasound prior to pleurodesis showed a sensitivity of 91% and a specificity of 88% in predicting the success of pleurodesis.

Conclusion

The success rate of pleurodesis in malignant pleurisy could potentially be enhanced by correct patient selection and early referral for pleurodesis. Ultrasonic assessment of pleural adhesions and potential lung expansion prior to pleurodesis is useful in clinical decision‐making.

     

Hemodynamic and coronary vasodilative action of two nitroglycerin oral spray formulations

Summary This study compared glycerol trinitrate (NTG) oral spray in a new hydrophilic formulation with a reference aerosol in a lipophilic base with respect to the time to onset of action on hemodynamics and on the coronary vasomotor tone. Differences in the profile of action between the two spray formulations were assessed in two groups of ten patients each. In each of the two groups the patients were randomly assigned to receive 0.8 mg of aerosolized NTG in either the hydrophilic or lipophilic base in double-blind fashion. The patients of group A had stable, exercise-induced angina pectoris, in whom responses to the sprays were evaluated under resting conditions. The patients of group B were suspicious of vasospastic or mixed form of angina pectoris, in whom the effects of the sprays were studied under diagnostic ergonovine provocation. The onset and extent of action of the sprays were assessed by serial measurements of hemodynamic parameters and repeat quantitative coronary angiography.The two formulation of NTG oral spray had a comparably potent coronary vasodilator effect in patients under resting conditions and under ergonovine provocation. As far as hemodynamic action is concerned, the new hydrophilic spray exerted its hemodynamic effect more rapidly than the lipophilic spray. Thus, the new NTG oral spray promises to afford therapeutic advantages for the relief of anginal attacks as well as hemodynamic unloading in congestive heart failure and acute pulmonary hypertension.     

Buccal spray insulin in subjects with impaired glucose tolerance: the prevoral study

Aim: Postprandial hyperglycaemia is a consequence of reduced first phase insulin response and is associated with increased cardiovascular risk and mortality. The aim of this proof‐of‐concept study was to investigate the safety and efficacy of treatment with buccal spray insulin (Oral‐lyn?, Generex Biotechnology Corporation, Toronto, Ontario, Canada) on postprandial plasma glucose and insulin levels in subjects with impaired glucose tolerance (IGT). Methods: A total of 19 female and 12 male Caucasian subjects, 52.2 ± 13.5 (SD) years old, having a body mass index of 33.1 ± 6 (SD) kg/m² with confirmed IGT were included in the study. Subjects were randomized to take 4, 6 or 12 Oral‐lyn puffs (1 puff = 1 s.c. rapid insulin UI) split into two equal doses each, one before and the second 30 min after a standard 75 g oral glucose tolerance test (OGTT). Glucose and insulin levels were measured at baseline and 30, 60, 90, 120 and 180 min afterwards. Results: Glucose fluctuations during OGTT were not modified by 4 or 6 Oral‐lyn puffs. Treatment with 12 puffs was followed by 29.6% decrease in plasma glucose at 2 h and 26.8% decrease at 3 h, altogether p = 0.01. Considering all time points of the OGTT, there was a mean reduction of 15.8% in glucose levels. With 6 of the total 12 puffs used in group C there was a significant increase in the insulin levels during OGTT at 30 min (p < 0.04) but not at 2 or 3 h. No hypoglycaemic episodes were observed at any time points of the OGTT. Conclusions: This proof‐of‐concept study demonstrates that treatment with buccal spray insulin is a simple and valuable therapy for reducing postprandial hyperglycaemia in obese subjects with IGT. Importantly, this treatment is safe and none of the study subjects experienced hypoglycaemia.     

DDT indoor residual spray, still an effective tool to control Anopheles fluviatilis-transmitted Plasmodium falciparum malaria in India

This study from two districts of Orissa State which are endemic for Plasmodium falciparum transmitted by Anopheles fluviatilis and A. culicifacies investigated the impact of dichlorodiphenyl trichloroethane (DDT) indoor residual spraying, in view of the ongoing discussion on phasing out DDT in India. Based on their high annual parasite incidence and logistical considerations, 26 villages in Malkangiri and 28 in Koraput district were selected for DDT spraying. For comparison, six and four unsprayed villages were chosen from the same districts. In each district, the prevalence of malaria infection and incidence of malaria fever, indoor resting density and parous rate of the vectors, and their susceptibility to DDT were monitored in six and three villages selected randomly from the sprayed and unsprayed groups respectively. Anopheles fluviatilis was susceptible to DDT while A. culicifacies was resistant. DDT residual spraying with 1 g/m(2), was carried out in October-November 2001. Spraying 74-86% of human dwellings and 100% of cattle sheds brought down the indoor resting density of A. fluviatilis by 93-95%. This was associated with a significant reduction of incidence of malaria fever as well as prevalence of malaria infection from November to February in both districts. The spraying also seemed to impact on vector longevity, and a residual effect of DDT on the sprayed walls was observed up to 10-12 weeks despite re-plastering. Hence DDT spraying can still be an effective tool for controlling fluviatilis-transmitted malaria. Although this species is exophilic, its nocturnal resting behaviour facilitates its contact with the sprayed surfaces. DDT is still useful for residual spraying in India, particularly in areas where the vectors are endophilic and not resistant.     

Oral spray insulin in treatment of type 2 diabetes: a comparison of efficacy of the oral spray insulin (Oralin) with subcutaneous (SC) insulin injection, a proof of concept study

OBJECTIVE: Proof-of-concept study of evaluation of metabolic effect of novel oral spray insulin (Oralin) formulation at breakfast time in subjects with type 2 diabetes on multiple daily injections. RESEARCH DESIGN AND METHODS: This was an open-label, crossover, randomized study in (n = 23) subjects with type 2 diabetes on multiple daily injections. Subjects received each treatment, in random order, 3 to 7 days apart-a daily dose of SC injection (0.1 u/kg) on one occasion and Oralin spray (100 u) at time 0 min on another occasion. Subjects were given a standard breakfast containing 360 cal (Sustacal liquid meal) 10 min after the dose. Blood samples were taken at regular intervals to measure glucose, insulin, and C-peptide. RESULTS: The 30- and 60-min postprandial glucose levels were significantly lowered with Oralin versus that with the injection treatment (146 +/- 5 mg/dL Oralin vs 184 +/- 7 mg/dL injection at 30 min and 192 +/- 6 mg/dL Oralin vs 236 +/- 9 mg/dL injection, p < 0.003 at 60 min). The rise in serum insulin levels was significantly higher (Cmax = 98 +/- 6 uU/mL for Oralin at 30 min vs 65 +/- 3 uU/ml injection, p < 0.001). The reduction in C-peptide was greater in Oralin during the first 60 min (1.38 +/- 0.21 ng/mL Oralin vs 1.75 +/- 0.38 ng/mL injection, p < 0.001). CONCLUSIONS: This proof-of-concept study results demonstrated that Oralin could be used as meal insulin in place of mealtime-insulin injections in subjects with type 2 diabetes to regulate the postprandial glucose levels.     

Effects of nicotine nasal spray on atherogenic and thrombogenic factors during smoking cessation

OBJECTIVES: To investigate changes in cardiovascular risk factor parameters when stopping smoking and to identify any impact of nicotine nasal spray on these factors. DESIGN AND SUBJECTS: In a placebo-controlled, double-blind 3-month prospective study, nicotine nasal spray (NNS) or a placebo was given to 157 subjects attending a smoking cessation programme. Blood samples from 46 subjects who remained abstinent for 3 months were analysed. Nasal spray use was given on an ad libitum basis. RESULTS: The haemoglobin (Hb) decreased from 149.0 to 143.2 g L(-1) (P<0.001). The haematocrit (Hct) decreased from 44.6 to 42.4% (P<0.001). The mean corpuscular volume (MCV) decreased from 93.4 to 92.3 fl (P<0.001). The mean corpuscular haemoglobin concentration (MCHC) increased from 333.9 to 338.1 g L(-1) (P = 0.029). The white blood cell count (WBC) decreased from 8.4 to 6.6x10(9) L(-1) (P<0.001). The total cholesterol decreased from 5.92 to 5.65 mmol L(-1) (P = 0.015). The high-density lipoprotein cholesterol (HDL) increased from 1.29 to 1.44 mmol L(-1) (P = 0.48) and low-density lipoprotein cholesterol (LDL) decreased from 4.00 to 3.54 mmol L(-1) (P = 0.004). The HDL/LDL ratio increased from 0.36 to 0.46 (P = 0.011). CONCLUSION: Stopping smoking resulted in positive effects on cardiovascular risk factors. Nicotine treatment for as long as 3 months did not have any significant effect on these 'stopping smoking changes'. In smoking cessation, nicotine substitution up to 3 months seems to be safe.     

Computer and electronic duster spray inhalation (huffing) injuries managed at emergency departments

ABSTRACT

Background: Computer and electronic duster sprays contain halogenated hydrocarbon gases. Intentional inhalation of computer and electronic duster sprays to induce intoxication, also known as huffing, may cause serious adverse effects and even death.

Objectives: Describe computer and electronic duster spray inhalation-related injuries managed at United States (US) emergency departments (EDs).

Methods: Data were obtained from the National Electronic Injury Surveillance System (NEISS), a database of consumer product-related injuries collected from the EDs of approximately 100 hospitals in the US. Cases were computer and electronic duster spray inhalation-related injuries included in NEISS during 2001–2017. The distribution by selected variables was determined for the resulting cases as well as a weighted estimate.

Results: A total of 320 computer and electronic duster spray inhalation-related injuries were identified, resulting in a national estimate of 14,715 (95% confidence interval 11,120–18,311) such injuries. The annual estimated number of injuries remained low during 2001–2008 then increased during 2008–2017. Of the estimated injury patients, 3.2% were aged 6–12 years, 20.3% 13–19 years, and 76.5% 20–59 years; 65.4% of the patients were male. The disposition of the patient was 71.4% treated and examined and released, 6.9% treated and transferred, 11.6% treated and admitted or hospitalized, 0.7% held for observation, and 8.7% left without being seen.

Conclusion: This study suggests that computer and electronic duster spray inhalation (huffing) may be an increasing issue of which hospital EDs and other clinicians should be aware. The pattern of injuries observed may be useful for targeting education, prevention and management activities.     

Prolonged pleural catheters in the management of pleural effusions due to breast cancer

Background

Breast cancer is the second most common etiologic cause in malignant pleural effusions (MPE). The aim of this study was to investigate the efficacy of long term pleural catheters in inducing self sclerosis in pleural effusions of breast cancer patients.

Methods

In this study, 26 patients with breast cancer relapleural effusions that occurred between January 2011 and July 2013, who were considered not to undergo any other treatments and managed with prolonged pleural catheters (Jackson-Pratt silicone flat drain), were retrospectively analyzed. Thirty pleural catheters were inserted in 26 patients. All patients were female, mean age was 52 (range, 37-66) years old. Drainage over 1,500 mL per day was not allowed in order to avoid a lung edema. The catheters were removed in patients who had restoration of lung expansion and drainage under 50 mL/day.

Results

The histologic subtypes in pleural effusions were invasive ductal carcinoma in 18 patients, ductal carcinoma in situ in 4, invasive lobular carcinoma in 2, tubular carcinoma in 1, and medullary carcinoma in 1. Three of the 26 patients underwent bilateral catheter insertion, and one patient underwent a reinsertion of the catheter into the same hemithorax due to a recurrence. The catheters were retained for a mean period of 18 days (range, 11-38 days). In one patient with invasive ductal carcinoma and paramalignant pleural effusion (PMPE) (3.8%), a recurrent pleural effusion was seen 34 days after removal of the catheter. There were no complications. One patient died while the catheter was in place.

Conclusions

Prolonged catheters for the management of pleural effusions in selected patients have become more popular than other treatment alternatives due to a shorter length of stay and lower costs. We recommend the use of Jackson Pratt (JP) silicone flat drains which in our opinion provide effective pleurodesis in addition to easy application in recurrent effusions caused by breast cancer.