Our team showed that tPA dose de-escalation from 10mg (largest open label study of tPA/DNase) to 5mg (ADAPT-1) and 2.5mg (ADAPT-2) maintained treatment efficacy in pleural infection. ADAPT-3 aims to evaluate the safety and efficacy of a starting dosage regimen of 1mg tPA (with 5mg DNase) administered intrapleurally twice daily for pleural infection. The results from this study will inform clinicians on the lowest effective dose of tPA or form the basis of future studies to investigate an even lower dose of tPA for the treatment of pleural infection.
This is a pragmatic, multi-centre, open-labelled, randomized trial designed to determine if preventive topical mupirocin reduces catheter-related infections in patients with an IPC. This study will randomize 220 patients fitted with an IPC to either topical antibiotics prophylaxis at the IPC exit-site or standard care (no antibiotics). The primary outcome is the proportion of patients who developed a catheter-related (pleural, tract or skin) infection from catheter insertion until death (or 6-month follow-up). Secondary outcomes include infection rates adjusted for days of catheter in situ, infection-related hospitalization (episodes and days), treatment acceptability for patients, complications and survival.
STOPPE is a pilot, multicentre, double-blinded, placebo-controlled randomised controlled trial to be conducted by the Western Australia pleural teams at Sir Charles Gairdner (lead site), Fiona Stanley, Royal Perth and SJoG Midland Hospitals. Eighty patients admitted with CAP who have an effusion will be randomized 2:1 to receive intravenous dexamethasone (4mg bd for 48 hours) or placebo. Exclusion criteria will include immunosuppression, long-term steroid use and poorly-controlled diabetes. Randomisation will be minimized for likelihood of a complicated effusion (Chalmers score), size of the effusion on chest x-ray and diabetes. Outcomes will include time to clinical stability, change in markers of inflammation, proportion requiring a pleural procedure, change in pleural effusion volume and adverse events.
The study will establish the feasibility and safety of adjunct corticosteroid therapy in patients with pneumonia and associated pleural effusions. Participants will be randomized at trial entry, on a 2:1 basis, to either IV dexamethasone 4mg bd for 48 hours or placebo. They will be further managed according to best clinical practice with decisions about care made by the treating physician.
The Australian Malignant PLeural Effusion (AMPLE) trial-3 is a multi-centre, open-labelled, randomised controlled (trial entry) study. One hundred and sixty patients with malignant pleural effusions (MPE), who are suitable for surgical pleurodesis and have a predicted survival of greater than 6 months, will be randomised 1:1 to either video assisted thoroscoscopic surgery (VATs) or indwelling pleural catheter (IPC) insertion with talc pleurodesis, if appropriate. MPE is defined as either histocytologically proven pleural malignancy or an exudative effusion with no other cause in a patient with known primary extra-pleural malignancy. Minimisation for i) cancer type (mesothelioma vs non-mesothelioma); ii) previous pleurodesis (vs not); iii) trapped lung, if known (vs not) will be performed. The nature of the intervention means that investigators and patients cannot be blinded to the treatment arms.
Primary endpoint: The primary outcome is the percentage of patients in each group requiring a repeat invasive pleural intervention for symptomatic recurrence of the effusion within 12 months or until death, if sooner. Pleural intervention is defined as an ipsilateral surgical procedure, chest drain insertion or thoracentesis with therapeutic intent. Clinically indicated diagnostic sampling procedures (e.g. to exclude infection) are excluded.
The Pleural Medicine Unit (PMU) is supporting this multicentre Australasian trial coordinated by the Centre for Clinical Research in Emergency Medicine(CCREM) at Royal Perth Hospital. At SCGH the PMU will be involved with the follow-up of participants following their recruitment and randomisation in the Emergency Department.
Primary spontaneous pneumothorax (PSP) is a significant global health problem affecting adolescents and young adults. Current management is variable, with sparse evidence from randomised controlled trials to guide treatment. Current guidelines emphasize the importance of intervention in most patients, which involves insertion of a chest drain, hospital admission, and thoracic surgery in some. This approach has recently been questioned and there is evidence to suggest that conservative management without intervention is effective and safe. The risk of recurrence may also be lower with conservative treatment because of better healing of the lung defect during slow re-expansion of the lung.
The trial proposes to address the fundamental management question of conservative versus invasive management in a multicentre randomised controlled trial that will be the largest study of PSP ever undertaken. It has the potential to reduce morbidity and deliver economic benefits through reductions in procedures, complications and hospital admissions.
The study paper will be written up to include one year follow up. The data is being analysed and the manuscript submitted for publication. It is hoped that the paper will be published in 2019.