Pleurodesis with iodized talc for malignant effusions using pigtail catheters

OBJECTIVE: To assess the efficacy of using an iodized talc slurry as a sclerosing agent instilled into the pleural space via a 12-French pigtail catheter for controlling malignant pleural effusions. DESIGN: A prospective study in which patients were followed until their death. SETTING: A university-affiliated tertiary-care teaching hospital. PATIENTS: Medical oncology patients admitted with symptomatic malignant pleural effusions were considered for iodized talc pleurodesis. MAIN OUTCOME MEASURES: The control of pleural effusion. Treatment failure was defined as any reaccumulation of fluid in the pleural space. RESULTS: Fifteen patients were treated for a total of 17 instillations. The median follow-up on all patients until death was 6 months (range 1-20). The most frequent adverse effect in the study group was pleuritic chest pain (60%). The probability of control of effusion, as determined by the method of Kaplan-Meier, was 81% (SEM 9.7%). The cost of preparing 5 g of iodized talc was $4.32 (US). CONCLUSIONS: Iodized talc slurry instilled through a small-bore pigtail catheter is a safe, economical, and effective treatment for malignant pleural effusion.     

X-linked female band heterotopia-male lissencephaly syndrome

OBJECTIVE: The purpose of this study was to determine if a small pneumothorax would influence the pleurodesis resulting from talc instillation. METHODS: Sixty rabbits received an intrapleural injection of 400 mg/kg talc slurry. One half also received 10 mL of air intrapleurally after the talc. Ten rabbits in each group were killed 2, 14, and 28 days after instillation. RESULTS: Two days after the injection, the mean volume of air in the animals that had received the air was 7.5+/-0.4 mL. There was no air present in any other rabbits. The volume of pleural fluid and the pleural fluid glucose, protein, cell count, and differential were similar in both groups on day 2, while the LDH level was significantly higher in the air group (p<0.05). The degree of gross adhesions and microscopic fibrosis was similar in both groups and increased with time. CONCLUSIONS: A small pneumothorax does not decrease the efficacy of talc pleurodesis in our experimental model. These results suggest that the presence of a small amount of intrapleural air is not a contraindication to talc pleurodesis in humans.     

Three- to 5-year prospective follow-up of outcome in major depression

STUDY OBJECTIVES: Recurrent chylothorax as a complication of lymphoma has had unsatisfactory outcomes. Serial thoracentesis, tube thoracostomy, and pleurodesis via chest tube have been ineffective and compromise the nutritional and immune status of the patient. Medical thoracoscopic talc pleurodesis has been safe and effective in the treatment of some other varieties of recurrent pleural effusions. Our objective was to investigate the safety and efficacy of medical thoracoscopic talc pleurodesis in the palliation of chylothorax related to lymphoma. DESIGN: This is a report of 24 hemithoraces treated in 19 consecutive patients with lymphoma-related chylothorax, failing chemotherapy or radiation therapy. The average patient age was 55 years. INTERVENTIONS: Medical thoracoscopy was performed under local anesthesia and conscious sedation in a bronchoscopy suite. Sedation included midazolam (mean dose, 6 mg; range, 2-14 mg) with either meperidine (mean dose, 94 mg; range 25-140 mg), or morphine (mean dose, 18 mg; range 4-40 mg). Pleurodesis was performed with insufflation of sterile asbestos-free talc, (4-8 g). After pleurodesis, chest tubes were placed, with the mean duration of chest tube placement being 4 days, range 3 to 10 days. RESULTS: One patient died a few days after the procedure due to causes related to the primary disease process. Follow-up was for at least 90 days following the procedure. Patients were assessed at 30, 60, and 90 days following the procedure. At each of these endpoints, all patients remaining alive were without recurrence of pleural effusions, which was confirmed by chest radiography. Eight patients in the series died of the effects of their malignancy during the 90-day evaluation interval. Complications included medication reactions in two patients (8.3%) and ARDS in one patient (4.1%). CONCLUSION: Many patients with lymphoma-related chylothorax are refractory to chemotherapy and/or radiation therapy. In this group, medical thoracoscopic talc pleurodesis has an acceptable complication rate and a 100% success rate in the prevention of recurrence of pleural effusions at 30, 60, and 90 days following the procedure.     

Malignant pleural effusions: recourse to early use of talc

INTRODUCTION: Our purpose was to assess the efficacy, permanence and safety of thoracoscopic talc poudrage (TTP) for pleurodesis in malignant effusions. We report the follow-up of 360 patients who received TTP in two centers in Marseille (France). CURRENT KNOWLEDGE AND KEY POINTS: Eighty-eight patients presented with mesothelioma and 272 had pleural metastasis. The mean follow-up time was 12 months (range: 2-120). Out of the 327 patients whose response could be evaluated, 90.2% had a successful pleurodesis at 1 month, and 82.1% had a life-long pleural symphysis. Adverse effects included one death 3 days after the procedure in an end-stage patient, fever (9.8%), infection of the parietal scar (2.5%) and pulmonary infection (0.8%). FUTURE PROSPECTS AND PROJECTS: TTP is an effective and safe method of life-long pleurodesis. It should be performed early on in the history of malignant effusions to avoid failures of the technic, mainly linked to trapped lung and to the general condition of patients.     

Serum levels of interleukin 1 and tumor necrosis factor alpha correlate with peritoneal adhesion grades in humans after major abdominal surgery

Peritoneal adhesions are a leading cause of potential morbidity and mortality. We undertook this prospective study to determine the clinical relevance of interleukin 1 (IL-1) and tumor necrosis factor alpha (TNF-alpha) levels as biological markers for peritoneal adhesion formation in humans. Fifteen patients who had previous colectomies and were undergoing re-exploration for an elective vascular procedure were studied. Blood samples were collected from each patient preoperatively and 30 minutes after the abdominal incision was made. Serum levels of IL-1 and TNF-alpha were determined using enzyme-linked immunosorbent assay kits. Adhesions were graded using an adhesion scale of 0 (none), 1 (mild), 2 (moderate), and 3 (extensive, dense). Preoperative levels of IL-1 and TNF-alpha did not differ significantly among all patients (IL-1 level was 60 +/- 14 pg/mL, and TNF-alpha level was 45 +/- 11 pg/mL; mean +/- standard deviation). Significant correlation was observed between grades of adhesions and early intraoperative levels of IL-1 [101 +/- 36 pg/mL for grade 1 (n = 8) vs 298 +/- 73 pg/mL for grade 3 (n = 6); P < 0.01] and TNF-alpha (88 +/- 23 pg/mL for grade 1 vs 261 +/- 88 mL for grade 3; P < 0.02). We conclude that early elevations of IL-1 and TNF-alpha are reliable biological markers for postoperative adhesions in humans. Studies utilizing cytokines antibodies to these markers may further elucidate the efficacy of this method for prevention of peritoneal adhesions.     

Pleural effusion: what next?

This article gives an overview of the aetiology, diagnostic evaluation and treatment of pleural effusions. A systematic approach including radiological and sonographic examinations and pleural fluid analysis is proposed with a view to selecting the most appropriate therapy. Common forms of exudative pleural effusions are explained in detail. For complicated parapneumonic effusions, new therapeutic options such as the use of fibrinolytics or thoracoscopic debridement are discussed. Talc slurry and thoracoscopic talc poudrage provide effective methods for pleurodesis in case of malignant effusions.     

Quantification of information transfer via cellular signal transduction pathways

OBJECTIVE: Symptomatic malignant pleural effusions are common sequelae in patients with certain malignancies. Pleurodesis via bedside thoracostomy is the current treatment option most commonly used. To our knowledge, this is the first prospective randomized trial to examine which agent, bleomycin or talc slurry, is superior in terms of effectiveness, safety, and cost. PATIENTS AND METHODS: Between July 1992 and March 1995, 35 patients presenting to our medical center with symptomatic malignant pleural effusions were prospectively randomized to undergo chemical pleurodesis with either bleomycin or talc slurry via bedside thoracostomy. The conditions of patients were assessed and graded before and after treatment concerning pain, dyspnea, and chest radiographs. RESULTS: Twenty-nine patients who underwent 33 treatments (14 with bleomycin and 19 with talc) were available for follow-up. Follow-up ranged from 2 weeks to 8 months (mean, 1.7 months). Both groups demonstrated notable improvement in both pain and dyspnea following treatment, but there were no statistically significant differences between groups in the amount of improvement (two-tailed Student's t test). Permanent control of effusions, defined objectively on chest radiograph, was achieved with 11 bleomycin treatments (79%) and 17 talc treatments (90%) (p=0.388). The procedures were well tolerated and no significant adverse effects were observed. Talc is a much less costly agent than bleomycin ($12.36 cost to our medical center per treatment for talc vs $955.83 for bleomycin). CONCLUSION: Given the similar efficacy and significant cost advantage, we conclude that talc is the agent of choice when utilizing pleurodesis for control of symptomatic malignant pleural effusions.     

Interaction between succinylcholine and ranitidine in rats

The primary objective of this study was to compare the effectiveness of expanded polytetrafluoroethylene (e-PTFE) and polypropylene (PPM) in a rabbit abdominal wall defect model using a double-layer repair technique. Fifty-four New Zealand white rabbits had full thickness resection of a 5 x 5-cm segment of the mid portion of at the abdominal wall. The defect was repaired with two 6 x 6-cm layers of prosthesis in an underlay/overlay fashion incorporating a 1-cm edge of abdominal wall and grouped accordingly. Group I: inner and outer layer of PPM; Group II: inner layer e-PTFE, outer layer PPM; Group III: inner and outer layer e-PTFE. Animals from each group were sacrificed at 3, 6, and 12 months. The abdominal wall was assessed for herniations and bowel adhesions to the inner layer of the prosthesis. Adhesions were graded according to an adhesion scoring system (grade 0-3). No herniations were observed. Intestinal adhesions to PPM were quite dense at 3 months with a mean adhesion score of 2.5; at 12 months, adhesions were more dense and extensive, having a mean score of 3. Adhesions to e-PTFE were thin and filmy with a mean score of 0.4 at 3 months and 0.6 at 12 months (P < 0.001, 95% CI for each time period). Histologically, PPM fibers were consistently surrounded by dense fibrous connective tissue; foreign body giant cells were present. A thin connective tissue capsule covered the inner e-PTFE layer; its pores were progressively infiltrated by fibroblasts. The double-layer technique prevented hernias in all groups.(ABSTRACT TRUNCATED AT 250 WORDS)     

Effects of interleukin-6 and its neutralizing antibodies on peritoneal adhesion formation and wound healing

This study investigates the effects of preoperative IV administration of IL-6 and anti IL-6 on peritoneal adhesion formation and wound healing. Thirty-six male Sprague-Dawley rats (350-400 mg) were divided into three groups: control (group 1); IL-6 (group 2); and anti IL-6 (group 3). Under sterile conditions, all rats underwent a midline laparotomy. Ten cm2 of cecal serosa was abraded, the cecum further irritated with 0.1 ml of 70 per cent alcohol, and the incision closed in layers. At 3 weeks, peritoneal adhesions were graded using a score of 0 (none) to 3 (extensive, dense). Skin samples from incisional sites were examined tensiometrically (true stress and true strain), biochemically (collagen content), and histologically. Adhesion formation score was significantly increased in IL-6 group (2.78 +/- 0.44, Mean +/- SD) and decreased in anti IL-6 group (1.40 +/- 0.52) compared to control (2.00 +/- 0.50). (P < 0.03 by Kruskal Wallis test). There was no significant difference in true stress, true strain, and collagen content between the two treatment groups and controls at the 0.05 level by ANOVA. Histological analysis showed higher number of inflammatory cells and fibroblasts in IL-6 treated groups. We conclude that IL-6 plays a major role in peritoneal adhesion formation. Selective immunosuppression, using IL-6 neutralizing antibodies preoperatively, leads to a reduction of such adhesion formation without a significant effect on wound healing.     

Diagnosis of renal malacoplakia by fine needle aspiration cytology. A case report

Talc administration into the pleural cavity induces pleurodesis. To obtain further insight into the inflammatory process that causes pleurodesis, the cellular kinetics in the pleural space after the administration of talc was studied, along with its relation to chemokine concentrations in the pleural fluid. Thirteen consecutive patients with idiopathic spontaneous pneumothorax and eight patients with malignant pleural effusions received talc pleurodesis. The first group was treated with talc poudrage, whereas the second group was treated with talc slurry. Pleural fluids were isolated before talc administration as well as 3, 6, 24, 48 and 72 h afterwards. The talc induced a rapid polymorphonuclear neutrophil (PMN) influx followed by an accumulation of macrophages. In addition, increased production of interleukin (IL)-8 and monocyte chemotactic protein (MCP)-1 was observed. The talc-induced PMN influx reached its maximum after 3-24 h, and was related to the IL-8 concentration. In contrast, the MCP-1 was not related to the macrophage accumulation. Talc-induced inflammation in patients with idiopathic spontaneous pneumothorax and malignant pleural effusion is characterized by an influx of polymorphonuclear neutrophils related to interleukin-8, followed by an accumulation of monocytes.     

Interstitial lung disease more than 40 years after a 5 year occupational exposure to talc

A 62 yr old woman was initially diagnosed with sarcoidosis until a thoracoscopic biopsy revealed the presence of numerous birefringent particles in fibrotic areas of the centrilobular lung zones. These particles were examined by electron microscopy and X-ray spectrometry and characterized as impure talc. Further inquiry into her occupational history revealed that she had worked from the age of 14-18 yrs in a factory making rubber hoses, where she had had an intense exposure to talc. There was no evidence of silicosis or asbestosis, and other significant causes of interstitial lung disease were excluded. This case emphasizes the importance of a thorough occupational history, which may reveal a remote and forgotten exposure to a significant cause of interstitial lung disease. Although this presentation of talcosis is unusual, this case suggests that even a relatively short, but presumably intense exposure to talc more than 40 yrs previously may be a cause of progressive lung fibrosis.     

Talc-induced expression of C-C and C-X-C chemokines and intercellular adhesion molecule-1 in mesothelial cells

Treatment of symptomatic carcinomatous pleural effusions is primarily directed at local palliation with a wide variety of sclerosing agents, of which talc is considered to be the most successful. The mechanism whereby talc achieves this effect is unknown. The objective of this study was to investigate whether talc stimulates pleural mesothelial cells (PMC) to release C-X-C and/or C-C chemokines and express adhesion molecules that initiate and amplify the inflammatory process in the pleural space. When PMC were challenged with talc in vitro, interleukin-8 (IL-8) and monocyte chemotactic protein-1 (MCP-1) levels were increased (p < 0.001) both at the protein and the mRNA level as compared with unstimulated cultures. Talc-stimulated PMC culture supernatant showed chemotactic activity for neutrophils and monocytes. The chemotactic activity of PMC culture supernatant was blocked by 44.2% with IL-8-specific antibody and by 55.7% with MCP-1-specific antibody, demonstrating that PMC-derived chemokines are bioactive. Talc also enhanced intercellular adhesion molecule-1 (ICAM-1) expression in PMC. The data demonstrate that talc stimulates PMC to release chemokines and express adhesion molecules that may play a critical role in pleurodesis.     

Chemical pleurodesis for malignant pleural effusions

PURPOSE: To provide information about available agents for chemical pleurodesis. DATA SOURCES: A MEDLINE search (1966 to October 1992) was conducted using the terms malignant pleural effusion and pleurodesis. STUDY SELECTION: All articles containing references to patients with recurrent, symptomatic, malignant pleural effusions treated with chemical pleurodesis were selected and reviewed for pleurodesis regimen, number of patients treated, success rate (complete response), and adverse effects. The agents studied included doxycycline, minocycline, tetracycline, bleomycin, cisplatin, doxorubicin, etoposide, fluorouracil, interferon-beta, mitomycin-c, Corynebacterium parvum, methylprednisolone, and talc. DATA EXTRACTION: Independent extraction by three observers. RESULTS: Studies including a total of 1168 patients with malignant pleural effusions were reviewed for efficacy of the pleurodesis agent and studies including 1140 patients were reviewed for toxicity. Chemical pleurodesis produced a complete response in 752 (64%) of 1168 patients. The success rate of the pleurodesis agents varied from 0% with etoposide to 93% with talc. Corynebacterium parvum, the tetracyclines, and bleomycin had success rates of 76%, 67%, and 54%, respectively. The most commonly reported adverse effects were pain (265 of 1140, 23%) and fever (220 of 1140, 19%). CONCLUSIONS: Doxycycline and minocycline, with success rates of 72% and 86%, respectively, appear to be effective tetracycline-replacement agents in the few patients studied. Talc appears to be the most effective and least expensive agent; however, insufflation has the disadvantages of the expense of thoracoscopy and the usual need for general anesthesia. Bleomycin appears to be less effective than talc and the tetracyclines and is substantially more expensive.     

Copper-catalyzed oxidation mediates PAF formation in human LDL subspecies. Protective role of PAF:acetylhydrolase in dense LDL

Free radical-mediated oxidation of cholesterol-rich LDL plays a key role in atherogenesis and involves the formation of oxidized phospholipids with proinflammatory biological activity. We evaluated the production of platelet-activating factor (PAF), a potent inflammatory mediator, in human LDL subspecies on copper-initiated oxidation (4 mumol/L CuCl2, 80 micrograms/mL for hours at 37 degrees C). PAF formation was determined by biological assay of HPLC-purified lipid extracts of copper-oxidized lipoproteins; chemical identity was confirmed by gas chromatographic and mass spectrometric analyses. PAF, characterized as the C16:0 molecular species, was preferentially produced in intermediate LDL (d = 1.029 to 1.039 g/mL) (8.6 +/- 5.7 pmol PAF/3 h per mg LDL protein) and light LDL (d = 1.019 to 1.029 g/mL), but was absent from dense LDL particles (d = 1.050 to 1.063 g/mL). As PAF:acetylhydrolase inactivates PAF and oxidized forms of phosphatidylcholine, we evaluated the relationship of lipoprotein-associated PAF:acetylhydrolase to PAF formation. We confirmed that PAF:acetylhydrolase activity was elevated in native, dense LDL (41.5 +/- 9.5 nmol/min per mg protein) but low in LDL subspecies of light and intermediate density (d 1.020 to 1.039 g/mL) (3.5 +/- 1.6 nmol/min per mg protein) [Tselepis et al, Arterioscler Thromb Vasc Biol. 1995;15:1764-1773]. On copper-mediated oxidation for 3 hours at 37 degrees C, dense LDL particles conserved 20 +/- 14% of their initial enzymatic activity; in contrast, PAF:acetylhydrolase activity was abolished in light and intermediate LDL subspecies. Clearly, the elevated PAF:acetylhydrolase activity of dense LDL efficiently diminishes the potential inflammatory role of endogenously formed PAF; nonetheless, formation of proatherogenic lysophospholipids results. In contrast, LDL particles of the light and intermediate subclasses can accumulate PAF on oxidative modification.     

The effect of training and duration of surgery on adhesion formation in the rabbit model

In order to evaluate the effect of training upon postoperative adhesions, standard bipolar and mechanical, nonopposing injuries were performed in the uterine horns and side walls of 52 mature female rabbits using a conventional three-puncture laparoscopy, by an endoscopic surgeon with limited experience. An additional injury, either bipolar or mechanical or both, was performed in the retro-uterine space. With experience, the duration of surgery decreased progressively from 12 +/- 2 to 8 +/- 1 min in the first and last 10 animals respectively. The amount of perioperative bleeding was not affected by experience. With experience the postoperative adhesions decreased in extent (P = 0.0001), tenacity (P = 0.004), type (P = 0.002) and inflammation (P = 0.003) and for total score (P = 0.0002). These changes were correlated with the briefer duration of surgery but not with the amount of perioperative bleeding. The strong correlations of adhesion scores in the pouch of Douglas, and around both uterine horns confirmed the importance of the inter-animal variability in making adhesions. By logistic regression, the adhesions in the pouch of Douglas were explained simultaneously by the adhesions on the uterine horns (P = 0.0004, thus correcting for inter-animal variability) by the amount of bleeding (P = 0.01) and the duration of surgery (P = 0.05). No major differences were found in adhesions following a mechanical or a bipolar injury or following such a lesion in the pouch of Douglas or at the uterine horns. In conclusion, experience, expressed by the duration of surgery and to a lesser extent perioperative bleeding, is a major co-factor in postoperative adhesions, suggesting that duration of surgery should be strictly standardized in endoscopic adhesion studies. The important inter-animal variability can be circumvented by using a standard control lesion, making each animal its own control.     

Perineal talc exposure and risk of ovarian carcinoma

BACKGROUND: Clinical and epidemiologic studies have indicated the possible existence of an association between ovarian carcinoma and talcum powder use. Talc particles have been detected in histologic sections of ovarian carcinomas. It has also been demonstrated that inert particles travel from the perineum to the ovaries. Results from epidemiologic investigations have varied, from risks increased by twofold to no significant risk detected. METHODS: A total of 450 patients with borderline and invasive ovarian carcinoma and 564 population controls in metropolitan Toronto and nearby areas of southern Ontario, Canada, were identified. These subjects were interviewed about their reproductive and menstrual histories as well as their exposure to dusting powders. Continuous unconditional logistic regression methods were used for analysis. RESULTS: Exposure to talc, via sanitary napkins, direct application to the perineum, or both, was significantly associated with risk of ovarian carcinoma (odds ratio [OR] 1.42, 95% confidence interval [CI] 1.08-1.86). A borderline-significant association was detected between duration of talc exposure and risk (OR 1.09, 95% CI 0.98-1.21, per 10 years of exposure). No significant association was found between frequency of exposure and risk. In comparing invasive and borderline carcinomas, risk remained elevated for both carcinoma types. Only risk for invasive carcinoma was statistically significant. CONCLUSIONS: This investigation supports previous contentions that exposure to talc may increase risk of ovarian carcinoma. Questionable trends in duration and frequency of exposure suggest that further studies may be needed to clarify the role of talc in the etiology of this disease.     

Adhesion formation is reduced after laparoscopic surgery

BACKGROUND: Adhesion formation after abdominal operations causes significant morbidity. METHODS: Adhesion formation in pigs was compared after placement of prosthetic mesh during celiotomy (group 1), laparoscopy with large incision (group 2), and laparoscopy (group 3). After peritoneum was excised, polypropylene mesh was fixed to the abdominal wall, then to the opposite abdominal wall in the preperitoneal space followed by peritoneal closure. Adhesion area, grade, and vascularity were measured. RESULTS: More adhesions (p < 0.02) covered intraperitoneal mesh (7.57 +/- 1.89 cm2) than covered reperitonealized mesh (2.16 +/- 1.13 cm2), and adhesion grade was significantly greater (p < 0.02). Adhesion areas were significantly greater in groups 1 and 2 than in group 3 (p = 0.001 and 0.03, respectively). Adhesion grade was significantly greater in groups 1 and 2 than in group 3 (p = 0.02 and p = 0.04, respectively). Groups 1 and 2 had more vascular adhesions than group 3 (p < 0.01 and p = 0.02, respectively) CONCLUSIONS: A foreign body within the peritoneum stimulates more numerous and denser adhesions. Tissue trauma distant from the site of adhesions increases their formation. A major advantage of laparoscopic surgery is decreased adhesion formation.     

Ultrastructural study on adhesions in internal derangement of the temporomandibular joint

PURPOSE: This study examined the ultrastructural characteristics of adhesions in the upper joint compartment of temporomandibular joint (TMJ). MATERIALS AND METHODS: Tissue biopsy specimens of adhesions were obtained during arthroscopic operation on 36 joints in 22 patients with internal derangement (ID). The biopsy specimens were examined by light and transmission electron microscopy. RESULTS: Adhesions were grossly divided into two types based on arthroscopic observation: 1) a band-like type, which connected the articular fossa and TMJ disc, and 2) a pseudowall-like type, which faced the synovial fluid and was lined by articular tissue. Two types of collagen arrangement were observed at the electron microscopic level: orderly arranged collagen bundles and randomly arranged collagen bundles. Orderly arranged collagen bundles were prominent in the band-like adhesions. In pseudowall-like adhesions, mainly the randomly arranged collagen bundles were seen. However, in some dense fiber parts, orderly arranged collagen bundles also were observed. In other pseudowall-like adhesions, only orderly arranged collagen bundles were seen. Elastic fibers were abundant in some pseudowall-like adhesions with randomly arranged collagen bundles. There were no elastic fibers in the band-like adhesions, some dense fiber parts of the pseudowall-like adhesion, pseudowall-like adhesions consisting of only orderly arranged collagen bundles, and in the synovial membrane. CONCLUSION: The different arrangement of collagen fibers and presence or absence of elastic fibers were observed in the two types of adhesions. These findings served to show that extracellular components correspond to a dysfunction involving an ID of TMJ.     

Management of malignant pleural effusion

Malignant pleural effusion is a frequent cause of morbidity in cancer patients. Pleural aspiration relieves dyspnoea usually only for a matter of days, and if the tumour type is not chemosensitive, some form of pleurodesis is commonly required. Tube thoracostomy is widely used to achieve pleural drainage prior to attempting pleurodesis by instillation of a variety of 'sclerosants'. Recently thoracoscopic instillation of talc has been advocated and some authors report high rates of fluid control. Randomised trials comparing this approach compared to tube thoracostomy and chemical pleurodesis are required.     

Reduction of adhesions after uterine myomectomy by Seprafilm membrane (HAL-F): a blinded, prospective, randomized, multicenter clinical study. Seprafilm Adhesion Study Group

OBJECTIVE: To assess the safety and efficacy of Seprafilm (HAL-F), Bioresorbable Membrane, (Genzyme Corporation, Cambridge, MA) in reducing the incidence, severity, extent, and area of uterine adhesions after myomectomy. DESIGN: Prospective, randomized, blinded, multicenter study. Adhesion reduction was assessed by an independent, blinded, gynecologic surgeon who reviewed videotapes of each patient's second-look laparoscopy. SETTING: Nineteen institutions across the United States. PATIENT(s): One hundred twenty-seven women undergoing uterine myomectomy with at least one posterior uterine incision > or = 1 cm in length. INTERVENTION(s): Patients were randomized to treatment with Seprafilm or to no treatment at the completion of the myomectomy. MAIN OUTCOME MEASURE(s): The incidence, severity, extent, and area of uterine adhesions at second-look laparoscopy. RESULT(s): The incidence, measured as the mean number of sites adherent to the uterine surface, was significantly less in treated patients (4.98 +/- 0.52 [mean +/- SEM] sites) than in no treatment patients (7.88 +/- 0.48 sites) as were the mean uterine adhesion severity scores (1.94 +/- 0.14 versus 2.43 +/- 0.10; treatment versus no treatment, respectively), mean extent scores (1.23 +/- 0.12 versus 1.68 +/- 0.10), and mean area of adhesions (13.2 +/- 1.67 versus 18.7 +/- 1.66 cm2). No adverse events occurred that were judged to be related to the use of Seprafilm. CONCLUSION(s): In this multicenter study, treatment of patients after myomectomy with Seprafilm significantly reduced the incidence, severity, extent, and area of postoperative uterine adhesions. Additionally, Seprafilm treatment was not associated with an increase in postoperative complications.