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  1. Candy Lee
  1. Correspondence to Dr Candy Lee, ST7 Specialty Trainee in Respiratory Medicine and General Internal Medicine, Cardiff & Vale University Health Board, University Hospital LLandough, Penlan Road, Llandough, Penarth CF64 2XX, UK; clee128{at}doctors.org.uk

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Use of prophylactic radiotherapy in mesothelioma

A well-recognised complication of pleural intervention in mesothelioma patients are pleural tract metastases. Prophylactic radiotherapy is often used to prevent this complication but clinical practice varies greatly due to lack of evidence regarding the efficacy of its use. In this multi-centred, open labelled, phase 3, randomised controlled trial (Lancet Oncol 2016;17:1094–104), researchers demonstrated no significant difference in the incidence of pleural tract metastases in patients who received immediate prophylactic radiotherapy following a large-bore pleural procedure and in those that had treatment-focused radiotherapy when metastases occurred (9% vs 16% respectively, p=0.14). No benefits in symptom control, analgesia use, survival or quality of life were reported with the use of prophylactic radiotherapy. The authors concluded that the routine use of prophylactic radiotherapy, post large-bore pleural interventions in all mesothelioma patients, was not justified.

Another reason to stop smoking

In this prospective population study (Stroke 2016;47:1975–81. doi: 10.1161/STROKEAHA.116.012957), smoking was found to have dose-dependent and cumulative associations with subarachnoid haemorrhage risk. Smoking was demonstrated to increase the risk of bleeding for both male and female smokers. However, the associations were found to be particularly magnified in female heavy smokers, with women who smoked between 21 and 30 cigarettes per day reported to have a greater than eight-fold risk of subarachnoid haemorrhage when compared to female non-smokers. The risk in smokers who had stopped smoking, for at least 6 months, were comparable to those of non-smokers. The findings of this study further emphasises the importance of promoting smoking cessation in the prevention of smoking related diseases.

Shorter duration of antibiotics in pneumonia

According to this multi-centred, randomised Spanish trial (JAMA Intern Med. Published online 25 July 2016. doi: 10.1001/jamainternmed.2016.3633), shorter courses of antibiotics were found to be safe for hospitalised patients treated for community acquired pneumonia. Patients were randomised at day 5 of antibiotic treatment to stop antibiotics if clinically stable (intervention group) or to continue antibiotics (control group), the duration of which was determined by the physician. Patients were assessed to be clinically stable if apyrexial for 48 hours and if they had no more than one instability criteria consisting of hypotension, tachycardia, tachypnoea or hypoxia. Median length of antibiotic duration in the control group was 10 days. Clinical success rate was similar for both groups at day 10 (intervention group 56.3% vs control group 48.6%). There was no significant difference in time until clinical improvement, days to return to normal activity, radiographic resolution, adverse effects, mortality, in-hospital complications or length of hospital stay between the two groups.

Novel therapy for asthma

Fevipiprant, a selective orally available prostaglandin D2 receptor antagonist, has been demonstrated in a single centred, randomised control clinical trial (Lancet Resp Med doi://dx.doi.org/10.1016/S2213-2600(16)30179-5) to significantly decrease eosinophilic airway inflammation with reported reduction of asthma symptoms and improvement in lung function. 61 patients with moderate to severe asthma with elevated sputum eosinophil count (>2%) were randomised to receive either placebo or Fevipiprant, in addition to patients' usual asthma management. Compared with baseline measurements and measurements taken at 12 weeks, mean sputum eosinophil percentage was reduced by 4.5 times in the treatment group and by 1.3 times in the placebo group (p=0.0014). Fevipiprant was also demonstrated to have a favourable safety profile with no serious adverse events or death reported. Further research is still required before Fevipiprant is available for clinical use.

Pirfenidone use in idiopathic pulmonary fibrosis patients with preserved lung function

Patients with idiopathic pulmonary fibrosis may benefit from pirfenidone regardless of disease stage and baseline lung function according to this Italian study (ERJ Jul 2016, ERJ-01966-2015; doi: 10.1183/13993003.01966-2015). The authors performed post hoc analysis of trial data from three phase 3 randomised control trials (CAPACITY 004, CAPACITY 006 and ASCEND study). Patients were stratified into groups by baseline lung function using FVC >80% (more preserved group) versus FVC <80% (less preserved group). Both patient groups had clinically significant disease progression at 12 months measured by decline in FVC, 6-min walk test distance and symptom scores. Pirfenidone effectively reduced disease progression at 12 months for both groups of patients and its efficacy in both groups, assessed by changes in the functional measures, were found to be comparable regardless of baseline FVC. The authors concluded that the findings support the initiation of pirfenidone irrespective of stage of baseline lung function in patients with idiopathic pulmonary fibrosis.

Opioid use in COPD

Initiation of opioids was associated with a two-fold increased risk of COPD or pneumonia-related mortality in older COPD patients according to this Canadian retrospective, population-based, cohort study (ERJ July 2016 doi: 10.1183/13993003.01967-2015). Opioid use was also associated with a 14% increased risk of emergency department visits and a 76% higher all-cause mortality risk. The highest risks were reported in patients receiving more potent or higher doses but the risks were increased regardless of dose in patients who had recently been commenced on opioids. This raises the possibility of safety concerns about the use of opioids in COPD patients, particularly in the elderly population. It is noted however, that the study could only show association but causality could not be demonstrated.

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Footnotes

  • Competing interests None declared.

  • Provenance and peer review Commissioned; internally peer reviewed.

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