Rachelle Asciak

Churchill Hospital

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Co-Authors

Najib M. Rahman

University of Oxford

Rachel Mercer

Churchill Hospital

Rob Hallifax

Oxford University Hospitals NHS Trust

Maged Hassan

Iraqi University

Ioannis Psallidas

AstraZeneca (United Kingdom)

Eihab O. Bedawi

University of Oxford

David McCracken

Piedmont HealthCare

Nikolaos I. Kanellakis

Oxford University Hospitals NHS Trust

Nick Maskell

University of Bristol

John Wrightson

Oxford University Hospitals NHS Trust

Cooperative Institutions

University of Oxford

106

Oxford University Hospitals NHS Trust

Churchill Hospital

Oxford Centre for Diabetes, Endocrinology and Metabolism

John Radcliffe Hospital

Mater Dei Hospital

National Institute for Health Research

Oxford BioMedica (United Kingdom)

National Health Service

University of Patras

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A diagnostic dilemma in a case of pulmonary inflammatory myofibroblastic tumour

BMJ Case Reports (2016)

Rachelle Asciak Caroline Gouder David Bilocca Stephen Montefort

An 18-year-old man presented to the local hospital in Malta, with dyspnoea, cough, mild haemoptysis, chest pain and night sweats. CT revealed a right hilar mass. Pleural tap, bronchoscopy and open lung biopsy were inconclusive. Biopsies obtained at repeat bronchoscopy and endobronchial ultrasound (EBUS) revealed a likely diagnosis of inflammatory myofibroblastic tumour (IMT). The patient subsequently underwent right pneumonectomy, and histology revealed the presence of two further nodules apart from the main tumour. Follow-up with positron emission tomography (PET)/CT showed the development of a right basal paracardial lesion due to recurrence and the presence of lymph node, pleural and skeletal disease. Despite radiotherapy to the recurrent nodule and chemotherapy, there was skeletal disease progression. Treatment with an anaplastic lymphoma kinase inhibitor, ceritinib, resulted in very good metabolic response. This case report highlights the importance of keeping IMT in mind when the diagnosis of lung tumours is difficult, as delayed diagnosis may lead to worsened prognosis.

Nodule (geology)

10.1136/bcr-2016-215168

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Citations (2)

The bacteriology of pleural infection (TORPIDS): an exploratory metagenomics analysis through next generation sequencing

The Lancet Microbe (2022)

Nikolaos I. Kanellakis John Wrightson Stephen Gerry Nicholas E. Ilott John Corcoran

Bacteriology

Streptococcus anginosus

10.1016/s2666-5247(21)00327-x

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Citations (41)

The effect of a hospital oxygen therapy guideline on the prescription of oxygen therapy

Rachelle Asciak Caroline Gouder Maria Ciantar Julia Tua Valerie Anne Fenech

Aim: To assess the effect of a hospital oxygen therapy guideline on oxygen prescription and administration at the emergency Department (ED) and medical wards of Mater Dei Hospital, Malta. Methods: Patients admitted to medical wards through the ED with conditions most likely to require oxygen therapy were recruited over 2 months in 2011. Data was collected on oxygen therapy prescription and administration. A hospital guideline on oxygen therapy was introduced and disseminated in 2015, following which data was collected again and compared to the 2011 data. A p value <0.05 was deemed to be statistically significant. Results: 248 and 293 patients were recruited in 2011 and 2015 respectively. Oxygen therapy was indicated in 34.3% and 31.4% of patients respectively (p=0.47). Oxygen saturation on air was not documented in 14.1% (2011) and 4.4% (2015) (p<0.01). In patients in whom oxygen therapy was indicated, correct documentation (including delivery device and flow rate) of oxygen therapy administered at ED improved from 23.5% to 73.9% (p<0.01), and correct oxygen therapy prescription in the management plan improved from 34.1% to 76.1% (p<0.01). In the medical wards, correct oxygen therapy administration according to prescription improved from 7.1% to 48.9% (p<0.01). 56.8% of patients in whom oxygen therapy was not indicated were prescribed oxygen anyway in 2011, improving to 27.1% after the guideline (p<0.05). Conclusion: Oxygen saturation, oxygen therapy prescription and documentation at the ED and oxygen therapy administration in the medical wards improved significantly at Mater Dei hospital, Malta, after a hospital guideline was introduced.

Oxygen therapy

Guideline

Oxygen Saturation

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Citations (1)

Prospective Analysis of the Predictive Value of Sonographic Pleural Fluid Echogenicity for the Diagnosis of Exudative Effusion

Respiration (2019)

Rachelle Asciak Maged Hassan Rachel Mercer Rob Hallifax John Wrightson

Background: Pleural effusion echogenicity on ultrasound has previously been suggested to allow identification of exudates. A case series suggested that homogenously echogenic effusions are always exudates. With modern imaging techniques and more advanced ultrasound technology, this may no longer be true. Objectives: This study aims to prospectively assess the predictive value of echogenicity in the identification of exudates. Method: Patients undergoing thoracic ultrasound before pleural fluid sampling were analysed prospectively (n = 140). Pleural fluid was classified as an exudate if both fluid total protein (TP) > 29 g/L and fluid lactate dehydrogenase (LDH) > 2/3 upper limit of normal serum LDH (which is 255 IU/L in females and 235 IU/L in males) were present. If only one of these criteria was met, the effusion was considered to have discordant biochemistry. Results: Fifty-five (39%) patients had non-echogenic and 85 (61%) had echogenic effusions. Six (7.1%) patients with echogenic effusions had transudates; the median fluid TP for this group was 18.5 g/L (IQR 9.75) and median LDH 63.0 IU/L (IQR 40.3). The specificity of echogenicity identifying exudates from transudates, excluding patients with discordant biochemistry, was 57.1%, positive predictive value (PPV) 90.3%, sensitivity 65.1%, and negative predictive value (NPV) 21.0%. The specificity of echogenicity identifying exudates (including discordant biochemistry) from transudates was 57.1%, PPV 92.9%, sensitivity 62.7%, and NPV 14.5%. Conclusions: Echogenicity of a pleural effusion has a low specificity for identifying an underlying exudate, and the echogenic qualities of the fluid should not influence clinical decision-making.

Echogenicity

Transudate

10.1159/000496153

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Citations (21)

Pacemaker lead-associated thrombosis in cardiac resynchronisation therapy

BMJ Case Reports (2015)

Jesmar Buttigieg Rachelle Asciak Charles Mallia Azzopardi

Pacemaker lead-associated thrombosis is a possible complication of any cardiac implantable electronic device. We present a case of a middle-aged woman with a history of ischaemic left ventricular failure, who presented with fever and other non-specific symptoms 4 months after cardiac resynchronisation therapy. A transoesophageal echocardiogram confirmed a vegetation-like structure originating from the pacemaker lead in the right atrium. The patient was treated with intravenous antibiotics followed by open heart surgery in order to remove this mass as well as the pacing device, including all three pacing leads. Histology and culture of the retrieved mass confirmed a sterile thrombus with no features to suggest an infected mass (vegetation). The patient made an uncomplicated recovery and there were no long-term sequelae on follow-up during the 2 years after the event.

Lead (geology)

Interatrial septum

10.1136/bcr-2015-210314

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Citations (11)

Transudative malignant pleural effusions

David McCracken Rachel Mercer Mata Tsikrika Rebecca Varatharajah Andrew Thayanandan

Introduction: The incidence of transudative malignant pleural effusion is unclear but is suggested to be between 1- 17.4%.[1] Management and prognostication is also poorly defined. We present results from the largest cohort to date. Method: Complete follow up data was retrospectively collected and analysed for all patients undergoing pleural fluid sampling at Oxford University Hospitals NHS Foundation Trust between January 2015 and December 2017 inclusive. This included samples obtained from procedures performed by the pleural, respiratory and radiology teams. Results: 981 patients were included of which 306 had malignant pleural effusion. 10 of these were transudative (3.3%). 5 patients (50%) were male with an average age of 69.2 years. 9 of 10 (90%) had either a known current or previous diagnosis of malignancy. 5/10 (50%) demonstrated positive pleural fluid cytology, 1/10 (10%) had malignant pleural disease confirmed on histology from a subsequent pleural biopsy and 4/10 (40%) received a clinical diagnosis of malignant pleural effusion. Only 2 patients underwent talc pleurodesis of which neither was successful. 1 was managed with an indwelling pleural catheter and the rest with either symptomatic drainage or palliative care. Median survival was 34 days with an interquartile range of 11-76.5. Conclusions: A small but significant number of malignant pleural effusions demonstrate transudative features, suggesting that MPE should not be excluded solely using biochemistry. Talc pleurodesis may have a lower success rate in transudative effusions, however long term management considerations may be less relevant in this cohort as patients appear to have a much lower median survival. 1. Ferreiro, L. et al. J thorac dis, 2017. 9(1):106-116

Pleurodesis

Pleural disease

Interquartile range

10.1183/13993003.congress-2019.oa488

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Citations (1)

P86 A systematic review of malignant versus benign solitary fibrous tumours of the pleura (SFTP)

RM Mercer Charlotte Wigston Mohamad Hasyizan Hassan Rachelle Asciak David McCracken

Background

SFTP are rare tumours arising from mesothelial parenchymal cells. The majority follow a benign course, but these tumours do have the potential to metastasise. England et al developed a set of criteria to define which tumours are malignant including mitotic index, cellularity, pleomorphism, haemorrhage and necrosis. SFTP are heterogenous and a malignant diagnosis can be missed if limited areas are examined, although histologically benign tumours can still follow a malignant course. There is no agreed treatment or management strategy for SFTP – we therefore performed a systematic review of the available literature regarding the diagnosis of benign versus malignant SFTP.

Methods

A broad search strategy of four large databases was undertaken for any articles related to SFTP from inception of the database until November 2017. There were no randomised control trials thus large case series were the mainstay of evidence for the systematic review. Data was collected according to a pre-specified protocol and assessed by two reviewers.

Results

21 papers were suitable for data extraction for this question from an initial review of 3447 abstracts. Rates of malignancy ranged from 0% to 57%. The criteria proposed by England et al was used in 14/21 papers with another 4/21 using part of this criteria. 8/21 studies specifically assessed factors which could help differentiate between malignant and benign tumours. 6/8 studies found that large tumours were more likely to be malignant. 3/3 studies showed that the presence of a pleural effusion was associated with malignancy. Non-visceral origin and sessile attachment were not found to have any association in 3/4 studies. There was no association with age and likelihood of a malignant diagnosis. Further associations were reported in solitary papers such as PET avidity, inverted tumours, hypervascularity, lobulated margins and fibrous adherences.

Conclusion

Features such as size and the presence of a pleural effusion suggest a SFTP is likely to be histologically malignant. Previous criteria such as sessile attachment and non-visceral origin are not consistently predictive of malignancy. Whilst being able to identify which SFTP are likely to be malignant is important, benign tumours can still follow a malignant course and thus further work is needed to identify all tumours which require a more aggressive management/monitoring strategy.

10.1136/thorax-2018-212555.244

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Citations (0)

Oxygen prescription and administration at the Emergency Department and medical wards in Mater Dei Hospital

Rachelle Asciak Valerie Anne Fenech Jurgen Gatt Stephen Montefort

Aims: The aim of this study was to audit current practices on oxygen prescription in the Emergency Department (ED), and on accurate oxygen administration in the wards of Mater Dei Hospital. Method: Two hundred and forty eight adult patients attending the ED with diagnoses most likely to require oxygen therapy (mainly cardio-respiratory conditions) were randomly selected during 5 winter weeks. Data were collected on oxygen saturation, arterial blood gases, oxygen administration at the ED, oxygen prescription and its documentation, and oxygen administration in wards. The z-test was used to assess statistical significance of results and Fisher’s exact test was used to determine the effect of oxygen prescription documentation in treatment charts.

Oxygen therapy

Oxygen Saturation

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Citations (3)

A rare case of pulmonary alveolar microlithiasis

BMJ Case Reports (2015)

Rachelle Asciak Richard Pullicino Adrian Mizzi Stephen Montefort

A 47-year-old asymptomatic man with no significant family history was referred to our faculty because of an abnormal chest X-ray (CXR). The CXR, similar to his CXR 10 years previously, showed bilaterally increased interstitial markings suggestive of pulmonary fibrosis. High-resolution CT (HRCT) showed multiple bilateral branching calcifications, mostly in the lung bases (figures 1 and 2), with ground-glass opacities in the lingula, and no enlarged mediastinal lymph nodes. Spirometry was normal (forced expiratory volume in 1 s 102%, forced vital capacity 118%), as were total lung capacity, 117%, and diffusion capacity of the lung …

Rare disease

10.1136/bcr-2015-212804

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Citations (2)

Chest Drain Fall-Out Rate According to Suturing Practices: A Retrospective Direct Comparison

Respiration (2018)

Rachelle Asciak Dinesh Addala Juzer Karimjee Maaz Suhail Rana Stamatoula Tsikrika

Background: Chest drains often become displaced and require replacement, adding unnecessary risks to patients. Simple measures such as suturing of the drain may reduce fall-out rates; however, there is no direct data to demonstrate this and no standardized recommended practice that is evidence based. Objectives: The study aimed to analyze the rate of chest drain fall out according to suturing practice. Methods: Retrospective analysis of all chest drain insertions (radiology and pleural teams) in 2015–2016. Details of chest drain fall out were collected from patient electronic records. Drain “fall out” was pre-hoc defined as the drain tip becoming dislodged outside the pleural cavity unintentionally before a clinical decision was taken to remove the drain. Results: A total of 369 chest drains were inserted: sutured (n = 106, 28.7%; 44 male [41.5%], median age 74 [interquartile range (IQR) 21] years), and unsutured (n = 263, 71.3%; 139 male [52.9%], median age 68 [IQR 21] years). Of the sutured drains, 7 (6.6%) fell out after a mean of 3.3 days (SD 2.6) compared to 39 (14.8%; p = 0.04) unsutured drains falling out after a mean of 2.7 days (SD 2.0; p = 0.8). Conclusions: Within the limits of this retrospective analysis, these results suggest that suturing of drains is associated with lower fall-out rates.

Interquartile range

10.1159/000489230

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Citations (9)