David P. Breen

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Update April 2007

So, another month has been completed with plenty of procedures – pleural and endoscopic and ongoing research. As promised, this month I would like to write about my research activities in Marseille. Of course, the primary aim of the fellowship is to obtain training and become expert in the field of Interventional Pulmonology and Thoracoscopy and as can be seen in my previous reports, this aspect of my year is progressing very well.
However, it is essential for me to obtain an academic C.V. to improve my chances of obtaining a good consultants post in Ireland. Therefore I must aim to publish research and articles and with this in mind I have been working on 3 separate areas of research with the various teams in Marseille.
These are as follows:

1. Research in the field of interventional pulmonology (I.P.)
2. Research in the field of pleural diseases and
3. Oncological research.

I would like to present the papers that have been accepted to date. There are a number of other papers that have been submitted and I will highlight these in future reports, if and when they are accepted to journals. To date, I have 2 papers accepted and 1 paper has had the reviewers’ comments addressed and revised and hopefully will be accepted for publication soon. One paper is now indexed on Pubmed. These papers are as follows:

1. Results and impact of routine assessment of co-morbidity in elderly NSCLC patients over 80 years

David Breen1,2, MD, Fabrice Barlési1, MD, PhD, Myriam Zemerli1, MD, Christophe Doddoli3, MD, Jean-Philippe Torre4, MD, Pascal Thomas3, MD, Philippe Astoul1, MD, PhD.
To be published in Clinical Lung Cancer
2. A Rare Cause of an Endobronchial Tumour in Children:
The role of interventional bronchoscopy in the diagnosis and treatment of tumours while preserving anatomy and lung function

David P. Breen, Jean-Christophe Dubusb, Marie-José Payanc, Hervé Dutaua*
To be published in Respiration.

I also have two other papers submitted, one in interventional pulmonology and one in oncology and we are awaiting the reviewers’ comments on these papers. I am also working on a review article and a case report in the area of oncology and I will also be performing basic research in this area.
In addition, I have two ongoing projects in the field of pleural disease and thoracoscopy. I also hope to perform further research and obtain further publications with Dr. H. Dutau in the area of I.P.

As can be seen from the above, Professor P. Astoul and Dr H. Dutau and their respective teams have put in place a very active programme of research that will strengthen my C.V. and greatly assist me in interviews in the near future. This, in conjunction with my ongoing training in I.P. and Thoracoscopy is ensuring that the year is both very busy but fruitful.

Update March 2007

I have decided to postpone the report on my research until next month. In this report, I would like to write about a week I spent in Brescia, Italy learning Pleural Ultrasound.

I believe that procedures should be made as safe as possible. With regards to pleural procedures- for example, pleural puncture, chest drain insertion and Thoracoscopy, these can be made safer and more successful with the use of pleural ultrasound. This is in effect, a technique to examine the pleural space non-invasively prior to performing a pleural intervention. With ultrasound, pleural fluid can be identified with ease and the best site for pleural puncture can be chosen. Therefore, this adds a greater level of safety and success to the procedure and, in turn, reduces the risk of damage to the lung or other neighbouring structures.

I arranged this week in Brescia with Dr GF Tassi whom I met in Marseille when he attended to lecture at the Thoracoscopy course in December 2006. He invited me to attend his unit for training. I received a very warm welcome and spent a very productive week in the unit under the supervision of Dr Tassi and Dr GP Marchetti. During the week, I learned the theory and application of pleural ultrasound in a number of clinical conditions including pleural infection and empyema, malignancy and thoracentesis. I performed ultrasound on cases each day and all this has enabled me to learn the procedure. Dr Tassi and his team provided me with many presentations and articles on topics in pleural medicine which will be invaluable to me. I also had many very interesting discussions on the subject of pleural diseases with Dr Tassi and the history of pleural disease, thoracoscopy and application of Ultrasound with Dr Marchetti.

Of course, this week in Brescia would not have been possible without the prior meeting with Dr Tassi in Marseille and therefore it is thanks to the ERS/ELF fellowship that I could go to Italy for this training. I would again like to extend my thanks to the ERS/ELF both for the opportunity to meet European leaders in the field of pleural disease and interventional bronchoscopy and for the ongoing funding that covers my training in Marseille and the cost of the trip to Brescia.

One of the hidden gains of the fellowship is the interaction with doctors from around the globe who attend Marseille for training and to lecture at the various courses. This provides a great opportunity to learn from the leaders in the field and to share ideas with them. The fellowship is not just about learning and training but provides to a physician in the early stages of his/her career an amazing chance to meet the experts in a relatively informal environment and to build up a personal network of friends in the speciality.

I would like to thank all the staff in Brescia especially Drs Tassi and Marchetti for their great welcome, hospitality and teaching during my week in their unit. I have learned a new procedure that will be invaluable to me in my future work and it will make pleural procedures safer for my patients.

Finally, I will lecture at the ERS Thoracoscopy course in Marseille which is running from the 3rd to the 6th of April. I am looking forward to these lectures as I believe that providing training and knowledge to others is an essential component of medicine. It also is rewarding to me as it shows to me that I have learned a huge amount during the first 6 months of my fellowship here.

Next month, I will return to the schedule of these reports and write about my research projects in Marseille.

Update: February 2007

I am now in the fifth month of a combined clinical and research fellowship in Marseille. I believe that my training is proceeding very well. This month I would like to provide some more details of the clinical work that I am performing and in my report next month I will concentrate on the research component of my fellowship.

There is a daily list of procedures in the endoscopy unit of the hospital. These range from pleural procedures such as pleural aspiration and thoracoscopy to bronchoscopic procedures. These include flexible bronchoscopy, autofluorescence, endobronchial ultrasound and rigid bronchoscopy, mechanical debulking, laser and stent placement. All these procedures have different roles in benign and malignant diseases.

In Ireland, I have trained and become proficient in flexible bronchoscopy and related procedures. Therefore, the aim of the fellowship from a clinical viewpoint was to gain experience and knowledge in rigid bronchoscopic procedures and techniques. I have learnt the necessary theory through various sources. As I stated in my last report, I attended the interventional bronchoscopy course in Marseille in October 2006 when I commenced my fellowship. This provided me with a lot of essential background knowledge of interventional bronchoscopy. Secondly, I have gained experience through discussion with the staff in the unit (both doctors and nurses) and by watching the medical staff perform the various procedures. It is an essential component of training in interventional bronchoscopy to observe the staff during procedures. This is for a number of reasons: it is necessary to learn how to hold the scope, what hand movements are necessary for various manoeuvres and how to use and effectively work a number of instruments at the one time. I have now watched a large number of procedures and I have learned a vast amount from this. Interventional bronchoscopy has a major role to play in both benign and malignant disease and I now have an understanding of its role in these settings.

I feel I have become part of the endoscopy team and I have performed procedures under the supervision of Dr Hervé Dutau. These procedures include, to date, rigid intubation (I have performed approximately 50 intubations) – the ERS/ATS guidelines state that 20 supervised intubations are necessary before attempting the procedure alone. I have also placed and removed stents, dilated with the rigid scope and performed laser. I feel that I am becoming proficient in performing these procedures and I still have 7 months of training left!

With regard to thoracoscopy, I have performed approximately 20 procedures to date. In some of these cases, I have been assisting and in the remainder I have been the primary operator. These procedures have been under the supervision of Professor P. Astoul and Dr. A. Fraticelli. As with interventional bronchoscopy, I have obtained the background theory and knowledge from the medical thoracoscopy course held in Marseille in December 2006. I attended and lectured at this course and there is another course scheduled for April which I will also lecture and demonstrate at. I have an understanding of the indications, contra-indications and complications associated with this procedure. During these procedures, I have induced pneumothorax, examined the pleural space, performed biopsies and talc pleurodesis.

In addition, I have performed pleural punctures for therapeutic and diagnostic purposes and I have observed the placement of Denver PleurX catheters, which have a small but important role in the management of malignant pleural disease that has not been controlled by talc pleurodesis.
I feel that the clinical component of my fellowship is proceeding very well and indeed, it is better than my expectations. I have learned both the theory and practice of multiple new procedures that will assist me in my clinical practice in Ireland and will benefit the lives of my patients.
Next month, I will discuss the research component of my fellowship and provide details of forthcoming publications. I will also discuss in future reports the precise role of these procedures in a variety of benign and malignant diseases.












First report

Firstly, I would like to thank the ERS/ELF for selecting my project for receipt of a fellowship. It is a great honour and has provided me with a wonderful opportunity to advance my knowledge and to learn new procedures for the diagnosis and treatment of respiratory diseases.

I have been training in respiratory medicine in Ireland for the last 5 years. Prior to coming to France, I was working in the Department of Respiratory Medicine, CResT Directorate, St. James’s Hospital, Dublin, Ireland. It was in this post that I have developed a particular interest in lung cancer.

I became aware that there was a huge need for Interventional Pulmonology services in Ireland as at present the majority of bronchoscopy is diagnostic with minimal therapeutic procedures been performed. I researched centres in Europe that could provide training in this field and I came to the conclusion that the service in Marseille was both a pioneer and a continuing leader in interventional bronchoscopy and Thoracoscopy. My supervisor, Dr. Finbarr O’Connell and I made contact with Professor Astoul and with their support I applied for the fellowship.

I commenced my fellowship on the 1st October 2006 and I will spend one year in Marseille. The principal aim of my year in the Hôpital St Marguerite is to become proficient in interventional bronchoscopy and Thoracoscopy and to perform research in these fields.

I have been given a very warm welcome by all the staff in the departments of Pulmonary Disease and Thoracic Oncology (the service of Professor Astoul) and the Thoracic Endoscopy Unit (the service of Dr. Hervé Dutau) at Hôpital St Marguerite. My timetable is very structured involving both clinical work and research. During the morning, I have an active role in the endoscopy unit where I am learning rigid bronchoscopy and Thoracoscopy. I have performed both of these procedures under the guidance of my supervisors and I am becoming more comfortable with these techniques. Importantly, I am also learning the associated theory, in particular indications, risks and benefits etc.

Over the last four months I have been involved in many very interesting cases and have seen the benefit interventional bronchoscopy procedures can provide patients both with benign and malignant disease.  With regard to thoracoscopy, I have learned the crucial role that this procedure has in the work up of undiagnosed pleural effusions. I am obtaining experience in mesothelioma, a disease that I had minimal experience of in Ireland.

I have attended an Interventional Bronchoscopy Course shortly after my arrival in October. I have also attended and lectured at the Medical Thoracoscopy Course,(European School Of Respiratory Medicine Course under the auspices of the ERS), in December.

In the afternoons, I have an active research programme both in lung cancer and pleural diseases (Dr. Fabrice Barlési, Dr Anne Fraticelli and Professor Astoul) and Interventional Bronchoscopy (Dr. Hervé Dutau) and this component of my fellowship is proceeding very well.

Next month, I will discuss further aspects of my clinical work and in particular I will provide more details of this ongoing research.


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