Small-bore Catheters Research Articles

Outpatient Pleurodesis of Malignant Pleural Effusions Using a Small-Bore Pigtail Catheter

Patients with symptomatic malignant pleural effusion are usually treated with large-bore chest tube placement and pleurodesis requiring > or = 3 days of hospitalization. We sought to demonstrate the feasibility of ambulatory drainage and sclerosis using a small-bore pigtail catheter in patients with malignant pleural effusions. We reasoned that this approach would improve symptoms and quality of life at a reduced cost. A 14F pigtail catheter was percutaneously inserted into the pleural space and connected to a closed gravity-drainage bag system. The patients were instructed in the use of the drainage system and discharged to return for sclerosis with 4 g of talc after the drainage was < 100 mL/24 h. Patients were graded for dyspnea and performances status using the Eastern Cooperative Oncology Group score (ECOG) and baseline and transitional dyspnea index score (BDI-TDI) before tube placement and again at 30 days. Radiographic response was graded as total response, partial response, or failure. Telephone follow-up was initiated when the patient could not return for evaluation. Ten ambulatory women, ages 41 to 79 years, were enrolled. The chest tube was left in place from 1 to 10 days, draining a mean of 2,956 mL (1,685 to 6,050 mL). Only two patients were unable to undergo sclerosis owing to catheter dislodgment and minimal drainage. Six reported symptomatic improvement at 30 days confirmed by TDI and ECOG scores in four of six. One with a prior history of a lobectomy was found to have a chylous pleural effusion and experienced a hydropneumothorax, for which sclerosis was unsuccessful. One died in hospital on day 26 after sclerosis despite radiographic resolution. Of the four patients who had improved dyspnea and functional status by TDI and EGOG scores, radiographic response was complete in three and partial in one. Two of the six were not able to return for follow-up because of weakness but reported improvement by telephone inquiry. Ambulatory sclerosis of malignant effusion using a small-bore catheter is a feasible alternative to inpatient sclerosis with a large-bore chest tube, especially in patients with strong preferences for outpatient care.

Chest Drains: Does Size Matter?: Review

Hippocrates first advocated pleural drainage 2400 years ago when he described the use of incision, cautery and metal tubes to treat empyema [1]. The technique became widely used during the influenza epidemic of 1917 to drain post-pneumonic empyema [2]. In recent years, large-bore drains have been the mainstay of treatment for percutaneous drainage of pleural collections and they remain in use for post-surgical thoracic drainage. Indications for tube placement within the chest include pneumothorax, benign and malignant pleural effusion, parapneumonic effusion and empyema, and haemothorax. Traditional surgical teaching dictates that viscous fluid collections require large tubes for successful drainage [3,4]. Recent publications suggest that a variety of pleural collections can be adequately drained using small-bore catheters, often inserted under imaging guidance, avoiding the complications associated with the ‘blind’ insertion of large-bore chest tubes. It is likely that the evidence supporting the use of small-bore drains within the abdomen and pelvis may be applicable in the chest. It is also possible, but perhaps less likely, that dissemination of this evidence may end the not infrequent assertion by clinicians that patients ‘would have been better treated with a bigger drain’.

Chest drainage: clinical evaluation of a Seldinger drainage kit

Chest drain insertion is required in the intensive care unit and high dependency care setting. Catheter insertion may be required for pneumothorax both spontaneous and iatrogenic, for the drainage of pleural effusions, or for the drainage of empyemas. Large bore catheters are difficult to insert and may be associated with adverse complications.1 A new catheter system developed by SIMS Portex has been introduced to insert a small catheter into the chest. This has been developed to minimise the complications associated with conventional tube drainage. The catheter is inserted over a guide wire with dilation of the chest wall. The catheter is 285 mm long has two lateral eyes and an open end. Data are presented on 20 small-bore (12 French gauge) Seldinger chest drainage catheters. Three were placed in children two with spontaneous pneumothorax (10 and 15 yr) and one with parapneumonic effusion (7 yr). Seventeen further catheters were placed in adults: seven for pneumothoraces and 10 for effusions. Four catheters were inserted as emergencies for deteriorating respiratory function. These patients were all being ventilated on the intensive care unit. All catheters were inserted with ease into the pleural space. Ultrasound guidance for effusions to assess the presence of loculations, or X-ray diagnosis of the pneumothorax prior to catheter insertion was used for all cases. One catheter system needed to be removed due to apparent blockage. All the other catheters performed well draining an average of 2.1 litre of fluid for the effusions and reinflating the lung in all the patients with pneumothoraces. Small-bore catheter chest drainage is simple and effective.2 The use of a guide wire system has advantages over conventional open chest drain insertion. There is less possibility of damage to the underlying lung tissue, less probability of the introduction of air into the thoracic cavity and greater operator confidence. The catheter is more comfortable, easier to insert, and effective in clinical use. This study confirms that small catheters are effective for emergency and non-emergency pneumothorax and effusion drainage.3

07-47 Percutaneous abdominal abscess drainage: Effective use of small-bore catheters in selected patients

07-47 Percutaneous abdominal abscess drainage: Effective use of small-bore catheters in selected patients

Sclerotherapy for Malignant Pleural Effusions: A Prospective Randomized Trial of Bleomycin vs Doxycycline with Small-Bore Catheter Drainage

Malignant pleural effusions are a common problem for patients with metastatic disease. Most patients are treated with tube thoracostomy and sclerotherapy, although there remains no standard approach. The purpose of this study was to compare the efficacy of bleomycin with doxycycline sclerotherapy for the treatment of malignant pleural effusions using small-bore catheters. All patients with a symptomatic malignant pleural effusion referred for chest tube drainage and sclerotherapy over a 2-year period were considered eligible. Using image guidance, a 14F self-retaining catheter was inserted into the pleural space and connected to continuous wall suction. When drainage fell below 200 mL/d, patients were randomized to 60 U of bleomycin or 500 mg of doxycycline sclerotherapy. Response at 30 days was determined. One hundred six patients were enrolled in the study. Fifteen men (29%) and 37 women (71%) with a mean age of 57 years received bleomycin sclerotherapy. Twenty-one of the 29 patients (72%) alive and evaluable at 30 days had successful sclerotherapy. Twenty-three men (43%) and 31 women (57%) with a mean age of 61 years received doxycycline sclerotherapy. Twenty-three of the 29 patients (79%) alive and evaluable at 30 days had successful sclerotherapy. There was no significant difference in response rates between doxycycline and bleomycin (p=0.760). These data continue to support a role for small-bore chest drainage and sclerotherapy, although there was no significant difference in 30-day response rates between doxycycline and bleomycin.

Malignant Pleural Effusions: Recent Advances and Ambulatory Sclerotherapy

Malignant pleural effusions are a common problem in cancer patients with advanced disease. Patients typically present with progressive dyspnea, cough, and/or chest pain that significantly compromises their quality of life. Treatment is often palliative, usually consisting of sequential thoracenteses or tube thoracostomy with or without sclerotherapy. The traditional method of treatment--tube thoracostomy with large-bore chest tubes connected to continuous wall suction--requires hospitalization, is expensive, limits patient mobility, and can cause significant patient discomfort. More recent trials have explored new techniques, including thoracoscopic insufflation of talc and small-bore catheters. Most of these studies have been performed on inpatients, although a recent multi-institutional trial was initiated to evaluate the feasibility and efficacy of ambulatory (outpatient) pleural drainage and sclerotherapy using small-bore catheters. All patients fulfilling eligibility criteria had a small-bore catheter placed in the pleural space that was then connected to a closed gravity drainage bag system. When daily tube drainage was <100 mL, sclerotherapy was performed. Response rates at our institution demonstrated 10 patients (53%) had a complete response, 5 (26%) had a partial response, and 4 (21%) had progressive disease at 30-day follow-up. These preliminary results suggest ambulatory sclerotherapy is a safe, viable alternative to conventional inpatient treatment of malignant pleural effusions in a select group of patients.

Treating Malignant Pleural Effusions Cost Consciously

Malignant pleural effusions are associated with significant morbidity. Prompt clinical evaluation followed by aggressive treatment often results in successful palliation. This report summarizes the traditional and experimental approaches used in the management of malignant pleural effusion and provides an attempt at analysis of cost comparison and resource utilization associated with the use of various sclerosing agents. The standard sclerotherapy for malignant pleural effusions has routinely been performed as an inpatient procedure using a large-bore chest tube for drainage and instillation of a sclerosing agent. Use of a small-bore catheter for drainage and pleurodesis is associated with reduced patient discomfort and appears to be feasible and equally efficacious in the ambulatory setting. Results with the ambulatory procedure are preliminary but promising. Future comparisons with the traditional approach will allow therapy to be based not only on efficacy, but also on the use and expense of related resources.

Local reactions after injection of iodinated contrast material: Detection, management, and outcome

The authors assessed the frequency, sequelae, and risk factors of extravasation of intravenously administered iodinated contrast media. All patients with local reactions after intravenous injection of contrast media between November 1994 and December 1996 were studied. Comparison was made with data obtained from a control group of 100 patients with no local reactions who underwent contrast material-enhanced computed tomography (CT). Local reactions were reported in 56 (0.25%) of 22,254 patients who received intravenous injections of iodinated contrast media. Fifty-one patients experienced extravasation, and five patients experienced local irritation in the absence of clinically detectable extravasation. Extravasation occurred during CT (n = 46), urography (n = 4), and venography (n = 1). Contrast material was nonionic in 37 cases and conventional ionic in 14 cases of extravasation. Extravasated volumes exceeded 30 mL in 22 patients and 100 mL in six patients. Forty-five (80%) of 56 patients with local reactions had complete resolution of symptoms within 24 hours. Only four patients had symptoms for more than 48 hours. No surgery was required. Compared with the control group, patients with extravasation were significantly more likely to have been injected with small-bore catheters (21 or 22 gauge) and to have been injected at low or high rates. Symptoms of contrast medium extravasation usually resolve quickly. In patients with extravasation, injections are more likely to have been performed with techniques that vary from normal practice.

Pneumothorax after small-bore catheter placement for malignant pleural effusions.

The objective of this study was to evaluate the incidence and significance of pneumothorax after small-bore chest tube placement for symptomatic malignant pleural effusions. Over a 2-year period, 90 patients with a known primary malignant tumor and symptomatic pleural effusion were referred to the radiology service at Duke University Medical Center. All patients underwent placement of a small-bore chest tube with fluid drainage in preparation for intrapleural sclerotherapy. Two of these patients were excluded because of coexisting empyema (n=1) and thoracentesis (n=1). The remaining 88 patients (30 men and 58 women; 26-86 years old [mean, 60 years old], who had 90 chest tubes placed, formed our study group. The incidence, duration, and clinical significance of their pneumothoraces and the amount of pleural effusion drained were recorded. Among the 88 patients with 90 chest tubes, 27 patients with 28 chest tubes (31%) were found to have pneumothorax after the procedure. For 23 patients with 24 chest tubes, pneumothorax was evident on chest radiographs taken immediately after tube insertion and fluid drainage. Four patients with four chest tubes were found to have pneumothorax on chest radiographs taken the next day. No significant difference in the amount of fluid drained during the procedure was noted for patients with or without pneumothorax (831 ml versus 853 ml). No relationship between the size of each pneumothorax and the size of each drainage catheter was seen. The duration of pneumothorax ranged from 2 hr to 18 days (average, 3.5 days). Resolution of pneumothorax was seen in 22 (79%) of 28 cases; the remaining six cases of pneumothorax (21%) were stable, and the patients showed eventual fluid reaccumulation after chest tube removal and no sclerotherapy. No patient developed tension pneumothorax, respiratory distress, or other complications. Pneumothorax should be recognized as a common finding after chest tube placement and immediate fluid drainage for malignant pleural effusions. We suggest that this finding is related to rapid removal of fluid from a relatively stiff, noncompliant lung. Patients whose lungs do not fully re-expand in several days will probably not benefit from sclerotherapy. Their tubes may be removed without risk of an enlarging tension pneumothorax.

Palliative treatment of malignant pleural effusions: value of small-bore catheter thoracostomy and doxycycline sclerotherapy.

This study evaluates small-bore catheter thoracostomy combined with doxycycline sclerotherapy for palliative treatment of presumed malignant pleural effusions. Forty-seven consecutive patients referred from the medical oncology department to the thoracic radiology section with known primary malignant tumors and symptomatic pleural effusions over a 2-year period were treated with small-bore pleural catheter drainage followed by doxycycline sclerotherapy. Of the 47 patients, 20 (43%) died less than 30 days after sclerotherapy, one (2%) died without radiographic follow-up, and five (11%) were lost to follow-up. Twenty-one patients formed the study group. Response to treatment was defined based on findings on follow-up chest radiographs obtained 30 days after sclerotherapy as complete (no reaccumulation of pleural effusion), partial (accumulation above postpleurodesis level but below that at presentation), or as a failure (reaccumulation to the amount seen at presentation). Seventeen (81%) evaluable patients showed complete response to sclerotherapy, three (14%) showed a partial response, and one (5%) showed no response. All complete and partial responders were clinically improved with resolution of their shortness of breath. Therefore, 95% of evaluable patients had clinically and radiographically successful treatment. Six patients underwent sclerotherapy when their tube output was greater than 100 ml/24 hr. Five of the six had completely successful pleurodesis, and one failed to respond. Two (10%) of the 21 patients had greater than 150 ml drainage in the 24 hr after initial doxycycline administration and were therefore given a second dose of intrapleural doxycycline. Both of these patients subsequently had less than 150 ml drainage in an additional 24-hr observation period and went on to complete response. Complications included three patients (14%) with mild discomfort at the chest tube site during drainage, one patient (5%) with pain during instillation of doxycycline, and one patient (5%) with transient fever (38.3 degrees C body temperature) one day after sclerotherapy. Small-bore catheter thoracostomy followed by doxycycline sclerotherapy successfully resolves symptomatic pleural effusion in patients with known primary malignant tumors.

Hydrodynamic evaluation of intravenous infusion systems

We investigated the hydrodynamic characteristics of IV infusion sets for rapid fluid resuscitation. A simple technique has been devised for quantitative evaluation of the hydrodynamic characteristics of IV sets, including their components, for a range of infusion pressures. Previous investigations have measured the overall flow rate of infusion sets with and without IV catheters. This study presents a quantitative technique for measuring the resistance to flow of the IV delivery set as a whole as well as its components. An infusion set was measured with 14- and 18-gauge IV catheters while delivering fluid at infusion pressures between 50 (gravity) and 400 mm Hg. At gravity-driven infusion, the drip chamber imposes a resistance to flow of the same order as that of the catheter. At pressurized infusion with small-bore catheters, the catheter consumes the majority of the overall pressure drop. At pressurized infusion with a large-bore catheter or tubing, the standard drip chamber becomes the limiting component and imposes the largest resistance to flow. At gravity-delivered pressures (50 and 100 mm Hg), the only effective way of increasing flow rate (more than twofold) is to use a low-resistance drip chamber or to use two infusion sites. At pressurized delivery pressures (more than 200 mm Hg), increasing catheter size from 18 to 14 gauge would be more effective than doubling the number of infusion sets. Also, a more efficient drip chamber adds an important advantage. Finally, increasing the tubing diameter adds only minimal benefit.

Syringe-actuated metered dose inhalers: a quantitative laboratory evaluation of albuterol delivery through nozzle extensions.

The metered dose inhaler (MDI) is a device that can be used to supply aerosolized bronchodilators to the tracheobronchial tree of patients requiring endotracheal intubation. Because direct actuation of the MDI into the breathing circuit is inefficient, a technique of extending the MDI nozzle with small-bore, long, intravenous catheters has been devised. To facilitate connecting the MDI to the extension and actuating the release of aerosol, insertion of the MDI cannister into the barrel of a large syringe attached to the Luer hub of the extension has been proposed but not quantitatively evaluated. The purpose of this study was to test, in a laboratory model, the performance of syringe-actuated MDIs attached to nozzle extensions. The deposition of the bronchodilator albuterol in the delivery device and distal to the extension was quantified spectrophotometrically. Maximum distal delivery of drug from nozzle extensions fashioned from small-bore (19-gauge) catheters was 80% of the actuated release. Loss of drug to the inner surface of the syringe plus extension varied inversely with the number of successive actuations. Syringes from two manufacturers in two sizes were compared and found to perform comparably. Syringes could be attached to the Luer connector of the secondary sampling channel of special pediatric-sized endotracheal tubes (ETTs) and the channels were evaluated as nozzle extensions, with distal delivery > 80% as efficient as the 19-gauge intravenous catheter. We conclude that syringe actuation of MDIs through nozzle extensions is an efficient method for supplying the aerosol distal to the tip of the ETT.(ABSTRACT TRUNCATED AT 250 WORDS)

Continuous spinal anaesthesia

Summary We have reviewed the history, advantages and disadvantages, technique, materials, and problems associated with continuous spinal anaesthesia. While the recent reports of cauda equina syndrome after continuous spinal anaesthesia prompted the FDA to remove microcatheters from the USA market, continuous spinal anaesthesia with small-bore catheters is still used without complications in many countries. The mechanism that caused cauda equina syndrome to develop after continuous spinal anaesthesia may be the displacement of cerebrospinal fluid and exposure of the cauda equina to poorly distributed local anaesthetics that, at certain concentrations, are neurotoxic per se . We suggest steps that can be taken to prevent this from happening and we believe it is therefore possible to do continuous spinal anaesthesia safely and advantageously in selected patients.

The Clinician's Perspective on Parapneumonic Effusions and Empyema

Respondents at an interactive symposium on pleural space infections (n = 339) at the 1991 American College of Chest Physicians Annual Scientific Assembly recorded their personal management preferences for hypothetical patients with empyema. The group's preference was to treat pleural sepsis from an anaerobic multiloculated empyema by pleural decortication (49 percent); however, open thoracotomy with directed chest tube placement (22 percent), chest tube placement with intrapleural streptokinase (14 percent), placement of a single chest tube into the largest pleural loculus (8 percent), and placement of multiple small-bore catheters with computed tomographic guidance (7 percent) all had proponents. In the case of a multiloculated empyema not completely drained by a first chest tube in a nontoxic patient, the preference was drainage by a second chest tube, either a small-bore (42 percent) or a large-bore (36 percent) tube. The heterogeneity of responses suggests that prospective trials comparing treatment modalities are needed.

Changing clinical spectrum of spontaneous pneumothorax

The epidemiology and etiology of spontaneous pneumothorax (SP) are shifting away from the predominance of subpleural bleb disease as emphasized by most reports since that of Kjaergaard (Sweden, 1932). We conducted a retrospective review of all patients admitted to a large urban hospital with the diagnosis of SP over the past 8 years. Of 120 patients, 32 had the acquired immunodeficiency syndrome (AIDS) (group 1, 26.6%), 43 patients had classic subpleural bleb disease or chronic obstructive pulmonary disease with blebs (group 2, 35.8%), and 45 patients had nonbleb disease exclusive of AIDS (group 3, 37.5%). These three groups were studied with respect to primary success rates with differing modalities of therapy. Bilateral SP occurred in 34% of group 1 patients, 2% of group 2 patients, and 11% of group 3 patients. The in-hospital mortality was 34% in group 1 compared with 2% in group 2 and 4% in group 3. Thirty-four percent of group 1 patients had recurrent SP compared with 16% of group 2 patients and 8% of group 3 patients. This report describes the changing etiology and epidemiology of SP in a large urban hospital from 1983 to 1991 and represents the largest single-institution report of AIDS-related pneumothorax. Standardized therapy was shown to have predictably favorable results in patients with bleb disease and nonbleb disease exclusive of AIDS. SP in patients with AIDS was associated with a high mortality rate and primary treatment failure; small-bore catheters and nondrainage therapies have a very limited role in these patients.

Percutaneous CT-controlled cutting-needle biopsy of diffuse interstitial and alveolar lung diseases--the technic and results

Twenty-three patients underwent CT-guided large-bore biopsy of diffuse lung disease of clinically and radiologically indeterminate etiology. The procedure was preceded by negative transbronchial biopsy in 20 cases. CT-guided biopsies were performed with a 14-gauge Trucut-needle. Obtaining at least 3 specimens of different parts of the diseased area, a correct histologic diagnosis was achieved in all cases. The size of the histologic specimens (mean: 5-6 mm) exceeded that of the specimens obtained by transbronchial biopsy as reported in the literature. Two major complications occurred and included a rapidly developing tension pneumothorax treated by a small-bore catheter and one self-limited hemoptysis. Major advantages of percutaneous CT-guided biopsy are the nonsuperimposed and very sensitive imaging of lung alterations in diffuse lung diseases that allows evidence of adjacent less and more involved areas accessible by one biopsy approach. CT-guided large-bore biopsy with a cutting needle seems to be a very promising, accurate method in the pathomorphologic work-up of diffuse lung diseases rendering open biopsy unnecessary in many cases.

Sclerotherapy of malignant pleural effusion through sonographically placed small-bore catheters.

Pleural sclerosis after drainage with a small-bore catheter was performed in 21 patients with malignant pleural effusions. Intrapleural catheters 7- to 24-French in size were placed by using sonographic guidance. Tetracycline (18 patients) and bleomycin (four patients) were used as sclerosing agents (one patient had both). Clinical and radiologic follow-up was available on all patients until they died (range, 2 weeks to 25 months; mean, 3.6 months). Pleural sclerosis was successful in 15 (71%) of 21 patients. Two patients in whom pleurodesis failed had pleural sclerosis repeated, with one success and one failure. All of the failures were in patients in whom the amount of chest-tube drainage was more than 100 ml/day. Pleurodesis with tetracycline was painful in six patients; no pain was associated with use of bleomycin. Small pneumothoraces developed in four patients at the time of chest-tube placement, without consequence. A superimposed infection that developed in a patient having continuous drainage of pleural fluid was successfully treated with antibiotics. Pleural sclerotherapy can be performed through sonographically placed small-bore catheters with results comparable to those seen with large-bore, surgically placed catheters.

Permanent inflation of detachable balloons with a low-viscosity, hydrophilic polymerizing system.

A polymer system was developed for use in permanent inflation of detachable balloons, to avoid long-term reliance on the integrity of balloon shells or valve mechanisms. This system is based on 2-hydroxy-ethyl methacrylate (HEMA) as the monomer, in combination with a cross-linking agent and a water-soluble curing system. The low-viscosity, hydrophilic mixture can be exchanged through a small-bore catheter into a detachable balloon and polymerizes in 40-60 minutes at body temperature. Partially polymerized HEMA can cause vascular occlusion; hence, careful timing of balloon detachment is required. The evolution of the radiographic appearance of HEMA-filled balloons is predictable. The balloons remain radiopaque on plain radiographs as long as the balloon shell and valve mechanisms are competent. After rupture of the shell or failure of the valve mechanism, the balloons become invisible on plain radiographs but remain hyperattenuating on computed tomography scans.

Percutaneous Small Bore Catheter Drainage in the Management of Lung Abscesses

For patients with pyogenic lung abscesses who do not respond to medical therapy, thoracotomy with pulmonary resection is the widely-accepted treatment of choice. Six patients with lung abscess who failed to respond to conservative medical management were treated by percutaneous catheter drainage using small catheters (10 Fr or smaller). Five patients showed prompt clinical improvement and the sixth improved after a modification in antibiotic therapy. All patients recovered with radiographic resolution of the abscess and were well at followup periods from two months to two years. In such patients, percutaneous drainage with small catheters provides an excellent clinical result with minimal risk and trauma.

"Pigtail" catheter drainage in thoracic surgery.

Small-bore percutaneous drainage catheters have been used extensively in the management of abdominal disorders and are gaining acceptance in thoracic problems. The records have been reviewed in 44 consecutive patients in whom 53 small-bore catheters were placed for thoracic disease, including empyema, 20; effusion, 9; pneumothorax, 10; lung abscess, 4; and mediastinal cyst, 1. Insertion was performed under fluoroscopy in 88%, computed tomography in 6%, and ultrasonography in 6%. Catheters ranged in size from 6.5F to 12F, but catheter size did not seem to influence outcome (p = 0.6). There was complete resolution of the problem in 75% (33 of 44) of the patients, although 20% of them required more than one catheter. Treatment was successful in all cases of lung abscess. These patients had been previously treated with standard medical therapy for 12 to 53 days without significant improvement in their clinical condition. Patients with empyema composed the largest group treated. Eighty percent (16 of 20) of them had a loculated (LOC) process. The LOC group appeared to have a slightly better success rate than did the non-LOC group (75 versus 50%, p = 0.33). When the catheters failed to resolve the problem (empyema, 6; chylous effusion, 1; malignant effusion, 3; and spontaneous pneumothorax, 1, either operation (9.1%) or a standard thoracostomy tube (13.6%) was required. The complications rate was 20%, but most of these were minor problems including pneumothorax, 5; catheter occlusion 3; fractured catheter, 1; infection, 1; and significant subcutaneous emphysema, 1.(ABSTRACT TRUNCATED AT 250 WORDS)