Recommendations for Lung Ultrasound in Internal Medicine.

A growing amount of evidence prompts us to update the first version of recommendations for lung ultrasound in internal medicine (POLLUS-IM) that was published in 2018. The recommendations were established in several stages, consisting of: literature review, assessment of literature data quality (with the application of QUADAS, QUADAS-2 and GRADE criteria) and expert evaluation carried out consistently with the modified Delphi method (three rounds of on-line discussions, followed by a secret ballot by the panel of experts after each completed discussion). Publications to be analyzed were selected from the following databases: Pubmed, Medline, OVID, and Embase. New reports published as of October 2019 were added to the existing POLLUS-IM database used for the original publication of 2018. Altogether, 528 publications were systematically reviewed, including 253 new reports published between September 2017 and October 2019. The new recommendations concern the following conditions and issues: pneumonia, heart failure, monitoring dialyzed patients' hydration status, assessment of pleural effusion, pulmonary embolism and diaphragm function assessment. POLLUS-IM 2020 recommendations were established primarily for clinicians who utilize lung ultrasound in their everyday clinical work.

Essential Image Acquisition Protocols for Thoracic Ultrasonography.

Image acquisition is the technique of correct placement, holding, and manipulation of the ultrasound probe in an ultrasound examination for the purpose of answering a specific clinical question. We review the literature and discuss the image acquisition protocols used for thoracic ultrasound, explaining, where possible, the associated advantages, disadvantages, and alternatives. A better understanding of how to fine-tune image acquisition specifically for thoracic ultrasound will help physicians on all levels to standardise their practice and improve networking and collaboration. It will also lead to better-quality investigations and, potentially, new applications.

Competence in thoracic ultrasound.

Ultrasound examination is traditionally considered a safe and repeatable exam, but its use is highly operator-dependent. Because of this, lack of sufficient operator skills could lead to diagnostic errors and damage to patient safety related to unnecessary tests or interventional procedures. The indications for lung ultrasound include: diagnosis, quantification, and follow-up of different conditions for which acute respiratory failure or chest pain are the main clinical presentation. Clinicians should have theoretical and practical knowledge on: physics and technology of ultrasound, indications and methodology of ultrasound examination, normal thoracic anatomy identification by echography, and detection of signs of pleuro-pulmonary pathology. Consequently, according to international recommendations, core basic skills and minimum training recommendations for the practice of medical ultrasound and image acquisition are needed to ensure competence of clinicians using ultrasound.

Do declarative titles affect readers' perceptions of research findings? A randomized trial.

BACKGROUND: Many journals prohibit the use of declarative titles that state study findings, yet a few journals encourage or even require them. We compared the effects of a declarative versus a descriptive title on readers' perceptions about the strength of evidence in a research abstract describing a randomized trial. METHODS: Study participants (medical or dental students or doctors attending lectures) read two abstracts describing studies of a fictitious treatment (Anticox) for a fictitious condition (Green's syndrome). The first abstract (A1) described an uncontrolled, 10-patient, case series, and the second (A2) described a randomized, placebo-controlled trial involving 48 patients. All participants rated identical A1 abstracts (with a descriptive title) to provide baseline ratings and thus reduce the effects of inter-individual variability. Participants were randomized so that half rated a version of A2 with a descriptive title and half with a declarative title. For each abstract, participants indicated their agreement with the statement "Anticox is an effective treatment for pain in Green's syndrome" using 100 mm visual analogue scales (VAS) ranging from "disagree completely" to "agree completely." VAS scores were measured by an investigator who was unaware of group allocation. RESULTS: One hundred forty-four participants from four centres completed the study. There was no significant difference between the declarative and the descriptive title groups' confidence in the study conclusions as expressed on VAS scales-in fact, the mean difference between A1 and A2 was smaller for the declarative title group than that for the descriptive title group (32.6 mm, SD 27.4 vs. 39.8 mm, SD 22.6, respectively, p = 0.09). CONCLUSIONS: We found no evidence that the use of a declarative title affected readers' perceptions about study conclusions. This suggests that editors' fears that declarative titles might unduly influence readers' judgements about study conclusions may be unfounded, at least in relation to reports of randomized trials. However, our study design had several limitations, and our findings may not be generalizable to other situations.

Basic thoracic ultrasound for the respiratory physician.

Thoracic ultrasound (TUS) evolved in the last ten years as the method of choice for evaluating pleural abnormalities and for guiding lung procedures. TUS can "see" almost all structures in the chest, including thoracic wall, pleura, pleural space, the heart, the great vessels and the peripheral layers of the lungs. However, there is still a great need to develop TUS services in respiratory departments in Romania. To facilitate this development we reviewed the literature and selected what we considered to be essential practical information for the beginner in TUS, including technique, normal findings, and common abnormalities. Moreover, we describe here a step-by-step scanning technique for chest physicians. Our aim is to raise awareness of TUS. Because TUS is rapid, accurate, noninvasive and can be applied in any ward, we recommend facilitating the training of all junior respiratory doctors in this technique, as it is likely to improve patient experience, clinical effectiveness and to reduce costs with chest radiographs or CT scans in the future.

Assessing and combining repeated prognosis of physicians and temporal models in the intensive care.

OBJECTIVE: Recently, we devised a method to develop prognostic models incorporating patterns of sequential organ failure to predict the eventual hospital mortality at each day of intensive care unit (ICU) stay. In this study, we investigate using a real world setting how these models perform compared to physicians, who are exposed to additional information than the models. METHODS: We developed prognostic models for days 2-7 of ICU stay by data-driven discovery of patterns of sequential qualitative organ failure (SOFA) scores and embedding the patterns as binary variables in three types of logistic regression models. Type A models include the severity of illness score at admission (SAPS-II) and the SOFA patterns. Type B models add to these covariates the mean, max and delta (increments) of SOFA scores. Type C models include, in addition, the mean, max and delta in expert opinion (i.e. the physicians' prediction of mortality). RESULTS: Physicians had a statistically significantly better discriminative ability compared to the models without subjective information (AUC range over days: 0.78-0.79 vs. 0.71-0.74) and comparable accuracy (Brier score range: 0.15-0.18 vs. 0.16-0.18). However when we combined both sources of predictions, in Type C models, we arrived at a significantly superior discrimination as well as accuracy than the objective and subjective models alone (AUC range: 0.80-0.83; Brier score range: 0.13-0.16). CONCLUSION: The models and the physicians draw on complementary information that can be best harnessed by combining both prediction sources. Extensive external validation and impact studies are imperative to further investigate the ability of the combined model.

[The non-invasive ventilation protocol in use at the University Lewisham Hospital--London]. / Protocolul University Hospital Lewisham--Londra pentru ventilatia non-invaziva.

The term non-invasive ventilation (NIV) includes both continuous positive pressure ventilation (CPAP) and non-invasive (bi-level) positive pressure ventilation (NIPPV). The introduction of NIV in clinical practice improved significantly the outcomes in patients with respiratory failure. The fact that NIV machines are simple to use, do not require endotracheal intubation, and can save lives, has led to their increased use by non ITU personnel. However, for an efficient use of NIV it is very important that the patients are treated according to strict local protocols. In order to support the writing of local NIV protocols in Romania, we present here the NIV protocol in use at the University Lewisham Hospital, London, United Kingdom.

Learning predictive models that use pattern discovery--a bootstrap evaluative approach applied in organ functioning sequences.

An important problem in the Intensive Care is how to predict on a given day of stay the eventual hospital mortality for a specific patient. A recent approach to solve this problem suggested the use of frequent temporal sequences (FTSs) as predictors. Methods following this approach were evaluated in the past by inducing a model from a training set and validating the prognostic performance on an independent test set. Although this evaluative approach addresses the validity of the specific models induced in an experiment, it falls short of evaluating the inductive method itself. To achieve this, one must account for the inherent sources of variation in the experimental design. The main aim of this work is to demonstrate a procedure based on bootstrapping, specifically the .632 bootstrap procedure, for evaluating inductive methods that discover patterns, such as FTSs. A second aim is to apply this approach to find out whether a recently suggested inductive method that discovers FTSs of organ functioning status is superior over a traditional method that does not use temporal sequences when compared on each successive day of stay at the Intensive Care Unit. The use of bootstrapping with logistic regression using pre-specified covariates is known in the statistical literature. Using inductive methods of prognostic models based on temporal sequence discovery within the bootstrap procedure is however novel at least in predictive models in the Intensive Care. Our results of applying the bootstrap-based evaluative procedure demonstrate the superiority of the FTS-based inductive method over the traditional method in terms of discrimination as well as accuracy. In addition we illustrate the insights gained by the analyst into the discovered FTSs from the bootstrap samples.

Discovery and integration of univariate patterns from daily individual organ-failure scores for intensive care mortality prediction.

OBJECTIVES: The current established mortality predictive models in the intensive care rely only on patient information gathered within the first 24 hours of admission. Recent research demonstrated the added prognostic value residing in the sequential organ-failure assessment (SOFA) score which quantifies on each day the cumulative patient organ derangement. The objective of this paper is to develop and study predictive models that also incorporate univariate patterns of the six individual organ systems underlining the SOFA score. A model for a given day d predicts the probability of in-hospital mortality. MATERIALS AND METHODS: We use the logistic framework to combine a summary statistic of the historic SOFA information for a patient together with selected dummy variables indicating the occurrence of univariate frequent temporal patterns of individual organ system functioning. We demonstrate the application of our method to a large real-life data set from an intensive care unit (ICU) in a teaching hospital. Model performance is tested in terms of the AUC and the Brier score. RESULTS: An algorithm for categorization, discovery, and selection of univariate patterns of individual organ scores and the induction of predictive models. The case-study resulted in six daily models corresponding to days 2-7. Their AUC ranged between 0.715 and 0.794 and the Brier scores between 0.161 and 0.216. Models using only admission data but recalibrated for days 2-7 generated AUC ranging between 0.643 and 0.761 and Brier scores ranged between 0.175 and 0.230. CONCLUSIONS: The results show that temporal organ-failure episodes improve predictions' quality in terms of both discrimination and calibration. In addition, they enhance the interpretability of models. Our approach should be applicable to many other medical domains where severity scores and sub-scores are collected.

Reduction of persistent air leak with endoscopic valve implants.

The standard management of air leaks due to persistent bronchopleural fistula involves chest drainage and occasionally pleurodesis, with intractable cases requiring surgical decortication or surgical repair. However, some of these patients may be at high risk for surgery, particularly if they have already had thoracic surgery or have other medical problems; for this group there is a need for less invasive methods of stopping or reducing air leaks. Emphasys endobronchial valves (EBV) are occlusive devices designed primarily for endoscopic lung volume reduction in emphysema. Because the device is a one-way inspiratory airway blocker, it is possible that it could be used in controlling persistent air leaks while maintaining the drainage of secretions. Two cases are reported of persistent air leaks that were managed by endoscopic occlusion with EBV. In one case complete stoppage of the air leak was achieved with immediate clinical benefits. The second patient died 5 days after treatment from additional complications apparently not related to the procedure. Endobronchial blockage may be a useful salvage procedure for patients with persistent air leak for whom there is no other treatment available.

Discovery and inclusion of SOFA score episodes in mortality prediction.

Predicting the survival status of Intensive Care patients at the end of their hospital stay is useful for various clinical and organizational tasks. Current models for predicting mortality use logistic regression models that rely solely on data collected during the first 24h of patient admission. These models do not exploit information contained in daily organ failure scores which nowadays are being routinely collected in many Intensive Care Units. We propose a novel method for mortality prediction that, in addition to admission-related data, takes advantage of daily data as well. The method is characterized by the data-driven discovery of temporal patterns, called episodes, of the organ failure scores and by embedding them in the familiar logistic regression framework for prediction. Our method results in a set of D logistic regression models, one for each of the first D days of Intensive Care Unit stay. A model for day d

Mechanisms of immunotherapy in allergic rhinitis.

Allergic rhinitis is a common condition, but many people still experience suboptimal control of symptoms despite measures such as allergen avoidance, intra-nasal steroids and antihistamines. Specific immunotherapy (SIT) has been used for many years, but though many studies show clinical efficacy, its mechanism of action is still not clearly understood. Earlier studies showed changes in antibodies and it may be that SIT works through mechanisms that alter the ratio of 'protective' IgG4 to 'pro-allergenic' IgE. Other studies have shown a reduction in eosinophil migration to nasal mucosa as well as a reduction in inflammatory mediator release including basophil histamine release. More recent studies have proposed that SIT works through inhibition of T-helper 2 lymphocytes (Th2) which preferentially produce cytokines that promote allergic responses. SIT may cause a deviation from Th2 to Th1 (T-helper 1 lymphocytes) or may induce T-regulatory cells (T-regs) which inhibit Th2 responses directly or through inhibitory cytokines.