Risk of pulmonary diseases in osteogenesis imperfecta in Denmark - A register-based cohort study.

BACKGROUND: Osteogenesis Imperfecta (OI) is a rare hereditary disease mainly resulting in reduced or altered collagen type I. Collagen type I is a major constituent of the respiratory system, and normal collagen type I is vital for the pulmonary tissue function. RESEARCH QUESTIONS: Does patient with OI have increased admission rates due to pulmonary diseases compared to the general population? STUDY DESIGN AND METHODS: This is a register-based, nationwide, cohorts study, including all patients with OI in Denmark and a reference population. From 1st of January 1995 until the 31st of December 2018, we evaluated the rates of admissions due to asthma, chronic obstructive pulmonary disease (COPD) and pneumonia as well as the use of broncodilatator drugs and antibiotics comparing individuals with OI to the reference population. RESULTS: We included 862 individuals with OI and 4,283 persons in the reference population covering 15952 and 79471 person years of observation respectively in the two cohorts. Admissions rate (IR) was highest in women with OI aged 65+ years with 56.3 admissions per 1000 person years and 29.4 admissions per 1000 person years in the reference population (amounting to an admissions rate ratio (IRR) 1.91 [95%CI 1.38-2.70]) . The highest admission rate in men with OI was found amongst the participants aged 0-18 years IR 30.4 per 1,000 person years and IR 7.7 per 1,000 person years in the reference population (IRR 4.92 [3.79-6.38]). We found a higher proportion of long and short acting broncodilatator drug users in the OI cohort, but no increased use of antibiotics. INTERPRETATION: Overall, the admission rates for respiratory diseases were low in the OI cohort, but a higher relative risk of hospitalizations due to respiratory disease than in the general population. Timely diagnosis and treatment of respiratory complications in individuals with OI is warranted.

Effect of a Point-of-Care Ultrasound-Driven vs Standard Diagnostic Pathway on 24-Hour Hospital Stay in Emergency Department Patients with Dyspnea-Protocol for A Randomized Controlled Trial.

Purpose: Point-of-care ultrasound (POCUS) helps emergency department (ED) physicians make prompt and appropriate decisions, but the optimal diagnostic integration and potential clinical benefits remain unclear. We describe the protocol and statistical analysis plan for a randomized controlled trial. The objective is to determine the effect of a POCUS-driven diagnostic pathway in adult dyspneic ED patients on the proportion of patients having a hospital stay of less than 24 hours when compared to the standard diagnostic pathway. Patients and Methods: This is a multicenter, randomized, investigator-initiated, open-labeled, pragmatic, controlled trial. Adult ED patients with chief complaint dyspnea are eligible. Patients are randomized (1:1) to the POCUS-driven diagnostic pathway or standard diagnostic pathway, with 337 patients in each group. The primary outcome is the proportion of patients having a hospital stay (from ED arrival to hospital discharge) of less than 24 hours. Key secondary outcomes include hospital length-of-stay, 72-hour revisits, and 30-day hospital-free days. Conclusion: Sparse evidence exists for any clinical benefit from a POCUS-integrated diagnostic pathway. The results from this trial will help clarify the promising signals for POCUS to influence patient care among ED patients with dyspnea.

Handheld Ultrasound Devices Used by Newly Certified Operators for Pneumonia in the Emergency Department-A Diagnostic Accuracy Study.

The diagnostic accuracy of handheld ultrasound (HHUS) devices operated by newly certified operators for pneumonia is unknown. This multicenter diagnostic accuracy study included patients prospectively suspected of pneumonia from February 2021 to February 2022 in four emergency departments. The index test was a 14-zone focused lung ultrasound (FLUS) examination, with consolidation with air bronchograms as diagnostic criteria for pneumonia. FLUS examinations were performed by newly certified operators using HHUS. The reference standard was computed tomography (CT) and expert diagnosis using all medical records. The sensitivity and specificity of FLUS and chest X-ray (CXR) were compared using McNemar's test. Of the 324 scanned patients, 212 (65%) had pneumonia, according to the expert diagnosis. FLUS had a sensitivity of 31% (95% CI 26-36) and a specificity of 82% (95% CI 78-86) compared with the experts' diagnosis. Compared with CT, FLUS had a sensitivity of 32% (95% CI 27-37) and specificity of 81% (95% CI 77-85). CXR had a sensitivity of 66% (95% CI 61-72) and a specificity of 76% (95% CI 71-81) compared with the experts' diagnosis. Compared with CT, CXR had a sensitivity of 69% (95% CI 63-74) and a specificity of 68% (95% CI 62-72). Compared with the experts' diagnosis and CT diagnosis, FLUS performed by newly certified operators using HHUS devices had a significantly lower sensitivity for pneumonia when compared to CXR (p < 0.001). FLUS had a significantly higher specificity than CXR using CT diagnosis as a reference standard (p = 0.02). HHUS exhibited low sensitivity for pneumonia when used by newly certified operators.

Advances in the diagnosis and follow-up of pleural lesions: a scoping review.

INTRODUCTION: Pleural lesions may have heterogeneous presentation and causes. In recent years, there have been significant advances in pleural lesions diagnostics. The aim of this review is to provide an overview of the state-of-the-art, and recent updates for diagnostic modalities and monitoring regimes for pleural lesions. AREAS COVERED: A literature search was conducted through PubMed and Web of Science for relevant articles published from 1 January 2000- 1 March 2023. This article critically appraises the radiological modalities and biopsy techniques that are employed in pleural lesions diagnostics, including chest radiography, thoracic ultrasound, computed tomography, F-fluorodeoxyglycose positron emission tomography, magnetic resonance imaging, percutaneous, and thoracoscopic pleural biopsies with reference to their strengths, limitations, and clinical use. The review asserts also the available literature regarding monitoring algorithms. EXPERT OPINION: Despite the recent advances in the field, there are several key areas for improvement, including the development and validation of minimal invasive methods and tools for risk stratification, the integration of multi-omics technologies, the implementation of standardized, evidence-based diagnostic and monitoring guidelines and increased focus on research and patient-centric approaches. The broad establishment of dedicated pleural clinics may significantly assist toward this direction.

Utility of ultrasound in the diagnostic work-up of suspected pulmonary embolism: an open-label multicentre randomized controlled trial (the PRIME study).

Background: Prevalence of pulmonary embolism (PE) in patients referred to diagnostic imaging is decreasing, indicating a need for improving patient selection. The aim of this study was to assess reduction in referral to diagnostic imaging by integrating a bespoke ultrasound protocol and describe associated failure rate and adverse events in patients with suspected PE. Methods: In a randomized open-label multicentre trial spanning June 18, 2021, through Feb 1, 2023, adult patients with suspected PE and 1) a Wells score of 0-6 and elevated age-adjusted D-dimer or 2) Wells score >6 were randomly assigned 1:1 to direct diagnostic imaging (controls) or focused lung, cardiac, and deep venous ultrasound by unblinded investigators. Ultrasound could: 1) dismiss PE if no signs of PE and low clinical suspicion or an alternate diagnosis, 2) confirm PE in case of visible venous thrombus, ≥2 subpleural infarctions, McConnell's, or D-sign, or 3) refer to diagnostic imaging if neither category was fulfilled or a patient with confirmed PE by ultrasound required admission. Primary endpoint was proportion of patients referred to diagnostic imaging. Outcome assessors were not blinded to group assignment. All included participants were included in safety analyses. The trial was registered at clinicaltrials.gov (NCT04882579). Findings: A total of 150 patients were recruited, of whom 73 were randomized to ultrasound. Among 77 controls referred to diagnostic imaging, 26 patients had PE confirmed. In the ultrasound group, 40 patients were referred to diagnostic imaging of whom 20 had PE, reducing referral for diagnostic imaging by 45.2% (95% CI: 34.3-56.6, p < 0.0001). Three further PEs were diagnosed by presence of a DVT. During 3-month follow-up, the number of patients who did not receive anticoagulation but was diagnosed with PE was two (4%; 95% CI: 1.1-13.5) and none (0%; 95% CI: 0.0-7.0) in the ultrasound and control group, respectively. Interpretation: Ultrasound substantially reduced referral to diagnostic imaging in suspected PE. Albeit with an unacceptable failure rate. Funding: University of Southern Denmark, Odense University Hospital, Master Carpenter Sophus Jacobsen and wife's foundation, Engineer K. A. Rhode and wife foundation.

ERS Statement on Benign Pleural Effusions in Adults.

The incidence of non-malignant pleural effusions (NMPE) far outweighs that of malignant pleural effusions (MPE) and is estimated to be at least 3-fold higher. These so called "benign" effusions do not follow a "benign course" in many cases, with mortality rates matching and sometimes exceeding that of MPEs. In addition to the impact on patients, healthcare systems are significantly affected, with recent US epidemiological data demonstrating that 75% of resource allocation for pleural effusion management is spent on NMPEs (excluding empyema). Despite this significant burden of disease, and by existing at the junction of multiple medical specialties, reflecting a heterogenous constellation of medical conditions, NMPEs are rarely the focus of research or the subject of management guidelines. With this ERS Taskforce, we assembled a multi-specialty collaborative across eleven countries and three continents to provide a Statement based on systematic searches of the medical literature to highlight evidence in the management of the following clinical areas: a diagnostic approach to transudative effusions, heart failure, hepatic hydrothorax, end stage renal failure, benign asbestos related pleural effusion, post-surgical effusion and non-specific pleuritis.

Added value of EUS-B-FNA to bronchoscopy and EBUS-TBNA in diagnosing and staging of lung cancer.

Background: Bronchoscopy and EBUS are standard procedures in lung cancer work-up but have low diagnostic yield in lesions outside the central airways and hilar/mediastinal lymph nodes. Growing evidence on introducing the EBUS endoscope into the oesophagus (EUS-B) in the same session as bronchoscopy/EBUS gives access to new anatomical areas that can be safely biopsied. Objective: To summarize the current evidence of the added value of EUS-B-FNA to bronchoscopy and EBUS-TBNA in lung cancer work-up. Methods: A narrative review. Results: Few randomized trials or prospective studies are available. Prospective studies show that add-on EUS-B-FNA increases diagnostic yield when sampling abnormal mediastinal lymph nodes, para-oesophageal lung and left adrenal gland. A large retrospective series on EUS-B-FNA from retroperitoneal lymph nodes suggests high diagnostic yield without safety concerns, as do casuistic reports on EUS-B-FNA from mediastinal pleural thickening, pancreatic lesions, ascites fluid and pericardial effusions. No study has systematically assessed both diagnostic yield, safety, patient reported outcomes, adverse events and costs. Conclusion: The diagnostic value of add-on EUS-B to standard bronchoscopy and EBUS in lung cancer work-up appears very promising without safety concerns, giving the pulmonologist access to a variety of sites out of reach with other minimally invasive techniques. Little is known on patient-reported outcomes and costs. Future and prospective research should focus on effectiveness aspects to clarify whether overall benefits of add-on EUS-B sufficiently exceed overall downsides.

Patient-Reported Outcome Measures in Patients with and without Non-Expandable Lung Secondary to Malignant Pleural Effusion-A Single-Centre Observational Study.

BACKGROUND: Malignant pleural effusion (MPE) affects up to 15% of patients with malignancy, and the prevalence is increasing. Non-expandable lung (NEL) complicates MPE in up to 30% of cases. However, it is not known if patients with malignant pleural effusion and NEL are more symptomatic in activities of daily living compared to patients with MPE with expandable lung. METHODS: This was an observational study on consecutively recruited patients with MPE from our pleural clinic. Before thoracentesis, patients completed patient-reported outcomes on cancer symptoms (ESAS), health-related quality of life (5Q-5D-5L), and dyspnoea scores. Following thoracentesis, patients scored dyspnoea relief and symptoms during thoracentesis. Data on focused lung ultrasound and pleural effusion biochemistry were collected. The non-expandable lung diagnosis was made by pleural experts based on radiological and clinical information. RESULTS: We recruited 43 patients, including 12 with NEL (28%). The NEL cohort resembled those from previous studies concerning ultrasonography, pleural fluid biochemistry, and fewer cases with high volume thoracentesis. Patients with and without NEL were comparable concerning baseline demography. The 5Q-5D-5L utility scores were 0.836 (0.691-0.906) and 0.806 (0.409-0.866), respectively, for patients with and without NEL. We observed no between-group differences in symptom burden or health-related quality of life. CONCLUSION: While the presence of NEL affects the clinical management of recurrent MPE, the presence of NEL seems not to affect patients' overall symptom burden in patients with MPE.

The effect of focused lung ultrasonography on antibiotic prescribing in patients with acute lower respiratory tract infections in Danish general practice: study protocol for a pragmatic randomized controlled trial (PLUS-FLUS).

BACKGROUND: The use of antibiotics is a key driver of antimicrobial resistance and is considered a major threat to global health. In Denmark, approximately 75% of antibiotic prescriptions are issued in general practice, with acute lower respiratory tract infections (LRTIs) being one of the most common indications. Adults who present to general practice with symptoms of acute LRTI often suffer from self-limiting viral infections. However, some patients have bacterial community-acquired pneumonia (CAP), a potential life-threatening infection, that requires immediate antibiotic treatment. Importantly, no single symptom or specific point-of-care test can be used to discriminate the various diagnoses, and diagnostic uncertainty often leads to (over)use of antibiotics. At present, general practitioners (GPs) lack tools to better identify those patients who will benefit from antibiotic treatment. The primary aim of the PLUS-FLUS trial is to determine whether adults who present with symptoms of an acute LRTI in general practice and who have FLUS performed in addition to usual care are treated less frequently with antibiotics than those who only receive usual care. METHODS: Adults (≥ 18 years) presenting to general practice with acute cough (< 21 days) and at least one other symptom of acute LRTI, where the GP suspects a bacterial CAP, will be invited to participate in this pragmatic randomized controlled trial. All participants will receive usual care. Subsequently, participants will be randomized to either the control group (usual care) or to an additional focused lung ultrasonography performed by the GP (+ FLUS). The primary outcome is the proportion of participants with antibiotics prescribed at the index consultation (day 0). Secondary outcomes include comparisons of the clinical course for participants in groups. DISCUSSION: We will examine whether adults who present with symptoms of acute LRTI in general practice, who have FLUS performed in addition to usual care, have antibiotics prescribed less frequently than those given usual care alone. It is highly important that a possible reduction in antibiotic prescriptions does not compromise patients' recovery or clinical course, which we will assess closely. TRIAL REGISTRATION: ClinicalTrials.gov NCT06210282. Registered on January 17, 2024.

More than 20 procedures are necessary to learn small bowel capsule endoscopy: Learning curve pilot study of 535 trainee cases.

Background and study aims The number of procedures needed to acquire a sufficient level of skills to perform an unassisted evaluation of small bowel capsule endoscopy (SBCE) is unknown. We aimed to establish learning curves, diagnostic accuracy, and the number of procedures needed for reviewing small bowel capsule endoscopies unassisted. Methods An expert panel developed a 1-day course including lessons (examination, anatomy, and pathology) and hands-on training. After completing the course, participants received 50 cases in a randomized sequence. An interactive questionnaire about landmarks, findings, and diagnosis followed each case. After submitting the questionnaire, participants received feedback. Data are presented using CUSUM (cumulative sum control chart) learning curves and sensitivity/specificity analyses compared with expert opinions. Results We included 22 gastroenterologists from 11 different Danish hospitals. A total of 535 cases were reviewed (mean: 28; range: 11-50). CUSUM plots demonstrated learning progression for diagnosis and findings during the course, but none of the participants reached a learning plateau with sufficient competencies. The sensitivity for all findings was 65% (95% confidence interval [CI] 0.51-0.82) for the first 20 procedures and 67% (95% CI 0.58-0.73) from case 21 until completion or dropout. The specificity was 63% (95% CI 0.52-0.74) for the first 20 procedures and 57% (95% CI 0.37-0.77) for the rest. Conclusions Our data indicate that learning SBCE may be more difficult than previously recognized due to low discriminative abilities after 20 cases except for the identification of CD. This indicates that 20 SBCE cases may not be sufficient to achieve competency for reviewing SBCE without supervision.

Proteome and Dihydrorhodamine Profiling of Bronchoalveolar Lavage in Patients with Chronic Pulmonary Aspergillosis.

Neutrophil and (alveolar) macrophage immunity is considered crucial for eliminating Aspergillus fumigatus. Data derived from bronchoalveloar lavage (BAL) characterizing the human immuno-pulmonary response to Aspergillus fumigatus are non-existent. To obtain a comprehensive picture of the immune pathways involved in chronic pulmonary aspergillosis (CPA), we performed proteome analysis on AL of 9 CPA patients and 17 patients with interstitial lung disease (ILD). The dihydrorhodamine (DHR) test was also performed on BAL and blood neutrophils from CPA patients and compared to blood neutrophils from healthy controls (HCs). BAL from CPA patients primarily contained neutrophils, while ILD BAL was also characterized by a large fraction of lymphocytes; these differences likely reflecting the different immunological etiologies underlying the two disorders. BAL and blood neutrophils from CPA patients displayed the same oxidative burst capacity as HC blood neutrophils. Hence, immune evasion by Aspergillus involves other mechanisms than impaired neutrophil oxidative burst capacity per se. CPA BAL was enriched by proteins associated with innate immunity, as well as, more specifically, with neutrophil degranulation, Toll-like receptor 4 signaling, and neutrophil-mediated iron chelation. Our data provide the first comprehensive target organ-derived immune data on the human pulmonary immune response to Aspergillus fumigatus.

Ultrasound in predicting improvement in dyspnoea after therapeutic thoracentesis in patients with recurrent unilateral pleural effusion.

Background: In patients with recurrent pleural effusion, therapeutic thoracentesis is one way of relief. Correct prediction of which patients will experience relief following drainage may support the management of these patients. This study aimed to assess the association between ultrasound (US) characteristics and a relevant improvement in dyspnoea immediately following drainage. Methods: In a prospective, observational study, patients with recurrent unilateral pleural effusion underwent US evaluation of effusion characteristics and diaphragm movement measured by M-mode and the Area method before and right after drainage. The level of dyspnoea was assessed using the modified Borg scale (MBS). A minimal important improvement in dyspnoea was defined as delta MBS ≥ 1. Results: In the 104 patients included, 53% had a minimal important improvement in dyspnoea following thoracentesis. We found no association between US-characteristics, including diaphragm shape or movement (M-mode or the Area method), and a decrease in dyspnoea following drainage. Baseline MBS score ≥ 4 and a fully drained effusion were significant correlated with a minimal important improvement in dyspnoea (OR 3.86 (1.42-10.50), p = 0.01 and 2.86 (1.03-7.93), p = 0.04, respectively). Conclusions: In our study population, US-characteristics including assessment of diaphragm movement or shape was not associated with a minimal important improvement in dyspnoea immediately following thoracentesis.

Pleural disease.

The incidence of pleural disease is increasing and the mortality and morbidity is high. Many recent RCTs have resulted in evidence-based guidelines published in 2023, pointing towards a more individualized and specialized management. Most patients with pleural disease are admitted at the A and E but can be managed in outpatient clinics. Thus, there is a need to establish specialized, multidisciplinary pleural clinics to ensure optimal, individualized and evidence-based management of the increasing number of patients with pleural disease in Denmark, as argued in this review.

Improving diagnostics using extended point-of-care testing during in-home assessments of older adults with signs of emerging acute disease: a prospective observational non-randomised pilot and feasibility study.

BACKGROUND: Delayed recognition of acute disease among older adults hinders timely management and increases the risk of hospital admission. Point-of-Care testing, including Focused Lung Ultrasound (FLUS) and in-home analysis of biological material, may support clinical decision-making in suspected acute respiratory disease. The aim of this study was to pilot test the study design for a planned randomised trial, investigate whether in-home extended use of point-of-care testing is feasible, and explore its' potential clinical impact. METHODS: A non-randomised pilot and feasibility study was conducted during September-November 2021 in Kolding Municipality, Denmark. A FLUS-trained physician accompanied an acute community nurse on home-visits to citizens aged 65 + y with signs of acute respiratory disease. The acute community nurses did a clinical assessment (vital signs, capillary C-reactive protein and haemoglobin) and gave a presumptive diagnosis. Subsequently, the physician performed FLUS, venipuncture with bedside analysis (electrolytes, creatinine, white blood cell differential count), nasopharyngeal swab (PCR for upper respiratory pathogens), and urine samples (flow-cytometry). Primary outcomes were feasibility of study design and extended point-of-care testing; secondary outcome was the potential clinical impact of extended point-of-care testing. RESULTS: One hundred consecutive individuals were included. Average age was 81.6 (SD ± 8.4). Feasibility of study design was acceptable, FLUS 100%, blood-analyses 81%, PCR for upper respiratory pathogens 79%, and urine flow-cytometry 4%. In addition to the acute community nurse's presumptive diagnosis, extended point-of-care testing identified 34 individuals with a condition in need of further evaluation by a physician. CONCLUSION: Overall, in-home assessments with extended point-of-care testing are feasible and may aid to identify and handle acute diseases in older adults.

Detection of Interstitial Lung Disease in Rheumatoid Arthritis by Thoracic Ultrasound: A Diagnostic Test Accuracy Study.

OBJECTIVE: To determine the diagnostic accuracy of thoracic ultrasound (TUS) for detecting interstitial lung disease (ILD) in rheumatoid arthritis (RA) with respiratory symptoms. METHODS: Individuals with RA visiting rheumatologic outpatient clinics in the Region of Southern Denmark were systematically screened for dyspnea, cough, recurrent pneumonia, prior severe pneumonia, or a chest x-ray indicating interstitial abnormalities. Eighty participants with a positive screening were consecutively included. Individuals were not eligible if they had a chest high-resolution computed tomography (HRCT) less than 12 months ago or were already diagnosed with ILD. A blinded TUS expert evaluated TUS, and TUS was registered as positive for ILD if at least 10 B-lines or bilateral thickened and fragmented pleura were present. The primary outcomes were TUS's sensitivity, specificity, and positive predictive value and negative predictive value. An ILD-specialized thoracic radiologist assessed HRCT, followed by a multidisciplinary team discussion, which was the reference standard. The accepted window of HRCT was less than 30 days after TUS was performed. RESULTS: A total of 77 participants received HRCT less than 30 days after TUS, and 23 (30%) were diagnosed with ILD. TUS had a sensitivity of 82.6% (95% confidence interval [CI] 61.2%-95.0%) and a specificity of 51.9% (95% CI 37.8%-65.7%), corresponding to a positive predictive value of 42.2% (95% CI 27.7%-57.8%) and a negative predictive value of 87.5% (95% CI 71.0%-96.5%). CONCLUSION: To our knowledge, this prospective study is the first to use respiratory symptoms in RA as inclusion criteria. Systematic screening for respiratory symptoms combined with TUS can reduce the diagnostic delay of ILD in RA.

Lung Ultrasound Reproducibly Outperforms Computed Tomography in the Detection of Extravascular Lung Water in Patients Undergoing Haemodialysis.

BACKGROUND: Lung ultrasound (LUS) is increasingly used as an extension of physical examination, informing clinical diagnosis, and decision making. There is particular interest in the assessment of patients with pulmonary congestion and extravascular lung water, although gaps remain in the evidence base underpinning this practice as a result of the limited evaluation of its inter-rater reliability and comparison with more established radiologic tests. METHODS: 30 patients undergoing haemodialysis were prospectively recruited to an observational cohort study (NCT01949402). Patients underwent standardised LUS assessment before, during and after haemodialysis; their total LUS B-line score was generated, alongside a binary label of whether appearances were consistent with an interstitial syndrome. LUS video clips were recorded and independently scored by two blinded expert clinician sonographers. Low-dose non-contrast thoracic CT, pre- and post dialysis, was used as a "gold standard" radiologic comparison. RESULTS: LUS detected a progressive reduction in B-line scores in almost all patients undergoing haemodialysis, correlating with the volume of fluid removed once individuals with no or minimal B-lines upon pre-dialysis examination were discounted. When comparing CT scans pre- and post dialysis, radiologic evidence of the change in fluid status was only identified in a single patient. CONCLUSIONS: This is the first study to demonstrate that LUS detects changes in extravascular lung water caused by changing fluid status during haemodialysis using a blinded outcome assessment and that LUS appears to be more sensitive than CT for this purpose. Further research is needed to better understand the role of LUS in this and similar patient populations, with the aim of improving clinical care and outcomes.

National survey on management of spontaneous pneumothorax from emergency department to specialised treatment: room for improvement.

Introduction: Spontaneous pneumothorax (SP) affects both young, otherwise healthy individuals and older persons with known underlying pulmonary disease. Initial management possibilities are evolving and range from observation to chest tube insertion. SP guidelines suggest an individualized approach based on multiple factors such as symptoms, size of pneumothorax, comorbidity and patient preference. Aim: With this Danish national survey we aimed to map organization of care including involved specialties, treatment choice, training, and follow-up plans to identify aspects, and optimization of spontaneous pneumothorax management. Method: A survey developed by the national interest group for pleural medicine was sent to all departments of emergency medicine, thoracic surgery, respiratory medicine, and to relevant departments of abdominal or orthopaedic surgery. Results: The response rate was 75 % (47 of 65). Overall, 21% of responding departments had no guideline for SP management, which was provided by multiple specialties with marked heterogeneity in choice of treatment including tube size, management during admission, and referral procedure to follow-up. Few departments required procedure training, and nearly all of the responders called for improvements in management of pneumothorax. Conclusion: This survey suggests that SP management and care is delivered heterogeneously across Danish hospitals with marked difference between respiratory physicians, emergency physicians, general surgeons and thoracic surgeons. It is therefore likely that management is sub-optimal. There is a need for a common Danish SP guideline to ensure optimal treatment across involved specialties.

Thrombelastography and Conventional Coagulation Markers in Chronic Obstructive Pulmonary Disease: A Prospective Paired-Measurements Study Comparing Exacerbation and Stable Phases.

Chronic Obstructive Pulmonary Disease (COPD) exacerbation is known for its substantial impact on morbidity and mortality among affected patients, creating a significant healthcare burden worldwide. Coagulation abnormalities have emerged as potential contributors to exacerbation pathogenesis, raising concerns about increased thrombotic events during exacerbation. The aim of this study was to explore the differences in thrombelastography (TEG) parameters and coagulation markers in COPD patients during admission with exacerbation and at a follow-up after discharge. This was a multi-center cohort study. COPD patients were enrolled within 72 h of hospitalization. The baseline assessments were Kaolin-TEG and blood samples. Statistical analysis involved using descriptive statistics; the main analysis was a paired t-test comparing coagulation parameters between exacerbation and follow-up. One hundred patients participated, 66% of whom were female, with a median age of 78.5 years and comorbidities including atrial fibrillation (18%) and essential arterial hypertension (45%), and sixty-five individuals completed a follow-up after discharge. No significant variations were observed in Kaolin-TEG or conventional coagulation markers between exacerbation and follow-up. The Activated Partial Thromboplastin Clotting Time (APTT) results were near-significant, with p = 0.08. In conclusion, TEG parameters displayed no significant alterations between exacerbation and follow-up.

Extended use of point-of-care technology versus usual care for in-home assessment by acute community nurses in older adults with signs of potential acute respiratory disease: an open-label randomised controlled trial protocol.

BACKGROUND: Due to ageing-related physiological changes, diagnosing older adults is challenging. Delayed disease recognition may lead to adverse health outcomes and increased hospitalisation, necessitating the development of new initiatives for timely diagnosis and treatment of older adults. Point-of-care technology, such as focused lung ultrasound scan and bedside analysis of blood samples (leucocytes with differential count, electrolytes, and creatinine) conducted in the patients' home, may support clinical decision-making, and potentially reduce acute hospital admissions. We present the protocol for a randomized controlled trial, which aims at assessing the effect of focused lung ultrasound scan and bedside blood analysis during in-home assessments among older adults with signs of potential acute respiratory disease on hospital admissions. METHOD: We will use a parallel open-label, individually randomised controlled trial design in an acute community healthcare setting. The trial will initiate on October 2022 and is expected to end one year later. The study population will include older adults (65 + year), with at least one of the following inclusion criteria: Cough, dyspnoea, fever, fall, or rapid functional decline. Expected study sample will comprise 632 participants. Participants in the control group will receive usual care, while the intervention group will undergo extended point-of-care technology (focused lung ultrasound scan and bedside venous blood analysis), in addition to usual care. The primary outcome is acute hospital admission within 30 days follow-up. Secondary outcomes include readmissions, mortality, length of hospital stay, hospital-free days, complications during hospital admission, treatment initiations or changes, functional level, re-referrals to the acute community healthcare service, and contacts to the primary care physician. A tertiary outcome is the diagnostic accuracy of Acute Community Nurses for conducting focused lung ultrasound compared with a specialist. Outcomes will be analysed as intention-to-treat. DISCUSSION: To our knowledge, this is the first randomised controlled trial examining the effect of extended use of point-of-care technology conducted in an in-home setting. We expect that the results may contribute to the development of new interventions aiming to improve timely diagnostics, treatment decisions, and reduce acute hospital admissions. TRIAL REGISTRATION: www. CLINICALTRIALS: org NCT05546073 (Date of registration: September 19th, 2022).

Chronic Pulmonary Aspergillosis as a Considerable Complication in Post-Tuberculosis Lung Disease.

Post-tuberculosis lung disease (PTLD) has only recently been put in the spotlight as a medical entity. Recent data suggest that up to 50% of tuberculosis (TB) patients are left with PTLD-related impairment after completion of TB treatment. The presence of residual cavities in the lung is the largest risk factor for the development of chronic pulmonary aspergillosis (CPA) globally. Diagnosis of CPA is based on four criteria including a typical radiological pattern, evidence of Aspergillus species, exclusion of alternative diagnosis, and a chronic course of disease. In this manuscript, we provide a narrative review on CPA as a serious complication for patients with PTLD.