Pulmonary sclerosing pneumocytoma - approaching a solitary pulmonary nodule and the limitations of risk prediction models.

Our case is an asymptomatic, non-smoking, East Asian woman in her 40s presenting with a solitary pulmonary nodule (SPN). On imaging, the 1.7 cm solid SPN located in the left upper lobe, was rounded in morphology and moderately fluorodeoxyglucose avid. The clinical pretest probability of malignancy assessed by risk prediction models such as Brock (19.1%), Mayo Clinic (56.2%) and Herder (51.4%) was discordant. She underwent a percutaneous CT-guided needle biopsy, establishing a diagnosis of pulmonary sclerosing pneumocytoma (PSP). PSP is a rare benign lung neoplasm with indolent growth characteristics that has been described predominantly in non-smoking women. Our case illustrates the limitations of applying existing risk prediction models in Asia where the epidemiology and biology of lung cancer differ significantly from the Caucasian derivation cohorts. Additionally, the risk models do not account for tuberculosis, which is endemic in Asia and can mimic malignancy. Non-surgical lung biopsy remains useful in minimising unnecessary thoracotomy.

Heterogeneity of non-cystic-fibrosis bronchiectasis in multiethnic Singapore: A prospective cohort study at a tertiary pulmonology centre.

INTRODUCTION: Non-cystic fibrosis bronchiectasis (NCFB) is a highly heterogenous disease. We describe the clinical characteristics of NCFB patients and evaluate the performance of Bronchiectasis Severity Index (BSI) in predicting mortality. METHODS: Patients attending the bronchiectasis clinic between August 2015 and April 2020 with radiologically proven bronchiectasis on computed tomography were recruited. Clinical characteristics, spirometry, radiology, microbiology and clinical course over a median period of 2.4 years is presented. RESULTS: A total of 168 patients were enrolled in this prospective cohort study. They were predominantly women (67.8%), Chinese (87.5%) and never-smokers (76.9%). Median age of diagnosis was 64 years (interquartile range 56-71) and the most common aetiology was "idiopathic" bronchiectasis (44.6%). Thirty-nine percent had normal spirometries. Compared to female patients, there were more smokers among the male patients (53.8% versus 8.5%, P<0.001) and a significantly larger proportion with post-tuberculous bronchiectasis (37.0% vs 15.8%, P=0.002). Fifty-five percent of our cohort had a history of haemoptysis. Lower body mass index, presence of chronic obstructive pulmonary disease, ever-smoker status, modified Reiff score, radiological severity and history of exacerbations were risk factors for mortality. Survival was significantly shorter in patients with severe bronchiectasis (BSI>9) compared to those with mild or moderate disease (BSI<9). The hazard ratio for severe disease (BSI>9) compared to mild disease (BSI 0-4) was 14.8 (confidence interval 1.929-114.235, P=0.01). CONCLUSION: The NCFB cohort in Singapore has unique characteristics with sex differences. Over half the patients had a history of haemoptysis. The BSI score is a useful predictor of mortality in our population.

A 27-Year-Old Man With Persistent Breathlessness After an Inhalational Injury.

CASE PRESENTATION: A 27-year-old man was hospitalized in the burn unit after sustaining an acute inhalational injury and facial burns after an accidental occupational exposure to an industrial disinfectant consisting of a mixture of hydrogen peroxide (15%-30%), acetic acid (5%-15%), and peracetic acid (5%-15%). He demonstrated cough, shortness of breath, and hoarseness of voice at presentation that had developed 6 h after exposure. In addition to the inhalational injury of the vocal cords and lower airways on bronchoscopy (Fig 1), the patient also was diagnosed with acute inhalational pneumonitis based on the findings of hypoxemic respiratory failure and bilateral perihilar airspace opacities on chest radiography (Fig 2). He required intubation and mechanical ventilation initially for 2 days for upper airway edema and was discharged 19 days after exposure with resolution of hypoxemia and reduction of airspace opacities on chest radiography. However, symptoms of productive cough and shortness of breath on exertion persisted, and he was rehospitalized 27 days after exposure. He was a nonsmoker with no prior history of atopy, asthma, or lung disease. His medical history was remarkable for hypertension and severe obesity with a BMI of 34.7 kg/m2.

Chronic Cough With Non-Resolving Mass-like Consolidation.

CASE PRESENTATION: A 72-year-old Chinese man presented with a 5-month history of chronic dry cough, weight loss, and progressive dyspnea. There was no associated hemoptysis, hoarseness, epistaxis, or fever on systemic review. He was a nonsmoker and had no family history of malignancy. He was treated for pulmonary TB 40 years ago. A chest radiograph (Fig 1) showed mass-like consolidation in the right midzone with loss of the right hilar border, a small right pleural effusion, and bi-apical scarring. On physical examination, he was afebrile and normotensive, and he had pulse oxygen saturation of 97%. Examination of the chest was remarkable only for reduced breath sounds over the right chest. He did not have digital clubbing, distended neck veins, or cervical lymphadenopathy.

Characteristics and Outcomes of COVID-19 Patients with Respiratory Failure Admitted to a "Pandemic Ready" Intensive Care Unit - Lessons from Singapore.

INTRODUCTION: Singapore was one of the first countries affected by the coronavirus disease 2019 (COVID-19) pandemic but has been able to prevent its healthcare system and intensive care units (ICU) from being overwhelmed. We describe the clinical features, management and outcomes of COVID-19 patients with respiratory failure admitted to our ICU. MATERIALS AND METHODS: A case series of COVID-19 patients admitted to our ICU for respiratory failure from 7 February, with data censoring at 30 June 2020, was performed from a review of medical records. RESULTS: Twenty-two COVID-19 patients were admitted to our ICU for respiratory failure. The median age was 54.5 years (IQR 30-45.5), 72.7% were male and had at least one comorbidity. The Sequential Organ Failure Assessment (SOFA) and Acute Physiology and Chronic Health Evaluation (APACHE) II scores were 2.5 (IQR 1.25-7) and 10 (8.25-12) respectively. Thirteen patients required invasive mechanical ventilation (IMV) and had a median PaO2/FiO2 ratio of 194 mmHg (IQR 173-213) after intubation. The 28-day survival was 100%, with 2 patients demising subsequently. The overall ICU mortality rate was 9.1% at the time of data censoring. In IMV survivors, length of IMV and ICU stay were 11 days (IQR 9-17.75) and 16 days (IQR 12-32) respectively. CONCLUSION: Low COVID-19 ICU mortality was observed in our "pandemic-ready" ICU. This was achieved by having adequate surge capacity to facilitate early ICU admission and IMV, lung protective ventilation, and slow weaning. Being able to maintain clinical standards and evidence-based practices without having to resort to rationing contributed to better outcomes.

Improving asthma care with Asthma-COPD Afterhours Respiratory Nurse at Emergency (A-CARE).

BACKGROUND: Emergency departments (ED) are important providers of asthma care, particularly after-hours. We identified gaps for quality improvement such as suboptimal adherence rates to three key recommendations from the Global Initiative for Asthma (GINA) guidelines for discharge management asthma guidelines. These were: the prescription of oral and inhaled corticosteroids (OCS and ICS) and issuance of outpatient follow-up for patients discharged from the ED. AIM: To achieve an adherence rate of 80% to GINA guidelines for ED discharge management by providing after-hours asthma counselling services. METHODS: We implemented Asthma-COPD Afterhours Respiratory Nurse at Emergency (A-CARE) according to the Plan-Do-Study-Act (PDSA) framework to provide after-hours asthma counselling and clinical decision support to ED physicians three nights a week. Data on adherence rates to the GINA guidelines were collected and analysed on a run chart. RESULTS: After 17 months' follow-up, a sustained improvement was observed in patients reviewed by A-CARE in the median adherence rates to OCS prescription (58% vs 86%), ICS initiation (27% vs 67%) and issuance of follow-up (69% vs 92%), respectively. The overall impact was, however, limited by a suboptimal referral rate to A-CARE (16%) in a clinical audit of all ED patients with asthma. Nonetheless, in this audit, attendance rates for patients referred to our respiratory department for follow-up were higher in those receiving asthma counselling compared with those who did not (41.7% vs 15.9%, p=0.0388). CONCLUSION: Sustained improvements in the adherence rates to guidelines were achieved for patients reviewed by A-CARE but were limited in overall impact due to suboptimal referral rate. We plan to improve the quality of asthma care by implementing further PDSA cycles to increase the referral rates to A-CARE.

A 78-Year-Old Man With Recurrent Hemoptysis and Persistent Pulmonary Nodule.

CASE PRESENTATION: A 78-year-old Chinese man presented in March 2019 with a 2-day history of small-volume hemoptysis. He did not report any associated chronic cough, sputum production, epistaxis, night sweats, unintentional weight loss, or fever. He was an ex-smoker of 10 pack years. His medical history was significant for ischemic heart disease on aspirin, as well as hospitalizations in 2016 and 2017 for hemoptysis. The patient's evaluation for hemoptysis was only notable for a right middle lobe nodule on chest CT imaging and Klebsiella pneumoniae on sputum cultures, for which he was treated with antibiotics.

Making Clinical Practice Guidelines Pragmatic: How Big Data and Real World Evidence Can Close the Gap.

Clinical practice guidelines (CPGs) have become ubiquitous in every field of medicine today but there has been limited success in implementation and improvement in health outcomes. Guidelines are largely based on the results of traditional randomised controlled trials (RCTs) which adopt a highly selective process to maximise the intervention's chance of demonstrating efficacy thus having high internal validity but lacking external validity. Therefore, guidelines based on these RCTs often suffer from a gap between trial efficacy and real world effectiveness and is one of the common reasons contributing to poor guideline adherence by physicians. "Real World Evidence" (RWE) can complement RCTs in CPG development. RWE-in the form of data from integrated electronic health records-represents the vast and varied collective experience of frontline doctors and patients. RWE has the potential to fill the gap in current guidelines by balancing information about whether a test or treatment works (efficacy) with data on how it works in real world practice (effectiveness). RWE can also advance the agenda of precision medicine in everyday practice by engaging frontline stakeholders in pragmatic biomarker studies. This will enable guideline developers to more precisely determine not only whether a clinical test or treatment is recommended, but for whom and when. Singapore is well positioned to ride the big data and RWE wave as we have the advantages of high digital interconnectivity, an integrated National Electronic Health Record (NEHR), and governmental support in the form of the Smart Nation initiative.