Effects of Active Chronic Cigarette-Smoke Exposure on Circulating Fibrocytes.

PURPOSE: This study aimed to evaluate the hypothesis that active smoking impacts upon mediators and abundance of circulating fibrocyte cells in smoking-related disease characterised by fibrosis. METHODS: Flow cytometry and enzyme-linked immunosorbent assays were used to investigate blood from five patient groups: healthy never-smokers, healthy current smokers, stable chronic obstructive pulmonary disease (COPD) active smokers, idiopathic pulmonary fibrosis (IPF) never-smokers, and IPF active smokers. RESULTS: A significant inverse dose-response relationship was observed in healthy smokers among cumulative smoking burden (pack-years) and fibrocyte abundance (p = 0.006, r = -0.86). Among serum profibrotic fibrocyte chemokines measured, CCL18 rose significantly alongside fibrocyte numbers in all five subject groups, while having an inverse dose-response relationship with pack-year burden in healthy smokers (p = 0.003, r = -0.89). In IPF, CCL2 rose in direct proportion to fibrocyte abundance irrespective of smoking status but had lower serum levels in those currently smoking (p = < 0.001). For the study population, CXCL12 was decreased in pooled current smokers versus never-smokers (p = 0.03). CONCLUSION: The suppressive effect of current, as distinct from former, chronic smoking on circulating fibrocyte abundance in healthy smokers, and modulation of regulatory chemokine levels by active smoking may have implications for future studies of fibrocytes in smoking-related lung diseases as a potential confounding variable.

Management of comorbidities in difficult and severe asthma.

Difficult-to-treat and severe asthma are challenging clinical entities. In the face of suboptimal asthma control, the temptation for clinicians is to reflexively escalate asthma-directed therapy, including increasing exposure to corticosteroids and commencement of costly but potent biologic therapies. However, asthma control is objectively and subjectively assessed based on measurable parameters (such as exacerbations or variability in pulmonary physiology), symptoms and patient histories. Crucially, these features can be confounded by common untreated comorbidities, affecting clinicians' assessment of asthma treatment efficacy.

Analysis of tissue lipidomics and computed tomography pulmonary fat attenuation volume (CTPFAV ) in idiopathic pulmonary fibrosis.

BACKGROUND AND OBJECTIVE: There is increasing interest in the role of lipids in processes that modulate lung fibrosis with evidence of lipid deposition in idiopathic pulmonary fibrosis (IPF) histological specimens. The aim of this study was to identify measurable markers of pulmonary lipid that may have utility as IPF biomarkers. STUDY DESIGN AND METHODS: IPF and control lung biopsy specimens were analysed using a unbiased lipidomic approach. Pulmonary fat attenuation volume (PFAV) was assessed on chest CT images (CTPFAV ) with 3D semi-automated lung density software. Aerated lung was semi-automatically segmented and CTPFAV calculated using a Hounsfield-unit (-40 to -200HU) threshold range expressed as a percentage of total lung volume. CTPFAV was compared to pulmonary function, serum lipids and qualitative CT fibrosis scores. RESULTS: There was a significant increase in total lipid content on histological analysis of IPF lung tissue (23.16 nmol/mg) compared to controls (18.66 mol/mg, p = 0.0317). The median CTPFAV in IPF was higher than controls (1.34% vs. 0.72%, p < 0.001) and CTPFAV correlated significantly with DLCO% predicted (R2 = 0.356, p < 0.0001) and FVC% predicted (R2 = 0.407, p < 0.0001) in patients with IPF. CTPFAV correlated with CT features of fibrosis; higher CTPFAV was associated with >10% reticulation (1.6% vs. 0.94%, p = 0.0017) and >10% honeycombing (1.87% vs. 1.12%, p = 0.0003). CTPFAV showed no correlation with serum lipids. CONCLUSION: CTPFAV is an easily quantifiable non-invasive measure of pulmonary lipids. In this pilot study, CTPFAV correlates with pulmonary function and radiological features of IPF and could function as a potential biomarker for IPF disease severity assessment.

A qualitative study of clinician perceptions regarding the potential role for digital health interventions for the management of COPD.

Effective self-management of chronic obstructive pulmonary disease (COPD) can lead to increased patient control and reduced health care costs. However, both patients and healthcare professionals encounter significant challenges. Digital health interventions, such as smart oximeters and COPD self-management applications, promise to enhance the management of COPD, yet, there is little evidence to support their use and user-experience issues are still common. Understanding the needs of healthcare professionals is central for increasing adoption and engagement with digital health interventions but little is known about their perceptions of digital health interventions in COPD. This paper explored the perceptions of healthcare professionals regarding the potential role for DHI in the management of COPD. Snowball sampling was used to recruit the participants (n = 32). Each participant underwent a semi-structured interview. Using NVivo 12 software, thematic analysis was completed. Healthcare professionals perceive digital health interventions providing several potential benefits to the management of COPD including the capture of patient status indicators during the interappointment period, providing new patient data to support the consultation process and perceived digital health interventions as a potential means to improve patient engagement. The findings offer new insights regarding potential future use-cases for digital health interventions in COPD, which can help ease user-experience issues as they align with the needs of healthcare professionals.

A qualitative study of chronic obstructive pulmonary disease patient perceptions of the barriers and facilitators to adopting digital health technology.

OBJECTIVE: Non-adherence to self-management plans in chronic obstructive pulmonary disease (COPD) results in poorer outcomes for patients. Digital health technology (DHT) promises to support self-management by enhancing the sense of control patients possess over their disease. COPD digital health studies have yet to show significant evidence of improved outcomes for patients, with many user-adoption issues still present in the literature. To help better address the adoption needs of COPD patients, this paper explores their perceived barriers and facilitators to the adoption of DHT. METHODS: A sample of convenience was chosen and patients (n = 30) were recruited from two Dublin university hospitals. Each patient completed a qualitative semi-structured interview. Thematic analysis of the data was performed using NVivo 12 software. RESULTS: Barrier sub-themes included lack of perceived usefulness, digital literacy, illness perception, and social context; facilitator sub-themes included existing digital self-efficacy, personalised education, and community-based support. CONCLUSION: The findings represent a set of key considerations for researchers and clinicians to inform the design of patient-centred study protocols that aim to account for the needs and preferences of patients in the development of implementation and adoption strategies for DHT in COPD.

Exploring the potential benefits of digital health technology for the management of COPD: a qualitative study of patient perceptions.

Engaging chronic obstructive pulmonary disease (COPD) patients to actively participate in self-management has proven difficult. Digital health technology (DHT) promises to facilitate a patient-centred care model for the management of COPD by empowering patients to self-manage effectively. However, digital health studies in COPD have yet to demonstrate significant patient outcomes, suggesting that this research has still to adequately address the needs of patients in the intervention development process. The current study explored COPD patients' perceptions of the potential benefits of DHT in the self-management and treatment of their disease. A sample of convenience was chosen and participants (n=30) were recruited from two Dublin university hospitals and each underwent a qualitative semi-structured interview. Thematic analysis of the data was completed using NVivo 12 software. Six themes were identified: symptom management, anxiety management, interaction with physician, care management, personalising care and preventative intervention. In our findings, patients reported a willingness to take a more active role in self-management using DHT. They perceived DHT potentially enhancing their self-management by improving self-efficacy and engagement and by supporting healthcare professionals to practise preventative care provision. The findings can be used to inform patient-centred COPD digital interventions for researchers and clinicians who wish to develop study aims that align with the needs and preferences of patients.

Cleaning up the paper trail - our clinical notes in open view.

Purpose Ireland's physicians have a legal and an ethical duty to protect confidential patient information. Most healthcare records in Ireland remain paper based, so the purpose of this paper is to: assess the protection afforded to paper records; log highest risk records; note the variations that occurred during the working week; and observe the varying protection that occurred when staff, students and public members were present. Design/methodology/approach A customised audit tool was created using Sphinx software. Data were collected for three months. All wards included in the study were visited once during four discrete time periods across the working week. The medical records trolley's location was noted and total unattended medical records, total unattended nursing records, total unattended patient lists and when nursing personnel, medical students, public and a ward secretary were visibly present were recorded. Findings During 84 occasions when the authors visited wards, unattended medical records were identified on 33 per cent of occasions, 49 per cent were found during weekend visiting hours and just 4 per cent were found during morning rounds. The unattended medical records belonged to patients admitted to a medical specialty in 73 per cent of cases and a surgical specialty in 27 per cent. Medical records were found unattended in the nurses' station with much greater frequency when the ward secretary was off duty. Unattended nursing records were identified on 67 per cent of occasions the authors visited the ward and were most commonly found unattended in groups of six or more. Practical implications This study is a timely reminder that confidential patient information is at risk from inappropriate disclosure in the hospital. There are few context-specific standards for data protection to guide healthcare professionals, particularly paper records. Nursing records are left unattended with twice the frequency of medical records and are found unattended in greater numbers than medical records. Protection is strongest when ward secretaries are on duty. Over-reliance on vigilant ward secretaries could represent a threat to confidential patient information. Originality/value While other studies identified data protection as an issue, this study assesses how data security varies inside and outside conventional working hours. It provides a rationale and an impetus for specific changes across the whole working week. By identifying the on-duty ward secretary's favourable effect on medical record security, it highlights the need for alternative arrangements when the ward secretary is off duty. Data were collected prospectively in real time, giving a more accurate healthcare record security snapshot in each data collection point.

Smoking-Related Interstitial Fibrosis: Evidence of Radiologic Regression with Advancing Age and Smoking Cessation.

More data are needed regarding the radiology, co-morbidities and natural history of smoking-related interstitial fibrosis (SRIF), a common pathological finding, mainly described heretofore in association with lung cancer, where respiratory bronchiolitis (RB) usually co-exists. We prospectively acquired high resolution CT scan data (edge-enhancing lung reconstructions) to detect any radiologic interstitial lung abnormality (ILA) in individuals who ultimately underwent surgical lobectomy for lung cancer (n = 20), for radiologic/pathologic correlation. We also re-examined other smoking-related benign histologic cases: chronic obstructive pulmonary disease (COPD lung explants, n = 20), alpha 1-antitrypsin deficiency (A1AT, explanted lungs n = 20), combined pulmonary fibrosis and emphysema (CPFE, n = 8) and idiopathic pulmonary fibrosis (IPF, n = 10). Finally, we pooled our data with all peer-reviewed published data describing histologic SRIF of known ILA status. SRIF was observed in 40% of cancer lobectomies, mean (±SD) age 65.8 ± 8.7 years, none of whom had ILA. SRIF was observed in other smoking-related benign diseases (COPD 35%, A1AT 20%, CPFE 25%, and IPF 10%). 71.4% of benign SRIF cases had no RB (nearly all ex-smokers) versus 0% of cancer-associated SRIF cases (P = 1.7 × 10-3). Pooled data showed that those SRIF subjects without ILA were 15.05 years older than those with ILA (95% confidence interval 8.99 to 21.11, P = 2.5 × 10-5) and more likely to be former smokers (P = 7.2 × 10-3). SRIF is frequently found without lung cancer, and mostly without RB in former smokers. SRIF is less likely to have ILA in older subjects and with smoking cessation, which could represent RB+/-SRIF regression.

Idiopathic pulmonary fibrosis with emphysema: evidence of synergy among emphysema and idiopathic pulmonary fibrosis in smokers.

BACKGROUND: Emphysema and fibrosis, typically the idiopathic pulmonary fibrosis (IPF) form of usual interstitial pneumonia (UIP), can co-exist as combined pulmonary fibrosis emphysema (CPFE). It is unknown whether there is a pathobiologic basis for CPFE beyond the coexistence of fibrosis and emphysema. The aim of this study was to ascertain radiologic differences in severity of fibrosis and emphysema in smokers with IPF versus other forms of UIP. METHODS: Computed tomography thorax images were prospectively rescored in retrospectively identified smokers (minimum 5-pack-year history) with radiologic UIP (any etiology). Radiologic severity (emphysema/fibrosis/reticulation) was scored in consensus by two radiologists, blinded to clinical details, across 5 lung regional levels, and then correlated with clinical data. RESULTS: For the whole cohort (IPF, n=102; non-IPF UIP [mainly rheumatoid arthritis/asbestosis/scleroderma], n=30), IPF and non-IPF UIP smokers were similar regarding pack-year, age, gender, and lung function (P>.1). IPF smokers had greater whole lung fibrosis and reticulation scores (P<.04 in all cases). CPFE was present in n=61 (IPF, n=49; non-IPF UIP, n=12). Compared with smokers with non-IPF CPFE, smokers with IPF and emphysema (IPFE) were similar regarding confounders (P>.1). There were significantly greater regional reticulation severity (P=.009), cumulative emphysema severity (P=.04), and cumulative reticulation severity (P<.001) scores in IPFE versus non-IPF CPFE. CONCLUSIONS: When controlled for confounders, smokers with IPFE have worse radiologic CPFE than other smokers with non-IPF UIP and emphysema, suggesting an interactive synergy among IPF, emphysema, and smoking, with more extensive emphysema due to either inherent susceptibility and/or traction effects. IPFE should be considered separately from other CPFE in future work. It is currently unknown whether CPFE is a distinct pathobiologic entity; therefore, we identified subjects with radiologic UIP (any etiology) who had been similarly exposed to smoke, and asked whether there are differences in the extent/severity of radiologic fibrosis and/or emphysema in those with IPF versus individuals with non-IPF UIP. Although relevant confounders were similar, IPF smokers had greater whole lung fibrosis and reticulation scores than smokers with secondary forms of UIP, and in the CPFE subgroup, smokers with IPF/emphysema had worse radiologic CPFE findings than smokers with non-IPF UIP/emphysema. It is shown for the first time that relevant confounding variables do not explain the observed excess radiologic severity of emphysema and fibrosis in smokers with IPF compared with smokers with non-IPF UIP, lending support to the hypothesis that there is a pathobiologic mechanism or synergy involved in IPF with emphysema that is distinct from the mere co-existence of UIP and emphysematous processes.

Why is your patient sedated?

PURPOSE: The purpose of this paper is to examine the recording of clinical indication for prescribed sedative/hypnotic (SH) medications in a large, acute tertiary referral hospital. DESIGN/METHODOLOGY/APPROACH: All hospital inpatients' medications (n = 367) were audited for prescription details regarding SH medications. Medical notes were then examined for evidence of a recorded indication for such medications. FINDINGS: SH medications were prescribed to many hospital inpatients (42.5 per cent) during admission. An indication was documented in the nursing or medical records for 24.4 per cent of patients who were prescribed such medications. Nurses rather than by doctors prescribed most SH medications (74 vs 26 per cent, respectively, p = 0.003). Some patients receiving SH medications were both over 65 and impaired in their mobility (19.2 per cent). The treatment indication was documented in 47 per cent. PRACTICAL IMPLICATIONS: Most patients prescribed SH medications have nothing in their medical record explaining why these drugs are being used, including half of the elderly, less mobile patients. All health professionals dealing with SH medications and doctors in particular need to justify the use of such medications in the medical record. For the particularly high-risk groups where SH medications are potentially more dangerous, explicit guidance on why and how such medications are to be used must be provided by prescribers. ORIGINALITY/VALUE: For the first time, data are presented on documentation rates for clinical indication of prescribed SH medications across a large acute hospital, and highlights significant shortcomings in practice. This study should inform other organisations of the need to be mindful of facilitating greater compliance with good prescribing practice.

Metastatic chordoma detected by endobronchial ultrasound-guided transbronchial needle aspiration.

Chordomas are rare, slow-growing malignant bone tumours arising from cellular remnants of the notochord. These tumours are locally invasive but have also a metastastic potential.Chordomas are characterized by the presence of physaliferous cells in a myxofibrillary stromal background. In cytological aspirates, these characteristic cells are usually absent, revealing only clusters of cells with varying degrees of vacuolation. This makes definitive diagnosis of chordoma difficult as the tumor can mimic other myxoid neoplasms including renal cell carcinomas and well-differentiated chondrosarcomas. In such situations, a confident diagnosis of chordoma requires comparison with histology of the primary tumor.We describe the first case of metastatic chordoma diagnosed by endobronchial ultrasound-guided transbronchial needle aspiration (EBUS-TBNA).

Poststernotomy lymphadenopathy: prevalence, size, and location on chest CT.

PURPOSE: We aimed to determine the prevalence of enlarged lymph nodes (LNs) in chest computed tomography (CT) scans of patients with a history of sternotomy. MATERIALS AND METHODS: The chest CT scans of 271 patients with a history of sternotomy (mean age, 68.3±14.4 years; range, 15-93 years; 178 males) were retrospectively scored in a blind and random manner for the presence, size, and location of enlarged LNs. Scans with known etiologies for enlarged LNs were excluded. Serial scans were available for 15 patients with enlarged LNs. Twenty patients (mean age, 61.2±7.0 years; range, 54-64 years; 15 males) that had cardiac CT data with no cardiac surgery were included as controls. RESULTS: Of the 271 patients, 189 had other identifiable etiologies for enlarged LNs. Of the remaining 82 patients, 36 (44%) demonstrated enlarged LNs. None of the control patients presented with enlarged LNs (n=20). The mean size of the enlarged nodes was 13.0±2.0 mm. Enlargement of the lymph nodes in station 4R was most common (n=18, 50%; size, 13.1±2.0 mm), followed by the enlargement of nodes in station 7 (n=16, 44%; size, 12.3±2.2 mm). The majority of patients had one (n=20, 56%) or two (n=12, 33%) nodal stations that showed enlargement. We did not observe any significant association between the number or types of grafts and enlarged LNs. Serial CT scans did not show any significant changes in LN enlargement for any nodal station. CONCLUSIONS: Enlarged mediastinal and/or hilar LNs are common in patients with a history of previous sternotomy. It is important for radiologists to be aware of this association to avoid misdiagnosis and further unnecessary procedures for nodal sampling.