Pulmonologist evaluation on new CT visualization for guidance to lung lesions during bronchoscopy.

OBJECTIVE: Endoluminal visualization in virtual and video bronchoscopy lacks information about the surrounding structures, and the traditional 2 D axial, coronal and sagittal CT views can be difficult to interpret. To address this challenge, we previously introduced a novel visualization technique, Anchored to Centerline Curved Surface, for navigated bronchoscopy. The current study compares the ACCuSurf to the standard ACS CT views as planning and guiding tools in a phantom study. MATERIAL AND METHODS: Bronchoscope operators navigated in physical phantom guided by virtual realistic image data constructed by fusion of CT dataset of phantom and anonymized patient CT data. We marked four different target positions within the virtual image data and gave 12 pulmonologists the task to navigate, with either ACCuSurf or ACS as guidance, to the corresponding targets in the physical phantom. RESULTS: Using ACCuSurf reduced the planning time and increased the grade of successful navigation significantly compared to ACS. CONCLUSION: The phantom setup with virtual patient image data proved realistic according to the pulmonologists. ACCuSurf proved superior to ACS regarding planning time and navigation success grading. Improvements on visualisation or display techniques may consequently improve both planning and navigated bronchoscopy and thus contribute to more precise lung diagnostics.

Use of Inhaled Corticosteroids and the Risk of Lung Cancer, the HUNT Study.

BACKGROUND: Inflammation plays a central role in chronic obstructive pulmonary disease and lung cancer carcinogenesis. Inhaled corticosteroids (ICS) reduce inflammation. This study has investigated whether ICS use is associated with a lower risk of lung cancer. MATERIALS AND METHODS: Data from the Nord-Trøndelag Health Study (HUNT2 Survey, 1995-1997) were merged with The Cancer Registry of Norway and Norwegian Cause of Death Registry. From a total of 65,215 participants, those with chronic airway inflammation, defined by FEV1% < 70 and/or chronic cough and expectorate phlegm, were included (N = 4136). Of these, 3041 individuals reported regarding ICS use and were observed for a period of 12 years. Cox regression models were used to calculate the risk of lung cancer with a 95% confidence interval (CI) with sex, age, smoking pack years and FEV1% < 70 as known confounders. RESULTS: Among ICS users (N = 1095). we found a higher, but not significant, incidence of lung cancer N = 39 (3.6%), compared to non-users (N = 1946) with N = 65 (3.3%) cases. Age and smoking were associated with a higher risk, while sex and lung function were not. After adjusting for confounders, ICS use did not change the risk of lung cancer, hazard ratio (HR) 0.968, (95% CI, 0.608-1.540), and p value 0.890. CONCLUSION: ICS use is not associated with a reduced risk of lung cancer in our study population.

Rate of avoidable deaths in a Norwegian hospital trust as judged by retrospective chart review.

BACKGROUND: The proportion of avoidable hospital deaths is challenging to estimate, but has great implications for quality improvement and health policy. Many studies and monitoring tools are based on selected high-risk populations, which may overestimate the proportion. Mandatory reporting systems, however, under-report. We hypothesise that a review of an unselected sample of hospital deaths will provide an estimate of avoidability in-between the estimates from these methods. METHODS: A retrospective case record review of an unselected population of 1000 consecutive non-psychiatric hospital deaths in a Norwegian hospital trust was conducted. Reviewers evaluated to what degree each death could have been avoided, and identified problems in care. RESULTS: We found 42 (4.2%) of deaths to be at least probably avoidable (more than 50% chance of avoidability). Life expectancy was shortened by at least 1 year among 34 of the 42 patients with an avoidable death. Patients whose death was found to be avoidable were less functionally dependent compared with patients in the non-avoidable death group. The surgical department had the greatest proportion of such deaths. Very few of the avoidable deaths were reported to the hospital's report system. CONCLUSIONS: Avoidable hospital deaths occur less frequently than estimated by the national monitoring tool, but much more frequently than reported through mandatory reporting systems. Regular reviews of an unselected sample of hospital deaths are likely to provide a better estimate of the proportion of avoidable deaths than the current methods.

Learning endobronchial ultrasound transbronchial needle aspiration - a 6-year experience at a single institution.

INTRODUCTION: Endobronchial ultrasound with transbronchial needle aspiration (EBUS-TBNA) has become an important diagnostic tool for the pulmonologist. Learning this procedure and maintaining technical skills requires continuous practice and evaluation. OBJECTIVES: The aims of the study were a retrospective evaluation of the diagnostic quality of the EBUS-technique and the learning profile of the endoscopy team during the first years (2007-2013) of experience in an unselected population. METHODS: EBUS-TBNA procedures were analysed for clinical data, including results from surgery or clinical/radiological follow-up for at least 6 months. Rapid on-site cytological evaluation (ROSE) was introduced on regular basis the forth year. RESULTS: A total of 711 EBUS-TBNA from 635 patients were included. The percentage of representative EBUS-TBNA initially decreased the first years (minimum 60,9%), before increased to a final result of 82,4%. There was a lower proportion of representative EBUS-TBNA in the benign group (76,8%) vs the malignant group (85,8%). A significant increase in the proportion of representative EBUS-TBNA was seen after ROSE had been introduced. The major indications were diagnosing/staging of lung cancer (54%) and mediastinal lymphadenopathy of unknown cause (25,7%). The sensitivity detecting malignancy was 94,9%, negative predictive value 81,2% and diagnostic accuracy 95,8%. During the study period the percentage of re-examinations with EBUS-TBNA declined from 18,0% to 8,2%. CONCLUSION: After an initial run-in period with declining results, the overall diagnostic yield of EBUS-TBNA increased and reached acceptable levels. These results underline the importance of continuously evaluation of our own results when new methods are implemented in clinical practice.

Self-reported cardiovascular disease and the risk of lung cancer, the HUNT study.

INTRODUCTION: Inflammation is involved in development of lung cancer and cardiovascular disease (CVD), and we hypothesize that self-reported CVD is an independent risk factor for lung cancer. METHODS: Data from the Nord-Trøndelag Health Study (1984-2008) linked to the Norwegian Cancer and Death Cause Registry were analyzed stratified by smoking status. In total, 97,087 persons (1,634,967 person years) were included (never smokers 567,575 person years, former smokers 295,685 person years, current smokers 444,922 person years, and unknown 326,785 person years) and followed for an average of 15 years. The proportional hazard model was applied to estimate the hazard ratio (HR) with a 95% confidence interval (CI) for self-reported CVD on lung cancer incidence rate adjusted for age, sex, body mass index, burden of tobacco smoking and chronic cough with phlegm. RESULTS: 1080 cases of lung cancer (1.1%) occurred. A total of 5981 (6.9%) participants had at baseline or developed during follow-up self-reported CVD. After adjusting for confounders, self-reported CVD was an independent risk factor for the development of lung cancer in former (HR [95% CI] 1.74 [1.11-2.73]) and current smokers (HR [95% CI] 1.38 [1.04-1.83]), but not in never smokers (HR [95% CI] 0.87 [0.34-2.23]). CONCLUSIONS: Self-reported CVD was independently associated with increased occurrence of lung cancer in former and current smokers. CVD may be a novel risk factor for lung cancer screening.

Bone mass density, fracture history, self-reported osteoporosis as proxy variables for estrogen and the risk of non-small-cell lung cancer--a population based cohort study, the HUNT study: are proxy variables friends or faults?

Lung cancer has the highest mortality of all cancers. Patients with early stage disease have the best cure rates and that emphasizes the importance of early detection. About half of all non-small cell lung cancers (NSCLC) are estrogen receptor positive. The impact of estrogen and its receptors for NSCLC carcinogenesis has been studied but is still unclear. Low estrogen levels are associated with osteoporosis. We hypothesize that low bone mineral density (BMD), a positive history of fracture or self-reported osteoporosis, used as a proxy variable for life time estrogen exposure, are associated with a low incidence of NSCLC. We analyzed data from a cohort study, the Nord-Trøndelag Health Study 2 (1995-1997) linked to the Norwegian Cancer Registry. Using the logistic regression model we calculated the odds ratio (OR) with a 95% confidence interval (CI) for the risk of NSCLC for the three proxy variables, stratified by sex. Participants older than 50 years of age, having measured bone density (N = 18,156), having answered the questions on self-reported fracture (N = 37,883) and osteoporosis (N = 25,701) and known body mass index (BMI) (N = 29,291), were evaluated for inclusion. In 6996 participants all these information was available in addition to tobacco use, and in women also hormonal replacement therapy (HRT). Lung function (FEV1 percent of predicted) was included in a sensitivity analysis. We identified 132 (1.9%) cases of NSCLC, 59 (1.2%) and 73 (3.3%) cases in women and men, respectively. Low BMD was associated with a higher risk of NSCLC, OR: 2.38, 95% CI: 1.09-5.18 and OR: 2.67, 95% CI: 1.39-5.16 in women and men, respectively. No association was found between the two other proxy variables and the risk of NSCLC. Inclusion of lung function in the model did not change the results. Contrary to our hypothesis, women and men with low BMD had a higher risk for NSCLC. In addition the study demonstrates that the risk depends on which proxy variable was chosen, and we may ask: are proxy variables reliable?

Prolonged survival in patients with lung cancer with diabetes mellitus.

INTRODUCTION: Patients with lung cancer have a high frequency of comorbidity. Data on the impact of diabetes mellitus, the most frequent endocrine disorder, on the prognosis of lung cancer are conflicting. The aim was to investigate the impact of diabetes mellitus on survival in lung cancer. METHOD: We analyzed data from a cohort, the Nord-Trøndelag Health Study (HUNT study) linked to the Norwegian Cancer Registry and controlled the results using two lung cancer studies, the Pemetrexed Gemcitabine study and the Norwegian Lung Cancer Biobank. Survival in lung cancer with and without diabetes mellitus was compared using the Kaplan-Meier method and Cox regression model for each study and the studies combined. RESULTS: One thousand six hundred seventy-seven cases of lung cancer were included, 1031 from HUNT study, 436 from the Pemetrexed Gemcitabine study, and 210 from the Norwegian Lung Cancer Biobank registry, and among these 77 patients had diabetes mellitus. In the combined analysis, patients with lung cancer with diabetes mellitus had increased survival compared with those without (p = 0.005). The 1-, 2-, and 3-year survival in patients with lung cancer with and without diabetes mellitus were 43% versus 28%, 19% versus 11%, and 3% versus 1%, respectively. Adjusting for age, gender, histology, and stage of disease in the Cox regression model, the hazard ratio for survival in patients with lung cancer with diabetes mellitus was 0.55 (95% CI, 0.41-0.75) as compared with without. CONCLUSION: Patients with lung cancer with diabetes mellitus have an increased survival compared with those without diabetes mellitus.