Bronchoscopic Lung Cryobiopsy Increases Diagnostic Confidence in the Multidisciplinary Diagnosis of Idiopathic Pulmonary Fibrosis.

RATIONALE: Surgical lung biopsy is often required for a confident multidisciplinary diagnosis of idiopathic pulmonary fibrosis (IPF). Alternative, less-invasive biopsy methods, such as bronchoscopic lung cryobiopsy (BLC), are highly desirable. OBJECTIVES: To address the impact of BLC on diagnostic confidence in the multidisciplinary diagnosis of IPF. METHODS: In this cross-sectional study we selected 117 patients with fibrotic interstitial lung disease without a typical usual interstitial pneumonia pattern on high-resolution computed tomography. All cases underwent lung biopsies: 58 were BLC, and 59 were surgical lung biopsy (SLB). Two clinicians, two radiologists, and two pathologists sequentially reviewed clinical-radiologic findings and biopsy results, recording at each step in the process their diagnostic impressions and confidence levels. MEASUREMENTS AND MAIN RESULTS: We observed a major increase in diagnostic confidence after the addition of BLC, similar to SLB (from 29 to 63%, P = 0.0003 and from 30 to 65%, P = 0.0016 of high confidence IPF diagnosis, in the BLC group and SLB group, respectively). The overall interobserver agreement in IPF diagnosis was similar for both approaches (BLC overall kappa, 0.96; SLB overall kappa, 0.93). IPF was the most frequent diagnosis (50 and 39% in the BLC and SLB group, respectively; P = 0.23). After the addition of histopathologic information, 17% of cases in the BLC group and 19% of cases in the SLB group, mostly idiopathic nonspecific interstitial pneumonia and hypersensitivity pneumonitis, were reclassified as IPF. CONCLUSIONS: BLC is a new biopsy method that has a meaningful impact on diagnostic confidence in the multidisciplinary diagnosis of interstitial lung disease and may prove useful in the diagnosis of IPF. This study provides a robust rationale for future studies investigating the diagnostic accuracy of BLC compared with SLB.

Idiopathic pulmonary fibrosis: diagnosis and prognostic evaluation.

Idiopathic pulmonary fibrosis (IPF) is the most common type of idiopathic interstitial pneumonia and has a dismal prognosis. Median age at IPF onset is 60-70 years and it is mainly related to cigarette smoke exposure. Its clinical profile is heterogeneous and different clinical phenotypes are now better defined: familial IPF, slow and rapid progressors, combined pulmonary fibrosis and emphysema, anti-neutrophil cytoplasmic antibodies/microscopic polyangiitis and IPF, and IPF associated with lung cancer. Acute exacerbation associated with rapid functional decline is an event that does not happen infrequently and affects survival. Diagnosis requires a typical usual interstitial pneumonia (UIP) pattern on computed tomography in the appropriate clinical setting or morphological confirmation of the UIP pattern when imaging findings are not characteristic enough. Surgical lung biopsy is the gold standard to obtain valuable information for histological analysis. However, less invasive procedures (transbronchial lung biopsy or even improved transbronchial lung biopsy by cryoprobes) are now under consideration. Prognostic indicators are mainly derived by pulmonary function tests. Recently, staging systems have been proposed.

A multidimensional index and staging system for idiopathic pulmonary fibrosis.

BACKGROUND: Idiopathic pulmonary fibrosis (IPF) is a progressive fibrotic lung disease with an overall poor prognosis. A simple-to-use staging system for IPF may improve prognostication, help guide management, and facilitate research. OBJECTIVE: To develop a multidimensional prognostic staging system for IPF by using commonly measured clinical and physiologic variables. DESIGN: A clinical prediction model was developed and validated by using retrospective data from 3 large, geographically distinct cohorts. SETTING: Interstitial lung disease referral centers in California, Minnesota, and Italy. PATIENTS: 228 patients with IPF at the University of California, San Francisco (derivation cohort), and 330 patients at the Mayo Clinic and Morgagni-Pierantoni Hospital (validation cohort). MEASUREMENTS: The primary outcome was mortality, treating transplantation as a competing risk. Model discrimination was assessed by the c-index, and calibration was assessed by comparing predicted and observed cumulative mortality at 1, 2, and 3 years. RESULTS: Four variables were included in the final model: gender (G), age (A), and 2 lung physiology variables (P) (FVC and Dlco). A model using continuous predictors (GAP calculator) and a simple point-scoring system (GAP index) performed similarly in derivation (c-index of 70.8 and 69.3, respectively) and validation (c-index of 69.1 and 68.7, respectively). Three stages (stages I, II, and III) were identified based on the GAP index with 1-year mortality of 6%, 16%, and 39%, respectively. The GAP models performed similarly in pooled follow-up visits (c-index ≥71.9). LIMITATION: Patients were drawn from academic centers and analyzed retrospectively. CONCLUSION: The GAP models use commonly measured clinical and physiologic variables to predict mortality in patients with IPF.

Operating room data management: improving efficiency and safety in a surgical block.

BACKGROUND: European Healthcare Systems are facing a difficult period characterized by increasing costs and spending cuts due to economic problems. There is the urgent need for new tools which sustain Hospitals decision makers work. This project aimed to develop a data recording system of the surgical process of every patient within the operating theatre. The primary goal was to create a practical and easy data processing tool to give hospital managers, anesthesiologists and surgeons the information basis to increase operating theaters efficiency and patient safety. METHODS: The developed data analysis tool is embedded in an Oracle Business Intelligence Environment, which processes data to simple and understandable performance tachometers and tables. The underlying data analysis is based on scientific literature and the projects teams experience with tracked data. The system login is layered and different users have access to different data outputs depending on their professional needs. The system is divided in the tree profile types Manager, Anesthesiologist and Surgeon. Every profile includes subcategories where operators can access more detailed data analyses. The first data output screen shows general information and guides the user towards more detailed data analysis. The data recording system enabled the registration of 14.675 surgical operations performed from 2009 to 2011. RESULTS: Raw utilization increased from 44% in 2009 to 52% in 2011. The number of high complexity surgical procedures (≥120 minutes) has increased in certain units while decreased in others. The number of unscheduled procedures performed has been reduced (from 25% in 2009 to 14% in 2011) while maintaining the same percentage of surgical procedures. The number of overtime events decreased in 2010 (23%) and in 2011 (21%) compared to 2009 (28%) and the delays expressed in minutes are almost the same (mean 78 min). The direct link found between the complexity of surgical procedures, the number of unscheduled procedures and overtime show a positive impact of the project on OR management. Despite a consistency in the complexity of procedures (19% in 2009 and 21% in 2011), surgical groups have been successful in reducing the number of unscheduled procedures (from 25% in 2009 to 14% in 2011) and overtime (from 28% in 2009 to 21% in 2011). CONCLUSIONS: The developed project gives healthcare managers, anesthesiologists and surgeons useful information to increase surgical theaters efficiency and patient safety. In difficult economic times is possible to develop something that is of some value to the patient and healthcare system too.

Transbronchial biopsy is useful in predicting UIP pattern.

BACKGROUND: Usual interstitial pneumonia (UIP), is a necessary feature pathologically or radiologically for the diagnosis of idiopathic pulmonary fibrosis (IPF). The predictive value of transbronchial biopsy (TBB) in identifying UIP is currently unknown. The objective of this study is to assess the accuracy with which histopathologic criteria of usual interstitial pneumonia (UIP) can be identified in transbronchial biopsy (TBB) and to assess the usefulness of TBBx in predicting a the diagnosis of UIP pattern. We conducted a retrospective blinded and controlled analysis of TBB specimens from 40 established cases of UIP and 24 non-UIP interstitial lung diseases. RESULTS: Adequate TBB specimens were available in 34 UIP cases (85% of all UIP cases). TBB contained histopathologic criteria to suggest a UIP pattern (ie. at least one of three pathologic features of UIP present; patchy interstitial fibrosis, fibroblast foci, honeycomb changes) in 12 cases (30% of all UIP cases). Sensitivity, specificity, positive and negative predictive values for the two pathologists were 30% (12/40), 100% (24/24), 100% (12/12), 46% (24/52) and 30% (12/40), 92% (22/24), 86% (12/14), 55% (22/40) respectively. Kappa coefficient of agreement between pathologists was good (0.61, 95% CI 0.31-0.91). The likelihood of identifying UIP on TBB increased with the number and size of the TBB specimens. CONCLUSION: Although sensitivity is low our data suggest that even modest amount of patchy interstitial fibrosis, fibroblast foci, honeycomb changes detected on TBB can be highly predictive of a UIP pattern. Conversely, the absence of UIP histopathologic criteria on TBB does not rule out UIP.

Survey of Knowledge and Attitudes about Obstructive Sleep Apnoea Among Italian Anaesthetists.

OBJECTIVE: As the care of Obstructive Sleep Apnoea (OSA) patients remains heterogeneous, we hypothesized that it may reflect insufficient OSA knowledge/awareness among clinicians. METHODS: OSA Knowledge/Attitude Questionnaire (OSAKA) was translated into Italian and distributed to anaesthetists attending SIAARTI National Congress and Airways courses and Hands-on Workshops from October 2012 to June 2013. RESULTS: In total, 370 anaesthetists returned the questionnaires (response rate, 62%); the median (interquartile range [IQR]) knowledge score was 12 (10-14), and the range was 1-17 with no difference by gender, age, professional title or years of practice. The knowledge items achieved a mean rate of corrected response of 66%±0.14%. With regard to attitude items, median (IQR) score was 15 (13-17) and range was 0-20. Females and anaesthetists with >15 years of practice reached higher scores, while anaesthesia residents showed a lower attitude score. Gender and professional title were statistically associated with the attitude score (gender: F=14.6, p=0.0002; professional title: F=4.72, p=0.0099), whereas a weak association was observed within years in practice and attitude score (F=2.6, p=0.0519). Knowledge score correlated positively with attitude score (r=0.4, p<0.0001). For knowledge domains, there was a positive correlation between pathophysiology (mid-grade: r=0.3, p<0.0001), symptoms (low grade: r=0.2, p<0.0001), diagnosis (mid grade: r=0.3, p<0.0001) and the attitude score. Correlation close to zero was observed for epidemiology and treatment domains (r=0.09, p=0.06; r=-0.01, p=0.78, respectively). CONCLUSION: The results of our survey demonstrate lack of knowledge about OSA and its treatment, revealing the need to update the syllabus of teaching in medical practice and in national health care policies to improve perioperative care.

[Post analysis simulated correlation of the El-Ganzouri airway difficulty score with difficult airway]. / Correlação simulada após análise dos escores de El-Ganzouri para via aérea difícil.

BACKGROUND: Difficult airway (DA) occurs frequently (5-15%) in clinical practice. The El-Ganzouri Risk Index (EGRI) has a high sensitivity for predicting a difficult intubation (DI). However difficult mask ventilation (DMV) was never included in the EGRI. Since DMV was not included in the EGRI assessment, and obstructive sleep apnea (OSA) is also correlated with DMV, a study correlating the prediction of DA and OSA (identified by STOP-Bang questionnaire, SB) seemed important. METHODS: We accessed a database previously collected for a post analysis simulation of the airway difficulty predictivity of the EGRI, associated with normal and difficult airway, particularly DMV. As secondary aim, we measured the correlation between the SB prediction system and DA, compared to the EGRI. RESULTS: A total of 2747 patients were included in the study. The proportion of patients with DI was 14.7% (95% CI 13.4-16) and the proportion of patients with DMV was 3.42% (95% CI 2.7-4.1). The incidence of DMV combined with DI was (2.3%). The optimal cutoff value of EGRI was 3. EGRI registered also an higher ability to predict DMV (AUC=0.76 (95% CI 0.71-0.81)). Adding the SB variables in the logistic model, the AUC increases with the inclusion of "observed apnea" variable (0.83 vs. 0.81, p=0.03). The area under the ROC curve for the patients with DI and DMV was 0.77 (95% CI 0.72-0.83). CONCLUSIONS: This study confirms that the incidence of DA is not negligible and suggests the use of the EGRI as simple bedside predictive score to improve patient safety.

Post analysis simulated correlation of the El-Ganzouri airway difficulty score with difficult airway.

BACKGROUND: Difficult airway (DA) occurs frequently (5-15%) in clinical practice. The El-Ganzouri Risk Index (EGRI) has a high sensitivity for predicting a difficult intubation (DI). However difficult mask ventilation (DMV) was never included in the EGRI. Since DMV was not included in the EGRI assessment, and obstructive sleep apnea (OSA) is also correlated with DMV, a study correlating the prediction of DA and OSA (identified by STOP-Bang questionnaire, SB) seemed important. METHODS: We accessed a database previously collected for a post analysis simulation of the airway difficulty predictivity of the EGRI, associated with normal and difficult airway, particularly DMV. As secondary aim, we measured the correlation between the SB prediction system and DA, compared to the EGRI. RESULTS: A total of 2747 patients were included in the study. The proportion of patients with DI was 14.7% (95% CI 13.4-16) and the proportion of patients with DMV was 3.42% (95% CI 2.7-4.1). The incidence of DMV combined with DI was (2.3%). The optimal cutoff value of EGRI was 3. EGRI registered also an higher ability to predict DMV (AUC=0.76 (95% CI 0.71-0.81)). Adding the SB variables in the logistic model, the AUC increases with the inclusion of "observed apnea" variable (0.83 vs. 0.81, p=0.03). The area under the ROC curve for the patients with DI and DMV was 0.77 (95% CI 0.72-0.83). CONCLUSIONS: This study confirms that the incidence of DA is not negligible and suggests the use of the EGRI as simple bedside predictive score to improve patient safety.

The impact of lung cancer on survival of idiopathic pulmonary fibrosis.

BACKGROUND: Lung cancer (LC) is frequently associated with idiopathic pulmonary fibrosis (IPF). Despite this well-known association, the outcome of LC in patients with IPF is unclear. The objective of this study was to evaluate the impact of LC on survival of patients with associated IPF. METHODS: A total of 260 patients with IPF were reviewed, and 186 IPF cases had complete clinical and follow-up data. Among these, five cases were excluded because LC was radiologically suspected but not histologically proven. The remaining 181 cases were categorized in two groups: 23 patients with biopsy-proven LC and IPF (LC-IPF) and 158 patients with IPF only (IPF). Survival and clinical characteristics of the two groups were compared. RESULTS: Prevalence of histologically proven LC was 13%, and among those with LC-IPF cumulative incidence at 1 and 3 years was 41% and 82%. Patients with LC were more frequently smokers (91.3% vs 71.6%, P = .001), with combined pulmonary fibrosis and emphysema (52% vs 32%, P = .052). Survival in patients with LC-IPF was significantly worse than in patients with IPF without LC (median survival, 38.7 months vs 63.9 months; hazard ratio = 5.0; 95% CI, 2.91-8.57; P < .001). Causes of death in the study group were respiratory failure in 43% of patients, LC progression in 13%, and LC treatment-related complications in 17%. CONCLUSIONS: In patients with IPF, LC has a significant adverse impact on survival. Diagnosis and treatment of LC in IPF are burdened by an increased incidence of severe complicating events, apparently as lethal as the cancer itself.

eHCM: Resources Reduction & Demand Increase, cover the gap by a managerial approach powered by an IT solutions.

The economic and financial crisis has also had an important impact on the healthcare sector. Available resources have decreased, while at the same time costs as well as demand for healthcare services are on the rise. This coalescing negative impact on availability of healthcare resources is exacerbated even further by a widespread ignorance of management accounting matters. Little knowledge about costs is a strong source of costs augmentation. Although it is broadly recognized that cost accounting has a positive impact on healthcare organizations, it is not widespread adopted. Hospitals are essential components in providing overall healthcare. Operating rooms are critical hospital units not only in patient safety terms but also in expenditure terms. Understanding OR procedures in the hospital provides important information about how health care resources are used. There have been several scientific studies on management accounting in healthcare environments and more than ever there is a need for innovation, particularly by connecting business administration research findings to modern IT tools. IT adoption constitutes one of the most important innovation fields within the healthcare sector, with beneficial effects on the decision making processes. The e-HCM (e-Healthcare Cost Management) project consists of a cost calculation model which is applicable to Business Intelligence. The cost calculation approach comprises elements from both traditional cost accounting and activity-based costing. Direct costs for all surgical procedures can be calculated through a seven step implementation process.

Features and outcome of familial idiopathic pulmonary fibrosis.

BACKGROUND: Idiopathicpulmonary fibrosis (IPF) has a sporadic occurrence in most instances,but can also occasionally occur in familial form. While clinicalfeatures of sporadic IPF are well defined, clinical presentation,complications, and outcome of familial IPF are still undefined. Thisretrospective study was undertaken to establish clinical parametersand survival time in a consecutive series of patients with familialIPF and to establish whether the phenomenon of anticipation could beobserved. METHODS: 30 patients had received a diagnosis of familial IPF at ourinstitution over the period from January 2005 and December 2011; in7 of them there was a parent-child relation.Clinical features and patient outcome were analyzed and contrasted toa well characterized cohort of 127 patients with non familial IPF. RESULTS: there was no significant difference in presenting symptoms and theoverall outcomes were quite similar in the two groups, but thefamilial group was much more enriched for females and we found astatistically significant lower age at onset in the youngergenerations (mean age 57,8 years versus 74,2 years, p 0,001). Acuteexacerbations, IPF progression and lung cancer were more frequent inthe familial IPF group as a cause of death (p < 0,005). CONCLUSION: familial IPF seems indistinguishable from sporadic IPF with respectto most clinical and physiologic findings; however the age of onsetwas slightly lower among the familial cases than in the sporadiccases of IPF and the phenomenon of anticipation could be observed.

Post analysis simulated correlation of the El-Ganzouri airway difficulty score with difficult airway / Correlação simulada após análise dos escores de El-Ganzouri para via aérea difícil

ABSTRACT BACKGROUND: Difficult airway (DA) occurs frequently (5-15%) in clinical practice. The El-Ganzouri Risk Index (EGRI) has a high sensitivity for predicting a difficult intubation (DI). However difficult mask ventilation (DMV) was never included in the EGRI. Since DMV was not included in the EGRI assessment, and obstructive sleep apnea (OSA) is also correlated with DMV, a study correlating the prediction of DA and OSA (identified by STOP-Bang questionnaire, SB) seemed important. METHODS: We accessed a database previously collected for a post analysis simulation of the airway difficulty predictivity of the EGRI, associated with normal and difficult airway, particularly DMV. As secondary aim, we measured the correlation between the SB prediction system and DA, compared to the EGRI. RESULTS: A total of 2747 patients were included in the study. The proportion of patients with DI was 14.7% (95% CI 13.4-16) and the proportion of patients with DMV was 3.42% (95% CI 2.7-4.1). The incidence of DMV combined with DI was (2.3%). The optimal cutoff value of EGRI was 3. EGRI registered also an higher ability to predict DMV (AUC = 0.76 (95% CI 0.71-0.81)). Adding the SB variables in the logistic model, the AUC increases with the inclusion of "observed apnea" variable (0.83 vs. 0.81, p = 0.03). The area under the ROC curve for the patients with DI and DMV was 0.77 (95% CI 0.72-0.83). CONCLUSIONS: This study confirms that the incidence of DA is not negligible and suggests the use of the EGRI as simple bedside predictive score to improve patient safety.

RESUMO JUSTIFICATIVA: A via aérea difícil (VAD) ocorre com frequência (5-15%) na prática clínica. O Índice de Risco de El-Ganzouri (EGRI) tem uma alta sensibilidade para prever intubação difícil (ID). No entanto, a ventilação difícil via máscara (VDM) nunca foi incluída no EGRI. Como a VDM não foi incluída na avaliação EGRI e a apneia obstrutiva do sono (AOS) também está correlacionada com a VDM, um estudo que correlacionasse a previsão da VAD e AOS (identificada pelo questionário STOP-Bang, SB) pareceu importante. MÉTODOS: Acessamos um banco de dados previamente coletados para simular uma análise posterior da previsibilidade do EGRI para via aérea difícil, associado à via aérea normal e difícil, particularmente VDM. Como objetivo secundário, avaliamos a correlação entre o sistema de previsão do SB e da VAD, em comparação com o EGRI. RESULTADOS: Foram incluídos no estudo 2.747 pacientes. A proporção de pacientes com ID foi de 14,7% (IC de 95%; 13,4-16) e a proporção de pacientes com VDM foi de 3,42% (IC de 95% 2,7-4,1). A incidência da VDM combinada com a de ID foi de 2,3%. O valor de corte ideal do EGRI foi 3. EGRI também registrou uma capacidade maior de prever VDM (ASC = 0,76 (IC de 95%; 0,71-0,81)). Ao somar as variáveis do SB no modelo logístico, a ASC aumenta com a inclusão da variável "apneia observada" (0,83 vs. 0,81, p = 0,03). A área sob a curva ROC para os pacientes com ID e VDM foi de 0,77 (IC de 95%; 0,72-0,83). CONCLUSÕES: Este estudo confirma que a incidência de VAD não é desprezível e sugere o uso do EGRI como um escore de cabeceira preditivo simples para melhorar a segurança do paciente.