Assessment of the impact and reorganization of interventional pulmonology services at a tertiary care centre during nationwide lockdown for COVID-19 pandemic.

COVID 19 pandemic has brought about a sea change in health care practices across the globe. All specialities have changed their way of working during the pandemic. In this study, we evaluated the impact of COVID-19 on the practice of interventional pulmonology at our centre. All interventional pulmonology procedures done during the three months after implementation of lockdown were evaluated retrospectively for patient demographics, clinical diagnosis, indication for procedure and diagnostic accuracy. The changes in practices, additional human resources requirement, the additional cost per procedure and impact on resident training were also assessed. Procedures done during the month of January 2020 were used as controls for comparison. Twenty-two flexible bronchoscopies (75.8%), four semirigid thoracoscopies (13.7%) and three EBUS-TBNAs (10.3%) were carried out during three month lockdown period as compared to 174 during January 2020. Twenty-three of the procedures were for the diagnostic indication (79%), and six were therapeutic (20.6%). The diagnostic yield in suspected neoplasm was 100% while for suspected infections was 58.3%. The percentage of independent procedures being done by residents reduced from 45.4% to 0%. The workforce required per procedure increased from 0.75 to 4-8, and the additional cost per procedure came out to be 135 USD. To conclude, COVID 19 has impacted the interventional pulmonology services in various ways and brought about a need to reorganize the services, while also thinking of innovative ideas to reduce cost without compromising patient safety.

International Practice Patterns of Antibiotic Therapy and Laboratory Testing in Bronchiolitis.

BACKGROUND AND OBJECTIVES: International patterns of antibiotic use and laboratory testing in bronchiolitis in emergency departments are unknown. Our objective is to evaluate variation in the use of antibiotics and nonindicated tests in infants with bronchiolitis in 38 emergency departments in Pediatric Emergency Research Networks in Canada, the United States, Australia and New Zealand, the United Kingdom and Ireland, and Spain and Portugal. We hypothesized there would be significant variation, adjusted for patient characteristics. METHODS: We analyzed a retrospective cohort study of previously healthy infants aged 2 to 12 months with bronchiolitis. Variables examined included network, poor feeding, dehydration, nasal flaring, chest retractions, apnea, saturation, respiratory rate, fever, and suspected bacterial infection. Outcomes included systemic antibiotic administration and urine, blood, or viral testing or chest radiography (CXR). RESULTS: In total, 180 of 2359 (7.6%) infants received antibiotics, ranging from 3.5% in the United Kingdom and Ireland to 11.1% in the United States. CXR (adjusted odds ratio [aOR] 2.3; 95% confidence interval 1.6-3.2), apnea (aOR 2.2; 1.1-3.5), and fever (aOR 2.4; 1.7-3.4) were associated with antibiotic use, which did not vary across networks (P = .15). In total, 768 of 2359 infants (32.6%) had ≥1 nonindicated test, ranging from 12.7% in the United Kingdom and Ireland to 50% in Spain and Portugal. Compared to the United Kingdom and Ireland, the aOR (confidence interval) results for testing were Canada 5.75 (2.24-14.76), United States 4.14 (1.70-10.10), Australia and New Zealand 2.25 (0.86-5.74), and Spain and Portugal 3.96 (0.96-16.36). Testing varied across networks (P < .0001) and was associated with suspected bacterial infections (aOR 2.12; 1.30-2.39) and most respiratory distress parameters. Viral testing (591 of 768 [77%]) and CXR (507 of 768 [66%]) were obtained most frequently. CONCLUSIONS: The rate of antibiotic use in bronchiolitis was low across networks and was associated with CXR, fever, and apnea. Nonindicated testing was common outside of the United Kingdom and Ireland and varied across networks irrespective of patient characteristics.

Comparison of clinical tools for dengue diagnosis in a pediatric population-based cohort.

BACKGROUND: We aimed to estimate and compare the ability of clinical tools for dengue diagnosis in a pediatric population. METHODS: We prospectively evaluated episodes of acute febrile syndrome identified during the follow-up of a population-based cohort of children and adolescents residing in a dengue endemic city. We estimated the area under the receiver operating characteristic curve (AU-ROC) for dengue diagnosis of three clinical tools: the summation of manifestations of the WHO case definition, a predefined clinical scale and a logistic regression model obtained in this study. RESULTS: We compared 219 dengue cases (confirmed by laboratory) and 286 patients with other febrile illnesses. In a multiple model, variables independently associated with dengue included the duration of fever, sleepiness and exanthema. Rhinorrhea, cough and minimal leukocyte count were inversely associated with dengue. This model reached an accuracy of 84.2% (for a cut-off of >0.5, sensitivity: 79.5%, specificity: 87.9%, positive predictive value: 83.7%, negative predictive value: 84.6%). The AU-ROC of this model (89.8%) was significantly higher than that obtained with either the predefined scale (82.1%) or the WHO definition manifestations (77%). CONCLUSION: We validated a predefined scale and identified a multiple model suitable for the clinical diagnosis of dengue in the pediatric population.

Barriers to timely diagnosis of interstitial lung disease in the real world: the INTENSITY survey.

BACKGROUND: The diagnosis of idiopathic pulmonary fibrosis (IPF) and other interstitial lung diseases (ILD) presents significant clinical challenges. To gain insights regarding the diagnostic experience of patients with ILD and to identify potential barriers to a timely and accurate diagnosis, we developed an online questionnaire and conducted a national survey of adults with a self-reported diagnosis of ILD. METHODS: A pre-specified total of 600 subjects were recruited to participate in a 40-question online survey. E-mail invitations containing a link to the survey were sent to 16 427 registered members of the Pulmonary Fibrosis Foundation. Additionally, an open invitation was posted on an online forum for patients and caregivers ( www.inspire.com ). The recruitment and screening period was closed once the pre-defined target number of respondents was reached. Eligible participants were adult U.S. residents with a diagnosis of IPF or a non-IPF ILD. RESULTS: A total of 600 eligible respondents met the eligibility criteria and completed the survey. Of these, 55% reported ≥ 1 misdiagnosis and 38% reported ≥ 2 misdiagnoses prior to the current diagnosis. The most common misdiagnoses were asthma (13.5%), pneumonia (13.0%), and bronchitis (12.3%). The median time from symptom onset to current diagnosis was 7 months (range, 0-252 months), with 43% of respondents reporting a delay of ≥ 1 year and 19% reporting a delay of ≥ 3 years. Sixty-one percent of respondents underwent at least one invasive diagnostic procedure. CONCLUSIONS: While a minority of patients with ILD will experience an appropriate and expedient diagnosis, the more typical diagnostic experience for individuals with ILD is characterized by considerable delays, frequent misdiagnosis, exposure to costly and invasive diagnostic procedures, and substantial use of healthcare resources. These findings suggest a need for physician education, development of clinical practice recommendations, and improved diagnostic tools aimed at improving diagnostic accuracy in patients with ILD.

Access to affordable medicines and diagnostic tests for asthma and COPD in sub Saharan Africa: the Ugandan perspective.

BACKGROUND: Equitable access to affordable medicines and diagnostic tests is an integral component of optimal clinical care of patients with asthma and chronic obstructive pulmonary disease (COPD). In Uganda, we lack contemporary data about the availability, cost and affordability of medicines and diagnostic tests essential in asthma and COPD management. METHODS: Data on the availability, cost and affordability of 17 medicines and 2 diagnostic tests essential in asthma and COPD management were collected from 22 public hospitals, 23 private and 85 private pharmacies. The percentage of the available medicines and diagnostic tests, the median retail price of the lowest priced generic brand and affordability in terms of the number of days' wages it would cost the least paid public servant were analysed. RESULTS: The availability of inhaled short acting beta agonists (SABA), oral leukotriene receptor antagonists (LTRA), inhaled LABA-ICS combinations and inhaled corticosteroids (ICS) in all the study sites was 75%, 60.8%, 46.9% and 45.4% respectively. None of the study sites had inhaled long acting anti muscarinic agents (LAMA) and inhaled long acting beta agonist (LABA)-LAMA combinations. Spirometry and peak flow-metry as diagnostic tests were available in 24.4% and 6.7% of the study sites respectively. Affordability ranged from 2.2 days' wages for inhaled salbutamol to 17.1 days' wages for formoterol/budesonide inhalers and 27.8 days' wages for spirometry. CONCLUSION: Medicines and diagnostic tests essential in asthma and COPD care are not widely available in Uganda and remain largely unaffordable. Strategies to improve access to affordable asthma and COPD medicines and diagnostic tests should be implemented in Uganda.

Trends in the Incidence of Lung Cancer Hospitalizations in Spain, 2001-2011. / Tendencias en la incidencia de hospitalizaciones por cáncer de pulmón en España entre 2001 y 2011.

OBJECTIVE: To analyze changes in the incidence, diagnostic procedures, comorbidity, length of hospital stay and costs of patients hospitalized for lung cancer in Spain between 2001 and 2011. PATIENTS AND METHODS: Retrospective study including all patients hospitalised with a primary diagnosis of lung cancer between 2001 and 2011. Data were collected from the National Hospital Discharge Database, encompassing the entire Spanish population. Economic and sociodemographic characteristics and health-related variables were analyzed. RESULTS: A total of 298,435 hospitalizations occurred. The overall crude incidence increased from 61.18 per 100,000 inhabitants in 2001 to 65.08 per 100,000 in 2011 (P <.05), with a decrease in men and a proportionate increase in women. The age group with the highest incidence was 70 to 79 years. In 2001, 4.5% of patients had a Charlson comorbidity index (CCI) >2, and in 2011, prevalence of CCI >2 increased to 9.1% (P<.05). Mean length of hospital stay decreased during the study period. Computed tomography was the most common procedure. Mean cost per patient increased from €4,471.22 in 2001 to €5,562.54 (P<.05) in 2011. Factors related to the incidence of hospitalizations were age, sex and year of study in the multivariate analysis. CONCLUSIONS: We found a decrease in the rate of hospitalizations in men and an increase in women, with a concomitant increase in comorbidities and cost; however, length of hospital stay decreased. Factors related to incidence of hospitalizations were age, sex and year of study.

An official American Thoracic Society/American College of Chest Physicians policy statement: the Choosing Wisely top five list in adult pulmonary medicine.

The American Board of Internal Medicine Foundation's Choosing Wisely campaign aims to curb health-care costs and improve patient care by soliciting lists from medical societies of the top five tests or treatments in their specialty that are used too frequently and inappropriately. The American Thoracic Society (ATS) and American College of Chest Physicians created a joint task force, which produced a top five list for adult pulmonary medicine. Our top five recommendations, which were approved by the executive committees of the ATS and American College of Chest Physicians and published by Choosing Wisely in October 2013, are as follows: (1) Do not perform CT scan surveillance for evaluation of indeterminate pulmonary nodules at more frequent intervals or for a longer period of time than recommended by established guidelines; (2) do not routinely offer pharmacologic treatment with advanced vasoactive agents approved only for the management of pulmonary arterial hypertension to patients with pulmonary hypertension resulting from left heart disease or hypoxemic lung diseases (groups II or III pulmonary hypertension); (3) for patients recently discharged on supplemental home oxygen following hospitalization for an acute illness, do not renew the prescription without assessing the patient for ongoing hypoxemia; (4) do not perform chest CT angiography to evaluate for possible pulmonary embolism in patients with a low clinical probability and negative results of a highly sensitive D-dimer assay; (5) do not perform CT scan screening for lung cancer among patients at low risk for lung cancer. We hope pulmonologists will use these recommendations to stimulate frank discussions with patients about when these tests and treatments are indicated--and when they are not.

[An analysis of treatment delays of thoracic cancers: a prospective study]. / Analyse des délais de prise en charge des cancers thoraciques: étude prospective.

INTRODUCTION: Lung cancer is the main cause of cancer death in France. The diagnosis is often late and the delay between the onset of symptoms and management is considered an aggravating factor. MATERIAL AND METHODS: Our prospective study collected the dates of the start of management of 139 consecutive patients receiving first line treatment for thoracic cancer in our hospital between November 2008 and May 2009. The aim of this study was to evaluate the delays in medical or surgical treatments in patients with thoracic cancer and to determine the cause of these delays. RESULTS: The median delay between the first abnormal chest X-ray and treatment was 9.6 weeks. The delays were significantly shorter in the late stages and in small cell cancer (P=0.001). There was a tendency for shorter delays in women and for longer delays in older patients. CONCLUSION: Evaluation of the delays in treatment, particularly in the early stages, is part of the quality control of management of these diseases.

[Validity of the Keith Edwards scoring system for the diagnosis of childhood pulmonary tuberculosis]. / Validité du score de Keith Edwards dans le diagnostic de la tuberculose pulmonaire chez l'enfant.

INTRODUCTION: The diagnosis of childhood pulmonary tuberculosis remains a challenge. The effectiveness of the Keith Edwards scoring system used to diagnose tuberculosis is controversial. We evaluated this scoring system in the present study. METHODS: A prospective randomized study was conducted between March 2008 and December 2011 at the Kimpese General Evangelical Hospital in the Democratic Republic of Congo. The results of the Keith Edwards score were considered for the 161 children (100 pulmonary tuberculosis and 61 case controls) who were enrolled in the study. The association between different parameters and the score and between these parameters and pulmonary tuberculosis were statistically analyzed using univariate and multivariate tests. RESULTS: Eighty-five (85%) out of the 100 children diagnosed as having pulmonary tuberculosis and 20 (32.8%) of the case controls had a positive score. The age of the patient, duration of the disease, nutritional status, tuberculosis contact, positive tuberculin skin test, and lymph node enlargement showed a significant statistical association with the score and pulmonary tuberculosis (P<0.05). The score's sensitivity and specificity were 85% and 67.2%, respectively. The positive predictive value and negative predictive value were found to be 80.9% and 73.2%, respectively. The positive likelihood ratio was 2.57, the negative likelihood ratio was 0.22, and overall agreement was 76.1%. CONCLUSION: The Keith Edwards score could be good tool for public health purposes, but it might be less effective for individual diagnosis of childhood pulmonary tuberculosis because of low specificity. Further studies are required to evaluate and validate the diagnostic value of clinical and radiological symptoms in childhood pulmonary tuberculosis.

[Implementation of respiratory rehabilitation in the municipalities of Valparaíso, Viña del Mar, Quilpué and Villa Alemana in 2013]. / Implementación de la rehabilitación respiratoria en las comunas de Valparaíso, Viña del Mar, Quilpué y Villa Alemana durante el año 2013.

INTRODUCTION: Pulmonary rehabilitation is a keystone in the treatment of patients with Chronic Obstructive Pulmonary Disease. Significantly reduces the costs to the health system, the use of health resources by reducing hospital stay and consultations to emergency services. OBJECTIVE: Describe the current condition of respiratory rehabilitation in primary care centers located in the region of Valparaíso. METHOD: A closed survey in the respiratory centers of primary health care was applied. The sample consisted of 32 health centers corresponding to the communes of Valparaíso, Viña del Mar, Quilpué and Villa Alemana. RESULTS: 9 centers (28%) of the total sample performed pulmonary rehabilitation and the same number have a structured rehabilitation program. In 15 (47%) of the centers there is a Nutritionist in the health team. In 100% of hospitals patients assessed by spirometry and dyspnea scales. Most centers (89%) training upper and lower extremities. Among the factors that limit the performance of respiratory rehabilitation, 20 (63%) report that the schedule are one of the most limiting factors, while 23 (72%) report that centers do not have adequate space and 22 (69%) centers relate not have the minimum equipment necessary. DISCUSSION: Our findings suggest that most respiratory rehabilitation center did not performed as part of the treatment of patients with chronic obstructive pulmonary disease, mainly due to problems of human, material and infrastructure.

Introducción: La rehabilitación respiratoria es un pilar fundamental en el tratamiento del paciente con Enfermedad Pulmonar Obstructiva Crónica. Reduce importantemente los costos para el sistema de salud, el uso de recursos sanitarios, disminuyendo la estadía hospitalaria y las consultas a servicios de urgencia. Objetivo: Describir la condición actual de la rehabilitación respiratoria en los centros de atención primaria ubicados en la región de Valparaíso. Método: Se aplicó una encuesta cerrada a cada profesional a cargo del área respiratoria en los centros de atención primaria de salud. La muestra estuvo conformada por 32 centros de salud correspondientes a las comunas de Valparaíso, Viña del Mar, Quilpué y Villa Alemana. Resultados: 9 centros (28%) del total de la muestra realizan rehabilitación respiratoria y el mismo número tiene un programa de rehabilitación estructurado. En 15 (47%) de los centros existe un Nutricionista dentro del equipo de salud. En el 100% de los centros se evalúa a los pacientes mediante espirometría y escalas de disnea. La mayoría de los centros (89%) realiza entrenamiento de extremidades superiores e inferiores. Dentro de los factores que limitan la realización de la rehabilitación respiratoria, 20 (63%) centros refieren que el horario de atención es uno de los factores más limitantes, mientras que 23 (72%) centros refieren que no cuentan con espacio físico adecuado y 22 (69%) centros relatan no contar con los implementos mínimos necesarios. Discusión: Los datos obtenidos indican que en la mayoría de los centros encuestados no se realiza rehabilitación respiratoria como parte del tratamiento del paciente con Enfermedad Pulmonar Obstructiva Crónica, principalmente por problemas de recursos humanos, materiales e infraestructura.

Nasal potential difference measurements in diagnosis of cystic fibrosis: an international survey.

BACKGROUND: The role of nasal potential difference (NPD) measurement as a diagnostic test for cystic fibrosis (CF) is a subject of global controversy because of the lack of validation studies, clear reference values, and standardized protocols for diagnostic NPD. METHODS: To determine diagnostic NPD frequency, protocols, interpretation, and rater agreement, we surveyed the 18 NPD centres of the European Cystic Fibrosis Society Diagnostic Network Working Group. RESULTS: Fifteen centres reported performing 373 diagnostic NPDs in 2012. Most use the CFF-TDN-SOP (67%) and the chloride-free + isoproterenol response of the side with the largest response (47%) as diagnostic criteria and use centre-specific reference ranges. Rater agreement for five NPD tracings - in general - was good, but poor in tracings with different responses between the two nostrils. CONCLUSIONS: NPD is frequently used as a diagnostic and research tool for CF. Performance is highly standardized, centre-specific reference ranges are established, and rater agreement - in general - is good. Centre-independent diagnostic criteria and reference ranges must be defined by multicentre validation studies to improve standardized interpretation for diagnostic use.

Evaluation of the use of a rapid diagnostic consultation of lung cancer. Delay time of diagnosis and therapy.

OBJECTIVE: To analyze the results obtained in a lung cancer screening program since its inception five years ago regarding correct referrals, diagnostic and therapeutic delay times and days of hospitalization. To compare the diagnostic-therapeutic delays and hospital stays with those obtained in patients evaluated with the standard system. PATIENTS AND METHODS: Included for study were all those patients evaluated in our Lung Cancer Screening Program (LCSP) in the last five years. For the cases with LC, we recorded the dates the patients were referred to a specialist, the first consultation, diagnostic tests, stage, start of treatment and days of hospitalization. We compared these same data with lung cancer patients who did not partake in the LCSP and were diagnosed between October 2008 and October 2010. RESULTS: We evaluated 179 patients remitted to the LCSP, which represented 26.7% of the consultations; 166 (92.7%) of the referrals were correct, out of which 44.5% were LC. In 75.6% of these, the entire study was completed in the outpatient setting, and more than 85% of the cases met the current recommendations related with diagnostic-therapeutic delays. When these results were compared with the non-LCSP group (n=151), differences were found in the data for hospitalizations: there was a lower percentage of hospitalizations (P<.0001) and shorter hospital stays (P<.0001) in the LCSP group. There were no differences between the two groups for diagnostic or therapeutic delays. CONCLUSION: In our setting, lung cancer screening programs allow for cancer studies to be carried out in the outpatient consultations in a large percentage of cases, and within the time periods recommended by current guidelines. In spite of this fact, we have detected that these programs are underused.

Management of acute bronchiolitis in emergency wards in Spain: variability and appropriateness analysis (aBREVIADo Project).

UNLABELLED: Most patients with acute bronchiolitis have a mild course and only require outpatient care. However, some of them have to go to emergency departments, because they have respiratory distress or feeding problems. There, they frequently receive diagnostic and therapeutic procedures. We want to know the variability and appropriateness of these procedures. A cross-sectional study (October 2007 to March 2008) was carried out on 2,430 diagnosed cases of bronchiolitis in hospital emergency departments, which required no hospitalization. An analysis of the appropriateness of the treatments was made in 2,032 cases gathered in ten departments with at least 100 cases, using as criterion the recommendations of a consensus conference. We estimated the adjusted percentages of each department. Most of the bronchiolitis were mild, in spite that they underwent multiple diagnostic and therapeutic procedures. In the acute phase, different treatments were used: inhaled beta 2 agonists (61.4%), antipyretics (17.1%), oral steroids (11.3%), and nebulized adrenaline (9.3%). In the maintenance phase, the most common treatments were: inhaled beta 2 agonists (50.5%), oral steroids (17%), oral beta 2 agonists (14.9%), and antibiotics (6.1%). The 64% of the treatments used in the acute phase and the 55.9% in the maintenance phase were considered inappropriate in the appropriateness analysis; a great heterogeneity among centers was found. CONCLUSIONS: There are discrepancies between clinical practice and evidence-based management of bronchiolitis in Spanish emergency departments. Inappropriate treatments were used in more than half of patients. The wide variation between centers shows the influence of local prescribing habits and reveals the scope for improvement.

[Follow-up of subjects occupationally exposed to asbestos, what are the objectives, the benefits, and the possible risks?]. / Quels sont les objectifs du suivi post-professionnel, les bénéfices attendus et les risques possibles? Objectifs médicaux en termes de morbidité, mortalité et qualité de vie.

The follow-up of workers occupationally exposed to asbestos has two possible beneficial effects: (1) individually, both medical by screening for diseases related to asbestos and social by notification of occupational disease and/or compensation from the indemnity funds for asbestos victims; (2) collectively, by the establishment of epidemiological surveillance (follow-up of cohorts) and evaluation of the impact of follow-up in terms of health benefits and compensation. The respiratory disorders related to asbestos are: cancer (malignant pleural mesothelioma and bronchial carcinoma), asbestos-related pulmonary fibrosis, and pleural disease (plaques, pleural fibrosis and benign pleurisy). In the light of the data currently available and the effectiveness of the tools used, medical and public health benefits of screening for mesothelioma have not been demonstrated. The early diagnosis of primary bronchial carcinoma can theoretically improve the prognosis of the subjects screened, particularly by identification of stage I disease on CT (pulmonary nodules). This is a common finding but there are a large number of false-positives. While we await the results of several international randomised trials, the benefits of a screening programme for bronchial carcinoma in the population at risk have not been demonstrated. There is no effective treatment for asbestosis but this is an independent risk factor for bronchial carcinoma and it is evidence of heavy asbestos exposure. Stopping smoking in subjects suffering from asbestosis will reduce the incidence of bronchial carcinoma. There is no effective treatment for asbestos-related benign pleural diseases but these are markers of exposure. The presence of pleural plaques has not been shown to be an aetiological factor for thoracic cancers. Post-occupational follow-up may involve risks to health, particularly repeated irradiation and invasive diagnostic procedures. It is also necessary to consider the psychological consequences inherent in all screening programmes. In conclusion, post-occupational follow-up might reduce the mortality of lung cancer by screening for localised disease and its incidence by a targeted anti-smoking programme. The theoretical benefits, that have not yet been demonstrated, have to be seen in perspective with the risks to physical and psychological health related to both screening and diagnostic procedures.

Reproducibility of multiple breath washout indices in the unsedated preterm neonate.

Multiple breath inert gas washout (MBW) is gaining popularity for measurements of resting lung volume and ventilation inhomogeneity. Test reproducibility is an important determinant of the clinical applicability of diagnostic tests. The between-test reproducibility of variables derived from MBW tests in newborn infants is unknown. We aimed to determine the within-test repeatability and short-term between-test reproducibility of MBW variables in unsedated preterm infants. We hypothesized that measurements obtained within a 3-day interval in clinically stable preterm infants would be reproducible and suitable for use as an objective clinical outcome measurement. In this cross-sectional observational study, clinically stable hospitalized preterm infants whose parents had given informed consent for MBW studies were tested twice within 72 hr during quiet, unsedated sleep. Functional residual capacity (FRC), lung clearance index (LCI), and the first and second to zeroeth moment ratios (M(1):M(0); M(2):M(0)) were computed from MBW traces obtained using a mainstream ultrasonic flowmeter and 4% sulphur hexafluoride (MBW(SF6)). Within-test repeatability and between-test reproducibility were determined. Within-test repeatability (expressed as a coefficient of variability (C(v))) for differences between two and four replicate measurements on the same test occasion, were 9.3% (FRC), 9.0% (LCI), 7.6% (M(1):M(0)), and 15.6% (M(2):M(0)), respectively. The within-test C(v)'s were not statistically different to the between-tests C(v)'s, which were 7.7% (FRC), 10.3% (LCI), 6.1% (M(1):M(0)), and 13.0% (M(2):M(0)), respectively. Among unsedated preterm infants, between-test reproducibility over a 3-day interval was similar to within-test repeatability. The wide limits of agreement may limit the application of these measures to detect a clinically significant change in condition in small preterm infants.

Spectrum of practice in the diagnosis of nosocomial pneumonia in patients requiring mechanical ventilation in European intensive care units.

OBJECTIVES: Information on clinical practice regarding the diagnosis of pneumonia in European intensive care units is limited. The aim of this study was to describe the spectrum of actual diagnostic practices in a large sample of European intensive care units. DESIGN: Prospective, observational, multicenter study. SETTING: Twenty-seven intensive care units of nine European countries. PATIENTS: Consecutive patients requiring invasive mechanical ventilation for an admission diagnosis of pneumonia or receiving mechanical ventilation for >48 hrs irrespective of admission diagnosis. INTERVENTIONS: None. MEASUREMENTS AND MAIN RESULTS: A total of 2,436 patients were evaluated; 827 were admitted with or developed nosocomial pneumonia (hospital-acquired pneumonia [HAP], 27.1%; ventilator-associated pneumonia [VAP], 56.2%; very early onset VAP, 16.7%). Mean age was 59.4 +/- 18.1 yrs, 65.0% were men, and mean admission Simplified Acute Physiology Score II was 46.7 +/- 17.1. Worsening oxygenation (76.8%), purulent/changing respiratory secretions (72.1%), and new temperature elevation (69.2%) were the most frequent clinical signs of nosocomial pneumonia. Etiological diagnosis was based on noninvasive respiratory specimens in 74.8% of episodes. Bronchoscopy was performed in 23.3% of episodes. Bronchoscopy performance, after adjustment by severity of illness, age, and type of hospital, were predicted by worsening oxygenation (odds ratio 2.03; 95% confidence interval, 1.27-3.24) and male sex (odds ratio 1.77; 95% confidence interval, 1.19-2.65). Definite cause was documented in 69.5% of nosocomial pneumonia cases. The most common isolates were Staphylococcus aureus (16.3% methicillin-sensitive S. aureus and 16.0% methicillin-resistant S. aureus), Pseudomonas aeruginosa (23.1%), and Acinetobacter baumannii (19.1%). Presence of nosocomial pneumonia significantly prolonged mean length of mechanical ventilation (10.3 days, p < .05) and mean intensive care unit length of stay (12.2 days, p < .05) in intensive care unit survivors. Mortality rate was 37.7% for nosocomial pneumonia vs. 31.6% for patients without pneumonia (p < .05). CONCLUSIONS: Etiological diagnosis of nosocomial pneumonia in a large sample of European intensive care units was based mainly on noninvasive techniques. However, there was high variability in bronchoscopy use between the participating intensive care units.

Combining field imaging endoscopy with point analysis spectroscopy for improving early lung cancer detection.

We propose to combine field imaging endoscopy with point spectral analysis for improving the overall diagnostic accuracy in clinical lung cancer detection. For this purpose, we developed an integrated endoscopy system that uses autofluorescence imaging and white light reflectance imaging to obtain high diagnostic sensitivity, while at the same time uses non-contact point reflectance/fluorescence spectroscopy to reduce false positive biopsies, thus, achieve high diagnostic specificity. A pilot clinical test on 22 lung patients demonstrated that using this system the malignant lung lesions can be differentiated from the benign lesions with both diagnostic sensitivity and specificity of better than 80%. To further reduce the number of false positive diagnosis and allow even higher diagnostic accuracies, we have also developed an endoscopic laser Raman probe for in vivo real-time biochemical analysis of the suspicious tissue areas identified by the field imaging modalities (white light imaging and autofluorescence imaging). Preliminary Raman spectroscopy results will be reported at the conference.

Inter-observer agreement on apnoea hypopnoea index using portable monitoring of respiratory parameters.

BACKGROUND: Although portable polygraphy or portable monitoring of respiratory parameters (PM) is commonly used to confirm obstructive sleep apnoea syndrome, agreement on apnoea hypopnoea index (AHI), the main measure of disease severity, has not been evaluated. The aim of this study was to assess the agreement on AHI among multiple observers as well as between individual observers and automated analysis. METHODS: A total of 88 ambulatory sleep recordings ("Embletta") were independently scored by 8 physicians (observers). Agreement on AHI, using intraclass correlation coefficient (ICC), was measured among observers. Bland Altman plots were built to compare individual observers with PM. RESULTS: Among observers, ICCs were .73 for agreement on AHI, .71 for hypopnoea index and .98 for desaturation index. Compared to visual analysis, automated analysis underestimated AHI by 5.1 events on average. When comparing individual observers with automated analysis, systematic bias varied from -1. to +1 .5 events/h on AHI. CONCLUSIONS: Among observers who used PM in a clinical setting, agreement on AHI was limited. When automated and individual visual analyses were compared, the systematic bias varied from almost zero to values sufficient to affect clinical diagnosis. Much of the discordance was due to different counts of hypopnoea, whereas agreement on apnoea and desaturation index was better. Efforts should be directed towards standardisation of visual analysis, improvement and quality control of ambulatory sleep studies.